Endoscopic plantar fasciotomy versus open plantar fasciotomy for treatment of plantar fasciitis: a systematic review and meta-analysis

Abstract

Background

Plantar fasciitis is a degenerative pathology that most common causing heel pain in adults aged 40–60. Severe pain typically presents at morning or after prolonged activity. Treatment includes conservative measures, physical therapy, orthotics, and injections. Surgical intervention is considered for severe cases requiring prolonged treatment.

Objectives

The primary objective is to compare functional outcomes between open and endoscopic plantar fasciotomy, while the secondary objective is to compare their respective complication rates.

Materials and methods

A comprehensive search of the English-language literature was conducted using multiple databases, including PubMed, Cochrane, Scopus and Google Scholar in addition to a manual search. Studies regrading endoscopic plantar fasciotomy (EPF) and open plantar fasciotomy (OPF) were included in the meta-analysis. The methodological quality of the included studies was assessed using the appropriate tool. A sensitivity analysis was performed to evaluate the robustness of the findings. The analysis focused on outcomes such as pain relief (VAS scores), functional improvement (AOFAS scores), complications and operative time. A total of 19 articles met the inclusion criteria for this meta-analysis.

Results

This meta-analysis of 19 studies and 646 patients showed that both OPF and EPF resulted in excellent improvements in AOFAS and VAS scores. Comparative studies revealed a non-significant difference between the two groups, with Standardized Mean Difference (SMD) for VAS score {1.36 (95% CI (− 4.03, 6), p-value = 0.390} and {− 0.39 (95% CI (− 5.41, 4.63), p-value = 0.770} for AFOS score. Consistently and significantly shorter mean operative time for EPF (15.76 min) compared to OPF (36.78 min). EPF demonstrated a lower complication rate 5% (95% CI: 2%, 9%). Compared with OPF 11% (95% CI: 2%, 45%). However non-comparative studies demonstrated OPF slightly more pain relief (VAS score) and functional improvement (AOFAS score).

Conclusion

This study showed that both EPF and EPF appear to be effective treatments. EPF was associated with shorter operative times and a lower complication rate.

Introduction

Plantar fascia, or plantar aponeurosis, is a thick, fibrous band. It originates in the plantar tuberosity of calcaneus and distally dividing into 5 slips to insert in the proximal phalanges of the toes. Plantar fascia’s function is to maintain longitudinal arch of foot, protect underlying structures (i.e., nerves and vessels), and distribute plantar forces during loading [1, 2]. Plantar fasciitis is a degenerative pathology of band, rather than an inflammatory process, referred as plantar fasciopathy that results from repetitive microtrauma and excessive strain of plantar. Plantar fasciitis/plantar fasciopathy is the most common cause of heel pain in adults aged 40–60 years. Occurs in 10% of population and up to 17.5% of runners; bilateral in up to one-third of cases [3–5].

There are a lot of risk factors that increases tension at insertion of fascia on medial calcaneal tuberosity and contribute to development of plantar fasciopathy like obesity, weight bearing activities (running, walking and prolonged standing), anatomical alignment (pes cavus, pes planus), reduced ankle dorsiflexion (Achilles /gastrocnemius contracture) and pregnancy [2, 3, 6, 7].

Patients typically presented with severe heel pain (medial plantar location) that increase with initial steps after period of inactivity [8, 9]. PF diagnosis depend on of medical history and physical examination but x- ray, ultrasound and MRI can be helpful in ruling out other potential causes of heel or foot pain [10–12].

Plantar fasciitis is a self-limiting condition that typically resolves within 12 months and can be effectively managed with conservative measures in most cases [8, 13]. Initial treatment focuses on activity modification, relative rest, and the use of ice or NSAIDs [14, 15]. Comprehensive physical therapy encompassing exercises, biomechanical corrections, and joint or soft tissue mobilization is often combined with orthotics and night splints [16–18]. Advanced non-invasive options include high-energy extracorporeal shock wave therapy and various injections, such as corticosteroids, prolotherapy, or biologics [16–18]. Regarding specific modalities, manual stretching of the plantar fascia is superior to low-energy radial shock-wave therapy (RSWT) for acute symptoms [19], while a combination of stretching and RSWT is more efficient than shock-wave therapy alone for chronic cases [20].

Notably, Gold-Induced Cytokine (GOLDIC®) therapy has been shown to reduce pain and improve function sufficiently for a return to high-level competition [21]. If significant pain persists and restricts daily activities despite at least six months of conservative treatment, surgical intervention may be required in 5–10% of cases. Surgical options include open or endoscopic plantar fasciotomy, gastrocnemius release, radiofrequency microtenotomy, and dry needling [22, 23]. To minimize complications such as nerve injury or prolonged recovery, percutaneous release offers a minimally invasive approach [24], while the endoscopic plantar approach remains a viable alternative for managing recalcitrant fasciopathy [25].

Several studies have revealed that open and endoscopic plantar fasciotomy, are effective in providing short- to medium-term symptomatic relief for refractory plantar fasciitis and improvement in visual analogue scale (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) scores, with no major complications reported. The overall success rate of surgical release 70–90%, furthermore endoscopic procedure provides significantly good early postoperative results and shorter time to return to work or previous activities. However, the evidence supporting endoscopic plantar fasciotomy is still considered poor. Potential complications of surgical intervention include flattening of the longitudinal arch and hypoesthesia of the heel [26, 27]. While previous research by Nayar et al. [28] compared surgical options for plantar fasciitis, their analysis of open versus endoscopic techniques was limited to only two randomized controlled trials. Our study significantly expands on this literature by incorporating a larger evidence base consisting of three comparative and 16 non-comparative studies. By aggregating data from these 19 sources, this study provides a more comprehensive evaluation of functional outcomes, operation time and complication rates, offering a broader perspective on real-world clinical performance than previously available. The primary objective is to compare functional outcomes between open and endoscopic plantar fasciotomy, while the secondary objective is to compare their respective complication rates.

Methodology

Protocol and registration

This Meta-Analysis was reported following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) checklist [29]. The review was registered at Orthopedic Surgery Department, Faculty of Medicine, Cairo University. It was also registered on PROSPERO (International Prospective Register of Systematic Reviews) website, Center for Reviews and Dissemination under No.CRD420251012725 [30].

PICOT

P: Participants: Adult, healthy Patients, with plantar fasciitis and management by surgical.

I: Intervention: Open plantar fascia release method.

C: Comparison: Endoscopic plantar fascia release method.

O: Outcomes: Table 1: List of outcomes.

Table 1.

List of outcomes

Outcome	Measuring device/technique	Measuring unit
AOFAS [31]	Physical examination	(Grading 0–100):
VAS [32]	History	Grading from 0 to 10
Wound complication	Binary method	Yes/No
Operation time	Manual	Minutes (Mins.)

AOFAS, American orthopedic foot and ankle score; VAS, visual analogue scale

T: Time: follow-up periods at least 6 months after surgery

Eligibility criteria: This review included English-language interventional studies conducted on human adults (aged 16 years or older) with a minimum post-operative follow-up of six months. Studies were excluded if they involved animals or in vitro experiments, or if they utilized observational designs, including cross-sectional studies, case reports, and systematic reviews. Furthermore, studies were deemed ineligible if they involved patients with a history of previous foot or reconstructive surgery, or those presenting with exacerbations of comorbidities.

Search strategy

The researcher performed electronic search in PubMed, LILACS and Cochrane library databases at 13/03/2025. The researcher also hands searched 6 journals; The Journal of Bone and Joint Surgery (JBJS), British Medical Journal (BMJ), American Journal of Sports Medicine (AJSM), Foot and Ankle International (FAI), The Journal of Foot and Ankle Surgery (JFAS), The Egyptian Orthopedic Journal (EOJ) and till May 2025. Google Scholar and Cairo medicine school postgraduate Library were surfed for free hand searching. For acquiring studies, the researcher developed detailed search strategies for each database. These strategies were based on “I” and “C” elements of the PICO question. Terms was used for developing these search strategies were (open plantar fasciotomy OR open plantar fascia release OR plantar fasciotomy OR plantar fasciotomy release) AND (endoscopic plantar fasciotomy OR endoscopic plantar fascia release). One filter was used, namely; “English” language filter in all database.

Selection process

Records identified through electronic databases and manual searching were imported into EndNote X9 for data management and duplicate removal. Two independent reviewers (M.A.S. and A.S.) conducted a two-stage screening process, initially reviewing titles and abstracts to exclude irrelevant studies, followed by a full-text assessment of potentially relevant articles to ensure compliance with eligibility criteria. Any disagreements were resolved through discussion with a third independent reviewer (A.M.K.) (Figs. 1 and 2).

Fig. 1.

PRISMA 2020 flow diagram for new systematic reviews

Fig. 2.

Risk of bias domains

Data management and extraction

Data extraction was performed independently and in duplicate by two reviewers using paper-based data extraction forms. A preliminary form was utilized to record key details, including participants, interventions, comparators, outcomes, time points, and study design.

Quality assessment

The risk of bias for the included studies was assessed according to their design. Randomized Controlled Trials (RCTs) were evaluated using the Cochrane Risk of Bias tool, in accordance with the Cochrane Handbook for Systematic Reviews of Interventions (Version 5.1.0) [33]. This assessment covered seven domains: random sequence generation (selection bias), allocation concealment (selection bias), blinding of participants and personnel (performance bias), blinding of outcome assessment (detection bias), incomplete outcome data (attrition bias), selective outcome reporting (reporting bias), and other potential sources of bias. Non-randomized studies (non-RCTs) were assessed using the Newcastle–Ottawa Scale (NOS). The risk of bias for each outcome and across the included trials was categorized and reported to “low risk”, “some concerns”, or “high risk”. Any discrepancies between reviewers were resolved through discussion (Figs. 3 and 4). Finally, the robvis 2.0 tool was used to generate risk of bias visualizations [34].

Fig. 3.

Summary plot of bias

Fig. 4.

Forest plot of VAS score for endoscopic plantar fasciotomy post-operative 6 months

Data analysis

Data were entered and analyzed using R studio, version 1.1.463 (packages meta, metafor). The data were treated as mean, and the SD was obtained by dividing the inter-quartile range with 1.35 as suggested in the Cochrane Handbook for Systemic Reviews of Interventions [33]. For single arm study: The effect size of the continuous outcomes was reported as mean and the precision of effect size was reported as a 95% confidence interval (CI). The effect size of the categorical outcomes was reported as proportions, and the precision of effect size was reported as a 95% confidence interval (CI). While for comparative studies: the effect size of the continuous outcomes was reported as standard mean difference (SMD), and the precision of effect size was reported as a 95% confidence interval (CI).

The conversions of data were made using Meta-analysis accelerator (https://metaconverter.com). I² statistics were done to evaluate the heterogeneity and inconsistency of treatment effects across trials, respectively. Statistical significance was set at P-value < 0.05. The I2 statistics represent the degree of heterogeneity and the proportion of variation in treatment that is independent from sampling error. Moderate heterogeneity assumed as I2 was 30–60%. The funnel plot & Egger’s test for publication bias detection were not performed for the variables as they didn’t have more than 9 studies.

The subgroup analysis was done for different follow-up periods. The sensitivity analysis was used to examine the effect of heterogeneity and risk assessment on the overall estimates of effect and the review findings.

For comparative studies, the treatment effect was evaluated using the Standardized Mean Difference (SMD) to compare the post-intervention outcomes between the two surgical groups. Conversely, for single-arm studies, the pooled values reported for both VAS and AOFAS represent the absolute postoperative scores at final follow-up, rather than the mean change from baseline.

Results

Literature search

In a comprehensive systematic review, a total of 1396 records were initially identified from various databases, including PubMed (391), Cochrane (92), Scopus (455), and Google Scholar (68), with an additional 6 records found through manual searching. Before screening, 790 duplicate records were removed, leaving 606 unique records to be screened. All 606 records then underwent a full-text eligibility assessment. During this rigorous evaluation, a substantial number of reports were excluded due to various reasons: 47 were case reports, 49 were reviews, books, or expert opinions, 24 were cadaveric studies, 361 were deemed unrelated to the review’s scope, 91 were unavailable, 2 were not in English, and 13 were otherwise unsuitable for final analysis. After this meticulous filtering process, a final set of 19 studies were ultimately included in the review (Fig. 1).

Study characteristics

Table 2 summarizes 19 studies investigating surgical intervention: Endoscopic Plantar Fasciotomy (EPF) and Open Plantar Fasciotomy (OPF), for plantar fasciopathy. The studies were published between 2007 and 2024, originating from various countries including China, Egypt, USA, Spain, Brazil, Hungary, Turkey, Singapore, Australia, Vietnam, and the UK. Methodologically, the collection comprises 8 retrospective studies, 7 prospective studies, and 5 randomized controlled trials (RCTs), with one study explicitly noted as a as “Retrospective (comparative).” Cumulatively, these studies involved a total of approximately 646 patients.

Table 2.

Characteristics of included articles

Article NO	Year of publishing	Articles authors	Country	Study design	Age (mean)	Sex (male)	Type of interventions	Total sample size	Follow up
1	2013	Monteagudo et al. [35]	Spain	Retrospective	42 (22–61)	18	OPF	30	4 weeks, 6 months 12months
2	2024	Yingjie et al. [36]	China	RCT	52.9 ± 12.23	–	EPF	20	1 month, 3 months, 6 months
3	2012	Saxena et al. [37]	USA	Prospective	42.3 ± 11.4	6	EPF	12	6 months
4	2020	Yuan et al. [22]	China	Retrospective	49.63 ± 9.78	6	OPF	16	1, 2, 3, 12 months
5	2013	Nery et al. [25]	Brazil	Retrospective	52	10	EPF	22	Average 9.6 ± 2.31 years
6	2007	Marafko et al. [38]	Hungary	Prospective	47 ± 11	24	EPF	74 patients with 83 feet	1, 3, 6, 12 months
7	2021	Feng et al. [39]	China	Retrospective (comparative)	57.3 ± 7.1	11	OPF and EPF	29	3 months, 6 months, 1 year, 2 years
					55.8 ± 8.9	12		23
8	2023	Ali et al. [40]	Egypt	Prospective	45.4 ± 8.52	10	EPF	30	4 weeks, 8 weeks, 3 months, 6 months
9	2020	Çatal et al. [41]	Turkey	Randomised prospective	53.5 ± 6.7	14	EPF	23	3 weeks, 3, 6, 12 months
10	2016	Chou et al. [42]	Singapore	Retrospective	51.13 ± 9.38	8	OPF and EPF	28	3 months, 6 months, 1 year
					52.12 ± 9.43	3		14
11	2010	Othman and Ragab [43]	Egypt	Prospective	42 [29–59]	8	EPF	17	1 week, 2weeks, 6 weeks, 3 months, 6 months
12	2015	Othman and Hegazy [44]	Egypt	Prospective	39.14 (22 and 51)		EPF	23	18.25 months
13	2018	Gibbons et al. [45]	Australia	Retrospective	54.1 ± 9.7	19	OPF	74	4.8 ± 2.8 years
14	2012	Bader et al. [46]	USA	Retrospective	53.8(42–68)	15	EPF	41 patients with 49 feet	49.5 (6–142) months
15	2021	Toan et al. [47]	Vietnam	Prospective	53.2 ± 12.5	3	EPF	20	6 months, 12 months, 2 year
16	2012	Radwan et al. [48]	Egypt	Prospective	39.7	22	EPF	31	12 months
17	2017	Abouheif [49]	Egypt	RCT	Group 1: 39.52, group 2: 40.96	12/10	EPF and OPF	50(25/25)	6 months
18	2017	Yassin et al. [50]	Israel	Retrospective	51.5 ± 7	–	EPF	39	24 months
19	2017	Alhaj et al. [51]	Egypt	RCT	33.26 ± 6.81	25female + 5 males	EPF and OPF	15/15	4 weeks, 3 months, 6 months

Quality assessment of the selected studies

Figures 2 and 3 Summaries of the overall risk of bias for each study are presented in the provided figures. In general, the overall risk was judged as high for approximately one-third of the included studies, specifically involving Nery [25], Bader [46], Marafkó [38], Ali [40], Toan [47], and Gibbons [45]. Only a small minority of the cohort (approximately 15%), consisting of Radwan [48], Monteagudo [35], and Chou [42], demonstrated a low overall risk of bias. The remaining studies were categorized as having some concerns, primarily driven by moderate to high risk in the randomization process and deviations from intended interventions.

VAS score

The analysis for VAS score in Fig. 4 includes 9 studies revealed a pooled mean of 2.93 (95% CI (− 0.27, 6.13)). A significant high heterogeneity was found (I2 = 97.1%, p-value < 0.0001) & leave one test had no effect on lowering it. The significant statistical heterogeneity observed, particularly in the EPF group, may be attributed to several clinical factors. Most notably, the lack of a standardized surgical portal (varying between medial-medial and lateral-lateral approaches) and differences in surgical experience across centers play a major role.

The analysis for VAS score in Fig. 5 includes 3 studies revealed a pooled mean of 1.06 (95% CI (− 0.17, 2.3)). A significant high heterogeneity was found (I2 = 72.6%, p-value = 0.026) so we performed leave one test in Fig. 6:

Fig. 5.

Forest plot of VAS score of open plantar fascia release after 6 months

Fig. 6.

Forest plot of VAS score of open plantar fascia release after 6 months after sensitivity test

The analysis for VAS score in Fig. 6 became of a pooled mean of 0.5 (95% CI 0.01, 0.99)) after removing A. C. Chou 2016 study. A non-significant low heterogeneity was found (I2 = 0%, p-value = 1.00).

The analysis in Fig. 7 for the vas score comparative studies includes 3 studies revealed a non-significant difference between the two groups, with SMD 1.36 (95% CI (−4.03, 6.), p-value = 0.390) in favor of the plantar group. A significant high heterogeneity was found (I2 = 93.4%, p-value < 0.0001) so leave one test was performed in Fig. 8:

Fig. 7.

Forest plot of VAS score of open plantar fascia release vs. endoscopic method after 6 months for comparative studies

Fig. 8.

Forest plot of VAS score of Open plantar fascia release vs. endoscopic method after 6 months after sensitivity test

After application of leave one study test, the analysis in Fig. 8 for VAS score including 2 studies revealed a SMD of 0.18 (95% CI (− 1.72, 2.08)). A non-significant low heterogeneity was found (I² = 0%, p-value = 0.4835).

The analysis in Fig. 9 for VAS score for subgroups (6 & 3 months) includes 9 studies in the 6 months’ subgroup and 2 studies in the 3 months’ subgroup. The analysis of the 6 months’ subgroup revealed a pooled mean as mentioned previously, and the analysis of the 3 months’ subgroup revealed a pooled mean of 9.64 (95% CI (− 6.09, 25.37)). The total analysis revealed a pooled mean of 4.18(95% CI (0.43, 7.93)). A significant high heterogeneity was found in both subgroups and as total the heterogeneity was high and significant (I² = 98.1%, p-value < 0.0001).

Fig. 9.

Forest plot of VAS score for Endoscopic plantar fasciotomy post-operative (subgroups at 3 & 6 months)

AOFAS score

The analysis for AOFAS score in Fig. 10 includes 8 studies revealed a pooled mean of 89.58 (95% CI (87.00, 92.16)). A significant high heterogeneity was found (I² = 81.1%, p-value < 0.0001) so we performed leave one test as Fig. 11:

Fig. 10.

Forest plot of AOFAS score for Endoscopic plantar fasciotomy post-operative after 6 months

Fig. 11.

Forest plot of AOFAS score for Endoscopic plantar fasciotomy post-operative after 6 months after sensitivity analysis

The analysis for AOFAS score in Fig. 11 became of a pooled mean of 90.82 (95% CI 88.95, 92.68)) after removing B.atal 2020 study. A significant moderate heterogeneity was found (I2 = 58.3%, p-value = 0.0254).

The analysis for AOFAS score in Fig. 12 includes 3 studies revealed a pooled mean of 93.62 (95% CI (82.28, 104.95)). A significant high heterogeneity was found (I2 = 98.8%, p-value < 0.0001) so we performed leave one test in Fig. 13:

Fig. 12.

Forest plot of AOFAS score of open plantar fascia release after 6 months

Fig. 13.

Forest plot of AOFAS score of open plantar fascia release after 6 months after sensitivity analysis

The analysis for AOFAS score in Fig. 13 became of a pooled mean of 99.38 (95% CI 98.51, 100.25)) after removing Mohamed Abouheif 2017 study. A non-significant low heterogeneity was found (I2 = 0%, p-value = 1.00).

The analysis for the AOFAS score in Fig. 14 includes 3 studies revealed a non-significant difference between the two groups, with SMD −0.39 (95% CI (−5.41, 4.63), p-value = 0.770) in favor of the open group. A significant high heterogeneity was found (I² = 96%, p-value < 0.0001) and leave one test had no effect on lowering it. Also, meta regression analysis showed no significant result regarding age mean, design and location covariates (p-value > 0.05).

Fig. 14.

Forest plot of AOFAS score of open plantar fascia release vs. endoscopic method after 6 months for comparative studies

The analysis for AOFAS score in Fig. 15 for subgroups (3, 6, 12 months) includes 8 studies for the 6 months’ subgroup, 3 studies for the 3 months’ subgroup and 4 studies for the 12 months’ subgroup. The analysis of the 6 months’ subgroup revealed a pooled mean as mentioned previously, the analysis of the 3 months’ subgroup revealed a pooled mean of 74.74 (95% CI 66.47, 83.00)) and the analysis of the 12 months’ subgroup revealed a pooled mean of 86.54 (95% CI 79.68, 93.4)). The total analysis revealed a pooled mean of 85.75 (95% CI (81.86, 89.63)). A significant high heterogeneity was found in all subgroups and as total the heterogeneity was high and significant (I² = 96.1%, p-value < 0.0001).

Fig. 15.

Forest plot of AOFAS score for Endoscopic plantar fasciotomy post-operative subgroup analysis (3, 6, 12 months)

Operation time (minutes)

The analysis for operation time (min) in Fig. 16 includes 2 studies revealed a pooled mean of 15.76 (95% CI (14.9,16.63)). A non-significant low heterogeneity was found (I² = 0%, p-value = 0.4451).

Fig. 16.

Forest plot of operation time for endoscopic plantar fasciotomy after 6 months

The analysis for operation time (min) in Fig. 17 includes 3 studies revealed a pooled mean of 31.04 (95% CI (21.23,40.85)). A significant high heterogeneity was found (I2 = 78.2%, p-value = 0.0102) so we performed leave one test as follows:

Fig. 17.

Forest plot of operation time (min) of open plantar fascia release after 6 months

The analysis for operation time (min) in Fig. 18 became of a pooled mean of 36.78 (95% CI 28.94, 44.62)) after removing A. C. Chou [42] study. A non-significant low heterogeneity was found (I2 = 0%, p-value = 1.00).

Fig. 18.

Forest plot of operation time (min) of Open plantar fascia release after 6 months after sensitivity analysis

Wound complications

The analysis for complications in Fig. 19 shows that the complications for EPF reported in 5% with 95% CI (2%, 9%). A non-significant low heterogeneity was found (I² = 7.6%, p-value = 0.3633).

Fig. 19.

Forest plot of complications for endoscopic plantar fasciotomy 6 months

In Fig. 20 the complications for OPF were 11% of with 95% CI (2%, 45%). A significant high heterogeneity was found (I² = 86.3%, p-value = 0.0069) and leave one test can’t be done. This variation may be due to the different locations (Monteagudo [35] in Europe, Gibbons [45] in Australia) or age factor [42 (22–61)] years in Monteagudo [35], 54.1 ± 9.7 years in Gibbons [45]. Also may be due to the percentage of the planter fasciotomy.

Fig. 20.

Forest plot of complications of Open plantar fascia release after 6 months

Discussion

The purpose of this meta-analysis was to compare the clinical efficacy between of open plantar fasciotomy versus endoscopic plantar fasciotomy for plantar fasciitis. This meta-analysis synthesized findings on endoscopic plantar fasciotomy (EPF) and open plantar fasciotomy (OPF) across several key outcomes: VAS score for pain, AOFAS score for foot function, operative time, and complications.

Both endoscopic and open procedures showed reductions in VAS scores, the comparative studies revealed a non-significant difference between the two groups, with Standardized Mean Difference (SMD) for VAS score {1.36 (95% CI (− 4.03, 6.), p-value = 0.390}. The Visual Analogue Scale (VAS) is a simple yet powerful tool for measuring subjective experiences such as pain. Developed in the 1920s, it typically features a 100mm line anchored by descriptors like “no pain” and “worst pain imaginable.” Patients mark the line to reflect their perception, and the distance from the “no pain” end to their mark, measured in millimeters, becomes their score (0–100mm). Higher scores indicate greater intensity [32, 52, 53]. The results of this meta-analysis suggest that both procedures reduce pain. While non-comparative data suggest that OPF is slightly improving pain (VAS) after six months. For endoscopic plantar fasciotomy, the overall analysis of nine studies showed a pooled mean VAS score of 2.93 (95% CI: − 0.27, 6.13). While the pooled mean VAS score for open surgery was 0.5 (95% CI: 0.01, 0.99). A lower VAS score signifies better pain relief. OPF’s results for pain became highly consistent with virtually no heterogeneity (I2 = 0%) after a sensitivity analysis removed an outlier study, bolstering confidence in its pooled mean. In contrast, EPF’s VAS score consistently exhibited very high and significant heterogeneity (I² = 97.1%) that could not be resolved, making its average pain reduction less reliable and suggesting wide variability in outcomes across studies [54]. The significant statistical heterogeneity observed, particularly in the EPF group, may be attributed to several clinical factors. Most notably, the lack of a standardized surgical portal (varying between medial-medial and lateral-lateral approaches) and differences in surgical experience across centers play a major role.

Both endoscopic and open procedures showed excellent improvement in AOFAS scores, comparative studies revealed a non-significant difference between the two groups, with Standardized Mean Difference (SMD) for AFOS score was {− 0.39 (95% CI (− 5.41, 4.63), p-value = 0.770}. While the data from non-comparative suggest that OPF is slightly improving AOFAS score after six months. For endoscopic plantar fasciotomy, the pooled mean was 90.82 (95% CI: 88.95, 92.68), for open plantar fascia release the pooled mean AOFAS score was 99.38 (95% CI: 98.51, 100). The American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score is a clinical rating system used to assess outcomes after ankle and hindfoot injuries. A perfect score of 100 points indicates complete absence of symptoms or impairments [55].

This study highlights that while both procedures generally improve function, OPF appears to achieve a markedly higher level of functional improvement after six months among non-comparative studies. This finding is made particularly robust because the high variability initially observed in OPF studies was attributed to a single outlier, and once removed, the remaining data for OPF converged to show extremely consistent and excellent functional outcomes. For EPF, despite sensitivity analysis, the results for AOFAS score remained more scattered, indicating less consistent functional improvements across studies, that may be due to use of different surgical portals (medial-medial vs. lateral-lateral) and varying levels of surgeon experience. So comparative metanalysis compare between different EPF with considering surgical portals is recommended.

A systematic review and network meta-analysis of Surgical treatment options for plantar fasciitis, included two studies with 103 patients, found that both endoscopic and open plantar fasciotomy significantly improved pain and function for individuals with plantar fasciitis. However, the analysis revealed no statistical difference between the two surgical approaches [56]. This result agreed with our results from comparative studies and disagreed with results from single arm studies. This can be explained by the fact that comparative studies directly compare two or more interventions, which minimizes the impact of confounding variables. In contrast, single-arm studies lack a control group, making it impossible to determine if the observed improvement is due to the specific treatment or other factors. A systematic review and meta-analysis of 19 articles on the surgical treatment of Haglund’s deformity revealed that both open and endoscopic surgical approaches led to improvements in AOFAS scores. However, open surgery demonstrated a slightly improvement in AOFAS scores with an average increase of 33.8 points (95% CI: 24.5 to 39.1, p < 0.001), compared to endoscopic surgery, which showed an average increase of 31.1 points (95% CI: 24.2 to 38.0, p < 0.001) [57].

The current study reported that the Endoscopic Plantar Fasciotomy (EPF) is clearly superior to Open Plantar Fasciotomy (OPF) in terms of operation time and complication rate. Consistently and significantly shorter mean operative time for EPF (15.76 min) compared to OPF (36.78 min). This almost 2.5-fold difference is clinically meaningful. When comparing complications, endoscopic plantar fasciotomy demonstrated a lower rate, with our analysis showing 5% (95% CI: 2%, 9%). In contrast, open plantar fasciotomy had a higher complications rate of 11% (95% CI: 2%, 45%). Across the 19 studies and 646 patients, no major complications were reported. Adverse events were exclusively minor and transient, including temporary numbness (paresthesia), superficial wound discharge, delayed healing, and lateral column pain. These results are consistent with pervious systematic review and meta-analysis in orthopedics surgeries that reported that the endoscopic surgeries revealed fewer time operations and surgical complications. For example, a meta-analysis for open versus endoscopic surgical treatment of posterior ankle impingement involved 32 studies showed that endoscopic surgery demonstrated a lower proportion of postoperative complications (2%) compared to open surgery (24%). Similarly, minor complications were more prevalent in open surgery (15%) than in endoscopic surgery (11%) [58].

As well, a systematic review and meta-analysis analyzed 19 articles regrading surgical treatment of Haglund’s deformity showed that the open surgery had a higher overall complication rate, reported at 12.3% (with a range from 0 to 53%). In contrast, endoscopic surgery demonstrated a lower overall complication rate of 5.3% (ranging from 0 to 18%). In addition, this study found that the operating time for endoscopic surgery was, on average, significantly shorter than for open surgery [57]. In the same line a meta-analysis of randomized controlled trials involved 21 studies to compares the open versus endoscopic carpal tunnel release showed that complications like scar tenderness was less common after endoscopic release [59]. Finally, review of the literature study involved twenty-nine published articles showed that the endoscopic surgeries had shortened surgery time and reduced perioperative complications, but the functional result was the same as with conventional surgeries [60].This may be because EPF’s minimally invasive nature uses smaller incisions and requires less tissue dissection, unlike OPF, which involves larger incisions and greater dissection. This is despite the insufficient data available from 19 articles regarding operation time and complication rates.

Conclusion

This study demonstrates that both endoscopic plantar fasciotomy (EPF) and open plantar fasciotomy (OPF) are effective surgical interventions for refractory plantar fasciitis, yielding significant improvements in pain relief and functional outcomes. While comparative analyses indicate no statistically significant difference in efficacy between the two techniques, EPF offers distinct clinical advantages, including shorter operative times and a more favorable safety profile with fewer postoperative complications.

Abbreviations

CI

Confidence interval

SMD

Standardized Mean Difference

OPF

Open plantar fasciotomy

OR

Odds ratio

PF

Plantar Fasciitis

RCTs

Randomized controlled trials

VAS

Visual analogue scale

AFOAS

American Orthopaedic Foot and Ankle Society

Authors’ contributions

MAS, ASB and AMK conceptualized the research. MAS, ASB and AMK participated in data collection and writing the methods. MAS analyzed and interpreted the data. MAS, ASB and AMK drafted the original manuscript. All the authors critically reviewed the manuscript and approved it for publication.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

The data analyzed in this work were derived from previously published studies The data is available from the corresponding author upon reasonable request.

Declarations

Ethics approval

This study approved by IRB faculty of Medicine, Cairo University, code: MS-110-2024, date: 30-4-2024.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Clinical trial number

Not applicable.