Current Concepts In The Algorithm For Plantar Fasciitis

Start Page: 48
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Author(s): 
Patrick DeHeer, DPM, FACFAS, and Kellie Higgins, DPM

   If there is minimal improvement after this, one may consider immobilization of the patient with a below knee walking boot and have him or her initiate physical therapy. If the patient is still having pain and is actively following treatment plans, more invasive treatment becomes necessary. Before proceeding with a more invasive intervention, one can use MRI to evaluate the plantar fascia and specifically look for tears and any inflammation or irritation of the nerves.

   It is important to assess for Baxter’s neuropathy.16 Baxter’s nerve is the first branch of the lateral plantar nerve and can become entrapped and compressed with altered foot biomechanics, such as plantar fasciitis. If this is the case, one will need to address this along with any further treatment of the plantar fasciitis to resolve the patient’s pain.

Pertinent Pointers On ESWT And Platelet Rich Plasma

Some more invasive treatment options include shockwave therapy or platelet rich plasma (PRP) injections.

   Extracorporeal shockwave therapy (ESWT) is a procedure that one can perform in the office, using focused shockwaves to incite microtrauma in the plantar fascia to initiate the body’s healing process. In a meta-analysis of shockwave therapy by Ogdem and co-workers, 113 patients received high-energy shockwaves and 79 received low energy shockwaves.11 After one treatment session, 24.8 percent of the high-energy treatment patients were pain-free in comparison to 11.4 percent of low-energy patients.

   Odgem and colleagues also looked at 322 patients with plantar fasciitis for six to 18 months.11 These patients received extracorporeal shockwave therapy. At three months post-treatment, 56 percent of patients had reduced pain. At one year, 94 percent of patients were pain-free.

   In another study from 2010, 50 patients with unilateral plantar fasciitis were randomly placed into a control group of 25 patients and a treatment group of 25 patients.17 The treatment group received radial extracorporeal shockwave therapy set at 2,000 impulses per second at 8 Hz delivered in two sessions, each one week apart. The placebo group of radial ESWT was at 0 impulses. Ninety-two percent of radial ESWT patients had over 60 percent improvement in pain and quality of life in comparison to just 4 percent of the placebo group at four weeks after the first treatment. One hundred percent of treatment patients had 60 percent improvement of pain and quality of life at 24 weeks. Shockwave therapy has been well documented as a minimally invasive, in office procedure that works well for plantar fasciitis.

   In a randomized, double-blinded study, researchers distributed small, wearable pulsed radiofrequency devices in patients with plantar fasciitis.18 Forty-two patients received an active device and 28 had a non-active device, which they wore nightly for seven straight nights. Over the seven days, researchers found the morning pain level was reduced 40 percent in the active pulsed radiofrequency device group in comparison to a 7.9 percent reduction in the control group. Evening pain levels decreased 30 percent in the active group and 19 percent in the placebo group.

   Another option is PRP injections. Platelet rich plasma is concentrated platelets that are taken from the plasma of centrifuged autologous blood and injected in a peppering pattern into the fascia. Once injected, platelets activate and secrete proteins (including growth factors) as well as produce bioactive factors, promoting the healing process.19

   In a study from June 2012, 60 patients received either PRP injections or a steroid (methylprednisolone) injection.20 With a six-month follow up, there was no significant difference in the two treatment groups. The study found that both the steroid injection and PRP effectively treated plantar fasciitis with PRP having fewer potential side effects.

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