A Closer Look At Emerging Research On Plantar Fasciitis And Plantar Fibromatosis
- Allen Jacobs DPM FACFAS
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Here is a look at numerous recent studies on the diagnosis and various treatments of plantar fasciitis and plantar fibromatoses.
Knobloch and Vogt utilized high-energy focused extracorporeal shockwave therapy (ESWT) in six patients for the treatment of plantar fibromatosis.1 Three of the six patients had recurrent lesions following surgical excision. Physicians applied extracorporeal shockwave therapy utilizing a Storz Duolith SD1 device at 2,000 impulses, 3 Hz, 1.24 mJ/mm2 in two sessions separated by one week between applications. Following therapy, pain was dramatically reduced in the patients at 14 days with softening of the nodules reported in all patients.
Plantar fibromatosis is a commonly encountered pathologic condition. Surgical excision is associated with a high rate of recurrence, painful scarring, injury to branches of the medial plantar nerve, and patient dissatisfaction. The authors in the study suggest further investigation into the possible use of extracorporeal shockwave therapy in an effort to reduce symptoms and avoid the need for surgical intervention.1
In another shockwave study, Vahdatpour and colleagues evaluated ESWT for the treatment of plantar fasciitis utilizing ultrasonography and subjective evaluations.2 This was a randomized, placebo-controlled trial. Active therapy patients received 4,000 shockwaves/session at 0.2 mJ/mm2 in three sessions at weekly intervals. Control patients received sham therapy. Utilizing diagnostic ultrasound, authors found plantar fascia thickness was reduced in the active group but slightly increased in the sham group. Both groups showed significant pain improvement over the course of the study although the improvement was greater in the active therapy group than in the sham group.
New Insights On Diagnostic Testing For Plantar Fibromatosis
Kroeker and colleagues presented a case report in which a patient being evaluated for recurrent malignant melanoma demonstrated an area of increased focal uptake on the plantar surface of his right foot with fluorodeoxyglucose positron emission tomography.3 The authors thought the lesion was a metastatic lesion and performed a biopsy. The biopsy confirmed that the lesion was indeed plantar fibromatosis and not melanoma.
The authors called attention to the fact that plantar fibromatosis may demonstrate increased focal uptake with fluorodeoxyglucose positron emission tomography. Scheler and coworkers have also described increased focal uptake on positron admission tomography/computed tomography imaging with plantar fibromas.4
In a related study, Walker and colleagues reviewed the radiographic characteristics of superficial and deep fibromatosis in adult patients.5 They noted that the lesions of plantar fibromatosis typically blend with the adjacent plantar muscles with linear details of extension (“fascial tail sign”), and that the magnetic resonance imaging (MRI) characteristics of plantar fibromatosis are typical and reliable for diagnosis.
The clinical manifestations of plantar fibromatosis generally allow for an accurate diagnosis of the disorder without the need for biopsy. However, a small number of patients may present with soft tissue lesions including fibrosarcoma mimicking plantar fibromatosis. When these patients are going to receive non-operative management and a biopsy is not planned, MRI or diagnostic ultrasound would seem to be appropriate to confirm the diagnosis of fibromatosis. The MRI would allow the practitioner to proceed with treatment of fibromatosis without undue concern or alternate diagnoses. Particularly when such lesions are unilateral, it would appear to be prudent to confirm the diagnosis with musculoskeletal imaging when proceeding with non-operative management.
What A Physician Survey Showed About Approaches To Recalcitrant Plantar Fasciitis
DiGiovanni conducted a survey to determine the current preferred non-operative and operative treatment methods for the treatment of recalcitrant plantar fasciitis by foot and ankle orthopedic surgeons.6 Survey participants considered a hypothetical patient with recalcitrant plantar fasciitis. The authors reviewed the surgeons’ preferred treatment after four months of failed non-operative management and 10 months of failed non-operative management.
At the four month follow-up, 44 percent recommended plantar fascia stretching, 24 percent recommended supervised physical therapy, 20 percent recommended night splints, 6 percent recommended steroid injections, 4 percent recommended custom orthotics and 2 percent recommended cast or boot immobilization.6 At 10 weeks, 74 percent responded that they would proceed with surgery or extracorporeal shockwave therapy. The most popular surgical procedures selected were gastrocnemius recession with or without additional procedures and an open plantar fascia release with nerve decompression.
How Effective Is PRP For Plantar Fasciitis?
Aksahin and coworkers compared injection of 2 mL 40 mg methylprednisolone with 2 mL 2% prior lidocaine versus 3 mL of platelet rich plasma (PRP) following injection of 2 mL of 2% prilocaine.7 Patients received injections for the treatment of plantar fasciitis. The mean visual analogue scale (VAS) scores at six months after treatment were 3.4 in the steroid group and 3.93 in the PRP group. All patients demonstrated improvement from pre-treatment status. Doctors concluded that corticosteroids as well as PRP were effective for the treatment of plantar fasciitis. However, the authors considered that given the potential side effects from a corticosteroid injection, PRP represented a more viable alternative treatment.
In another study, Ragab and Othman studied the effectiveness of platelet rich plasma in 25 patients with chronic plantar fasciitis.8 They used the VAS scale and ultrasound to evaluate the patients’ response to treatment. The average follow-up was 10.3 months. The authors noted pain reduction from an average of 9.1 to 1.6 on the VAS with 80 percent of patients "completely satisfied.” Sixty percent of patients had no functional limitation post-injection and 32 percent of patients had minimal functional limitations. Ultrasound revealed decreased thickness and changes in signal intensity following PRP injection. The authors concluded that the injection of PRP for plantar fasciitis is safe and effective.
What You Should Know About Steroid Injections
Ball and colleagues evaluated 65 patients with inferior heel pain.9 Patients were randomized to ultrasound-guided steroid injection, palpation-guided steroid injection or ultrasound-guided placebo injection. There was a significant difference in pain at six and 12 weeks between the placebo- and steroid-injected groups. However, there was no difference in VAS score following steroid injection between the ultrasound-guided and palpation-guided injection groups. Utilizing ultrasound, the authors determined that plantar fascia thickness was significantly reduced in both groups receiving injection therapy.
Ball and coworkers concluded that steroid injection demonstrates a clear benefit over placebo in the treatment of plantar fasciitis with a duration of up to 12 weeks and that there was no difference between ultrasound- and palpation-guided injection.9
When Is Isolated Gastrocnemius Recession Indicated?
Barske and colleagues reviewed indications for an isolated gastrocnemius recession for the treatment of gastrocnemius contracture associated with a variety of foot and ankle disorders.10 The authors noted encouraging results with the use of isolated gastrocnemius recession for the treatment of plantar fasciitis as well as Achilles tendinopathy, metatarsalgia and forefoot ulceration. They also noted the increasingly recognized prevalence of isolated contracture of the gastrocnemius muscle in a variety of foot disorders.
What A Study Reveals About Plantar Fasciitis Symptom Duration
A study looked at the relationship of symptom duration of plantar fasciitis and demographic factors, intensity and location of pain, prior treatment, and self-reported pain and function.11 Klein and colleagues reviewed the charts of 182 patients who had a primary diagnosis of plantar fasciitis. Authors considered patients with symptoms for less than six months as acute and patients with symptoms for greater than six months as chronic. The two groups were similar in age, body mass index, gender and comorbid conditions. The pain was not significantly different between the two groups with reported equal levels of function on a daily basis including participation in sports. Patients in the chronic group were more likely to have seen more healthcare providers and had more attempted treatment.
The authors concluded that plantar fasciitis extending beyond six months did not result in increased pain or functional limitation.11 They noted no specific risks factors that identified those patients more likely to be affected by chronic pain.
When Conservative Management Of Plantar Fasciitis Fails
A prospective, nonrandomized trial focused on 48 patients with failed conservative management of plantar fasciitis.12 Treatment included a Topaz microdebridement (Arthrocare) by either open or closed (percutaneous) technique. Researchers evaluated the patients at three, six and 12 months post-op. Tay and colleagues noted VAS scores were improved in both groups at one year although those who had the open technique demonstrated a more significantly improved VAS at one year. Additionally, significant improvement in AOFAS scoring as well as SF-36 scores were present in both groups at one year with no significant difference between the percutaneous and the open groups.
What About Orthoses For Plantar Fasciitis?
Fong and coworkers compared the use of rocker sole shoes and custom-made orthotics prescribed jointly or separately for the treatment of plantar fasciitis.13 All patients in the study suffered from unilateral plantar fasciitis. The study’s outcome measures were intermediate heel pain intensity level reduction as measured by VAS pain ratings and measurement of plantar pressure redistribution. The authors compared the use of walking with no shoes, non-rocker-bottom shoes and rocker-bottom shoes with orthotics.
The study demonstrated that the combination of a rocker shoe and custom foot orthotic significantly lowered VAS in comparison to either rocker shoes alone or the use of an orthotic alone.13
1. Knobloch K, Vogt PM. High energy focused extracorporeal shockwave therapy reduces pain in plantar fibromatosis. BMC Res Notes. 2012; 5:542.
2. Vahdatpour B, Sajadieh S, Bateni V, et al. Extracorporeal shock wave therapy in patients with plantar fasciitis; a randomized, placebo controlled trial with ultrasonographic and subjective outcome assessments. J Res Med Sci. 2012; 17 (9):834-838.
3. Kroeker TR, Fisher SB, Lisle A, Dale PS. Plantar fibromatosis masquerading as metastatic melanoma. J Am Podiatr Med Assoc. 2009; 99(4):364-6.
4. Scheler J, Rehani B, Percy T, et al. Increased F-18 FDG uptake on positron emission tomography/computed tomography imaging caused by plantar fibromatosis. Clin Nucl Med. 2008; 33(4):280-1.
5. Walker EA, Petscavage JM, Brian PL, et al. Imaging features of superficial and deep fibromatosis in the adult population. Sarcoma. 2012; Epub ahead of print.
6. DiGiovanni BF, Moore AM, Zlotnicki JP, Pinney SJ. Preferred management of recalcitrant plantar fasciitis among orthopedic foot and ankle surgeons. Foot Ankle Int. 2012; 33(6):507-12.
7. Aksahin E, Dogruyol D, Yuksel HY, et al. The comparison of the effect of corticosteroids and platelet rich plasma the treatment of plantar fasciitis. Arch Orthop Trauma Surg. 2012; 132(6):781-5.
8. Ragab EM, Othman AM. Platelet rich plasma for treatment of chronic plantar fasciitis. Arch Orthop Trauma Surg. 2012; 132(8):1065-70.
9. Ball EM, McKeeman HM, Patterson C, et al. Steroid injection for inferior heel pain; a randomized controlled study. Ann Rheum Dis. 2013; 72(6):996-1002.
10. Barske HL, DiGiovanni BF, Douglass M, Nawoczenski DA. Current concepts review: Isolated gastrocnemius contracture and gastrocnemius recession. Foot Ankle Int. 2012; 33(10):915-21.
11. Klein SE, Dale AM, Hayes MH, et al. The presentation and self-reported patterns of pain and function in patients with plantar heel pain. Foot Ankle Int. 2012; 33(9):693-8.
12. Tay KS, Ng YC, Singh IR, Chong KW. Open technique is more effective than percutaneous technique for TOPAZ radiofrequency ablation for plantar fasciitis. Foot Ankle Surg. 2012; 18(4):287-92.
13. Fong D, Pang KY, Chung MM, et al. Evaluation of combined prescription of rocker sole shoes and custom-made foot orthoses for the treatment of plantar fasciitis. Clin Biomech (Bristol, Avon). 2012; 27(10):1072-7.