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Selective Plantar Fascia Release for Nonhealing Diabetic Plantar Ulcerations
J.-Young Kim, MD, PhD1; Seungkeun Hwang, MD2; Yoonjung Lee, MD, PhD3
1 Foot and Ankle Center, Department of Orthopedic Surgery, Heymin General Hospital, 627-3, Jayang dong, Gwangjingu, Seoul, South Korea. E-mail address: kjyos@yahoo.co.kr
2 Department of Orthopedic Surgery, Hankook General Hospital, Samdo 1-dong, Jeju City, Jejudo 690-715, South Korea. E-mail address: seungkeunh@hotmail.com
3 Department of Ophthalmology, Hanyang University Guri Hospital, Kyomoon 1-dong, Guri City, Kyungido 471-701, South Korea. E-mail address: lyjot@hanyang.ac.kr
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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

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Investigation performed at Heymin General Hospital, Seoul, South Korea

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Jul 18;94(14):1297-1302. doi: 10.2106/JBJS.K.00198
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Achilles tendon lengthening can decrease plantar pressures, leading to resolution of forefoot ulceration in patients with diabetes mellitus. However, this procedure has been reported to have a complication rate of 10% to 30% and can require a long period of postoperative immobilization. We have developed a new technique, selective plantar fascia release, as an alternative to Achilles tendon lengthening for managing these forefoot ulcers.


We evaluated sixty patients with diabetes for a mean of 23.5 months after selective plantar fascia release for the treatment of nonhealing diabetic neuropathic ulcers in the forefoot. Preoperative and postoperative dorsiflexion range of motion of the affected metatarsophalangeal joint and wound-healing data were used to evaluate the effectiveness of the procedure and to determine the relationship between plantar fascia release and ulcer healing. Complications were recorded.


Thirty-six (56%) of the ulcers healed within six weeks, including twenty-nine (60%) of the plantar toe ulcers and seven (44%) of the metatarsophalangeal joint ulcers. The mean range of motion of the affected metatarsophalangeal joint increased from 15.3° ± 7.8° to 30.6° ± 14.1° postoperatively (p < 0.05). All patients in whom the preoperative dorsiflexion of the affected metatarsophalangeal joint was between 5° and 30° and in whom the range of motion of that joint increased by ≥13° after the procedure experienced healing of the ulcer. No ulcer recurrence in the original location was identified during follow-up. No patients experienced any complications associated with the selective plantar fascia release.


Our results suggest that selective plantar fascia release can lead to healing of neuropathic plantar forefoot ulcers in diabetic patients. Ulcers in patients in whom the preoperative dorsiflexion angle of the affected metatarsophalangeal joint is between 5° and 30° and in whom the increase in range of motion is ≥13° postoperatively have the greatest chance of being cured.

Level of Evidence: 

Therapeutic Level IV. See Instructions for Authors for a complete description of the levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    J-Young Kim M.D.
    Posted on August 24, 2012
    Response to Dr. Laborde
    Foot and Ankle, Diabetic Foot Center, D & F Hospital, Chung-hwa dong, Chung-rang gu, Seoul

    Thanks for your concern and interest. The Achilles tendon lengthening procedure resulted in a 34% increase in peak pressures on the heel, an over-lengthened tendon leads to a calcaneal gait, and frank ulceration can happen in 2% to 15% of Achilles lengthening cases. Another problem with Achilles tendon lengthening is the long immobilization time (3-6 weeks), which can weaken the lower extremity and preclude normal walking. There is evidence that Achilles tendon lengthening may require anesthesia and a relatively long period of immobilization simply to manage minor ulcers, which can be a burden to patients.

    This procedure can be performed in an outpatient clinic. So SPFR has less risk, no immobilization and needs less money.

    The mechanisms of claw toe and plantar fascia contracture appear to be different. Because the causal mechanism is different, the clinical features are also different. Claw toe deformity results from the abnormality or contracture of long the flexor muscle. Plantar fascia contracture results from the abnormality of plantar fascia fiber. In those conditions, it is very hard to evaluate the treatment of whole toe ulcers which are come from claw toe, hammer toe, mallet toe, and plantar fascia contracture. One can easily discriminate and manage the lesser toe contractures.

    J. Monroe Laborde, MD; Director, Foot Surgery
    Posted on August 16, 2012
    Literature review incomplete
    Director, Foot Surgery, LSUHSC, New Orleans, LA

    Excellent article but article did not review and compare to literature on gastrocnemius-soleus recession (GSR) and toe tenotomy (TT) for forefoot ulcers, which have higher healing rates (90%+) and very low rates of recurrence & heel ulcers.1-5 These higher healing and low complication rates occurred in spite of not excluding patients with vascular disease, infection and 5th ray ulcers. Since GSR and TT have higher rates of healing and very low complication rates, I believe they should be tried before or at the same time as plantar fascia release.

    1. Dayer R: Chronic diabetic foot ulcers. JBJS Br 2009;9(4):487-493.
    2. Laborde JM: Neuropathic plantar forefoot ulcers. FAI 2008;29(4):378-384.
    3.Takahashi S: The Vulpius procedure. JBJS Br 2002;84(7):978-980.
    4. Laborde JM: Neuropathic toe ulcers. FAI 2007;28(8):952-959.
    5. Kearney TP: Safety & effectiveness of flexor tenotomy. Diab Res Clin Pract 2010;89(3):224-6

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