Pltr Fasc Refractory pt - AOSSM · 2020. 9. 14. · Allen BH, Fallat LM, Schwartz SM. Cryosurgery:...
Transcript of Pltr Fasc Refractory pt - AOSSM · 2020. 9. 14. · Allen BH, Fallat LM, Schwartz SM. Cryosurgery:...
-
Plantar Fasciitis: What to Do With Refractory Patients
Craig Young, MD
Medical College of Wisconsin
-
Goals
! Basic science background - brief
! Diagnosis - really brief
! Treatment ! Brief summary of treatment options ! Discuss my approach to patients
-
Etiology
! Acute (rare) - may occur from trauma
! Chronic ! Repetitive overloading of the plantar
fascia (Kogler 95,96,99) ! Tendonopathic & chronic enthesitic
changes ! Collagen degeneration ! Fiber disorientation ! Increased ground substance ! Absence of inflammatory cells
(Maffulli 03 & Yuan 03)
-
Key findings on history & exam
! Worse pain with 1st AM steps ! Pain after prolonged non-weight bearing
! Pain with barefoot walking
! No symptoms & signs of neurologic involvement
! Pain & tenderness over plantar fascia origin
! Windlass test
! Sensitivity 13.6%; Specificity 100%
! Weight-bearing windlass ! Sensitivity 31.8%; Specificity 100%
(DeGarceau 2003 Foot & Ankle Intl)
-
Treatment options
“Traditional” ! Stretching & strengthening
! Modalities
! NSAIDs
! Cortisone
! Night splints & walking boots
! Foot wear, orthotics, heel cups & arch supports
! Surgery
“Newer”
! Deep tissue techniques
! Extracorporeal & intracorporeal shock wave
! Prolotherapy, PRP, botox autologous blood injection
! Nitroglycerin patches
! Nerve ablasion ‒ cryo & RF
-
My approach
! Relative rest ! Stretching
! Consider night splint ! Physical therapy
! Strengthening?
! Arch support ! Check shoes ! Arch taping ! OTC ! Orthotic
! Patience
! Adjunctive ! Acetaminophen ! NSAIDs
-
My approach, continued
! More patience
! For chronic or those who like intervention ! Injection
! Autologous blood vs. vs. PRP vs. cortisone ! ECSW ! Surgery
-
Panel comments
-
Any questions?
-
http://pier.acponline.org/physicians/diseases/d065/d065.html
-
References
! Allen BH, Fallat LM, Schwartz SM. Cryosurgery: an innovative technique for the treatment of plantar fasciitis. J Foot Ankle Surg. 2007;46:75-9. (PMID:17331865)
! Babcock MS, Foster L, Pasquina P, Jabbari B. Treatment of pain attributed to plantar fasciitis with botulinum toxin a: a short-term, randomized, placebo-controlled, double-blind study. Am J Phys Med Rehabil. 2005;84:649-54. (PMID:16141740)
! Chuckpaiwong B, Berkson EM, Theodore GH. Extracorporeal shock wave for chronic proximal plantar fasciitis: 225 patients with results and outcome predictors. J Foot Ankle Surg. 2009;48:148-55. (PMID:19232966)
! De Garceau D, Dean D, Requejo SM, Thordarson DB. The association between diagnosis of plantar fasciitis and Windlass test results. Foot Ankle Int. 2003;24:251-5. (PMID:12793489)
-
! Dogramaci Y. Kalaci A. Emir A. Yanat AN. Gokce A. Intracorporeal pneumatic shock application for the treatment of chronic plantar fasciitis: a randomized, double blind prospective clinical trial. Arch Orthop Trauma Surg 2010. 130(4):541-6. UI: 19669773
! Donley BG, Moore T, Sferra J, Gozdanovic J, Smith R. The efficacy of oral nonsteroidal anti-inflammatory medication (NSAID) in the treatment of plantar fasciitis: a randomized, prospective, placebo-controlled study. Foot Ankle Int. 2007;28:20-3. (PMID:17257533)
! Fadale PD, Wiggins ME. Corticosteroid Injections: Their Use and Abuse. J Am Acad Orthop Surg. 1994;2:133-140. (PMID:10709001)
! Frater C, Vu D, Van der Wall H, Perera C, Halasz P, Emmett L, Fogelman I. Bone scintigraphy predicts outcome of steroid injection for plantar fasciitis. J Nucl Med. 2006;47:1577-80. (PMID:17015890)
-
! Gerdesmeyer L, Frey C, Vester J, Maier M, Weil L Jr, Weil L Sr, et al. Radial extracorporeal shock wave therapy is safe and effective in the treatment of chronic recalcitrant plantar fasciitis: results of a confirmatory randomized placebo-controlled multicenter study. Am J Sports Med. 2008;36:2100-9. (PMID:18832341)
! Gray RG. Gottlieb NL. Intra-articular corticosteroids. An updated assessment. Clin Orthop Rel Res. 1983. (177):235-63.UI: 6345042
! Haake M, Buch M, Schoellner C, Goebel F, Vogel M, Mueller I, et al. Extracorporeal shock wave therapy for plantar fasciitis: randomised controlled multicentre trial. BMJ. 2003;327:75. (PMID:12855524)
! Hammer DS, Adam F, Kreutz A, Kohn D, Seil R. Extracorporeal shock wave therapy (ESWT) in patients with chronic proximal plantar fasciitis: a 2-year follow-up. Foot Ankle Int. 2003;24:823-8. (PMID:14655885)
-
! Huang YC, Wei SH, Wang HK, Lieu FK. Ultrasonographic guided botulinum toxin type A treatment for plantar fasciitis: an outcome-based investigation for treating pain and gait changes. J Rehabil Med. 2010;42:136-40. (PMID:20140409)
! Höfling I, Joukainen A, Venesmaa P, Kröger H. Preliminary experience of a single session of low-energy extracorporeal shock wave treatment for chronic plantar fasciitis. Foot Ankle Int. 2008;29:150-4. (PMID:18315969)
! Hogan KA, Webb D, Shereff M. Endoscopic plantar fascia release. Foot Ankle Int. 2004;25:875-81. (PMID:15680100)
! Ibrahim MI, Donatelli RA, Schmitz C, Hellman MA, Buxbaum F. Chronic plantar fasciitis treated with two sessions of radial extracorporeal shock wave therapy. Foot Ankle Int. 2010;31:391-7. (PMID:20460065)
! Kiter E, Celikbas E, Akkaya S, Demirkan F, Kiliç BA. Comparison of injection modalities in the treatment of plantar heel pain: a randomized controlled trial. J Am Podiatr Med Assoc. 2006;96:293-6. (PMID:16868321)
-
! Kudo P, Dainty K, Clarfield M, Coughlin L, Lavoie P, Lebrun C. Randomized, placebo-controlled, double-blind clinical trial evaluating the treatment of plantar fasciitis with an extracoporeal shockwave therapy (ESWT) device: a North American confirmatory study. J Orthop Res. 2006;24:115-23. (PMID:16435344)
! Kogler GF, Solomonidis SE, Paul JP. In vitro method for quantifying the effectiveness of the longitudinal arch support mechanism of a foot orthosis. Clin Biomech (Bristol, Avon). 1995;10:245-252. (PMID:11415561)
! Kogler GF, Veer FB, Solomonidis SE, Paul JP. The influence of medial and lateral placement of orthotic wedges on loading of the plantar aponeurosis. J Bone Joint Surg Am. 1999;81:1403-13. (PMID:10535590)
! Kogler GF, Solomonidis SE, Paul JP. Biomechanics of longitudinal arch support mechanisms in foot orthoses and their effect on plantar aponeurosis strain. Clin Biomech. 1996;11:243-252. (PMID:11415628)
-
! Liden B, Simmons M, Landsman AS. A retrospective analysis of 22 patients treated with percutaneous radiofrequency nerve ablation for prolonged moderate to severe heel pain associated with plantar fasciitis. J Foot Ankle Surg. 2009;48:642-7. (PMID:19857819)
! Maffulli N, Wong J, Almekinders LC. Types and epidemiology of tendinopathy. Clin Sports Med. 2003;22:675-92. (PMID:14560540)
! Malay DS, Pressman MM, Assili A, Kline JT, York S, Buren B, et al. Extracorporeal shockwave therapy versus placebo for the treatment of chronic proximal plantar fasciitis: results of a randomized, placebo-controlled, double-blinded, multicenter intervention trial. J Foot Ankle Surg. 2006;45:196-210. (PMID:16818146)
! Martin RP. Autologous Blood Injection for Plantar Fasciitis: A Retrospective Study [abstract]. Clin J Sport Med. 2005; 15:387-8.
-
! McCallum SD. Paoloni JA. Murrell GA. Five-year prospective comparison study of topical glyceryl trinitrate treatment of chronic lateral epicondylosis at the elbow. Br J Sports Med 2011. 45(5):416-20. UI: 19553221
! Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int. 2004;25:303-10. (PMID:15134610)
! Ogden JA, Alvarez RG, Levitt RL, Johnson JE, Marlow ME. Electrohydraulic high-energy shock-wave treatment for chronic plantar fasciitis. J Bone Joint Surg Am. 2004;86-A:2216-28. (PMID:15466731)
! Paoloni JA. Murrell GA.Three-year followup study of topical glyceryl trinitrate treatment of chronic noninsertional Achilles tendinopathy. Foot & Ankle International 2007. 28(10):1064-8, UI: 17923056
-
! Roos E, Engstrom M, Soderberg B. Foot orthoses for the treatment of plantar fasciitis. Foot Ankle Int. 2006;27:606-11. (PMID:16919213)
! Rompe JD, Decking J, Schoellner C, Nafe B. Shock wave application for chronic plantar fasciitis in running athletes. A prospective, randomized, placebo-controlled trial. Am J Sports Med. 2003;31:268-75. (PMID:12642264)
! Rompe JD, Furia J, Weil L, Maffulli N. Shock wave therapy for chronic plantar fasciopathy. Br Med Bull. 2007;81-82:183-208. (PMID:17456546)
! Ryan MB. Wong AD. Gillies JH. Wong J. Taunton JE. Sonographically guided intratendinous injections of hyperosmolar dextrose/lidocaine: a pilot study for the treatment of chronic plantar fasciitis. Br J Sports Med 2009. 43(4):303-6. UI: 19019908
! Saxena A. Uniportal endoscopic plantar fasciotomy: a prospective study on athletic patients. Foot Ankle Int. 2004;25:882-9. (PMID:15680101)
-
! Sharma NK. Loudon JK. Static progressive stretch brace as a treatment of pain and functional limitations associated with plantar fasciitis: a pilot study. Foot & Ankle Specialist. 2010. 3(3):117-24. UI: 20508011
! Speed CA, Nichols D, Wies J, Humphreys H, Richards C, Burnet S, et al. Extracorporeal shock wave therapy for plantar fasciitis. A double blind randomised controlled trial. J Orthop Res. 2003;21:937-40. (PMID:12919884)
! Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med. 2002;36:95-101. (PMID:11916889)
! Theodore GH, Buch M, Amendola A, Bachmann C, Fleming LL, Zingas C. Extracorporeal shock wave therapy for the treatment of plantar fasciitis. Foot Ankle Int. 2004;25:290-7. (PMID:15134608)
-
! Tornese D, Mattei E, Lucchesi G, Bandi M, Ricci G, Melegati G. Comparison of two extracorporeal shock wave therapy techniques for the treatment of painful subcalcaneal spur. A randomized controlled study. Clin Rehabil. 2008;22:780-7. (PMID:18728131)
! Tong KB. Furia J. Economic burden of plantar fasciitis treatment in the United States. Am J Orthop 2010. 39(5):227-31.
! Tweed JL. Barnes MR. Allen MJ. An evaluation of the long-term effects of total plantar fasciotomy--a preliminary study. Foot 2009. 19(2):75-9. UI: 20307454
! Wang CJ, Wang FS, Yang KD, Weng LH, Ko JY. Long-term results of extracorporeal shockwave treatment for plantar fasciitis. Am J Sports Med. 2006;34:592-6. (PMID:16556754)
-
! Young CC, Rutherford DS, Niedfeldt MW. Treatment of Plantar Fasciitis. Am Fam Physician 63(3): 467-474, 2001.
! Young CC. Plantar fasciitis. American College of Physicians Physicians' Information and Education Resource (PIER) Project [serial online: http://pier.acponline.org/physicians/diseases/d065/d065-pdf.html]. 2007 Jan
! Young CC. Plantar fasciitis. eMedicine Journal [serial online: http://emedicine/sports]. Rev Jan 2012
! Young CC. In the clinic: Plantar fasciitis. Ann Int Med. 2012. 156(1):ITC1-1-16.
! Yuan J, Wang MX, Murrell GA. Cell death and tendinopathy. Clin Sports Med. 2003;22:693-701. (PMID:14560541)
-
Epidemiology
! 2 million person/yr in US
! 1 million patient visits/yr
! 3rd most common injury in runners
! Cost of treatment to third-party payers ranged from $192-376 million in 2007 in USA
(Riddle 2004, Tauton 2002, Tong 2010)
-
Radiologic studies
! Plain x-rays - only useful to r/o other conditions ! Heel spurs 2x more
likely in pt with PF
! MRI or Dx UTZ ! Both show
increases in fascia thickness in PF of 1.5 -1.9 mm
-
Differential diagnosis
! Plantar fascia rupture
! Calcaneal fracture
! Calcaneal apophysitis
! Heel fat pad syndrome
! Longitudinal arch strain
! Nerve entrapment
! Tumor
-
Modalities ! Studies including ultrasound, laser,
magnetic fields
! Overall - no significant improvement
! When to use ! Resistant cases ! Speed is of essence
-
NSAIDs
! A randomized, PC study of 29 patients ! 17 on placebo and 12 on NSAIDs
! Both groups improved at the 1, 2 & 6 month follow-up ! Trend toward improved pain control & disability in the
NSAID group
! Significant improvements overall in both groups.
(Donley 2007 Foot Ankl Intl)
-
Corticosteroid injection
! Short term benefits
! Risks/side effects ! Pain
! Post-injection flare (2-5%) ! Infection
! 0.072% with aseptic technique ! 0.0001% with sterile technique
! Bleeding ! HPA suppression Gray 1983
-
AAOS orthopaedic surgeons survey re: cortisone
! 90% use cortisone ! 73% injected plantar fascia in past yr
! 89% observed complication ! Subcutaneous fat atrophy (64%) ! Skin atrophy & pigment changes
(54%) ! Tendon rupture (39%) ! Cartilage damage (20%) ! Infection (18%)
Fadale & Wiggins 1994 J Am Acad Ortho Surg
-
Is a 3-phase bone scan a cortisone success prognosticator?
! 14/20 feet responding to injection had focal hyperemia on the blood-pool images
! None with diffuse uptake on the blood-pool images responded.
(Frater 2006 J Nuclear Med)
-
Injecting cortisone
! Dose ~ 40 mg of methylprednisolone
~ 1 cc of most corticosteroid preparations
+ 2 cc anesthetic
25 gauge 1.5” needles
-
Plantar fascia injection technique #1
! Advantage ! Easy to hit target
! Disadvantages ! Increased risk of heel fat pad
atrophy
! Increased risk of plantar fascia rupture?
-
Plantar fascia injection technique #2
! Advantages ! Decreased risk of heel
fat pad rupture ! Decreased risk of plantar
fascia rupture?
! Disadvantages ! Greater chance of
missing target ! Less effective?
! Ultrasound guidance?
-
Night splints
! Multiple trials including crossover and RCT show significant improvement ! 4 positive; 1 no effect
-
Walking boot? ! Pilot study 16 subjects in randomized single
blinded study
! Stretching vs. “SAS brace”
! No difference
! Sharma NK. 2010
-
Arch support
! Both taping & orthotics show increases in function &/or decreases VAS in most studies ! 5 positive; 1 no effect
-
Orthotics vs. night splints
! RCT of 43 patients to foot orthosis, foot orthosis and night splint, or night splint alone.
! All patients had significant improvement on their Foot and Ankle Outcome Scores at 12 week and 1 year follow-up visits.
! The foot orthosis had significantly ! better pain reduction ! better compliance ! fewer side effects.
(Roos 2006 Foot Ankle Intl)
-
Treatment
! Do nothing ! Most/many patients in control group of RCT eventually heal
! Key is proper framing
! Rest, ice, stretching, cross-friction massage
-
Shoe exam
! Beware of midshoe breakdown
! If shoe bends easily midsole instead of at MTP joint ! Cause overstretch of the plantar fascia with each footstep
-
Surgical
! Risks ! Infection, bleeding, pain ! Scarring, nerve damage ! Loss of arch
-
Surgical release
! Retrospective review of 22 consecutive patients with chronic plantar fasciitis & endoscopic plantar fascia release after at least 6 months postoperatively ! Satisfaction rate of 97.7% ! All patients reporting at least a 50% improvement in
pain. ! Modified Mayo Foot and Ankle Score, 15 of 22 (68%)
had good or excellent results
(Hogan 2004 Foot & Ankle Intl).
-
Surgical release
! 32 patients endoscopic plantar fasciotomy. ! 16 athletic patients all had results were excellent or
good. ! Good or excellent results in the non-athletic group were
obtained only in patients who walked for exercise ! All five patients with poor results having a BMI of more
than 27
(Saxena 2004 Foot & Ankl Intl)
-
Long term effects
! Change in center of pressure in gait analysis compared to non-operated foot (Tweed JL 2009)
-
“Newer” treatments
-
Deep tissue techniques
! A.R.T., ASTYM & Graston
! Theory ! Mechanical breakdown of scar tissue ! Stimulate healing cascade
-
Extracorporeal shock wave therapy (ECSW)
! High energy shock waves generated ! Mechanical pressure & tension
force plus trailing cavitation bubbles which collapse into “micro-jets” ! Both induce microtrauma
! Induces blood vessel formation ! Increased delivery of nutrients ! Increased dissolution of calcific
deposits
-
ECSW
! Low-energy shock wave ! Series of three or more treatments. ! Minimal to mildly painful
! High-energy shock wave ! Single session. ! Quite painful - require anesthesia
(regional block or general)
! Theory is to induce neovascularization & healing via creating localized inflammatory process
-
ECSW study results
Favorable Neutral Rompe 2003 Speed 2003 Ogden 2004 Haake 2003 Kudo 2006 Hammer 2003 Wang 2006 Theodore 2004 Malay 2006 Greve 2009 Gerdesmeyer 2008 Ibrahim 2010
-
Intracorporeal pneumatic shock application
! 50 patients in RCDB study
! 6 month follow-up ! Excellent & Good outcomes (92%) vs.
control group (24%) (P
-
Prolotherapy – the theory
! Proliferates cause local irritation triggering inflammatory cascade ! Irritants (phenol, tannic acid) & particulates (pumice granules) ! Osmotic agents (zinc sulfate, dextrose, glycerin) ! Chemotactic attracters (cod liver extract/sodium morrhuate)
-
Prolotherapy – the evidence
! Limited & mixed
! Side effects – short-term stiffness & pain
! Not usually covered by insurance
! (Ryan 2009) - Dextrose 3 tx q 6wk in 20 patients; G+Ex in 75% no change in 25%
-
Autologous blood injection (also enriched platelet plasma)
! Rationale: stimulate acute healing cascade ! Via cellular and humoral
mediators
! Procedure: 2cc of blood + 1cc lidocaine
-
Autologous blood injection
! RCT 44 patients treated with either autologous blood injection or methylprednisolone acetate.
! At the 6-month follow-up, both groups had similar significant decreases in VAS pain scores
Kiter 2006 Am Pod Med Assoc
-
Autologous blood injection
! 16 patients ! Pain decreased from 7.13 to 2.75. ! Nirschl activity staging scale decreased from 6.19 to
2.88. ! 62% were able to resume strenuous activity
! 70% that returned to strenuous activity could do so without pain.
! Nineteen percent reported no response to blood injection
(Martin 2005 Clin J Sports Med)
-
Platelet rich plasma (PRP)
-
Platelet rich plasma (PRP)
-
Botox injection ! Theory
! Abductor hallucis & FHB are the injection sites.
! Increases flexibility of the plantar musculature.
! Mostly case reports ! (Babcock 2005) RCT Botox vs. Saline
significant improvement in Pain @ 3 & 8 wks
! (Huang 2010) RDBC significant improvement in pain & decrease in PF thickness @ 3 & 12 weeks
-
Nitroglycerin patches ! Theory
! Dilates blood vessels leading to increased blood flow
! Increases levels of nitric oxide, which may stimulate healing
! Treatment regimen ! 1/4 patch 0.2 mg/hr for 18-24° ! 4/6 to 12+ week course
! Side effects – headache Paolini 2007, McCallum 2011
-
Cryosurgery: percutaneous denervation
! 61 cases of chronic plantar fasciitis.
! Mean VAS 8.38 to 1.26 after 1 day
! After 1 year ! Mean VAS score was 1.26 ! 32 heels being totally asymptomatic ! 90% having a VAS score < 4. ! Three patients eventually needed surgery
(Allen 2007 J Foot & Ankl Surg )
-
Radiofrequency nerve ablation
! 22 patients
! VAS 8.12 initially
! 3.26 after 1 week
! 1.46 1 month
! 1.96 3 months
! 2.07 6 months
! No further changes at 1 year
! Liden B 2009
-
Prevention
! Primary ! Congenital
! Hypermobile medial column cavus ! Pronation of subtalar joint ! Low medial longitudinal arch
! Equinus foot ! Weak intrinsic foot muscles
! Secondary