Advanced Regenerative Healing Options For Chronic Plantar Fasciitis

Bob Baravarian, DPM, and Rotem Ben-Ad, DPM

Plantar fasciitis is no doubt one of the most common presentations that foot and ankle specialists see. Although there are multiple causes for heel pain, biomechanical issues causing strain on the plantar fascia are by far the most common causes. A tight posterior muscle group causing an increase in pronation or even a cavus foot structure will result in inflammation of the fascia and subsequent pain.

   For most patients, conservative treatment with orthotics, anti-inflammatories, cortisone injections and/or physical therapy will decrease the inciting inflammation and provide relief of symptoms. The treatment dilemma more commonly occurs when this acute inflammation persists and chronic scar tissue forms. When this happens, the body’s inflammatory response stalls and healing no longer takes place.

   When a patient reaches this recalcitrant state, the practitioner must redirect his or her focus of treatment from decreasing inflammation to stimulating it. For years, the end-stage treatment for chronic plantar fasciitis has been surgical fasciotomy. We will discuss the newer, less invasive therapy options that are being incorporated in the podiatric practice.

What You Should Know About Extracorporeal Shockwave Therapy

One of the older techniques for increasing inflammation to the plantar fascia is extracorporeal shockwave therapy (ESWT). This technology administers sound waves that create vibrations transmitted through the tissue. These vibrations cause local injury and subsequently increase the blood flow and migration of growth factors to the area.1 One other hypothesis on the effects of the shockwave therapy is that hyperstimulation results in the inhibition of pain perception.1

   Malay and colleagues performed a randomized, double-blinded, multicenter study comparing treatment of chronic heel pain with ESWT versus a placebo.1 The study included 175 patients who had evaluation three months and one year after treatment. On the Visual Analogue Scale, patients who had treatment with ESWT had a mean pain reduction of 3.39 while those treated with the placebo only experienced a pain reduction of 1.78. The patients’ response as to whether they experienced a clinical improvement was also much greater in the ESWT group.

   One controversy that has arisen regarding this treatment is whether high- and low-energy ESWT are equally effective. For years, physicians thought that high-energy therapy was more effective as it only required one treatment. However, the need for anesthesia and the high expense of the procedure was a big deterrent for patients and physicians as well as insurance companies.2

   More recently, however, research has found that low-energy devices are just as effective in treating the pain associated with plantar fasciitis. Although three separate treatments are required about one to two weeks apart, the procedure can occur in the office and without anesthesia.2 Patients are able to bear weight immediately following the procedure with little to no overall downtime.

Pertinent Insights On Noninvasive Monopolar Capacitive Coupled Radiofrequency

Another procedure that physicians can perform in the office is known as the RelēF™ procedure (Alpha Orthopaedics). This technology uses noninvasive monopolar capacitive coupled radiofrequency to cause reactivation of the healing process.3 The radiofrequency increases the temperature of the tissue to 50ºC. This increase in temperature subsequently increases the threshold for collagen modulation and tissue shrinkage. The process also recruits macrophages, fibroblasts and heat shock protein factors to the damaged area to aid in the reparative process.

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