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1. Percutaneous fenestration of the anteromedial aspect of the
calcaneus for resistant heel pain syndrome
Freih Odeh Abu Hassan F.R.C.S. (Eng.), F.R.C.S. (Tr. & Orth.)*
Department of Orthopedics Surgery, Jordan University Hospital, P.O. Box 73, Jubaiha 11941, Amman, Jordan
Received 28 May 2008; received in revised form 13 August 2008; accepted 13 August 2008
Abstract
Introduction: The failure of conservative treatment of chronic heel pain might cause prolonged disability from continued discomfort and
pain, which mandates a further treatment modality.
Aim of study: The presentation of the results of percutaneous fenestration of the anteromedial aspect of the calcaneus for symptomatic relief
of resistant heel pain syndrome.
Material and methods: Between September 2001 and August 2006, 34 patients (38 feet) with chronic heel pain syndrome reported an
unacceptable level of pain despite intensive conservative treatment. There were 23 females and 11 males with an average age of 41 years (25–
59 years). The average follow-up was 46 months (range, 14–84 months). Clinical evaluation of the intensity of pain (VAS score system),
walking distance, standing duration, fascial tenderness, and ankle and subtalar joint motion were evaluated preoperatively and at regular
follow-up.
Results: The preoperative pain score level was 8.4 (range, 6–10). The mean postoperative VAS for pain at 4 weeks was 5.89 (range, 3–9), at 8
weeks the value was 3.98 (range, 2–7), at 4 months 2.46 (range, 2–5), at 8 months 1.7 (range, 0–3) and at 12 months zero. A clinical
improvement was seen in all patients irrespective of the duration of symptoms ( p = 0.0041). Three heels (7.9%) had partial relief of pain, but
after 43 weeks had complete subsidence of pain. Complications include three transient paraesthesias at the distribution of the medial calcaneal
nerve that resolved spontaneously after 8 weeks post-surgery.
Conclusion: The results suggest the technique of percutaneous fenestration is a significantly effective treatment modality for patients with
recalcitrant heel pain syndrome after failed conservative treatment.
The described technique may provide a useful method for treating refractory heel spur syndrome without resorting to invasive surgical
techniques and warrants further study.
# 2008 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Foot; Heel pains; Fenestration; Calcaneal spur; Fasciitis
1. Introduction
Heel pain is a frequent orthopaedic problem encountered
in daily practice and plantar fasciitis forms the most common
aetiology, affecting 10% of the population, which may lead to
significant morbidity and place strict activity limitations on
the patient [1]. The heel pain syndrome includes a continuum
of three different entities, including plantar fasciitis, calcaneal
periostitis and the calcaneal spur [2].
The aetiology is not known but it is believed to be the
result of chronic repetitive injury as a result of the nature of
upright human activity leading to repetitive tensile and
compressive stress of the fascia that has a cumulative ability
to damage or transform the tissue, causing a chronic
degenerative/reparative process with or without inflamma-
tory changes, which may include fibroblastic proliferation at
the calcaneal interface [3,4].
The majority of patients can be treated initially by a
combination of one or more of the following in a therapeutic
regimen: heel cord stretching, plantar fascia stretching, arch
support, heel pads, custom orthosis, taping, non-steroidal
anti-inflammatory drugs (NSAIDs), physiotherapy, ice,
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Available online at www.sciencedirect.com
Foot and Ankle Surgery 15 (2009) 90–95
* Tel.: +962 6 5240 346; fax: +962 6 5240 346.
E-mail address: freih@ju.edu.jo.
1268-7731/$ – see front matter # 2008 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.fas.2008.08.006

2. massage, lithotripsy, cast immobilization, activity modifica-
tions, night splints or steroid injections. Independent of the
mode of therapy used, if at all, 10–15% of patients fail to
respond to conservative treatment [5–9]. There is limited
evidence for the superiority of corticosteroid injections over
orthotic devices, stretching exercises and heel pads over
custom-made orthoses in people who stand for more than 8 h
per day [10]. Extracorporeal shock wave therapy is
ineffective in the treatment of chronic plantar fasciitis
[10,11]. Despite the used multiple modalities of treatment, it
takes a long time to heal. Many surgical techniques have
been tried with non-response rates varying from 2 to 35%
[12,13].
The aim of this study is to assess the effectiveness of
percutaneous fenestration of the anteromedial aspect of the
calcaneus at the insertion of the plantar fascia as a treatment
modality for chronic heel pain syndrome, to abate the
painful symptoms and to allow a rapid return to ordinary
activity, on the assumption of the degenerative and calcaneal
periostitis process as factors playing a role in the
pathogenesis of plantar fasciitis [2–4].
2. Material and methods
Between 2001 and 2006, 34 patients (38 feet) were
treated for their chronic heel pain syndrome after the
failure of conservative methods, using percutaneous
fenestration. There were 23 females and 11 males, with
an average age of 41 years (25–59 years). The left heel
was affected in 17 patients, the right heel in 13 and the
problem was bilateral in 4 patients; all were treated with
the same technique by the author. All the patients
diagnosed with painful plantar fasciitis were questioned
concerning the type of pain, site of pain, duration of pain,
walking distance, standing duration, extent of conserva-
tive therapy, previous surgical treatment and past medical
history. All the patients had an assessment of the range of
motion of the ankle and subtalar joints actively
and passively, and they were checked for gait pattern.
Each patient was treated for 3 months with conservative
methods, including physical therapy, Achilles tendon
and plantar fascia stretching, icing, heel pads and
NSAIDs. If the patient was not improving, an 8-week
course of additional therapy, including three courses of
ultrasound of six sessions each, and continued heel
pads and NSAIDs were prescribed before considering
surgery.
All the patients had weightbearing lateral radiographs of
the feet. Our inclusion criteria were the following: the
presence of a chronic pain of at least 6 months duration
(range 6–43 months) at the proximal insertion of the plantar
fascia at the anteromedial of the heel, which failed to
respond to a trial of conservative treatment. None of the
patients had symptoms of inflamed joints, tendon attach-
ments, inflammatory back pain, iritis, blood or mucus per
rectum, urethritis or skin problems as a manifestation of the
underlying inflammatory process.
Pain was evaluated using the subjective 11-point visual
analogue scale (VAS), where 10 represented unbearable
pain and 0 absence of pain. Patients were checked for any
signs of inflammation at the entry point of the fenestration
and impaired sensation of the sole using a pinprick. Pain and
gait pattern were evaluated preoperatively, 4 weeks, 8
weeks, 4 months, 8 months and 12 months after the
fenestration procedure. We defined the clinical results as
follows: excellent, patients who reported a subjective
decrease in pain ranging from 100 to 80% (VAS), no
complications and normal gait; very good, a decrease from
80 to 60% (VAS), no complications and minimal short-term
antalgic gait; good, a decrease of less than 60–40% (VAS),
minor complications and/or antalgic gait; and poor, a
decrease of less than 40–0% (VAS), major complications
and/or impossible gait.
2.1. Surgical technique
Under general anesthesia, the patient is placed in the
supine position with a sand bag under the opposite buttock
and the leg placed in external rotation. Without using the
tourniquet, the foot and ankle are draped. After a betadine
preparation of the skin, localization of the entry point is
performed under an image intensifier, followed by a
medial single 5 mm stab incision. Using the image
intensifier, the Steinmann pin is introduced through the
incision at the anteromedial aspect of the calcaneus and
multiple bone fenestration for about 1 cm made from the
same single hole in the superolateral direction, then
withdrawn slightly and directed posteriorly then anteriorly
and finally towards the lateral side perpendicular to the
calcaneus (Figs. 1 and 2).
No trial was made to break the plantar heel spur if
present. To infiltrate the heel at the end of operation, 5 ml
Marcaine local anesthesia is used. The entry site is not
sutured and a light, sterile compressive dressing with an
elastic bandage is applied.
2.2. Postoperative management
Postoperatively, the patient is given oral analgesia and
instructed for partial weight bearing for 7 days then to
continue with full weightbearing as tolerated. The dressing
is removed after 1 week and a small sterile dressing is
applied.
2.3. Statistical analysis
Statistical analysis of the data was performed by using a
PC program (SPSS 14 for Windows). Repeated measures
analysis (analysis of variance) was performed to compare
statistically pain ratings preoperatively, at 4 weeks, 8 weeks,
4 months, 8 months and 12 months.
F.O.A. Hassan / Foot and Ankle Surgery 15 (2009) 90–95 91

3. F.O.A. Hassan / Foot and Ankle Surgery 15 (2009) 90–95
92
Fig. 1. Serial clinical photographs of the fenestration technique.
Fig. 2. Serial radiological views of the fenestration technique.

4. 3. Results
The average follow-up was 46 months (range, 14–84
months). Five patients had diabetes mellitus, two hyperten-
sion, five carcinoma of the breast and four osteoarthritis of
the knee joints. In all cases, the exact cause of the plantar
fasciitis could not be defined. There were 23 heel spurs
noticed in the standing lateral plain radiograph of the foot.
Pain was graded by each individual patient preoperatively
and postoperatively.
Pain ratings before fenestration were significantly
reduced from the average pain ratings after the procedure.
The average pain score before fenestration was 8.4 (range,
6–10) on the VAS.
At regular follow-up, the mean postoperative VAS for
pain at 4 weeks dropped to 5.89 (range, 3–9), at 8 weeks the
value was 3.98 (range, 2–7), at 4 months 2.46 (range, 2–5), at
8 months 1.7 (range, 0–3) and at 12 months zero (Fig. 3).
Based on the aforementioned parameters, we analysed the
results at 4, 8 and 12 months.
We had excellent results in 78.94% (30 feet), 92.09% (35
feet) and 100% (38 feet) at 4, 8 and 12 months, respectively.
Very good results were observed in 13.15% (5 feet) at 4
months; all become excellent at 8 months. Good results in
7.9% (3 feet) at 4 months become very good at 8 months and
excellent at 12 months (Fig. 4). None of our patients had
poor results. There was significant heel pain relief as
indicated by ( p = 0.0041). Pain distribution revealed that
92.09% (N = 35) of the heels had complete or substantial
relief of heel pain after an average period of 10 weeks (4–34
weeks), with a pain rating of 1.7 on the VAS 8 months after
the procedure. Three heels (7.9%) had partial relief, but after
43 weeks they had complete subsidence of pain.
All the patients had a limited walking distance
preoperatively and they used to avoid prolonged standing.
Patients were able to walk for an average of 0.76 km (range,
70–2.5 km) and stand for an average of 24 min (range, 15–
60 min). The average postoperative walking distance was
4.1 km (range, 1.5–8 km) and the average postoperative
standing period was 3.9 h (range, 2.5–8 h). We observed a
persistent improvement in heel pain as evidenced by
prolonged walking distance and an improvement in standing
period ( p = 0.033).
None of the patients had localized tenderness at the
insertion of the plantar fascia at 12 months postoperatively.
All the patients showed a normal range of motion in the
subtalar joint preoperatively, although there was a limited
dorsal flexion of the ankle joint in 21 of 38 feet (0–58 in 14
feet and 6–108 in the other 7 feet).
Clinical examination showed a normal postoperative
range of motion in the subtalar joint and ankle joint. Gradual
recovery of the sensation occurred in the three patients with
neuropraxia of the medial calcaneal nerve in an 8-week
period. None of the patients were sent for rehabilitation.
No infections, hypertrophic scar formations or vascular
complications occurred in our patients. Complications
include three patients having impaired sensation at the
plantar aspect of the heel; this resolved spontaneously in 8
weeks.
4. Discussion
Although this problem is common, patients’ heel pain
improves spontaneously, demonstrating that the condition
is self-limiting in some patients [10]. Most patients of
plantar fasciitis respond very well to conservative
treatment. There was conflicting, limited or no evidence
for the effectiveness of topical steroids, low-energy
extracorporeal shock wave therapy, night splints, ther-
apeutic ultrasound or low-intensity laser therapy in
altering the clinical course of plantar heel pain [10].
The first line of management is by non-steroidal anti-
inflammatory drugs and heel pads [14]. After the failure of
all conservative options and permanent pain, an indication
for surgical intervention should be considered. The
literature is plethoric with different methods of surgical
treatment, and it seems there is no agreement on a single
method as the curative remedy.
F.O.A. Hassan / Foot and Ankle Surgery 15 (2009) 90–95 93
Fig. 3. The graph shows the mean value of pain (VAS) at the time of
preoperative and postoperative periods.
Fig. 4. The clinical results obtained with the treatment using percutaneous
fenestration.

5. Conventional open fasciotomy, fluoroscopic-assisted
fasciotomy, neurolysis, denervation, osteotomy or drilling
of the posterior calcaneus were the described surgical
methods [13,15–18]. Considerable attention was paid to the
complications of such procedures: healing problems,
vascular and neural lesions, hypertrophic scars and even
fractures of the calcaneus [19]. Apart from this, bad
results after operations are always frustrating for both the
patient and the surgeon [17]. Uni- or bi-cortical drilling in
the posterior body of the calcaneus has been tried before
as another modality of treatment to decrease the intraoss-
eous vascular congestion, with a 75–94% success rate
[18,20,21].
Drilling can be performed with an open procedure
through making 7–10 separate holes that traverse the
calcaneus from the lateral to the medial cortex or
percutaneous drilling of the calcaneus can be performed
over the medial surface of the heel by making three separate
small holes in the medial cortex, without traversing the
lateral cortex.
The aim of all described methods of drilling to decrease
the high intraosseus pressure in the calcaneus. Our method
based on the degenerative and periostitis process at the
calcaneal interface of the plantar fascia as possible
pathogenesis of this condition, the technique enhance
healing process and accelerate resolution of this challenging
problem.
By performing fenestration at anteromedial aspect
of the calcaneal interface of the plantar fascia, a
process of inflammation can be induced which will be
followed by opening the channels of the blood to
the site of pathology where the reparative cells
produce healing of the degenerative insertion of the
plantar fascia.
Again the described methods of drilling are performed
through the posterior body of the calcaneus away from the
pathology site in the anteromedial aspect of the heel and may
be associated with calcaneal fracture or nerve injury
[18,20,21].
Our technique is directed to the site of the pathological
process at the insertion of the plantar fascia in the
anteromedial aspect of the calcaneus at the inferior
calcaneal tubercle, by one fenestration and four
different directions of the Steinmann pin penetration
without perforating the lateral cortex. Compared with
other surgical procedures, our technique disturbs
neither the normal anatomy nor the biomechanical
function of the hind foot. With resolved chronic heel
pain in all treated feet, the clinical results are better than
those found in the literature, whether local calcaneal
drilling, minimal invasive procedure or open fasciotomy
[19,20,22,23]. We believe that there is no risk of
permanent damage to the branches of the sural nerve or
the medial calcaneal nerve or fracture of the calcaneus,
despite the three cases of the neuropraxia of the medial
calcaneal nerve which could be attributed to slippage of
the Steinmman pin during the targeting of the site of the
plantar fascia insertion or an abnormal course of the
nerve.
5. Conclusion
Despite the successful outcome of our technique, the
suggested method of healing needs further confirmation by
other laboratory methods or histological studies. These
results from a small group of patients studied over a few
years indicate that the described technique may provide a
useful method for treating this challenging refractory heel
pain syndrome. A larger study combined with random
variables would be helpful in the elimination of such
limitations.
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