Advanced Regenerative Healing Alternatives For Chronic Plantar Fasciitis

Plantar fasciitis is definitely one of the more common symptoms seen by ankle and foot specialists. Although heel pain has multiple causes, the most common cause by far is biomechanical issues that cause strain to be placed on the plantar fascia. When the posterior muscle group is tight it causes a cavus or increased pronation foot structure that results in the fascia becoming inflamed followed by pain.

For a majority of patients, conservative treatment using physical therapy, cortisone injections, anti-inflammatories and/or orthotics will help to reduce the inciting inflammation which helps to relieve the symptoms. When there is persistent acute inflammation and chronic scar tissue starts to form, which treatment to use can more commonly become a dilemma. When that occurs, the inflammatory response of the body will stall and healing will cease.

When this recalcitrant state is reached by a patient, the focus of treatment will need to be redirected by the practitioner from decreasing inflammation over to actually stimulating it. For many years, surgical fasciotomy has been the end-stage treatment used on chronic plantar fasciitis. We will be discussing less invasive, newer therapy options that podiatric practice is starting to use.

Essential Information On Extracorporeal Shockwave Therapy

Extracorporeal Shockwave Therapy (ESWT) is among the oldest techniques for increasing inflammation on the plantar fascia. The technology involves administering sound waves which create vibrations that get transmitted throughout the tissue. Local injury is caused by the vibrations which increases the blood flow subsequently as well as growth factors migrating to the area. Another hypothesis regarding the effects that shockwave therapy has is hyperstimulation inhibits the perception of pain.

A double-blinded, randomized, multicenter study was performed by Malay and colleagues to compare chronic heel pain treatment by comparing ESWT versus a placebo. There were 175 patients included in the study who were evaluated three months and then one year following treatment. Patients who were treated with ESWT on the visual Analogue Scale, had a 3.39 mean pain reduction, while those who received the placebo, experienced only a 1.78 pain reduction. In the ESWT group, the response from patients as to whether or not they had experienced an improvement was also a lot higher.

In regards to this treatment, there has been one controversy come up, which is whether low-energy and high-energy ESWT are equally effective. Physicians for years believed the more effective of the two was high-energy therapy since only one treatment was required. However, a major deterrent for physicians, patients and insurance companies was the high cost of the procedure and need for anesthesia.

However, more recently research has discovered that low-energy devices are actually as effective when it comes to treating pain stemming from plantar fasciitis. Despite the fact that three separate treatments are needed one or two weeks apart, this procedure can be done in the office and doesn’t require anesthesia. Patients can bear weight right after the procedure is performed and there is no or very little downtime overall.

Noninvasive Monopolar Capacitive Coupled Radiofrequency Insights

A procedure called Relef (Alpha Orthopaedics) is another procedure that can be performed at the office by a physician. Noninvasive monopolar capacitive coupled radiofrequency is used by the technology to cause the healing process to be reactivated. The tissue’s temperature is increased to 50 degrees C by the radiofrequency. The temperature increase then increases the threshold for tissue shrinkage and collagen modulation. In addition, the process recruits heat shock protein, fibroblasts and macrophage factors into the damage area to help with the reparative process.

Although radiofrequency is detrimental to the damaged tissue, it doesn’t disrupt the fascia that is healthy. To help keep the patient comfortable, a cool mist is administered by the treatment wand before the radiofrequency treatment is performed. Usually two separate procedures are required and take place around six weeks apart. Immediately after the procedure the patient can ambulate with very few restrictions.

Percutaneous Radiofrequency Microdebridement

Topaz microderidement (AthroCare Sports Medicine) is a procedure that takes place in the operating room that is slightly more invasive. A small Coblation wand is used in this procedure to increase cell proliferation and vascularity to promote healing. In general, weight bearing immediately is acceptable as long as a controlled ankle motion (CAM) boot is used and the patient transitions into a regular shoe slowly over a two to four week period.

A prospective study was performed by Sorensen and colleagues on 21 patients who were treated using bipolar radiofrequency microdebridement. Excellent results were experienced by 14 out of the 21 patients, 4 had good results, 1 had fair results, and 2 had poor results. Similar results were found by Hormozi and coworkers, where 11 out of their 14 patients said they would recommend this procedure to somebody that had similar symptoms to theirs.

Another Innovative Technique That Is Helping To Redefine Minimally Invasive Surgery

There are other innovative procedures currently emerging that can physically remove scar tissue from a diseased area with practically no incision or any recovery time. The Tenex procedure is one example of this. It is also referred to as the FAST technique (Fasciotomy and Surgical Tenotomy).

The procedure can be performed by surgeons with just a local anesthetic or the patient being under mild sedation. Ultrasound guidance is used by the technique for evaluating the fascia in addition to the scar tissue inside it. Once a small stab incision is made, the probe is then inserted, which utilizes ultrasonic energy for breaking up and removing diseased tissue. Although it is powerful enough for breaking scar tissue down, normal tissue isn’t affected by the frequency. The surgeon can visualize when enough scar removal has taken place.

After a soft dressing is applied the patient should be non-weightbearing for approximately one week and then slowly transition into full weightbearing over the next two weeks. We have found in our practice promising result using this technique to treat Achilles tendonitis in addition to plantar fasciitis.

The Impact Of Platelet Rich Plasma (PRP)

PRP is fractionated plasma that gets taken from a patient. It contains very concentrated platelet levels. A high level of growth factors are contained in the platelets that stimulate healing ultimately by promoting angiogenesis and collagen as well as through recruiting stem cells.

A small sample of nine patients were evaluated by Barret and Erredge who were treated using a PRP injection under the guidance of ultrasound. Three weeks following the injection the plantar fascia thickness decreased 2.29 mm on average. Hypoechoic changes and signal intensity improved post-injection as well. Six out of the nine patients had their symptoms completely resolved by their two-month follow-up. One of the patients had complete resolution but had received a steroid injection so was disqualified. One patient needed to have a second PRP injection and was completely relieved of pain eventually. The final patient had pain only occasionally when ambulating barefoot. At the one-year follow-up, there was just one patient who was viewed as having failed the treatment. The remain seven patients were asymptomatic still.

In our practice, we’ve also seen good success using PRP injection. Generally patients are non-weightbearing anywhere from two to seven days and then use a CAM boot for protected weightbearing for an additional week.

Amniotic Membrane Allograft And Stem Cell Therapy: A Glimpse Of The Future

The topics of amniotic membrane allografts and stem cell therapy are leading techniques for tissue healing. A stem cell injection, which is harvested out of the lateral calcaneus most commonly, provides pluripotent mesenchymal cells to the damaged tissue that differentiate into the appropriate type of cell for regeneration and repair.

We have in our practice, a response to this treatment in around two weeks. However, it may take as long as six weeks for some patients to see improvement in their symptoms. The biggest downfall of this therapy is mainly the expense for the patient since stem cells are not covered by insurance.

Using amniotic membranes for decreasing scar formation is the newest therapy option. Amniotic membrane allograft have anti-inflammatory properties. This differentiates it from all of the previously mentioned treatments. The innovative therapy has a significant impact on reducing scar formation as well as promoting growth factors for healing tissue.

A randomized, prospective study was conducted by Zelen and colleagues to assess the effectiveness of amniotic membrane allograft for treating chronic plantar fasciitis. Patients who were given micronized dehydrated amniotic membrane allograft, as opposed to a placebo saline injection, show significant improvement in function and pain at one week and again at eight weeks. By the eighth week, there was an increase in AOFAS hindfoot scores for the control group by a meanof 12.9, while the amniotic treatment group had a 51.6 mean score. These types of studies are reassuring since in the very near future regenerative medicine is going to be an integral part of podiatric practice.

References

1. Malay SD, Pressman MM, Assili A, et al. Extracorporeal shockwave therapy versus placebo for the treatment of chronic proximal plantar fasciitis: Results of a randomized, placebo-controlled, double-blinded multicenter interventional trial. J Foot Ankle Surg. 2006; 45(4):196-210.
2. Weil L, Zuckerman D. Is low-energy ESWT better than high-energy ESWT for plantar fasciitis? Podiatry Today. 2009; 22(11):52-58.
3. Whipple TL. From mini-invasive to non-invasive treatment using monopolar radiofrequency: The next orthopedic frontier. Orthop Clin North Am. 2009; 40(4):531-535.
4. Sorensen MD, Hyer CF, Philbin TM. Percutaneous bipolar radiofrequency microdebridement for recalcitrant proximal plantar fasciosis. J Foot Ankle Surg. 2011; 50(2):165-170.
5. Hormozi J, Lee S, Hong DK. Minimal invasive percutaneous bipolar radiofrequency for plantar fasciotomy: a retrospective study. J Foot Ankle Surg. 2011; 50(3):283-286.
6. Richardson PE, Dix BT, Adeleke AT, et al. Keys to optimal selection of orthobiologics. Podiatry Today. 2013; 26(9):54-61.
7. Barrett SL, Erredge SE. Growth factors for plantar fasciitis? Podiatry Today. 2004; 17(11):36-42.
8. Zelen CM, Poka A, Andrews J. Prospective, randomized, blinded, comparative study of injectable micronized dehydrated amniotic/chorionic membrane allograft for plantar fasciitis: a feasibility study. Foot Ankle Int. 2013. Epub ahead of print.