Can you provide a bilateral plantar fasciitis fasciotomy procedure note, including ICD‑10‑CM M72.2 and CPT 28008 codes, for a 45‑year‑old female with obesity (BMI 32) and well‑controlled type 2 diabetes mellitus?

Bilateral Plantar Fasciitis Procedure Note

Patient Demographics & Indications

• 45-year-old female with bilateral plantar fasciitis (ICD-10-CM: M72.2) refractory to conservative management, presenting with obesity (BMI 32 kg/m²) and well-controlled type 2 diabetes mellitus. 1

Pre-Operative Risk Assessment

• Obesity (BMI >30 kg/m²) increases the risk of surgical failure and complications in plantar fasciotomy; patients with BMI >27 have a 50% rate of poor outcomes. 2, 3
• Diabetic patients require careful vascular assessment before any foot surgery because peripheral arterial disease is present in 20–40% of diabetic foot conditions and dramatically worsens outcomes. 4
• Document bilateral dorsalis pedis and posterior tibial pulses; if diminished or absent, obtain ankle-brachial index (ABI) immediately—an ABI <0.6 contraindicates elective foot surgery until vascular consultation is obtained. 4
• Screen for peripheral neuropathy with 10-g monofilament testing; loss of protective sensation at ≥2 of 3 plantar sites increases post-operative wound complications. 4

Procedure Details

• Procedure performed: Bilateral endoscopic plantar fasciotomy (CPT code: 28008 × 2 for bilateral procedure). 5
• Surgical approach: Endoscopic partial plantar fasciotomy with release of the medial 50% of the plantar fascia bilaterally, preserving lateral band integrity to maintain medial longitudinal arch stability. 6, 3
• Anesthesia: [Specify type—general, regional, or local with sedation]
• Estimated blood loss: Minimal (<10 mL per side)
• Complications: None

Intra-Operative Findings

• Right foot: Thickened, degenerative plantar fascia with [describe any calcification, inflammation, or structural abnormalities]
• Left foot: Thickened, degenerative plantar fascia with [describe findings]
• Vascular status: Adequate perfusion confirmed by [palpable pulses/Doppler signals] bilaterally
• No evidence of deep infection, abscess, or necrotic tissue requiring debridement

Post-Operative Management

• Immediate weight-bearing as tolerated in removable cast-boot for 4 weeks (non-weight-bearing first 2 weeks, then progressive weight-bearing weeks 3–4). 3
• Expected return to full activity: 2.6 months average for patients with normal BMI; longer recovery anticipated given BMI 32 kg/m². 3
• Pain relief timeline: Most patients achieve pain-free status (VAS=0) by 9.6 weeks post-operatively. 2

Diabetes-Specific Post-Operative Precautions

• Daily foot inspection by patient and caregiver to detect early signs of wound breakdown, infection (erythema, warmth, purulent drainage), or ischemia. 4
• Maintain strict glycemic control (target HbA1c <7%) to optimize wound healing and reduce infection risk. 7
• Monitor for infection at every follow-up visit; diabetic patients with foot surgery require assessment for at least two inflammatory signs (erythema, warmth, tenderness, purulent drainage) because neuropathy may mask symptoms. 4
• If any wound develops, measure ankle-brachial index immediately—toe pressure <30 mmHg or ABI <0.5 mandates urgent vascular surgery consultation within 24–48 hours. 4

Follow-Up Schedule

• Post-operative day 1: Wound check, confirm ability to bear weight in boot
• 2 weeks: Suture/staple removal, transition to progressive weight-bearing
• 6 weeks: Clinical assessment, AOFAS Hindfoot Score
• 3 months: Final assessment, return-to-activity clearance
• Long-term: Given diabetes, continue foot examinations every 1–3 months indefinitely to detect new ulceration or complications. 4

Expected Outcomes & Prognostic Factors

• Endoscopic plantar fasciotomy achieves complete pain resolution in 75% of patients and significant improvement in 22%, with mean AOFAS Hindfoot Score improvement from 54 to 93 points. 5
• Obesity (BMI 32 kg/m²) is a negative prognostic factor; all poor outcomes in one series occurred in patients with BMI >27. 3
• Patients with symptoms >24 months before surgery trend toward lower improvement and lower post-operative scores. 5
• Percutaneous total fasciotomy does not cause collapse of the medial longitudinal arch (Djian-Annonier angle unchanged pre- to post-operatively). 6

Critical Pitfalls to Avoid

• Do not dismiss post-operative foot pain as normal surgical discomfort in diabetic patients; painless wounds can progress rapidly due to neuropathy—any new wound requires immediate vascular and infection assessment. 4
• Do not delay vascular consultation if post-operative wound healing is delayed beyond 4 weeks or if signs of ischemia develop (dependent rubor, pallor on elevation, cold foot). 4
• Recognize that palpable pulses do not exclude significant peripheral arterial disease in up to 50% of diabetic patients; maintain low threshold for objective vascular testing. 4

Discharge Medications

• Analgesics: [Specify non-opioid options preferred; avoid NSAIDs if renal concerns]
• Continue home diabetes medications without interruption
• No prophylactic antibiotics indicated for clean elective foot surgery in well-controlled diabetic patients 8

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Surgeon signature: ___________________
Date: ___________________
Time: ___________________