Plantar fasciitis is a common condition of heel pain with an incidence of up to 10% in a lifetime ^[1]. Plantar fasciitis is the most common cause of heel pain, accounting for 80% of cases of heel pain ^[2]. This condition tends to affect people between 40 and 60 years, showing a higher prevalence in women ^[1]. Risk factors associated are obesity, prolonged weight-bearing, and reduced ankle dorsiflexion, and it can occur bilaterally in one-third of cases ^[3,4]. Although plantar fascia pathology is not completely understood, it seems to be a non-inflammatory structural breakdown of fascia secondary to myxoid degeneration with microtears within the fascia, collagen necrosis, and angiofibroblastic hyperplasia ^[5]. Conservative management is considered the gold standard in the treatment of plantar fasciitis, which includes non-steroidal anti-inflammatory drugs, plantar fascia stretches and changes in footwear, ice, and activity modifications ^[6]. If these methods do not give relief, steroid/platelet-rich plasma (PRP) injections can be performed. For patients with recalcitrant plantar fasciopathy, focal extracorporeal shockwave can be used with success rates between 50% and 65% ^[2]. Conservative treatment gives effective relief in 90% of patients. When patients do not respond even after 6–12 months, surgical treatment is required in 5–10% of patients ^[7]. In this subset of patients, partial or total plantar fascia release has been the mainstay of treatment, with success rates of approximately 70–90% ^[7]. Different surgical treatments have been described for this purpose, including open fasciotomy or minimally invasive procedures that can be performed percutaneously or endoscopically ^[8]. Several clinical trials reported that endoscopic plantar fascia release (EPFR) resulted in excellent relief of pain, with patient satisfaction ranging from 60% to 80% and low complication rates ^[9,10]. Endoscopic fascia release has a steep learning curve. Many times, the beginners face difficulty in localising which part of the foot they are in and dissect a lot of tissue/fat pad unnecessarily. This case report is about a technique where we place a K-wire for localisation and as a guide during the surgery.

This is a 40-year-old female with severe pain in the heel while walking, particularly in the morning, for 2 years. She was treated earlier with physiotherapy, a change in footwear, steroids and a PRP injection. X-rays of the ankle show a calcaneal spur as in Fig. 1. The MRI shows an 8 mm-thick plantar fascia as in Fig. 2.

Figure 1: Radiograph showing calcaneum spur.

Figure 2: Magnetic resonance imaging showing thick plantar fascia.

The procedure is performed with the patient under spinal anaesthesia, and a tourniquet is applied. The patient’s leg is put in a figure of four as in Fig. 3, and a point 5 mm from the tangential line of the posterior edge of the medial malleolus to the plantar fascia (skin junction) is marked, which is going to be used as the primary viewing portal. The anterior medial entry was established two centimetres anterior to the posterior entry site, as in Fig. 4.

Figure 3: Position of limb (figure of four).

Figure 4: Medial portals.

The nick and spread technique is used for making portals. The primary viewing portal was made, and a 4 mm 30⁰ scope was introduced. A needle is introduced through the marked anterior portal site, and only after visualising the needle is the portal made as in Fig. 5. For beginners, it is always better to make portals under vision, as it decreases the chances of damaging important structures. A K-wire is put at the spur from the plantar side under C-arm guidance and left in situ as in Fig. 6.

Figure 5: 2nd portal after confirming with k wire.

Figure 6: C arm showing K wire at spur site.

Following the trajectory of the K-wire, a shaver and radiofrequency (RF) ablator are used alternatively to remove the excess fat tissue and localise the K-wire as in Fig. 7. Once we localise the K-wire, work along the K-wire until you reach its tip. Now remove the K-wire and expose the spur and excise with a burr under C-arm guidance as in Fig. 8. The plantar fascia is released with RF as in Fig. 9. Confirm spur excision under the C-arm as in Fig. 10. Portals are closed. Partial weight-bearing with crutches is allowed immediately. Full weight-bearing is allowed after wound healing, and stretching exercises are recommended.

Figure 7: K wire tip localized.

Figure 8: Burr at the spur site (*).

Figure 9: Plantar fascia release with ablator.

Figure 10: C arm picture after spur excision.

EPER is a minimally invasive technique that decreases complications related to open surgery, such as plantar heel hypertrophic scar formation, infection, or wound dehiscence. As a result, a shorter recovery time and early post-operative mobilisation therapy have been reported ^[11]. Nevertheless, the procedure has a steep learning curve. With experience, plantar fascia exposure and excision of the spur become easy with minimal dissection, but in the initial cases, one might dissect too much soft tissue or fat pad without knowing where exactly we are anatomically. Using a K-wire as a guide is the solution to these hurdles. The moment we identify the k wire, all we have to do is follow the k wire and remove tissue as required; no more blind dissection is done. The use of radiographic assistance also decreases once the k wire is identified. In particular, the identification of the spur is the most difficult part. One must release the entire fascia to visualise and excise the spur, which can lead to complications. With the help of the K-wire, once we reach the tip, remove the K-wire and dissect that area from posterior to anterior (calcaneum undersurface), minimising the damage to the plantar fascia.

A simple K-wire is a useful tool in a procedure like EPER, which has a steep learning curve. The use of K-wires alleviates the complications of excess soft tissue and fat pad dissection and reduces the radiographic assistance.

Endoscopic plantar fascia release is a great solution to long-standing and refractory plantar fasciitis. It has a steep learning curve. Use of a K-wire for guidance is a simple and easily reproducible technique, especially for beginners.