Developing A Comprehensive Plan To Treat Plantar Fasciitis

Bob Baravarian, DPM, FACFAS, and Lindsey Mae Chandler, DPM

Can PRP And ESWT Be Effective For More Chronic And Thickened Fascia?

If symptoms continue and patients do not report progress within three to six months, our next line of treatment includes platelet rich plasma (PRP) injection or extracorporeal shockwave therapy (ESWT) for the more chronic and thickened fascia. It is our belief that after a period of three to six months, the plantar fascia no longer has adequate blood supply for healing and is more of a plantar fasciosis case than a plantar fasciitis case. In such cases, increasing the blood supply to the damaged region may better resolve the chronic pain.

   Platelet-rich plasma is an autologous, biological, blood-derived product, which one can exogenously apply to a variety of tissues. The PRP releases high concentrations of platelet-derived growth factors that enhance wound, bone and tendon healing. Growth factors release when the platelets become activated, subsequently initiating the body’s natural healing response.4 Platelet-rich therapy is safe and the technique does not impair the biomechanical function of the foot. The patient may wear a short controlled ankle motion (CAM) boot walker for approximately two weeks after PRP injection to allow the body’s inflammatory response to heal the thickened, scarred fascia. Often, a second injection is required in severely thickened and damaged plantar fascias.

   An alternative to PRP is ESWT. Shockwave has a similar mechanism of action as PRP and can initiate an inflammatory response. Shockwave requires no period of immobilization, providing patients with an immediate return to work and resumption of full activities within two to three weeks. Weil and colleagues found electrohydraulic ESWT to be as effective for chronic plantar fasciitis as a percutaneous plantar fasciotomy.5 We will perform ESWT with a low-energy machine at 10-day intervals and have found three treatments to be optimal. We tell patients to limit activity and rest the treatment region after each procedure to allow the healing factors of the body to work optimally on the damaged fascia.

What You Should Know About Surgical Solutions

Surgical treatment, whether it be Topaz (Arthrocare) or an open release, is our last resort for patients with moderate to severe, persistent symptoms that have been resistant to at least six months of non-surgical therapy. We have found that less than 5 percent of our plantar fasciitis cases make it to the operating room. Surgical procedure alternatives for recalcitrant plantar fasciitis include: isolated partial or complete release of the plantar fascia or a fascial release in combination with a nerve decompression; calcaneal spur resection; or excision of abnormal tissue. Surgeons may perform these as either open or endoscopic procedures, both of which have advantages and disadvantages.

   The most common surgical procedures that we perform in our office include the Topaz and endoscopic plantar fasciotomy. Topaz Coblation is an alternative procedure to the endoscopic plantar fasciotomy that we find successful in our hands. It is a quick, straightforward and minimally invasive technique associated with patients’ speedy return to their daily activities.

   With this percutaneous procedure, one makes approximately 20 to 25 holes with a needle through the skin to the level of the plantar fascia in a grid pattern. Introduce the Topaz probe and release a Coblation energy force in each hole location, breaking up the scar tissue and increasing vascularity to the plantar fascia region. Topaz procedures have also been associated with increased strength in the plantar fascia insertion and decreased small nerve fiber pain in the region of the plantar fascia insertion. After using Topaz Coblation, we emphasize immobilization for one week with crutches and a CAM walker. The patient would subsequently have three to four weeks of passive and active range of motion exercises.

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