Focusing on a 32-year-old woman with chronic plantar fasciitis, these authors explore the novel technique of perforating fat injections into the plantar fascia for heel pain.
Plantar fasciitis is the most common cause of heel pain, accounting for 11 to 15 percent of medical foot inquires.1-4 Some etiologies of chronic plantar fasciitis or plantar fasciosis include overuse, abnormal gait, foot biomechanics that encourage excessive traction of the plantar fascia, and are likely multifactorial.5,6
There are a variety of current treatment options, including weight loss, anti-inflammatory medications, ice, orthotic management, stretching, ultrasound, steroid injections and other therapies.7,8 More recently, lasers, extracorporeal shockwave therapy, platelet rich plasma and dry needling have emerged. Chronic plantar fasciitis, which affects 10 percent of patients with plantar fasciitis, may result in significant pain that can progress to emotional and physical pain, leading to decreased productivity.9-12
Physicians have treated refractory cases of plantar fasciitis with surgical procedures including open fasciotomy and endoscopic plantar fasciotomy.13-32 However, recently there has been a plea for doctors to stop cutting the plantar fascia.33 Cutting the plantar fascia has the potential to destabilize the foot and increase scar tissue, encouraging other compensatory problems.
The etiology of recalcitrant plantar fasciitis, also called plantar fasciosis, is recurring traction of the plantar fascia on its insertion on the medial calcaneal tubercle. Repetitive inflammation and trauma to the plantar fascia leads to chronic thickening and degeneration of the plantar fascia. Ultimately, plantar fasciosis is no longer an inflammatory process.9 The plantar fascia on histological evaluation reveals thickening, myxoid degeneration, tears and fibrotic changes of the fascia.
After exhausting conservative treatment for chronic plantar fasciitis, one may attempt surgical interventions although satisfaction with surgery ranges between 50 and 90 percent.34 Current treatment modalities have a significant risk of complications. Steroid injections can lead to fascia rupture and heel fat pad atrophy. Surgical release of the fascia can potentially lead to nerve damage and numbness, wound infection, deep venous thrombosis with immobilization, calcaneal cuboid syndrome, lateral foot stress reaction, scar formation, recurrent plantar fasciitis, and require a prolonged recovery.
At our institution at the University of Pittsburgh Plastic Surgery Department, we are in the process of performing a prospective randomized crossover study to determine whether perforating fat injections into the substance of the thickened plantar fascia medial band are a safe method to improve pain, improve quality of life, reduce plantar fascia thickness and ultimately regenerate the traumatized fascial tissue.
A 32-year-old woman presented to our clinic with a complaint of chronic left foot plantar fasciitis of three years in duration. She had received cortisone injections, physical therapy, night splints, over-the-counter inserts and custom orthotic management with a failure to relieve her symptoms. She has a significant past medical history of ductal carcinoma in situ, hypercholesterolemia and hypertension. The patient had a double mastectomy with breast reconstruction in 2012 and has been in remission. At her initial screening visit in December 2016, she was 5”3 inches, 183 pounds and had a body mass index (BMI) of 32.4.
During the physical examination, the patient had palpable pedal pulses. She had no evidence of any neurologic deficiencies. There was no evidence of tarsal tunnel or nerve compression. The patient presented with a rigid cavus foot with no dermatological manifestations. She had no bone malalignment and no evidence of an inferior calcaneal spur on radiographic examination. The patient had considerable pain on palpation at the insertion of the plantar fascia medial band on the calcaneus. She had no pain on direct plantar central palpation of the calcaneus or on compression of the calcaneal bone. Ultrasound measurement of the plantar fascia of her left foot revealed a thickness of 0.46 cm and the right foot of 0.30 cm. A thickness of greater than 0.4 cm is indicative of plantar fasciosis. We took ultrasound measurements at the insertion of the medial band on the calcaneus.
On gait evaluation the patient was antalgic and supinated. She reported pain when first rising on her feet in the morning and when first standing from a seated position. She had pain at the end of the day and after activity.
She randomized into our standard of care group. We gave her a night splint to use diligently and asked her to document her progress. She used the night splint in addition to her current treatment modalities (i.e. custom orthotics). She returned for a follow-up visit at two months and reported increased pain with the night splint use. Due to the exacerbation of her plantar fasciosis, we changed her conservative management to a removable strap in conjunction with her other treatment modalities until her six-month standard of care visit. At the six-month standard of care visit, she continued to have significant pain at the plantar fascia band’s insertion and she continued to be study eligible. The patient therefore crossed over to the interventional fat graft procedure.
On June 7, 2017, the patient had perforating autologous fat grafting to her left medial plantar fascial band just distal to its insertion on the calcaneus at the UPMC Aesthetic Plastic Surgery Center. She received 10 mg of diazepam (Valium) 30 minutes prior to the procedure. We harvested fat from bilateral flanks via tumescent liposuction and processed it with centrifugation. The patient received an anesthetic consisting of a 50:50 lidocaine and Marcaine mixture via a tibial nerve block and locally around the medial aspect of the heel. After betadine prep and draping of the left heel, we performed plantar fascia perforating fat injections, using one site just distal to the insertion of the medial band. We injected 3 cc of fat through approximately 20 perforations and the medial band resistance notably eased.
At the patient’s one-month post-op visit, she reported her heel pain had returned to baseline, her pre-standard of care level of pain. She had experienced some cramping pain in her foot immediately after the procedure, which had completely dissipated by the one-month post-op visit. The patient reported some mild fifth ray discomfort as she confessed to increased walking on the lateral foot after the procedure. Upon examination, she only complained of some pinpoint discomfort on palpation of the injection site. She reported minimal use of ibuprofen for post-op pain.
We instructed the patient to walk slower with a heel to toe gait and continue to limit her exercise activity to swimming, and upper body and core activities that did not encourage weightbearing. We re-emphasized the importance of postoperative stretching of the Achilles tendon and use of the night splint for at least one hour a day.
On August 1, the patient presented for her two-month postoperative visit. At this visit, she reported “some good days and some bad days.” On the physical examination, she continued to have some discomfort on palpation of the plantar medial heel but stated it was improving. She no longer had fifth ray discomfort. The patient was using the night splint about an hour a night and we now permitted her to increase activity to tolerance.
The patient presented on December 5 for her final visit, six months postoperative. She reported significant improvement and the ability to walk long distances without consequence. The patient had no pain on physical examination and reported no pain with activity. Six weeks prior to this visit, she sprained her right ankle, the contralateral limb to the procedure. She was pleased to note that even with increased weightbearing on the left foot while healing the sprained right ankle, she had no exacerbation of her plantar fasciosis symptoms. On the ultrasound evaluation, her left plantar fascia at its insertion measured 0.34 cm (normal).
Chronic plantar fasciitis can be quite debilitating and very disruptive to the quality of one’s life. Limitations may range from getting out of bed in the morning to using the bathroom to grocery shopping to exercise. A vicious cycle of activity limitation and weight gain with increased risk of mental and physical health sequelae is a common story our plantar fasciosis patients relate to us.
Our autologous fat perforating procedure is showing promise as a novel treatment option to treat chronic plantar fasciitis. It is noninvasive, the risk of destabilizing the foot is limited, scar tissue development is nonexistent and the potential to ultimately remodel the fascia and eliminate pain is encouraging. Our preliminary pilot study is demonstrating safety and efficacy in a small sample of patients and we look forward to publishing our results to our one-year randomized clinical crossover trial in the near future.
Beth Freeling Gusenoff, DPM is a board-certified podiatric surgeon and a Clinical Assistant Professor of Plastic Surgery in the Department of Plastic Surgery at the University of Pittsburgh.
Jeffrey Gusenoff, MD is an Associate Professor of Plastic Surgery in the Department of Plastic Surgery at the University of Pittsburgh.
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