Endoscopic Decompression of the First Branch of the Lateral Plantar Nerve and Release of the Plantar Aponeurosis for Chronic Heel Pain

Abstract

Entrapment of the first branch of the lateral plantar nerve is a commonly missed cause of recalcitrant plantar heel pain. The diagnosis is made on a clinical ground with maximal tenderness at the site of nerve entrapment. Treatment of the nerve entrapment is similar to that for plantar fasciitis, with rest, activity modification, nonsteroidal anti-inflammatory drugs, stretching exercise, and local steroid injection. Surgical release of the deep abductor hallucis fascia is indicated when conservative treatment failed. Endoscopic release of the nerve through the dorsal and plantar portals, as well as endoscopic plantar aponeurosis release, is a feasible approach.

Figures

Fig 1

Endoscopic decompression of the first branch of the lateral plantar nerve of the right foot. (A) The patient is supine with the legs spread. The medial border of the plantar aponeurosis (MBPA) and the medial calcaneal tubercle (MCT) are outlined with the great toe dorsiflexed. (B) Percutaneous release of the medial 1 cm of the plantar aponeurosis through the plantar portal (PP) incision, which is just distal to the medial calcaneal tubercle and medial to the medial border of the plantar aponeurosis.

Fig 2

Endoscopic decompression of the first branch of the lateral plantar nerve of the right foot. The patient is supine with the legs spread. (A) A 2.7-mm, 30° arthroscope is introduced from the plantar portal (PP) and is advanced dorsally under arthroscopic visualization along the deep surface of the fascia to its upper border. The arthroscope is then removed leaving the cannula in situ. A Wissinger rod is inserted into the cannula. The fascial edge is probed by the tip of the rod until the fascial orifice for the entry of the first branch of the lateral plantar nerve is identified. (B) A 5-mm dorsal portal (DP) incision is made at this point. The cannula is switched to the dorsal portal. (MBPA, medial border of the plantar aponeurosis; MCT, medial calcaneal tubercle.)

Fig 3

Endoscopic decompression of the first branch of the lateral plantar nerve of the right foot. The patient is supine with the legs spread. The dorsal portal (DP) is the viewing portal (A), and the plantar half of the deep abductor hallucis fascia is released by a retrograde knife via the plantar portal (PP) (B). The arrow shows the direction of pull of the retrograde knife and release of the plantar half of the deep abductor hallucis fascia. (AbHm, abductor hallucis muscle; MBPA, medial border of the plantar aponeurosis; MCT, medial calcaneal tubercle; pAbHF, plantar half of the deep abductor hallucis fascia.)

Fig 4

Endoscopic decompression of the first branch of the lateral plantar nerve of the right foot. The patient is supine with the legs spread. (A) After release of the plantar half of the fascia, the scope is advanced to the plantar portal (PP) under arthroscopic visualization. (B) The arthroscope is removed, leaving the cannula in situ. The Wissinger rod is inserted into the cannula. (DP, dorsal portal; MBPA, medial border of the plantar aponeurosis; MCT, medial calcaneal tubercle.)

Fig 5

Endoscopic decompression of the first branch of the lateral plantar nerve of the right foot. The patient is supine with the legs spread. (A) The plantar portal (PP) is the viewing portal and the retrograde knife is inserted along the deep surface of the deep abductor fascia via the dorsal portal (DP). (B) The dorsal half of the fascia is released under arthroscopic guide. The arrow shows the direction of pull of the retrograde knife and release of the dorsal half of the deep abductor hallucis fascia. (AbHm, abductor hallucis muscle; dAbHF, dorsal half of the deep abductor hallucis fascia; MBPA, medial border of the plantar aponeurosis; MCT, medial calcaneal tubercle.)

Fig 6

Endoscopic decompression of the first branch of the lateral plantar nerve of the right foot. The patient is supine with the legs spread. (A) The dorsal portal (DP) is the viewing portal. (B) The medial portion of the plantar aponeurosis (PA) is released by means of an arthroscopic scissors via the plantar portal (PP).