Chronic Plantar Fasciitis is Mediated by Local Hemodynamics: Implications for Emerging Therapies

Photobiomodulation Therapy Plus Usual Care Is Better than Usual Care Alone for Plantar Fasciitis: A Randomized Controlled Trial

Background

Plantar fasciitis (PF) results in pain-related disability and excessive healthcare costs. Photobiomodulation therapy (PBMT) has shown promise for decreasing both pain and disability related to PF.

Purpose

The purpose was to assess the clinical impact of PBMT on pain and function in people with PF.

Study Design

Prospective, randomized controlled clinical trial.

Methods

A convenience sample of adults with PF were randomly assigned to one of three groups: (1) usual care, (2) usual care plus nine doses of PBMT with 25W output power over three weeks, or (3) usual care plus nine doses of PBMT with 10W output power over three weeks. Both 10W and 25W PBMT participants received the same total dose (10J/cm2) by utilizing a simple area equation. Pain (with Defense and Veterans Pain Rating Scale) and function (by Foot and Ankle Ability Measure) were measured at baseline, weeks 3, and 6 for all groups, and at 13 and 26 weeks for PBMT groups.

Results

PBMT groups experienced a reduction in pain over the first three weeks (from an average of 4.5 to 2.8) after which their pain levels remained mostly constant, while the UC group experienced a smaller reduction in pain (from an average of 4 to 3.8). The effects on pain were not different between PBMT groups. PBMT in both treatment groups also improved function more than the UC group, again with the improvement occurring within the first three weeks.

Conclusions

Pain and function improved during the three weeks of PBMT plus UC and remained stable over the following three weeks. Improvements sustained through six months in the PBMT plus UC groups.

Level of Evidence

Level II- RCT or Prospective Comparative Study.

Immunopathogenesis, early Detection, current therapies and prevention of plantar Fasciitis: A concise review

Plantar fasciitis or the inflammation of the fascial lining on the plantar aspect of the foot continues to be the leading cause of heel pain for many Americans. Common causes can range from anatomical deformities such as pes planus or flat foot, biomechanical etiology such as excessive pronation of the subtalar joint, or chronic diseases such as obesity and diabetes mellitus. The pathophysiology of plantar fasciitis can be either inflammatory due to vasodilation and immune system activation or non-inflammatory involving fibroblastic hypertrophy. Worsening pain of the inferior and medial heel after periods of prolonged rest and late in the day after hours of ambulation and weight-bearing activities is the most common symptom of plantar fasciitis. Common treatments for plantar fasciitis include plantar fascia stretching, physical therapy, orthotics, corticosteroid injections, and even surgery. Despite these treatment strategies, fasciitis remains a clinical problem and better treatment modalities are warranted. Late diagnosis is a common issue for prolonged and equivocal treatment and early diagnostic measures might be beneficial. In this concise review, we discussed the etiology, immunopathogenesis, current treatments of plantar fasciitis and potentially preventative measures prior to the onset of chronic treatment resistant condition.

Clinical And Plantar Fascial Morphologic Changes After Proximal Medial Gastrocnemius Release Treatment of Recalcitrant Plantar Fasciitis

BACKGROUND

Magnetic resonance imaging (MRI) has been used as a diagnostic and prognostic instrument to evaluate the results of conservative treatment for plantar fasciitis. However, there are scarce data available relative to changes in the plantar fascia after operative treatment. The primary objective of this study is to evaluate the imaging changes in patients with recalcitrant plantar fasciitis treated operatively by means of proximal medial gastrocnemius release.

METHODS

Thirteen patients with recalcitrant plantar fasciitis were studied with MRI preoperatively and 1 year after operative treatment. Quantitative (plantar fascia thickness) and qualitative variables (hyperintensity in the plantar fascia, insertional calcaneus bone edema, a plantar fascia tear, and the presence of perifascial collections) were assessed by 2 musculoskeletal radiologists. Clinical results were also measured with American Orthopaedic Ankle & Society (AOFAS), visual analog scale (VAS) pain, and 36-Item Short Form Health Survey (SF-36) scales.

RESULTS

The mean plantar fascia thickness was 6.59 mm preoperatively and 6.37 mm postoperatively (P = .972). No statistically significant differences were found in any of the qualitative variables on comparing the pre- and postoperative periods. Patients reported clinical improvements in pain VAS, AOFAS measurement, and the physical subdomains of the SF-36 scale.

CONCLUSION

Quantitative and qualitative variables assessed for the plantar fascia on MRI did not show any significant change after medial gastrocnemius release despite clear clinical improvement.

LEVEL OF EVIDENCE

Level II, perspective cohort study.

Patient-Perceived Recovery and Outcomes after Bipolar Radiofrequency Controlled Ablation with Platelet-Rich Plasma Injection for Refractory Plantar Fasciosis

Previous studies have documented persistent postoperative symptoms and limitations following plantar fasciotomy using patient-reported outcome measures (PROMs). The incomplete recovery (resolution) has been theorized to occur from altered foot biomechanics, and alternative treatment methods have continued to gained popularity for addressing refractory plantar fasciosis (RPF). The purpose of the present study was to assess patient-perceived recovery (PPR) and outcomes after bipolar radiofrequency controlled ablation (BRC) with platelet-rich plasma (PRP) injection for RPF. From July 2006 to July 2016, 43 patients (52 procedures) were enrolled. PROMS were prospectively obtained and compared between patients who perceived themselves as recovered without/residual deficits (recovered-resolved, recovered-not resolved) and those not recovered. Holistic satisfaction, procedure-specific satisfaction, complications, reoperations, and failure were recorded. Overall, 67.4% perceived themselves as recovered-resolved, 23.3% as recovered-not resolved, and 9.3% as not recovered. Holistic and procedure specific satisfaction were high (90.7% and 88.4%), with a mean modified Foot Function Index of 11.65, visual analog scale for pain 1.5, and failure rate of 9.3% at a median of 53 months (interquartile range 33 to 83). In the present study, outcomes with BRC with PRP injection compared favorably to the long-term outcomes reported for partial and complete plantar fasciotomy. Although 14 patients (32.6%) continued to have some postoperative symptoms, 71% indicated that they were satisfied with their symptoms, and 64% would undergo a similar procedure again. Therefore, despite the study's shortcomings, a patient's ability to cope appears to have a role in recovery from RPF.

Current Concepts of Minimally Invasive Treatment Options for Plantar Fasciitis: a Comprehensive Review

PURPOSE OF REVIEW

Chronic foot pain constitutes a large portion of the chronic pain burden in the overall population. Plantar fasciitis is one of the most common and most easily identifiable causes of chronic foot pain. The syndrome has been estimated to cause 11 to 15% of foot pain visits, requiring professional care. Moreover, studies have suggested that 1 in 10 people will develop plantar fasciitis at some point in their life. Conservative management has been shown to be effective and considered first-line treatment. Minimally invasive treatment options are typically reserved for those who fail conservative management. With the advent of new techniques and improvements in current therapeutic options, there has been an expansion of available minimally invasive treatment options. The purpose of this review is to provide a comprehensive update on the current understanding of minimally invasive treatments of plantar fasciitis.

RECENT FINDINGS

This review shows that conservative management continues to be the first-line therapy, whereas other treatment options were those who failed conservative management using modern techniques that have shown improving effectiveness, with successful restoration of patient functionality, recovery, and satisfaction. However, a multitude of these minimally invasive treatment options are evolving.

CONCLUSION

While conservative management continues to be the mainstay of treatment for plantar fasciitis, multiple minimally invasive treatment options are emerging with potential effectiveness in reducing pain and improving the function.

Evaluation and Treatment of Chronic Plantar Fasciitis

Plantar fasciitis is the most common cause of chronic heel pain in adults, affecting both young active patients and older sedentary individuals. It results from repetitive stress to the plantar fascia at its origin on the medial tubercle of the calcaneus and is often associated with gastrocnemius tightness. The diagnosis can be made clinically with a focused history and physical examination; imaging is reserved for atypical presentations and those that do not respond to initial treatment. The most common presenting symptom is aching plantar heel pain, which is worst with first step in the morning or after periods of rest. Diagnosis is confirmed with point tenderness at the origin of the plantar fascia on the medial tubercle of the calcaneus. Initial treatment consists of activity modification, anti-inflammatory medication, gastrocnemius and plantar fascia stretching, and an in-shoe orthosis that lifts and cushions the heel. These nonoperative treatments lead to complete resolution of pain in 90% of patients but can take 3-6 months. Patients who remain symptomatic despite a 6-month trial of nonoperative therapy may be considered for minimally invasive treatment or surgery. Platelet-rich plasma injections and therapeutic ultrasound are among a number of minimally invasive treatments that stimulate the body's healing response. Corticosteroid injections temporarily relieve pain, but may increase the risk of plantar fascia rupture and fat pad atrophy. Botulinum toxin injections relax the calf muscles, which decreases the stress in the plantar fascia. Operative treatments include gastrocnemius recession and medial head of gastrocnemius release, which decrease the stress on the plantar fascia and partial planter fasciotomy, which stimulates a healing response.

LEVEL OF EVIDENCE

Level V, expert opinion.

Relationship of Plantar Fascia Thickness and Preoperative Pain, Function, and Quality of Life in Recalcitrant Plantar Fasciitis

BACKGROUND

The measurement of plantar fascia thickness has been advocated as a diagnostic and prognostic instrument in patients with plantar fasciitis, but there are no data relative to it in recalcitrant plantar fasciitis. The aim of the study is to evaluate the correlation between plantar fascia thickness and pain, functional score, and health perception in patients with this condition.

METHODS

Thirty-eight feet were studied with ultrasound and magnetic resonance imaging to measure plantar fascia thickness. The visual analogue scale (VAS), American Orthopaedic Foot & Ankle Society Hindfoot Score (AOFAS), and SF-36 were then recorded for each patient. The relationship between the fascia and these scores was analyzed to evaluate the correlation of thickness with pain, functional level, and health perception of patients.

RESULTS

In patients with recalcitrant plantar fasciitis, plantar fascia thickness did not correlate with pain (VAS), AOFAS, or any item of the SF-36.

CONCLUSION

The thickness of the plantar fascia in patients with recalcitrant plantar fasciitis did not correlate with its clinical impact, and thus, we believe it should not be used in treatment planning.

LEVEL OF EVIDENCE

Level IV, case series.

Plantar fasciitis in athletes: diagnostic and treatment strategies. A systematic review

BACKGROUND

Plantar fasciitis (PF) is reported in different sports mainly in running and soccer athletes. Purpose of this study is to conduct a systematic review of published literature concerning the diagnosis and treatment of PF in both recreational and élite athletes. The review was conducted and reported in accordance with the PRISMA statement.

METHODS

The following electronic databases were searched: PubMed, Cochrane Library and Scopus. As far as PF diagnosis, we investigated the electronic databases from January 2006 to June 2016, whereas in considering treatments all data in literature were investigated.

RESULTS

For both diagnosis and treatment, 17 studies matched inclusion criteria. The results have highlighted that the most frequently used diagnostic techniques were Ultrasonography and Magnetic Resonance Imaging. Conventional, complementary, and alternative treatment approaches were assessed.

CONCLUSIONS

In reviewing literature, we were unable to find any specific diagnostic algorithm for PF in athletes, due to the fact that no different diagnostic strategies were used for athletes and non-athletes. As for treatment, a few literature data are available and it makes difficult to suggest practice guidelines. Specific studies are necessary to define the best treatment algorithm for both recreational and élite athletes.

LEVEL OF EVIDENCE

Ib.

Success and Recurrence Rate after Radial Extracorporeal Shock Wave Therapy for Plantar Fasciopathy: A Retrospective Study

Background and Aims. The exploration of an individualised protocol of radial extracorporeal shock wave therapy (rESWT) for plantar fasciopathy, assessing success rates and the recurrence rate over a 1-year period after treatment, is not yet identified in literature. Methods and Results. Between 2006 and 2013, 68 patients (78 heels) were assessed for plantar fasciopathy. An individualised rESWT treatment protocol was applied and retrospectively analysed. Heels were analysed for mean number of shock wave impulses, mean pressure, and mean frequency applied. Significant mean pain reductions were assessed through Visual Analogue Scale (VAS) after 1-month, 3-month, and 1-year follow-up. Success rates were estimated as the percentage of patients having more than 60% VAS pain decrease at each follow-up. 1-year recurrence rate was estimated. The mean VAS score before treatment at 6.9 reduced to 3.6, 1 month after the last session, and to 2.2 and 0.9, after 3 months and 1 year, respectively. Success rates were estimated at 19% (1 month), 70% (3 months), and 98% (1 year). The 1-year recurrence rate was 8%. Moderate positive Spearman's rho correlation (r = 0.462, p < 0.001) was found between pretreatment pain duration and the total number of rESWT sessions applied. Conclusions. Individualised rESWT protocol constitutes a suitable treatment for patients undergoing rESWT for plantar fasciitis.