Proximal Medial Gastrocnemius Recession and Stretching Versus Stretching as Treatment of Chronic Plantar Heel Pain

Proximal Medial Gastrocnemius Recession for Recalcitrant Plantar Fasciitis

BACKGROUND

Recalcitrant plantar fasciitis (RPF) is characterized by its unresponsiveness to conservative treatments, and its surgical management remains controversial. Although there is some evidence to suggest that gastrocnemius recession can be an effective treatment for RPF, no large series of patients with mid- to long-term follow-up has been published. The objective of this study was to compare physical performance, as measured by the Foot and Ankle Ability Measure activities of daily living score (FAAM-ADL), and pain levels before and 1 year after undergoing proximal medial gastrocnemius recession (PMGR) as a treatment for RPF. Additionally, we aimed to assess this cohort of patients in the mid- to long-term follow-up.

METHODS

This retrospective cohort study included 167 patients who underwent PMGR to address RPF between 2009 and 2021. Patients were examined with the FAAM ADL, visual analog scale (VAS) and satisfaction scores at baseline, 1 year, and at the end of follow-up. Other variables recorded were weight, duration of symptoms until surgery, time between surgery to substantial clinical improvement, calf power and Silfverskiold test, and postoperative complications.

RESULTS

We observed that before surgery patients had an FAAM-ADL score of 22.5 (SD 11.1) and a VAS score of 8.6 (SD 9.3). One year after surgery, patients had an FAAM-ADL score of 89 (SD 17) and VAS of 1.33 (SD 2) (P < .01). We also observed that the FAAM-ADL score in the long-term follow-up (>12.5 years) group had a median of 86.4 (SD 22.6), the VAS score was 1.90 (SD 2.84), and the patient satisfaction score had a median of 1 (interquartile range 0-1). Regarding complications, we observed 1 lateral gastrocnemius recession and 1 sural nerve neuritis.

CONCLUSIONS

Our study provides substantial evidence supporting the use of PMGR as an effective treatment for RPF. The long-term follow-up and large sample size of our series contribute to the existing literature on this topic.

LEVEL OF EVIDENCE

Level IV, case series.

Alteration of the calf strength by heel cord lengthening, gastrocnemius recession through tenotomy or fasciotomy. A retrospective clinical force analysis before and after surgery

BACKGROUND

Indications for surgical corrections about the Achilles tendon are increasing as additional measures in reconstructive interventions about the foot. These indications include shortened gastrocnemii, which cause a so-called 'functional pes equinus' and secondary forefoot imbalances, as well as corrections of pes planus and cavus. Surgery about the heel cord may also be indicated for achillodynia and diabetic pressure ulcers. However, there is a lack of evidence that quantifies the results of lengthening procedures about the heel cord. The aim of this study was to quantify the exact changes in calf strength one year after elongating the triceps surae, by measuring flexion forces in 90 degrees knee flexion and knee extension.

METHODS

This study involves 69 patients who were examined for calf strength preoperatively and 1 year after gastrocnemius release. A new device, the Leonardo Mechanograph® (Novotec Medical) was used to measure calf strength. Measurements were performed with the knee flexed and extended.

RESULTS

The operated leg had an overall statistically significant reduction in strength after surgery. Changes were similar on the contralateral leg. The difference in force reduction between the operated and non-operated leg was not statistically significant CONCLUSION: A correlation between measured plantar flexion forces of the foot after a reconstructive foot operation with or without a lengthening procedure about the calf musculature could not be established.

LEVEL OF EVIDENCE

Level III: retrospective cohort study.

Socioeconomic Status and Race Are Rarely Reported in Randomized Controlled Trials for Achilles Tendon Pathology in the Top 10 Orthopaedic Journals: A Systematic Review

Background

Randomized controlled trials (RCTs) are crucial in comparative research, and a careful approach to randomization methodology helps minimize bias. However, confounding variables like socioeconomic status (SES) and race are often underreported in orthopaedic RCTs, potentially affecting the generalizability of results. This study aimed to analyze the reporting trends of SES and race in RCTs pertaining to Achilles tendon pathology, considering 4 decades of data from top-tier orthopaedic journals.

Methods

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and used PubMed to search 10 high-impact factor orthopaedic journals for RCTs related to the management of Achilles tendon pathology. The search encompassed all articles from the inception of each journal until July 11, 2023. Data extraction included year of publication, study type, reporting of SES and race, primary study location, and intervention details.

Results

Of the 88 RCTs identified, 68 met the inclusion criteria. Based on decade of publication, 6 articles (8.8%) reported on SES, whereas only 2 articles (2.9%) reported on race. No RCTs reported SES in the pre-1999 period, but the frequency of reporting increased in subsequent decades. Meanwhile, all RCTs reporting race were published in the current decade (2020-2030), with a frequency of 20%. When considering the study location, RCTs conducted outside the United States were more likely to report SES compared with those within the USA.

Conclusion

This review revealed a concerning underreporting of SES and race in Achilles tendon pathology RCTs. The reporting percentage remains low for both SES and race, indicating a need for comprehensive reporting practices in orthopaedic research. Understanding the impact of SES and race on treatment outcomes is critical for informed clinical decision making and ensuring equitable patient care. Future studies should prioritize the inclusion of these variables to enhance the generalizability and validity of RCT results.

Outcomes After Proximal Medial Gastrocnemius Recession and Stretching vs Stretching as Treatment of Chronic Plantar Fasciitis at 6-Year Follow-up

BACKGROUND

Evidence from prospective short-term studies suggest that proximal medial gastrocnemius recession is a safe and efficient procedure to treat chronic plantar fasciitis resistant to nonoperative treatment. The aim of this study was to evaluate the long-term clinical outcomes of proximal medial gastrocnemius recession and stretching compared to a stretching exercise protocol for patients with chronic plantar fasciitis and an isolated gastrocnemius contracture (IGC).

METHODS

Forty patients with plantar fasciitis lasting more than 1 year were prospectively randomized to a home stretching exercise program only, or to proximal medial gastrocnemius recession in addition to the stretching program. Clinical and functional data in this study were obtained at baseline and 6-year follow-up. The main outcome was the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score. Secondary outcomes were the visual analog scale (VAS) for pain, the Manchester Oxford Foot Questionnaire (MOxFQ), ankle dorsiflexion, and Achilles complex performance.

RESULTS

Thirty-three of 40 patients completed the 6-year follow-up. Seven patients had crossed over from nonoperative treatment to operative treatment. At 6 years, the operative group demonstrated significantly better outcomes with AOFAS (88.9 vs 78.6, P = .012), for pain measured by VAS (2.5 vs 5.5, P < .001) and with the MOxFQ total score (24.4 vs 45.9, P = .05) (per protocol analysis excluding crossovers). No between-group differences were observed for ankle dorsiflexion or Achilles complex performance at 6 years.

CONCLUSION

This study demonstrates that the improved function and reduced level of pain by proximal medial gastrocnemius recession and stretching is better compared to stretching alone after 6 years of follow-up for patients with chronic plantar fasciitis and a concomitant isolated gastrocnemius contracture.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Medial gastrocnemius proximal fasciotomy in patients with chronic plantar fasciitis: A systematic review

INTRODUCTION

Plantar fasciitis is the main cause of heel pain in middle-aged patients. In chronic cases, limited ankle dorsiflexion caused by isolated gastrocnemius contracture is considered the main risk factor for suffering it. Therefore, in recent years the number of patients operated on by proximal fasciotomy of the medial gastrocnemius (FPGM) has increased to treat chronic plantar fasciitis.

MATERIAL AND METHODS

Systematic review following the PRISMA guidelines. We have carried out a bibliographic search in Pubmed, Science Direct, Cochrane Library and Web of Science databases. One hundred and eighty-four articles were found. Data extraction was performed using the Covidence software, and a quality and risk of bias analysis of the included articles was performed based on the Cochrane risk of bias Tool 2.0.

RESULTS

Three articles were included in the review: two randomized clinical trials and one cohort study with a total of 138 patients. In the analyzed studies, patients after proximal fasciotomy of the medial gastrocnemius showed significant improvements in pain and in the AOFAS score with high levels of patient satisfaction. Increases in ankle dorsiflexion angle were found after 12 months of follow-up, with no loss of gastrocnemius strength. The complication rate was low and fewer occurred in the proximal fasciotomy compared to plantar fasciotomy.

CONCLUSION

Proximal fasciotomy of the medial gastrocnemius provides clinical benefit in patients with chronic plantar fasciitis, with a low probability of complications and high patient satisfaction.

Isolated Gastrocnemius Contraction and Gastroc Recession Surgery in Case of Planter Fasciitis: A Systemic Review and Meta-Analysis

Objective

The current systematic and meta-static review aimed to analyze the correlation between isolated gastrocnemius contracture and plantar fasciitis and the effectiveness of gastroc recession surgery in the treatment of plantar fasciitis.

Methodology

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to conduct this meta-analysis. A literature search was carried out on the following databases, including Google Scholar, PubMed, EMBASE, and the Cochrane databases with the appropriate medical subject headings (MeSH) to identify the eligible articles.

Results

A total of 13 studies were included in this meta-analysis. In this study, there is a significant difference in chronic plantar fasciitis outcome when comparing experimental and control (RR: 0.02; 95% CI: 0.01 to 0.05; P < 0.001; I2 = 29%). There is a significant difference in pain scale outcome when comparing pre-treatment and post-treatment (RR: 3.25; 95% CI 1.44 to 7.32; P = 0.004 < 0.01; I2 = 0%). A significant difference in VAS scale outcome when comparing pre-treatment and post-treatment (RR: 2.58; 95% CI 1.52 to 4.38; P = 0.0004 < 0.01; I2 = 0%).

Conclusion

In conclusion, the current systematic review and meta-analysis of gastrocnemius recession and proximal medial gastrocnemius release and other treatment measures for plantar fasciitis suggests that the improvement of ankle dorsiflexion, reduction in pain, and patient satisfaction are almost similar in all the treatment measures. Among the five treatment measures, gastrocnemius recession remains the best, followed by proximal medial gastrocnemius release.

PROMIS Scores for Plantar Fasciitis Before and After Gastrocnemius Recession

BACKGROUND

There has been an established relationship between increased loading on the Achilles tendon and tension on the plantar fascia. This supports the idea that either tight gastrocnemius and soleus muscles or contractures of the Achilles tendon are risk factors for plantar fasciitis. Gastrocnemius recession has gained popularity as a viable surgical intervention for cases of chronic plantar fasciitis due to isolated gastrocnemius contracture. To our knowledge, this is the first study to investigate Patient-Reported Outcome Measurement Information Systems (PROMIS) scores in patients with plantar fasciitis before and after gastrocnemius recession.

METHODS

The Electronic Medical Record was queried for medical record numbers associated with Current Procedural Terminology code 27687 (gastrocnemius recession). Our study included all patients with a preoperative diagnosis of chronic plantar fasciitis with treatment via isolated gastrocnemius recession with 1-year minimum follow-up. Forty-one patients were included in our study. Patient variables were collected via chart review. Preoperative and postoperative PROMIS scores were collected in the clinic.

RESULTS

We followed up 41 patients with a median age of 48 years (interquartile range [IQR] 38-55) and median body mass index of 29.02 (IQR 29.02-38.74) for 1 year post surgery. Preoperative and postoperative PROMIS scores improved for physical function from 39.3 to 44.5 (P = .0005) and for pain interference from 62.8 to 56.5 (P = .0001). PROMIS depression scores were not significantly different (P = .6727). Visual analog scale (VAS) scores significantly decreased from 7.05 to 1.71 (P < .0001).

CONCLUSION

In this case series, we found the gastrocnemius recession to be an effective option for patients with refractory pain in plantar fasciitis. Our PROMIS and VAS data confirm this procedure's utility and highlight its ability to significantly decrease pain and improve physical function in patients with chronic plantar fasciitis, although final median scores did not reach normative standards for the population, suggesting some residual pain and/or dysfunction was, on average, present. Based on the results of this study, the authors conclude that gastrocnemius recession is a reasonable treatment option for chronic plantar fasciitis patients who fail nonoperative management.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Surgical treatment options for plantar fasciitis and their effectiveness: a systematic review and network meta-analysis

BACKGROUND

To date, there are no systematic reviews on the utility of surgical management for plantar fasciitis to guide best practice. This review aimed to evaluate the operative options for plantar fasciitis and their effectiveness.

METHODS

A systematic review and network meta-analysis were carried out in accordance with PRISMA guidelines. A search strategy was conducted on the MEDLINE, EMBASE, and Cochrane databases. Quality was assessed using the ROBINS-I tool.

RESULTS

17 studies involving 865 patients were included. Surgical options considered were open and endoscopic plantar fasciotomy, gastrocnemius release, radiofrequency microtenotomy and dry needling. All interventions resulted in improvement in VAS and AOFAS scores. No major complications were seen from any treatment modality.

CONCLUSIONS

Surgical interventions are effective in providing short- to medium-term symptomatic relief for plantar fasciitis refractory to non-operative management. Current evidence is equivocal regarding treatment choice. Further large randomised studies are required to establish long-term outcomes and a management algorithm.

LEVEL OF EVIDENCE

Level III.

Effects of therapeutic interventions on pain due to plantar fasciitis: A systematic review and meta-analysis

OBJECTIVE

To determine the effects of different therapeutic interventions that have ever been evaluated in randomized controlled trials on pain due to plantar fasciitis.

METHODS

We searched different electronic databases until September 2022. Mean differences (MDs) and 95% confidence intervals (CIs) were calculated. The Grading of Recommendations Assessment, Development and Evaluation was used to evaluate the overall certainty evidence.

RESULTS

A total of 236 studies met the study criteria, including 15,401 patients. Botulinum toxin MD -2.14 (CI: -4.15, -0.14), micronized dehydrated human amnion/chorion membrane injection MD -3.31 (CI: -5.54, -1.08), dry needling MD -2.34 (CI: -4.64, -0.04), low-dye taping MD -3.60 (CI: -4.16, -3.03), low-level laser therapy MD -2.09 (CI: -2.28, -1.90), myofascial releases MD -1.79 (CI: -2.63, -0.94), platelet-rich plasma MD -2.40 (CI: -4.16, -0.63), radiofrequency MD -2.47 (CI: -4.65, -0.29), and stretching MD -1.14 (CI: -2.02, -0.26) resulted in being effective treatments for pain when compared to the control in the short term. In the medium and long term, only extracorporeal shock wave therapy MD -0.97 (CI: -1.13, -0.81)/MD -2.49 (CI: -3.17, -1.82) was effective for improving pain when compared to the control.

CONCLUSIONS

Considering the available studies, this systematic review and meta-analysis showed that different therapeutic interventions seem to be useful strategies for improving pain in patients with plantar fasciitis. In the medium and long term, only extracorporeal shock wave therapy was effective in improving pain when compared to the control.

Surgical or non-surgical treatment of plantar fasciopathy (SOFT): study protocol for a randomized controlled trial

Background

Plantar fasciopathy is the most common reason for complaints of plantar heel pain and one of the most prevalent musculoskeletal conditions with a reported lifetime incidence of 10%. The condition is normally considered self-limiting with persistent symptoms that often last for several months or years. Multiple treatments are available, but no single treatment appears superior to the others. Heavy-slow resistance training and radiofrequency microtenotomy for the treatment of plantar fasciopathy have shown potentially positive effects on short- and long-term outcomes (> 3 months). However, the effect of heavy-slow resistance training compared with a radiofrequency microtenotomy treatment is currently unknown. This trial compares the efficacy of heavy-slow resistance training and radiofrequency microtenotomy treatment with supplemental standardized patient education and heel inserts in improving the Foot Health Status Questionnaire pain score after 6 months in patients with plantar fasciopathy.

Methods

In this randomized superiority trial, we will recruit 70 patients with ultrasound-confirmed plantar fasciopathy and randomly allocate them to one of two groups: (1) heavy-slow resistance training, patient education and a heel insert (n = 35), and (2) radiofrequency microtenotomy treatment, patient education and a heel insert (n = 35). All participants will be followed for 1 year, with the 6-month follow-up considered the primary endpoint. The primary outcome is the Foot Health Status Questionnaire pain domain score. Secondary outcomes include the remaining three domains of the Foot Health Status Questionnaire, a Global Perceived Effect scale, the physical activity level, and Patient Acceptable Symptom State, which is the point at which participants feel no further need for treatment.

Discussion

By comparing the two treatment options, we should be able to answer if radiofrequency microtenotomy compared with heavy-slow resistance training is superior in patients with plantar fasciopathy.

Trial registration

ClinicalTrials.gov NCT03854682. Prospectively registered on February 26, 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06785-w.

Benefits and Harms of Interventions With Surgery Compared to Interventions Without Surgery for Musculoskeletal Conditions: A Systematic Review With Meta-analysis

OBJECTIVE

To estimate the benefits and harms of interventions with and without surgery for musculoskeletal (MSK) conditions.

DESIGN

Intervention systematic review with meta-analysis of randomized controlled trials (RCTs).

LITERATURE SEARCH

MEDLINE, EMBASE, CINAHL, Web of Science, and CENTRAL, all up to January 7, 2021.

STUDY SELECTION CRITERIA

RCTs (English, German, Danish, Swedish, and Norwegian) of interventions with and without surgery conducted in any setting for any non-fracture MSK condition in adults (mean age: 18+ years) evaluating the outcomes on a continuous (benefits) or count (harms) scale. Outcomes were pain, self-reported physical function, quality of life, serious adverse events (SAEs), and death at 1 year.

DATA SYNTHESIS

Random-effects metaanalyses for MSK conditions where there were data from at least 2 trials.

RESULTS

One hundred RCTs (n = 12 645 patients) across 28 different conditions at 9 body sites were included. For 9 out of 13 conditions with data on pain (exceptions include some spine conditions), 11 out of 11 for function, and 9 out of 9 for quality of life, there were no clinically relevant differences (standardized mean difference of 0.50 or above) between interventions with and without surgery. For 13 out of 16 conditions with data on SAEs and 16 out of 16 for death, there were no differences in harms. Only 6 trials were at low risk of bias.

CONCLUSION

The low certainty of evidence does not support recommending surgery over nonsurgical alternatives for most MSK conditions with available RCTs. Further high-quality RCTs may change this conclusion. J Orthop Sports Phys Ther 2022;52(6):312-344. doi:10.2519/jospt.2022.11075.

What is the evidence for efficacy, effectiveness and safety of surgical interventions for plantar fasciopathy? A systematic review

Aims

To systematically review randomised control trials (RCT’s) assessing the effectiveness and safety of surgical interventions in adults with plantar fasciopathy (PF).

Materials and methods

We searched MEDLINE, EMBASE, Web of Science, Google Scholar, the Cochrane Central Register of Controlled Trials, trial registries and references lists. RCT’s comparing surgical interventions with non-surgical or surgical comparisons in adults with PF were included. Primary outcomes were changes in first step pain severity/intensity, and incidence/nature of adverse events. Secondary outcomes included foot and ankle related disability/function, health related quality of life, cost effectiveness, changes in other reported measures of pain and medication use. Data were extracted at short-term (≤3 months post-intervention), medium-term (>3months—≤6 months post-intervention) or long-term (>6 months—≤2 years post-treatment). Certainty of evidence was evaluated using the modified Grading of Recommendations Assessment, Development and Evaluation (GRADE).

Results

From 3620 screened records, we included 8 studies comprising 345 patients. Substantial variation across trials precluded meta-analysis, hence a narrative synthesis was conducted. We judged all studies to have high risk of bias. For all outcome comparisons our GRADE judgement for the certainty of the evidence was very low. Three studies compared one type of surgery with another largely showing little to no difference in outcomes for pain, function or quality of life. Five studies compared surgery with non-surgical interventions—three providing very low certainty evidence that surgery may improve pain and function at long-term follow-up compared to non-surgical comparisons, whereas two studies provided no long-term between-group differences. Reporting of adverse events were inadequate, inconsistent or absent across all studies.

Conclusion

There is a paucity of high certainty evidence to support or refute the effectiveness and safety of surgical interventions in the management of PF. We make recommendations for improving the evidence base in this field.

Gastrocnemius Release in the Management of Chronic Plantar Fasciitis: A Systematic Review

BACKGROUND

This systematic review aims to summarize the outcomes of gastrocnemius recession in the treatment of plantar fasciitis.

METHODS

A systematic review was performed according to PRISMA guidelines using the PubMed, Embase, Emcare, Web of Science, Scopus, and CINAHL databases. A 2-stage title/abstract and full text screening process was performed independently by 2 reviewers. Randomized controlled trials, cohort, and case-control studies reporting the results of gastrocnemius recession in patients with plantar fasciitis were included. The MINORS and Joanna Briggs Institute Criteria were used to assess study quality and risk of bias.

RESULTS

A total of 285 articles were identified, with 6 of these studies comprising 118 patients being ultimately included. Significant postoperative improvement in American Orthopaedic Foot & Ankle Society, visual analog scale, 36-Item Short Form Health Survey, Foot Forum Index, and Foot and Ankle Ability Measure scores were reported. Included studies also described an increase in ankle dorsiflexion range of motion and plantarflexion power. An overall pooled complication rate of 8.5% was seen, with persistent postoperative pain accounting for the most common reported complication. Gastrocnemius recession is associated with greater postoperative improvement than plantar fasciotomy and conservative stretching exercises.

CONCLUSION

The current evidence demonstrates that gastrocnemius recession is effective in the management of plantar fasciitis, specifically in patients with gastrocnemius contracture who do not respond to conservative treatment.

LEVEL OF EVIDENCE

Level III, Systematic review of level I-III studies.

Gastrocnemius Recession in Recalcitrant Plantar Fasciitis: A Systematic Review

Plantar fasciitis is a common cause of heel pain. Recalcitrant plantar fasciitis can be difficult to manage. Medial gastrocnemius recession is increasingly being used to treat recalcitrant plantar fasciitis, with advocates describing fewer complications and quicker recovery time than other surgical options. This systematic review aimed to determine the effectiveness of gastrocnemius recession for the treatment of patients with recalcitrant plantar fasciitis. Multiple databases were searched using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The level of evidence of each study was assessed according to the American Academy of Orthopaedic Surgeons Levels of Evidence. The level of bias for each study was assessed using the National Institutes of Health (NIH) Study Quality Assessment Tools. Seven studies were retrieved: 3 retrospective case series, 1 retrospective study that compared gastrocnemius recession to open plantar fasciotomy, 1 prospective cohort study (pre-post study with no control group), and 2 randomized controlled trials. All 6 studies that assessed pre- and postoperative pain using the Visual Analogue Scale showed a large reduction in pain postoperatively. Four studies that assessed pain at 12 months postoperatively showed a weighted mean of 76.06 ± 10.65% reduction in pain. No major complications were reported. Minor complications included sural neuritis. This review found a consistent reduction in pain following gastrocnemius release in patients with recalcitrant plantar fasciitis, suggesting it is a very promising treatment. However, the included studies are limited by low quality study designs and inherent biases, limiting the strength of recommendation. Further definitive, well-designed trials are required.

Gastrocnemius release is an effective management option for Achilles tendinopathy: a systematic review

PURPOSE

This systematic review aims to summarise the outcomes of gastrocnemius release in the management of Achilles Tendinopathy.

METHODS

A systematic review was performed according to PRISMA guidelines. A computer-based search was performed in PubMed, Embase, Cinahl, Scopus and ISI Web of Science. Two independent reviewers performed both title/abstract and full-text screening according to a-priori selection criteria. English-language original research studies reporting outcomes for gastrocnemius recession in patients with Achilles tendinopathy were included. Study quality and risk of bias were assessed using the MINORS criteria.

RESULTS

Of the 229 articles identified following database searching, nine studies describing 145 cases of gastrocnemius recession were included in the review. Clinically important differences were reported across a range of validated patient reported outcome scores including VISA-A, FFI, FAAM and VAS pain score. Outcomes appear to be superior in patients with noninsertional Achilles tendinopathy, however further research is required to confirm this. Studies also reported an increase in ankle dorsiflexion range of motion and a good rate of return to sport/work. The overall complication rate was 10/123 (8.1%), with sural nerve injury being the most common complication, occurring in 5/123 (4.1%) of cases.

CONCLUSION

The results of this review suggest gastrocnemius release to be an effective treatment option in the management of patients with Achilles tendinopathy, who have gastrocnemius contracture and have previously failed to respond adequately to non-operative treatment.

LEVEL OF EVIDENCE

Level IV.

Percutaneous plantar fasciotomy: radiological evolution of medial longitudinal arch and clinical results after one year

PURPOSE

Plantar fasciitis (PF) is the most common cause of plantar heel pain. Conservative treatment and corrections of risks factors are the first line of care. For the 10% of patients who do not respond to conservative treatment, surgical release can offer relief of symptoms. Due to the critical role of the PF in the function of the foot and its architectural maintenance, its surgical release could cause a collapse of the internal arch of the foot and an alteration of its function. With the hypothesis that an isolated percutaneous PF release may not lead to these alterations of the foot while providing relief to the patients, we evaluated the radiological evolution and clinical results of this surgery after one year.

MATERIAL AND METHOD

Between January 2013 and Augustus 2017, we conducted a single arm monocentric prospective study on 22 patients (25 feet) aged from 33 to 84 years, with plantar fasciitis and failure of conservative management who benefited a percutaneous total plantar fasciotomy through a plantar approach. The American Orthopedic Foot and Ankle Score (AOFAS) and the Djian-Annonier's angle were evaluated preoperatively and postoperatively.

RESULTS

Among the 22 patients, sixteen patients were female and six patients were male. Three patients (2 females and 1 male) for six feet were operated for bilateral plantar fasciitis. The mean pre-operative Djian-Annonier's angle was 117.6° (range 101-132.9°), and the mean post-operative angle was 119.3° (range 102-137°). There was no statistically significant difference in Djian-Annonier's angle before and after surgery. The mean pre-operative AOFAS was 42.8 (range 32-51). The scores at 15 days, six weeks, and three months show a gradual increase up to 89.9 in the results with significant differences between the groups (p < 0.05). There was no difference between the scores after three months.

CONCLUSION

Complete percutaneous plantar fasciotomy is simple and safe and allows a quick recovery to activity without impacting the MLA.

Association of Ankle Dorsiflexion With Plantar Fasciitis

This study aimed to compare the mean ankle dorsiflexion range between individuals with and without plantar fasciitis using passive ankle dorsiflexion with consistent pressure, and to identify the prevalence of an isolated gastrocnemius and gastrocnemius soleus complex contracture in 2 groups. 91 participants were prospectively classified into the plantar fasciitis group (45 subjects) and the control group (46 subjects). Ankle dorsiflexion was measured with the knee extended and with the knee flexed 90° using a standard orthopedic goniometer while a consistent force of 2 kg was applied under the plantar surface of the forefoot using a custom-made scale. Intraclass correlation coefficients (ICC) were calculated to determine the interobserver and intraobserver reliability of the current ankle dorsiflexion measurement. The current ankle dorsiflexion measurement revealed excellent interobserver and intraobserver reliability. The mean ankle dorsiflexion in the knee extended was -9.6° ± 8.1° and -11.2° ± 8.2° in the study and control groups, respectively (p = .353). The mean ankle dorsiflexion in the knee flexed was 7.8° ± 6.5° and 5.1° ± 7.4° in the study and control groups, respectively (p = .068). In the study and control groups, 68.9% and 65.2%, respectively, had an isolated gastrocnemius contracture and 24.4% and 30.4%, respectively, had a gastrocnemius-soleus complex contracture (p = .768). The present study demonstrated that there were no significant differences in passive ankle dorsiflexion and in the prevalence of an isolated gastrocnemius or gastrocnemius soleus complex contracture between individuals with and without plantar fasciitis.

The effect of lengthening the gastrocnemius muscle in chronic therapy resistant plantar fasciitis

BACKGROUND

The aetiology of chronic therapy resistant plantar fasciitis (CTRPF) is multifactorial with more focus in recent times on the gastroc-soleus complex. This study evaluates the effect of lengthening the gastrocnemius muscle in CTRPF.

METHODS

All patients with CRTPF complaints for at least one year underwent the same standard conservative treatment prior to surgery. 32 patients failed this treatment and underwent gastrocnemius recession. Silfverskiöld test, questionnaires and plantar pressure measurements were obtained at 5 visits.

RESULTS

One year follow up showed a significantly increase in dorsiflexion of the ankle (16 degrees), a decrease in VAS; 78 (SD: 19) to 20 (SD: 24) and significant improved functional scores. Plantar pressure measurements showed an increase of pressure under the medial proximal part of the midfoot and the 1 st metatarsal and a decrease under the hallux.

CONCLUSIONS

A gastrocnemius recession results in a significant gain in dorsiflexion, altered loading of the foot and good clinical outcome in patients with CTRPF.

LEVEL OF EVIDENCE

Level 2.

Pedobarography in Physiotherapy: A Narrative Review on Current Knowledge

Pedobarography is a modern technology enabling the assessment of the locomotor system based on the plantar pressure distribution. The technic is useful in the rehabilitation of various types of dysfunction of body movement. This chapter aims to describe the application of pedobarography in clinical therapy. The qualitative analysis is based on a review of articles in English, French, German, Polish, Portuguese, Spanish, Turkish, and Chinese in Medline/PubMed, Cochrane Library, Embase, and PEDro databases. The search covered the articles on clinical trials, randomized controlled trials, meta-analyses, and reviews published over 1984-2020. The literature shows that pedobarography is a safe non-invasive method that is useful for the examination of foot biomechanics with a reference to the entire musculoskeletal system. A pedobarographic examination enables insight into a motion disorder, its plausible relation to a systemic pathology, and monitoring the course of treatment and rehabilitation.

Development and Validation of a Novel Scoring System for Severity of Plantar Fasciitis

OBJECTIVES

Plantar fasciitis (PF) is the most common cause of heel pain. Though PF is self-limited, it can develop into chronic pain and thus treatment is needed. Early and accurate prognostic assessment of patients with PF is critically important for selecting the optimal treatment pathway. Nevertheless, there is no scoring system to determine the severity of PF and no prognostic model in choosing between conservative or surgical treatment. The study aimed to develop a novel scoring system to evaluate the severity of plantar fasciitis and predict the prognosis of conservative treatment.

METHODS

Data of consecutive patients treated from 2014 to 2018 were retrospectively collected. One hundred and eighty patients were eligible for the study. The demographics and clinical characteristics served as independent variables. The least follow-up time was 6 months. A minimal reduction of 60% in the visual analog scale (VAS) score from baseline was considered as minimal clinically important difference (MCID). Those factors significantly associated with achieving MCID in univariate analyses were further analyzed by multivariate logistic regression. A novel scoring system was developed using the best available literature and expert-opinion consensus. Inter-observer reliability and intra-observer reproducibility were evaluated. The appropriate cut-off points for the novel score system were obtained using receiver operating characteristic (ROC) curves.

RESULTS

The system score = VAS (0-3 point = 1; 3.1-7 point = 3; 7.1-10 point = 5) + duration of symptoms (<6 months = 1; ≥1 6 months = 2) + ability to walk without pain (>1 h = 1; ≤1 h = 4) + heel spur in X-ray (No = 0; Yes = 2) + high intensity zone (HIZ) in MRI (No = 0; Yes = 2). The total score was divided in four categories of severity: mild (2-4 points), moderate (5-8 points), severe (9-12 points), and critical (13-15 points). Inter-observer agreement with a value of 0.84 was considered as perfect reliability. Intra-observer reproducibility with a value of 0.92 was considered as perfect reproducibility. The optimum cut-off value was 10 points. The sensitivity of predictive factors was 86.37%, 84.21%, 91.22%, 84.12%, and 89.32%, respectively; the specificity was 64.21%, 53.27%, 67.76%, 62.37%, and 79.58%, respectively; the area under curve was 0.75, 0.71, 0.72, 0.87, and 0.77, respectively. The Hosmer-Lemeshow test showed a good fitting of the score system with an overall accuracy of 90.6%.

CONCLUSIONS

Based on prognostic factors, the present study establishes a novel scoring system which is highly comprehensible, reliable, and reproducible. This score system can be used to identify the severity of plantar fasciitis and predict the prognosis of conservative treatment accurately. The application of this scoring system in clinical settings can significantly improve the decision-making process.

Visual Analog Pain Scores Reported to a Nurse and a Physician in a Postoperative Setting

Background:

The purpose of this study was to compare postoperative foot and ankle patient-reported visual analog pain scores (VAS) to nursing staff and the treating surgeon during a single encounter. Prior literature established preoperative patients reported higher pain scores to a surgeon as compared to nursing staff. We hypothesized that there will be no differences in postoperative patients’ pain scores when reporting to nursing staff vs a surgeon.

Methods:

This study was a retrospective cohort of 201 consecutive postoperative foot and ankle patients with 3 follow-up encounters treated by a single surgeon. The patients were asked to rate their pain intensity using the VAS with 0 “no pain” and 10 “worst pain” at 2, 6, and 12 weeks postoperatively by a nurse and surgeon.

Results:

At all time intervals, the mean pain score was significantly higher when reported to the surgeon, although these were not clinically relevant. The mean scores at 2 weeks were 2.8 reported to the surgeon and 2.5 reported to the nurse (P < .001). The mean scores at 6 weeks were 2.0 reported to the surgeon and 1.8 reported to the nurse (P = .002). The mean scores at 12 weeks were 2.3 reported to the surgeon and 2.0 reported to the nurse (P = .005).

Conclusion:

This study found that postoperative foot and ankle patients did not overemphasize their VAS pain scores to the physician vs nursing staff. These findings contrast with our 2 previous studies that found preoperative and nonoperative patients reported clinically significant higher scores to the surgeon.

Level of Evidence:

Level III, comparative study.

Validity and reliability of the Turkish version of the Self-reported Foot and Ankle Score in patients with foot or ankle pain

OBJECTIVE

The aim of this study was to translate the Self-Reported Foot and Ankle Score (SEFAS) into Turkish and to determine the validity and reliability of the translated version in patients with foot or ankle pain.

METHODS

A total of 98 patients (65 females, 33 males, mean age=39 years, age range 18-65 years) who presented with foot or ankle pain for at least one week were included in the study. SEFAS was translated into Turkish (SEFAS-T) and then back-translated into English by two bilingual translators to ensure the accuracy of translation. To determine the validity of the translated version, SEFAS-T, The Foot and Ankle Outcome Score (FAOS), and the Short Form 36 (SF-36) were administered at the first assessment on the same day. SEFAS-T was repeated five days later (Spearman's rho). Intra-class correlation coefficients (ICCs) were used for assessment of the test re-test reliability, while the Cronbach's alpha coefficient was used to assess the internal consistency of the questionnaire Results: SEFAS-T showed good test-retest reliability (ICC: 0.887). Item 4 showed poor item-total correlation and inter-item correlations. When item 4 was excluded, the Cronbach's alpha value was found as 0.906. SEFAS-T total scores showed correlation with all the FAOS sub-scores (p<0.001) and all the SF-36 components (p≤0.001) except mental health (rho: 0.149, p: 0.143). The highest correlation was found between SEFAS-T Total Score and the Sports and Recreations subscale of FAOS (rho: 0.796, p<0.001).

CONCLUSION

SEFAS-T seems to be valid and reliable as a measure for foot or ankle pain in Turkish patients.

LEVEL OF EVIDENCE

Level II, Diagnostic study.

Plantar pressure distribution and spatiotemporal gait parameters after the radial shock wave therapy in patients with chronic plantar fasciitis

Radial shock wave therapy (RSWT) has been recommended as an appropriate, safe and effective method in the treatment of chronic plantar fasciitis (PF). The main purpose of this study was to examine how RSWT affects gait parameters. This study included 23 patients with unilateral, chronic PF. RSWT were administered in 5 interventions, during a consecutive 3-week period. Objective kinetic (force distribution under the forefoot, midfoot, rearfoot) and spatiotemporal parameters (cadence, step length, stance phase duration) during treadmill walking at, preferred" speed were evaluated on. 4 sessions: before therapy, immediately after (primary endpoint), 3 and 6 weeks after therapy. The mean reduction in the reported pain when taking first steps in the morning from baseline to the primary endpoint, 3- and 6-weeks post procedure was 42.7%, 50.1% and 66.9% respectively. Similar reduction was seen in the reported pain during walking. After the therapy during gait at the preferred speed patients had a significantly higher force beneath the rearfoot and forefoot of both limbs. Force beneath the midfoot was not significantly affected by treatment. The step length in both limbs increased by 3.3-3.6 cm after RSWT. After the therapy stance phase duration in symptomatic foot was longer by 7% and it slightly decreased until POST-6wk. Similar changes were seen in an asymptomatic limb. The spatiotemporal and kinetic results indicate that RSWT therapy induces changes in patient's gait structure and alter regional loading in the affected foot.

Shock-wave therapy improved outcome with plantar fasciitis: a meta-analysis of randomized controlled trials

BACKGROUND

Shock-wave therapy (SWT) has been widely applied and proven to be an effective treatment in ameliorating symptoms of plantar fasciitis (PF). Ultrasound therapy (UT) is another common treatment of PF, and several researches have documented its advantages when compared to corticosteroid injection. Despite this, few studies have focused on comparing the use of SWT and UT in the treatment of PF. The purpose of our meta-analysis is to evaluate whether SWT is better than UT in managing PF, both in terms of ameliorating pain and improving functionality.

METHODS

A systematic search of the literature was conducted to identify relevant articles that were published in Pubmed, Medline, Embase, the Cochrane Library, SpringerLink, Clinical Trials.gov and OVID from the databases' inception to October 2018. All studies comparing the efficacy of SWT and UT in terms of pain levels and functionality improvement were included. Data on the two primary outcomes were collected and analyzed using the Review Manager 5.3.

RESULTS

Five studies were included in the current meta-analysis. A significant difference in VAS score (MD = - 13.14, Cl - 14.07 to - 12.75 P < 0.00001, I² = 100%) was noted between the SWT group and the UT group. No significant difference was seen in the AOFAS (MD = 3.19, Cl - 1.72 to 8.10 P = 0.20, I² = 100%); FFI or PFPS score was not found significant difference either (SMD = - 1.17, Cl - 4.45 to 2.10 P = 0.48, I² = 96%).

CONCLUSIONS

The results from this meta-analysis highlight the effectiveness of both SWT and UT in the treatment of PF. Although inter-group differences were not significant, the VAS score was better improved in the SWT group, suggesting that SWT may be a superior alternative for the treatment of PF.