Heel Pain Study: Night Splints In, Stretching Out?

Author(s): 
By Brian McCurdy, Associate Editor

While plantar fasciitis is the most common cause of heel pain, there’s not exactly a universal approach when it comes to conservative treatment for this condition. Now a recent study suggests that prefabricated night splints may offer better results than the oft-recommended standing stretching in relieving symptoms of plantar fasciitis.
The open retrospective study, which was published in the July/August edition of The Journal of Foot And Ankle Surgery, revolved around 160 patients who had unilateral or bilateral plantar fasciitis. In addition to a standard treatment regimen, the researchers had 71 patients perform standing gastrocnemius-soleus stretching while the remaining 89 patients were given a prefabricated night splint.
What were the results? Those receiving night splint treatment had a mean time to recovery of 18.5 days with 1.78 follow-up visits and 1.83 additional treatments, according to Lance D. Barry, DPM, the lead author of the study. Those who underwent standing stretching had a mean time to recovery of 58.6 days, 3.07 follow-up visits and 2.14 additional interventions.
In other words, patients in the adjunctive night splint group experienced a resolution of symptoms in one-third the time of those in the adjunctive standing stretching group. Dr. Barry and his co-authors, Anna N. Barry, MS, and Yinpu Chen, PhD, also note in the study that the night splint group required fewer visits and treatment interventions.

Dr. Barry, a Fellow of the American College of Foot and Ankle Surgeons, believes the study supports a common sense approach to plantar fasciitis. He points out the traditional treatment of stretching “never made sense to me” because with a cut or broken bone, doctors would join the broken tissues together and not move them around.
“This is the only body tissue that when it was damaged, we were stretching like a maniac,” says Dr. Barry.
Night splints, on the other hand, can help address nighttime contracted position of the foot and keep the ankle in the anatomical position. Dr. Barry says wearing these splints can help patients reduce contracture of the gastrocnemius-soleus complex while they sleep and prevent further tension from the complex.
Harry F. Hlavac, DPM, praised the study for scientifically documenting an effective four-tier treatment plan prior to surgery and noted that it has changed his perception of treating plantar fasciitis.
“Prior to reading this article, I favored stretching,” says Dr. Hlavac, the Past President of the American Academy of Podiatric Sports Medicine. “Now I will include night splints in addition to stretching so I do not need to explain why the patient doesn’t need to stretch and the patient feels that he or she is part of the rehab process.”

New Study Questions Shockwave Therapy
Using extracorporeal shockwave therapy (ESWT) to treat plantar fasciitis has been a controversial subject. Now a new study published in the Journal of the American Medical Association (JAMA) says evidence does not support using the therapy.
Conducted in Melbourne, Australia, the study enrolled 166 patients with plantar fasciitis in the double-blind, randomized trial. Researchers gave 81 patients ultrasound-guided ESWT weekly for three weeks (to a total dose of at least 1,000 mJ/mm2) while 85 patients received a placebo (to a total dose of 6.0 mJ/mm2).
Researchers saw significant improvements at six weeks and 12 weeks out for both groups in overall pain, morning and activity pain, and walking ability, according to the JAMA study. However, they saw no significant differences for any of the measured outcomes.
Lowell Scott Weil, Sr., DPM, cautions against drawing too much from this study, pointing out a few flaws in the study’s inclusion criteria.
While he thinks the median numbers for duration were reasonable at 36 weeks, Dr. Weil says allowing patients who have only had heel pain of six weeks’ duration is questionable.
“It is well known in the foot and ankle world that people with heel pain of three months or less have a 80 percent or better chance of resolution of their pain,” explains Dr. Weil, a Fellow of the American College of Foot and Ankle Surgeons. “Therefore, the study could have compared the placebo to surgery and probably fared as well for the placebos.”
Dr. Weil notes that the study’s researchers also considered the plantar fascia pathologic if it measured 4 mm or more by ultrasound. However, he points out that most DPMs consider 2 to 4 mm thickness as normal.
“So many of these patients in both the placebo group and treatment group were going to get better with virtually any treatment,” emphasizes Dr. Weil, the CEO and President of the Weil Foot And Ankle Institute.
While naysayers may trumpet this study as validation of their doubts about the modality’s effectiveness, “those that have had experience in this area will not be swayed,” maintains Dr. Weil, who is currently involved in three randomized, double blind, placebo-controlled FDA studies on ESWT. “Good studies are needed not only with regard to the outcome of ESWT but with regard to the mechanism of action.”
(Editor’s Note: For more info, check out “What Studies Say About Shockwave Therapy” on page 48.)
– B.M.

Researchers Assess Prevalence Of Diabetes Complications Among Mexican Americans
Managing diabetes can often be a daunting task for patients and physicians and, in particular, little data exists on how certain ethnic populations are affected by diabetes-related complications.
With this in mind, researchers recently conducted a study of over 1,600 patients in order to examine diabetes-related lower extremity complications among Mexican Americans and non-Hispanic Whites. The researchers examined screening results and clinical outcomes over a 20 to 28-month period for the patients, all of whom were enrolled in a Baltimore-based diabetes disease management program.
They found a higher incidence of lower extremity amputation in Mexican Americans with diabetes (7.4 per 1,000 patients) compared to non-Hispanic Whites (4.1 per 1,000 patients), according to Lawrence Lavery, DPM, the lead author of the study.
According to the study, the only other difference between the two groups was a higher incidence of Charcot arthropathy in non-white Hispanics. Researchers found no significant difference based on ethnicity when it came to peripheral vascular disease, foot infection, lower extremity bypass or ulceration.
For the entire study population of Mexican-Americans and non-Hispanic Whites, the overall incidence of diabetic foot ulceration, infection, amputation and lower extremity bypass per 1,000 people per year totaled 64.6, 36.5, 5.9, and 7.7 respectively.
Dr. Lavery, an Associate Professor in the Department of Orthopedic Surgery and Rehabilitation at Loyola University Medical Center, believes this study is “one of the most comprehensive looks at complications” and says the study results correlate with what he has seen in treating these populations.
David G. Armstrong, DPM, co-author of the study and the Director of Research and Education within the Department of Surgery, Podiatry Section at the Southern Arizona Veterans Affairs Medical Center, also says the findings correlate “very well” to ethnic populations he treats in his practice. He did express some surprise over the “high prevalence of patients who required antibiotics — 56 percent — at some point during the life cycle of their wound.”
Dr. Lavery feels the research from the study will provide pilot data to pursue a larger, long-term study on diabetic foot complications among Hispanic populations. He adds that the study is currently being prepared for publication in an upcoming issue of a diabetes journal.
–G.D.

Clarification
In regard to the article, “Getting Shockwave Results With The Epos Ultra” (see “Technology In Practice,” pg. 88, August issue), Dornier MedTech says insurers are “paying for extracorporeal shockwave therapy performed on the Epos Ultra,” although it depends on the geographical region you’re in and it is usually on a pre-certified need.
Dornier MedTech, the manufacturer of the Epos Ultra, cites the following quote from reimbursement specialist Dawn Bailey, the Director of Advanced Medical Procedures:
“When reviewing the payer payment history for treatment management of plantar fasciitis, insurance payers find that this procedure is cost-effective and are providing coverage on an individual patient basis.”

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