Developing A Comprehensive Plan To Treat Plantar Fasciitis

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Author(s): 
Bob Baravarian, DPM, FACFAS, and Lindsey Mae Chandler, DPM

   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.

   We perform endoscopic plantar fasciotomy via a single minimally invasive incision on the medial aspect of the heel. We then introduce a camera that has a blade mounted on the end and release the medial and central bands of the plantar fascia in their entirety. Patients are non-weightbearing for one week on crutches followed by weightbearing as tolerated in a CAM walker boot for an additional week before progressing to regular shoe gear.

   Possible complications that can occur with open or endoscopic procedures include but are not limited to: persistent or recurrent pain; arch collapse; injury to the posterior tibial nerve; and complex regional pain syndrome. The perceived advantages of endoscopic techniques are a more rapid recovery and quicker return to activity following surgery.

In Conclusion

Our practice has been following an algorithm for the treatment of plantar fasciitis with relatively great results and patient satisfaction. We have seen an almost complete resolution of pain and symptoms without the need for surgery in over 95 percent of our patients.

   The main advance has been to differentiate the treatments for plantar fasciitis and plantar fasciosis. After making a diagnosis of plantar fasciitis, our patients start physical therapy and receive instructions to perform daily home stretching exercises. We emphasize supplementing therapy with supportive shoe gear and arch supports. If these modalities fail to relieve the symptoms, we attempt cortisone injections.

   If pain continues, a change of course to plantar fasciosis treatment starts and we initiate PRP or ESWT depending on the level of scar tissue and the length of time the symptoms have been present. Surgical intervention, whether it be Topaz Coblation or endoscopic plantar fasciotomy, is always the last step and we have found that it seldom comes to this after following the algorithm we have presented.

   Dr. Chandler is a fellow at the University Foot and Ankle Institute in Los Angeles.

   Dr. Baravarian is an Assistant Clinical Professor at the UCLA School of Medicine. He is the Chief of Podiatric Foot and Ankle Surgery at the Santa Monica UCLA Medical Center and Orthopedic Hospital, and is the Director of the University Foot and Ankle Institute in Los Angeles.

References
1. Ogden J, Alvarez R, Marlow M. Shockwave therapy for chronic proximal plantar fasciitis: a meta-analysis. Foot Ankle Int. 2002; 23(4):301-308.
2. Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. J Foot Ankle Surg. 2010; 49(3Suppl):S1-S19.
3. Barry L, Barry A, Chen Y. A retrospective study of standing gastrocnemius-soleus stretching versus night splinting in the treatment of plantar fasciitis. J Foot Ankle Surg. 2002; 41(4):221-227.
4. Peerbooms JC, van Laar W, Faber F, et al. Use of platelet rich plasma to treat plantar fasciitis: design of a multi center randomized controlled trial. BMC Musculoskelet Dis. 2010; 11:69.
5. Weil L, Roukis T, Weil L, Borrelli A. Extracorporeal shock wave therapy for the treatment of chronic plantar fasciitis: indications, protocol, intermediate results, and a comparison of results to fasciotomy. J Foot Ankle Surg. 2002; 41(3):166-172.

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