An Evidence-Based Medicine Approach To Plantar Fasciitis

Allen Jacobs, DPM, FACFAS

   Recently, authors have advocated PRP and autologous growth factors for the treatment of plantar fasciitis. Kiter and colleagues demonstrated a superior outcome when injecting autologous growth factors with 2% prilocaine versus prilocaine injection alone or the use of methylprednisolone acetate alone.46 The authors did note that all three techniques resulted in reduction of pre-treatment pain. Multiple studies have shown the injection of PRP for the treatment of plantar fasciitis is effective.47-50 A comparison of methylprednisolone/local anesthesia injection versus PRP/local anesthesia injections demonstrated superior outcome with the use of PRP although both techniques resulted in substantial diminution in pain reduction with no difference in Roles and Maudsley scores.51 However, others have demonstrated superior clinical results with the use of corticosteroid injection versus autologous growth factor injection although researchers found that both were efficacious.52

   OnabotulinumtoxinA (Botox, Allergan) injections have been particularly effective for the treatment of plantar fasciitis.53 Multiple studies have reported significant improvement in the treatment of plantar fasciitis utilizing Botox injections with or without the addition of local anesthesia, or the addition of autologous growth factors.54-57 In a study comparing botulinum toxin A versus corticosteroids for the treatment of plantar fasciitis, both groups improved although there was a slightly better outcome with the use of botulinum toxin A.58

What The Research Says About Surgery For Plantar Fasciitis

One common surgical approach for the treatment of plantar fasciitis is microdebridement via the Topaz device (ArthroCare). A recent study demonstrated the initial superiority of open Topaz technique versus a percutaneous technique at one year.59 Multiple studies have suggested that the use of radiofrequency Coblation is associated with success rates equivalent to open plantar fasciotomy and a faster return to normal activity with reduced complications and reduced pain in comparison to plantar fasciotomy.60-64

   Several studies have documented successful outcomes with radiofrequency nerve ablation in the treatment of chronic plantar fascia pain.65,66 Similarly, cryosurgical nerve ablation is reportedly successful in the treatment of recalcitrant plantar heel pain.67

   Various authors have advocated pronation limiting surgery, including gastrocnemius recession, subtalar joint arthroereisis and calcaneal osteotomy, for the treatment of recalcitrant plantar fasciitis.68-71

Assessing The Outcomes With Plantar Fasciotomy

One may perform plantar fasciotomy through a variety of techniques including a percutaneous approach, an in-step plantar fasciotomy, a single or dual-port endoscopic plantar fasciotomy or the DuVries type of open plantar fasciotomy. Traditional open surgical techniques have long been associated with good outcomes and one study reported 71 percent good or excellent results.72

   The in-step plantar fasciotomy has resulted in complete relief in 2.6 percent of patients while 97.8 percent of patients related an 80 percent resolution of pain.73 Other studies have reported percutaneous plantar fasciotomy to have 83 percent good to excellent outcomes.74,75 Endoscopic plantar fasciotomy utilizing a single or dual-port technique is associated with supportive studies generally demonstrating good outcome for the treatment of plantar fasciitis.76-79

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