Bipolar Radiofrequency Microtenotomy: Can It Be An Effective Alternative For Plantar Fasciosis?

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Bora Rhim, DPM

It has been estimated that more than 1 million visits have been made to office-based physicians and hospital outpatient departments each year for plantar heel pain.1 For foot and ankle surgeons, much of their practice time entails treating plantar heel pain. The literature has described plantar fasciitis as a painful heel with inflammation of the plantar fascia at the proximal insertion of the plantar fascia to the calcaneus.2

   In 2003, Lemont and colleagues reported histologic findings of 50 cases of heel spur samples from surgery for chronic plantar fasciitis.3 In all of the samples, there was no histopathologic evidence of inflammation. Instead, the study authors observed degenerative changes to the plantar fascia.

   Currently, many use the term plantar fasciosis to describe heel pain that is associated with pain from the plantar fascia. Plantar fasciitis, heel pain syndrome or plantar fasciosis are used interchangeably. The findings from Lemont and colleagues provide evidence to question the basis of using therapies aimed at reducing inflammation and the effectiveness of these treatments. There are more questions than ever as to the most effective conservative and surgical treatment modalities for targeting the degenerative changes to the plantar fascia.

   According to reports, up to 85 percent of patients treated conservatively for plantar fasciitis experience resolution of symptoms.4 For those remaining 15 percent, there is no clear consensus and limited or no supporting evidence of specific surgical treatment strategies for plantar fasciosis. Researchers agree that one should recommend surgical treatment to patients who do not improve with conservative treatment after six months.4,5

   There are numerous non-invasive and invasive surgical treatment options available to treat recalcitrant plantar fasciosis. These modalities include the in-step plantar fasciotomy, endoscopic plantar fasciotomy, extracorporeal shockwave therapy, cryotherapy and bipolar radiofrequency microtenotomy.

   Prior to deciding what surgical treatment of choice will be most effective for patients with recalcitrant heel pain, it is vital to have a correct diagnosis. Often, in the absence of a thorough workup, clinicians may lump patients with plantar heel pain into the diagnosis of plantar fasciosis. It is vital to rule out other causes of plantar heel pain such as neurogenic causes, arthropathy, infectious disease or an osseous mass.6 Matched case control studies concluded that decreased ankle joint dorsiflexion, high body mass index (>30/m2), pronated foot posture and increased work-related weightbearing are risk factors for developing plantar fasciosis.7,8 In treating patients conservatively and surgically, adjunctive treatment should aim at modifying risk factors.

How Bipolar Radiofrequency Works

When surgical intervention is necessary to treat recalcitrant plantar fasciosis, bipolar radiofrequency microtenotomy (Topaz MicroDebrider, ArthroCare Sports Medicine) can provide an alternative to the invasive procedures. Radiofrequency microtenotomy initially started in the orthopedic field for the treatment of tendinosis and has been successful in the treatment of tennis elbow and rotator cuff tendinosis.

   In theory, the bipolar radiofrequency microtenotomy technique stimulates angiogenesis to the avascular, fibrotic and degenerative fascia. This technique appears to be an optimal treatment approach for tendinosis/fasciosis as it reportedly stimulates and organizes the angiogenic healing response to attempt to reverse this condition. Research has shown this technique promotes angiogenesis in ischemic hearts in patients with congenital heart failure and accelerates wound healing to enhance cell proliferation.9 The bipolar radiofrequency system works by increasing fibroblastic growth factor, vascular endothelial growth factor and vascular cells.10 The possibility for treatment of a tendinosis/fasciosis by a radiofrequency based approach might therefore be valuable.

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