Are Orthoses Effective Against Plantar Fasciitis In The Long Run?

     Orthoses are an integral part of the podiatric armamentarium to treat plantar fasciitis. However, a recent study calls into question the long-term efficacy of using orthoses to treat the condition.

     The study, which was published in a recent issue of the Archives of Internal Medicine, looked at 135 patients with plantar fasciitis, who were randomized to wear either a prefabricated orthosis made of firm foam, a customized orthosis made of semirigid plastic or a sham orthosis. The follow-up period was 12 months. After three months, researchers found that both the prefab and customized orthoses provided better pain relief and improvement in function, although only the effects on function were statistically significant, according to the study. At 12 months, researchers said the study showed no significant effects on primary outcomes for those who wore custom or prefab orthoses.

     While the study authors noted small short-term benefits in function and reduction in plantar fasciitis pain with orthoses, they say orthoses do not have beneficial long-term effects when compared to a sham.

What The DPMs Have Found In Their Experience

     In contrast to the study, Russell Volpe, DPM, has found a better long-term orthotic efficacy for patients with plantar fasciitis. He says it may take time for symptoms to improve. The key, when using prefab or custom orthoses for plantar fasciitis, is combining them with other therapies, according to Dr. Volpe. One should undertake therapies such as oral medications, injections, icing, stretching, rehabilitation or shoe changes concurrently with the orthotic devices in order to improve pain and function, according to Dr. Volpe, the Chair of the Department of Orthopedics and Pediatrics at the New York College of Podiatric Medicine.

     Orthoses normalize and neutralize the biomechanical imbalances that cause pronatory compensation that contribute to or aggravate plantar fasciitis, according to Dr. Volpe. He adds that orthotic devices function best at preventing further damage or reinjury to the fascia that has been treated for an inflammatory condition.

     Ronald Valmassy, DPM, says his patients respond “exceptionally well” to custom orthoses in the short term.

      “I feel that a prescription device typically improves foot function throughout the day and is generally instrumental in improving the effectiveness of other forms of treatment such as corticosteroid injections and physical therapy,” says Dr. Valmassy, a Staff Podiatrist at the Center for Sports Medicine at St. Francis Memorial Hospital in San Francisco, Calif.

     Furthermore, Dr. Valmassy feels orthoses generally improve pre-existing abnormal foot function. His patients typically wear orthoses even after their plantar fasciitis symptoms improve. He notes that when his patients wear orthoses, they feel more stable, comfortable and functional in gait.

Questioning The Study And Suggesting More Specific Studies In The Future

     The fact that orthotic devices alone are often not enough is a “serious flaw” in the study, opines Dr. Volpe.

      “This may make for difficulties with research as combined therapies are very hard to assess when it comes to the effect of each therapy. However, we must be careful about these conclusions about orthoses when no other treatments were provided, given that this is not how orthoses are used by most serious, respected foot professionals,” cautions Dr. Volpe.

     Dr. Volpe also has a concern that the patients in the study were a generalized group of people with plantar fasciitis, noting there was no discussion of their biomechanics and pronation. He suggests the next study examine patients with plantar fasciitis in those with acquired pes plano valgus of biomechanical origin. Furthermore, he notes that those with plantar fasciitis and pronated feet respond better to orthoses than those with cavus feet, and says future studies should differentiate those groups.

     Dr. Valmassy feels additional studies would be beneficial but has a concern that the term customized orthoses is “painted with a very broad stroke,” saying the term means different things to different practitioners.

      “I might evaluate the customized devices used in this study and feel that they are not only not true functional devices but possibly no better than over-the-counter devices,” says Dr. Valmassy.

Study Says Linezolid Is Cost Effective Option For MRSA

By Brian McCurdy, Senior Editor

     As the prevalence of methicillin resistant Staphylococcus aureus (MRSA) continues to rise, DPMs can turn to a cost-effective antibiotic with demonstrated efficacy in treating MRSA. A recent study in the Annals of Pharmacotherapy reveals linezolid (Zyvox, Pfizer) is cost effective in comparison to vancomycin.

     The study tracked 717 patients, who were randomized into receiving either oral linezolid or vancomycin IV for seven to 21 days. Researchers evaluated costs for the patients by applying nationally representative per diem costs by hospital ward.

     Researchers found the length of stay was shorter for patients on linezolid. The mean cost for the intent-to-treat population in linezolid patients was $4,865 +/- $4,367 whereas the mean cost was $5,738 +/- $5,190 in the vancomycin patients, according to the study. The study also notes lower costs in treating MRSA patients with linezolid, citing mean costs at $4,881 +/- $3,987 for linezolid patients versus a mean cost of $6,006 +/- $5,039 for those taking vancomycin.

     Citing a recent hospital report, Peter Wilusz, DPM, says the rate of MRSA infections among patients with diabetes in the Detroit area is over 80 percent. He performed an independent study comparing linezolid with vancomycin in patients with diabetes and says the results are similar to the Annals of Pharmacotherapy study. In his own study, he notes the only poor outcome was thrombocytopenia in two of 40 patients, which required the cessation of linezolid in these patients.

     Dr. Wilusz feels linezolid is safer for patients with diabetes because of its lack of renal involvement and because it achieves the same bioavailability orally and intravenously. He also says linezolid has 52 percent penetration into bone compared to 6 percent for vancomycin compared to his independent study.

     The advantages of linezolid allow DPMs to treat patients as outpatients and patients do not have to travel for IV infusion, according to Dr. Wilusz, a Clinical and Surgical Instructor at the Foot and Ankle Clinic at the Southeastern Michigan Surgical Hospital in Warren, Mich.

     While he has not analyzed the cost data in his practice, Jeffrey Jensen, DPM, says the cost advantage to treating patients with linezolid versus vancomycin “is pretty obvious.” He says those taking linezolid leave the hospital sooner and receive effective antibiotic therapy. However, he adds that sometimes factors besides antibiotics prevent patients from going directly home from the hospital, notes Dr. Jensen, an Associate Professor at the University of Colorado Health Sciences Center.

New Version Of Exogen Ultrasound Device Garners FDA Approval

By Brian McCurdy, Senior Editor

     Is ultrasound effective in bone healing? The FDA has approved the Exogen 4000 Bone Healing System (Smith and Nephew), a new version of a bone healing system that uses ultrasound technology. In using the device, one can apply low-intensity pulsed ultrasound 20 minutes a day over the site of a broken bone. The 4000 model, which launches this fall, replaces the Exogen 2000.

     The company says Exogen’s ultrasound technology can treat fractures that have not healed and is also approved to heal fresh fractures more quickly. As Smith and Nephew notes, Exogen 4000 speeds up the healing of new fractures by 38 percent and effectively heals 86 percent of hard-to-heal fractures.

     For the last four to five years, George Vito, DPM, has used the Exogen system for Charcot reconstruction and acute fractures. He feels the ultrasound technology is quite beneficial, especially for patients who have not healed with other treatments.

     One advantage of the system is that one can use a bone stimulation product that uses electricity and if it does not work, the clinician can proceed to use the Exogen 4000’s ultrasound technology, according to Dr. Vito, the Director of the Atlanta Leg Deformity Correction Center in Macon, Ga. He notes the only disadvantage is the device’s cost, which he estimates is between $3,200 and $4,000.