Given the common nature of heel pain in podiatric practice, the panelists discuss the importance of differentiating between plantar fasciitis and plantar fasciosis. They also review new procedures and advances in this arena with a particular emphasis on therapy using the Topaz® device.
Kim Eickmeier, DPM: Can you discuss plantar fasciosis versus plantar fasciitis?
Bruce Werber, DPM: With plantar fasciitis — and we can look at the work of Harvey Lemont,DPM, on this subject — there is an initial inflammation which may be due to injury, biomechanical causes, overuse, weight or a change in shoe gear.1 When I was based in the Northeast, we would see those seasonal bumps in patients presenting with plantar fasciitis. Patients would go from a more rigid, lace-up shoe in the winter to wearing boat shoes and flip-flops in the summer.
There are various causes with plantar fasciitis. One should also consider neurological etiologies that are related. Recognize that it is not always plantar fasciitis. We need to get out of the tunnel and make sure we look at alternative differentials.
Fasciitis is an inflammatory condition. It is very acute with increased inflammation and increased tenderness. If one were to look at this via ultrasound, you would see hypervascularity in this very early acute phase. Most people think it is going to go away. They feel the pain in the morning and it dissipates during the day.
Months later, they present to our offices since it has become chronic. At 12 to 15 weeks the tissue decreases in vascularity and enters the fasciosis phase. This is where we see a thickening of the plantar fascia on ultrasound. We would see hypovascularity looking at a color Doppler image of the fascia. Now it is into this chronic phase and typically these are the patients who will usually not respond to steroid injections or mechanical treatments such as stretching or night splits.
Dr. Eickmeier: We know it is very important to have an accurate differential diagnosis for diagnosing plantar fasciosis. How do you traditionally go about this in the office/clinical setting?
Dr. Werber: The patient history is very important, especially when it comes to patients who have started making diet and exercise modifications. What happened at the onset of pain? When they first started noticing symptoms, what changed? I always find that these comments are important findings. They will help direct treatment. They also give a very good timeline as to when the pain started. Then I look at the past medical history. When it comes to patients with irritable bowel syndrome or fibromyalgia, for example, there is an added level of concern that they may not respond to traditional modalities and that there may be some other metabolic etiology to their pain.
I proceed to the physical examination with the clinical exam and localization of the pain. As I stated before, it is important to look at the possible existence of any nerve entrapment syndromes that might be the cause of the pain. These nerve entrapment syndromes may include lumbar radiculopathy, sciatic nerve entrapment, common peroneal entrapment or even locally down to the medial calcaneal nerve tarsal tunnel. These are important areas and I believe that a thorough neurological exam is very important when patients present with heel pain.
|  | | “With plantar fasciosis, we see a thickening of the plantar fascia on ultrasound. We would see a
hypovascularity if we were to look at a color Doppler image of the fascia.”
— Bruce Werber, DPM |
Then we look at the biomechanics and the structure of the foot. We assess how the patient is functioning and what level of equinus is present in the patient. We evaluate the patient’s shoe gear and watch him or her walk. Subsequently, we do an ultrasound. If you have access to ultrasound, it does provide significant information about the plantar fascia and the tendons. Certainly, you need to obtain a radiograph to rule out stress fractures or other osseous pathology. From there, you can put together your differential diagnosis and treatment plan.
Emphasizing The Potential Impact Of Diagnostic Imaging
Dr. Eickmeier: Dr.Werber, what type of diagnostic studies do you perform to diagnose plantar fasciosis?
Dr. Werber: I am very lucky to have an advanced ultrasound with color Doppler. I find this is extremely helpful in making the diagnosis. You can clearly measure the thickness of the fascia and see if there are any soft tissue lesions. One can also see the vascularity of the tissue. This type of exam or modality is tremendously useful.
Another imaging alternative is magnetic resonance imaging (MRI). You can measure the thickness of the fascia and rule out other pathology in this area. A traditional radiograph only gives us osseous components and in some patients we can only see the shadows of some of the soft tissue structures. For me, ultrasound with color Doppler is the ultimate diagnostic tool to have for this condition.
Dr. Eickmeier: Can you expound upon what pathology would be seen with ultrasound examination?
Dr. Werber: With traditional ultrasound, one is going to see the shell of the calcaneus, which will reflect back the ultrasound signal. Then you will be able to see the differentiation between the superior and inferior borders of the plantar fascia because their echo signals have different densities. Accordingly, we can clearly see the margins of the fascia as it extends out from the calcaneus. With the color Doppler, you will see the red and blue streaking of the vascular flow in and around the tissue.
Assessing The Role Of Coblation Therapy Within The Armamentarium For Plantar Fasciosis
Dr. Eickmeier: We know that traditional plantar fasciotomy has a biomechanical effect on the structure and the function of the foot and ankle. Can you discuss this and perhaps why you may prefer Coblation® therapy versus plantar fasciotomy?
Michael McGlamry, DPM: This is what has always bothered me about traditional plantar fascia procedures. I came through residency at the time that endoscopic plantar fasciotomy (EPF) was the new and upcoming thing, and I certainly did a few of them.
However, I saw the patients who had the calcaneocuboid syndrome or lateral column overload. Certainly, there have been a couple of published articles discussing tibialis posterior tendon rupture following a plantar fasciotomy.2 I certainly have dealt with some of these complications myself. One starts to step back and think that EPF is not an innocuous treatment. Yes, there is a pathology that is proceeding but what is the best way to treat it?
Whether you are talking about short-term fasciitis or long-term fasciosis, I do not think the best way to treat overloading is necessarily the release of the fascia. I think we can always keep that in our back pocket for treatment on a patient who has not responded to conservative treatments or even to Topaz but I certainly do not think that traditional plantar fasciotomy should be the first-line treatment.
I began to change my treatment algorithm for patients with plantar fasciitis/fasciosis two to three years ago when I was first exposed to Topaz. I started to realize there is not a lot of downside to it. It is a surgical procedure. It does carry with it the same inherent risk of infection that any invasive procedure does.
However, we have an opportunity to affect the local metabolism of the tissue and influence neovascularization of the tissues through the local mediators without causing a negative mechanical effect or destabilizing the midtarsal joint by releasing the fascia either partially or completely.
That has been my rationale on the change in the way I have handled treatment for chronic plantar fasciitis/fasciosis in these patients hopefully without disturbing mechanics. Even with my failures, though they may not have achieved relief of their local pain, I have not created any new problems as a result of the treatment that I have instituted.
|  | | (Photo courtesy of Stephen Barrett, DPM)
This MRI shows plantar fasciosis. With MRI, Bruce Werber, DPM, says one can measure the fascia’s thickness and rule out other pathology in this area. |
Dr. Eickmeier: Dr. Werber, when do you introduce Coblation technology to patients? Do you consider it after patients have failed conservative therapy for plantar fasciosis? After how many months do you introduce it? Can you elaborate on this?
Dr. Werber: If the patient’s diagnosis is affecting the plantar fascia and I have addressed the other issues, I may consider Coblation technology.The patient may be doing the stretching exercises. He or she has had the night splint and orthotics,and the patient still has biomechanical issues. If I look at my ultrasound and the plantar fascia is quite thickened,greater than 3 mm, or if there is hypovascularity (lack of blood flow), I am going to be more inclined to offer a surgical solution earlier in my treatment plan than later.
|  | | (Photo courtesy of Stephen Barrett, DPM)
This photo shows the origin of the plantar fascia, with the clinician evaluating the amount of tenderness with palpation of the medial calcaneal tubercle. |
Say a patient presents with heel pain and he or she has tried some over-the-counter NSAIDs as well as some shoe inserts, but that has been the extent of the patient’s treatment thus far. I am going to explain the condition to the patient. Assuming the ultrasound reveals a thickened hypovascular plantar fascia, I will start with the stretching routine. I will recommend that the patient do this frequently throughout the day. I want the patient to wear orthotics and a stable new shoe.If the patient does have a thickened hypovascular plantar fascia, I will not typically give him or her a prescription for nonsteroidal antiinflammatory drugs (NSAIDs) but will be more aggressive with mechanical modalities. I will have the patient do massage and stretching. If the patient comes back and there is absolutely no response or if it is worse, I am going to be more inclined to go with Coblation.
On the other hand, say a patient comes in with moderate heel pain and perhaps mild thickening of the plantar fascia. If this patient has responded to the stretching routine and the orthotics, I am going to be more inclined to continue my conservative care. I may possibly offer a steroid injection, physical therapy and continue with aggressive stretching and massage.
I may continue such treatment for six to 12 months for some patients because they are steadily progressing or improving. On the other hand, when it comes to patients who have absolutely no response or are just not improving at all, that is when I am going to look at using Topaz and a surgical approach.
Comparing New Procedures And Advances In The Treatment Of Plantar Fasciosis
Dr. Eickmeier: What newer surgical techniques and technologies are you aware of that can treat plantar fasciosis in addition to the Topaz procedure? How can you correlate those or relate those to each other in their outcomes?
Dr. McGlamry: Over the last several years,the arena of different treatments for plantar fasciosis has certainly exploded. In the past,you pretty much had your open plantar fasciotomy versus the EPF and that was about it. Extracorporeal shockwave therapy has certainly been on the rise over the last five years but there is still a disconnection between treatment and outcomes. It has been suggested that only high energy shockwave provides significant benefit for these patients. However, no one has adequately defined where the cutoff is between high-energy and low-energy shockwave.
|  | | “Topaz has changed my treatment protocol in that when I have a patient with plantar fasciosis who is not responding to conservative therapy, I am no
longer waiting a full six months.”
— Michael McGlamry, DPM |
When you look at the literature,shockwave therapy shows about an 80 percent response rate for patients with chronic plantar fasciosis.3-5 Then you compare shockwave to Topaz, which has greater than a 90 percent success rate. In explaining the difference between the two technologies to my patients, I note that while shockwave therapy is non-invasive and does not require an incision, both procedures are going to require anesthesia of some type. I am not sure there is a big difference when giving a patient sedation or a general anesthetic.
|  | | (Photo courtesy of James Losito, DPM)
Here one can see the typical location of pain in cases of proximal plantar fasciitis. Dr. Werber notes the importance of looking for the possible existence of any nerve entrapment syndromes as causes of pain. |
The only difference at that point is the potential risk of localized infection, which is typically somewhere under four percent for clean bone and joint surgery. I have seen quoted averages as low as about 2.3 to 2.6 percent, so there is a fairly limited risk.
Those are the issues that are really out there. There are individuals considering injection with platelet-rich
plasma to try to stimulate local neovascularization with some results. There is a cryotherapy group using these super-chilled probes for the fascia, Morton’s neuroma and Baxter’s nerve. I personally do not have any experience in these, which are some of the other treatments out there that have some degree of showing a
positive effect.
Pertinent Pearls On Performing The Topaz Procedure For Plantar Fasciosis
Dr. Eickmeier: Can you discuss how you perform Coblation therapy, or the Topaz procedure, for plantar fasciosis and any pearls that you may have?
Dr. Werber: I use a very traditional endoscopic approach. I would have localized the pain prior to
anesthetizing the patient. I would look and feel for the medial band of the plantar fascia as it is approaching the medial tubercle of the calcaneus,and make a medial incision. I then take a Kelly hemostat or a Freer elevator and I would feel for the inferior surface of the plantar fascia. I migrate my way across with the Kelly to create the tunnel.
Then I take my trocar and cannula and go through the initial tunnel I have created. Keeping the foot maximally dorsiflexed so the plantar fascia is extremely tight, I will then gradually, using a windshield wiper motion, move along the inferior surface of the plantar fascia until I reach the lateral margin of the heel. At this point, I will make a secondary incision that is curved with the skin lines.
I know this seems very minimal but going along with the skin lines on that lateral incision seems to decrease the postoperative pain in this area. As I bring the cannula and trocar across, I remove the trocar and take some cotton swabs to clean the cannula. Then I visualize the plantar fascia and make sure that I am well localized.
|  | | (Photo courtesy of Stephen Barrett, DPM)
Here one can see high-resolution ultrasound. With
ultrasound, Dr. Werber says one can clearly measure the thickness of the fascia, detect any soft tissue lesions and see the vascularity of the tissue. |
At this point, I introduce the Topaz wand and it certainly cannot be a dry field.We will flood the cannula with saline and then I create my matrix of insertions into the plantar fascia.I roll the cannula to the posterior, repeat the procedure, and roll it anteriorly. Sometimes I will lengthen my medial incision to angle and swing the cannula distally or proximally if I feel that I need to get more of the fascia. Remember that you have a thickened plantar fascia. Accordingly, when you are bringing the Topaz wand into the fascia, you do not want to just get the surface of the fascia. You need to get into the substance of the fascia and try to get to the superior surface with the wand. You need to make sure the insertions of the wand do penetrate the plantar fascia as opposed to just treating it superficially. Then I obviously flush the area, remove my instrumentation and do a closure.
Dr. McGlamry: Are you introducing the wand from medial with the cannula position lateral?
Dr. Werber: Yes.
Dr. Eickmeier: Dr. McGlamry, can you discuss any pearls that you may have for us?
Dr. McGlamry: My approach has really been more of the open approach through a traditional in-step fasciotomy-type incision. As Dr.Werber mentioned, pre-operatively, I try to isolate the patient’s point of maximal tenderness and put a bull’s eye right on it. We then create about a 2- to 2.5-cm incision, typically sweeping from the medial aspect of the heel just anterior to the tubercle area and then sweeping about halfway across the heel. We sharply dissect directly through the fat. One of the advantages with this is that it is typically directly in line with the medial calcaneal nerve branches. With a little bit of care, you can pretty much avoid this and if you do see calcaneal nerve branches, you can safely retract them
within the fatty layer.
Carry dissection directly down to the plantar fascia and insert a self-retaining retractor. This will give you a clear exposure of about 1 to 2 cm of the fascia. With that exposure, I am able to produce a treatment grid, typically with 12 to 16 penetrations of the fascia directly over the point of maximal tenderness. After a quick irrigation, we close it with some interrupted mattress stitches. We utilize a dry sterile dressing, typically with an Ace bandage around the top, and walk patients right out of the surgery center that day. They are fully weightbearing from day one.
My colleagues and I have done a lot with plantar incisions in the last few years. The old rhetoric about it being taboo to make incisions on the bottom of the foot and allowing immediate weightbearing has not held water. We have had beautiful incisions and beautiful results. Of course, sometimes you may get some little keratoma areas if you are using some wired stitches. However, we have not had any significant problems with these incisions to date. The plantar incisions have healed well with immediate weightbearing.
Perhaps the biggest pearl I can offer is making the incision directly over the point of maximal tenderness. I would imagine that my surgical time, which is not the measure of success, is typically under 20 minutes for these plantar fascial procedures. I do them under tourniquet. It gives us a nice dry field with clear visualization of the fascia. The patient is out of the surgery center or the hospital recovery room typically within 30 minutes or so afterward.
Reviewing Anectodal Results And Identifying Non-Responder Patients
Dr. Eickmeier:What has your success rate been with using the Topaz?
Dr. McGlamry: In my experience,Topaz has in excess of a 90 percent success rate. The failures that I have are on the non-traditional plantar fasciosis patients.
Dr. Eickmeier: When you refer to the non-traditional plantar fasciosis patient, what type of patient are you referring to?
Dr. McGlamry: The stereotypical heel pain patients most of us see in our offices are patients with increased body mass index (BMI), certainly higher weight and who are relatively sedentary. Virtually all of my failures with Topaz have been with people who probably fall in a near normal BMI category. I think I have had three actual failures and two of the three had an underlying cavus foot structure as well.
Dr. Eickmeier: Can you allude as to why some patients have failed to respond to the Topaz procedure?
Dr. McGlamry: I cannot give you a good explanation as to why I think they have failed. The only thing I can say is the observation that they are definitely in a different group. They are slender and generally have had a much longer history of heel pain. One of them is a runner with an eight-year history of heel pain who has previously failed every treatment from a conservative standpoint. She has had physical therapy, multiple pairs of orthotics, injections, antiinflammatories and oral steroids, all to no avail.
Another more recent failure is a male in manual labor and he falls into what you would typically see in a failure group with the EPF. He goes back to standing and walking on concrete even though I kept him out of work for a full month with limited activities in his orthotics. He is a big guy but certainly not obese. He does not have a weight that is out of proportion to his structural frame. Is he better than he was? He is not a failure but certainly not one of the glowing successes that I have.
It certainly has not been a frequent thing. I still reserve any kind of surgical treatment for non-responders who have effectively failed significant attempts at conservative care. I do not want to give the impression that I am doing Topaz procedures three times a week on heel pain patients. I am still probably only doing eight to 10 a year for my non-responders, the group that has shown no significant improvement with conservative care before I have proceeded to the Topaz procedure.
However, Topaz has changed my treatment protocol in that when I have a patient with plantar fasciosis who is not responding to conservative therapy, I am no longer waiting a full six months. If these patients do not have 60 to 80 percent improvement after two months of conservative care, I start to present Topaz as an alternative option and give them realistic statistics. I send them to the Web site (www.topazinfo.com). I try to give them other sources of information to look at as far as alternatives. I begin to present this as a treatment option in the two- to three-month range now for the patients whom I feel are non-responders,the ones who are more fasciosis patients than fasciitis patients.
Dr. Eickmeier: Dr.Werber,can you discuss your experience with patients who have not responded to the
Topaz procedure and why that may be the case?
Dr. Werber: I feel we need to look at both fasciosis and tendonosis. We have experienced about a 10 to 15 percent overall failure rate despite our very thorough exam and treatment. I look back at some of these failures and some of them may be due to a missed a nerve entrapment syndrome. They may have some lower back issues that may be contributory. I did find a couple that had a common peroneal nerve entrapment. We subsequently performed a common peroneal nerve decompression and it alleviated the symptoms for both patients. I am not saying this would work for everybody. It just happened to be the case with these two patients.
Sometimes I believe the failures are in my inability to fully diagnose and appreciate what is going on with the patient. I do agree with Dr.McGlamry’s categorization of the non-responders as having a classical high arch
cavus foot type, lean body mass and being runners. I have seen these same type of non-responders. You have to be aware that there are patients who will fail. Coblation therapy is not a cure-all. It is just another wonderful tool in our armamentarium to treat patients.
Final Notes
Dr. Eickmeier: Are there any closing remarks you would like to make in regard to this discussion of plantar fasciitis and plantar fasciosis?
Dr. McGlamry: Having the Topaz tool in my belt has affected my treatment of patients with plantar fasciosis. Traditionally, we are always taught somewhere along the line that we do not offer surgical intervention for patients with plantar fascial symptoms under six months to a year, depending on who trained you and different schools of thought. The minimally invasive nature of this procedure and the fact that we are not sacrificing normal anatomy have provided me the comfort level to offer patients an option when they are not responding to conservative care whereas before, I felt like I needed to satisfy an arbitrary time period with conservative therapy.
I certainly do discuss this with the patient. However, I am happy that I have yet another mechanism to treat and take care of patients instead of having them come in every three to four weeks for a refill of antiinflammatories and seeing their discouragement when they are not responding to typical conservative care.
I feel the Topaz procedure has advanced my ability to treat patients and give them a potential positive outcome. Certainly,there are no guarantees of success but it does provide us another option and mechanism to treat patients in a minimally invasive nature with a rapid recovery and,in my experience,very few downsides.
Dr. Werber: I have to agree with Dr.McGlamry. Topaz certainly has given us an alternative method of treating heel pain. It has expanded our vision as to why some patients respond very quickly while others have not. This has really advanced our understanding. We still have much to learn and I think the frequency and rapid nature of our expansion of this knowledge on plantar fasciitis and plantar fasciosis will be incredible over the next several years.
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