By Al Kline DPM

 

Plantar fasciitis is an acute inflammatory condition that causes typical heel pain.   It is characterized by post static dyskinesia or pain upon standing after rest.  A newer term introduced on the horizon is plantar fasciosis.  This condition suggests a more chronic degenerative condition associated with chronic heel pain.  Over 2 million people a year suffer from heel pain (plantar fasciitis or plantar fasciosis). 

In a recent Podiatry Today article, Dr. Stephen Barrett discusses the term plantar fasciosis and calls for a new paradigm to replace previous treatment regimes.  Dr. Barrett founded the endoscopic plantar fasciotomy technique or EPF.  Dr. Barrett argues that the term plantar fasciitis is erroneous and that we need to consider other diagnosis such as possible nerve entrapement syndromes.  Baxter and Pfeffer reported up to 89% success rate by surgical decompression of the first branch of the lateral plantar nerve in cases of chronic heel pain.  Barrett points out that researchers have been unable to find inflammatory cells microscopically in cases labeled fasciitis, but is rather a degenerative condition of the fascia.  He points to a landmark study performed by Lemont in 2003 that found ”no histological mediators of inflammation within 50 specimens sent by surgeons for pathological examination from their surgical cases treating plantar fasciitis.”  Dr. Barrett goes on to write:

 

”From a histological viewpoint, it is imperative to understand that the human plantar fascia is indiscernible from any other human tendonous tissue. With that said, we are able to draw on large amounts of well-accepted, sound, peer-reviewed scientific data.
       Animal studies conclusively demonstrate that within two to three weeks of insult to tendon tissue, inflammatory cells are not present.6 Anecdotally, I cannot recall a single heel pain patient telling me in the history of present illness that the pain was less than several weeks in duration.” 

 

Dr. Barrett also extrapolates that tendonitis is a myth and a misnomer and states:  ”If one extrapolates tendon to fascia and to aponeurosis, then plantar fasciitis also has to be a myth.”   

With this said, Dr. Barrett makes a compelling point.   However, I think it will be very tough to change treatment regimes overnight.  Inflammation  plays an important role in healing because it potentiates collagen proliferation that aids in the overall healing of tissue.  And, as we have all seen, acute inflammation is present in early heel pain.  Such as a patient who has recent heel pain for less than a months duration.  It seems, that these patients continue to do well conservatively with stretching therapy, arch supports and NSAIDS.  Also, some patients do respond well to conservative care even in chronic cases of plantar fasciosis. 

Of course, when conservative treatment fail, surgical intervention is still the patients best option for relief.  In cases of chronic pain, we are entering a new realm in the possible treatment of plantar fasciosis.  The most common and proven techniques have been the endoscopoic plantar fascial release and extracorporal shock wave therapy. 

 

Presently, a study is being conducted under the auspice of the NIH concerning Plantar Fasciosis Treatment Using  Coblation.  This is a phase IV study that began in August 2005 and ending in February 2007.  The study is funded and sponsored by the ArthroCare Corporation.  They are the makers of the ArthroCare TOPAZ™ MicroDebrider™.  The principal investigator for the study is  Lowell S. Weil, Sr. DPM.  This study continues to recruit patients. 

 

The basis for this treatment is based on a concept of using plasma RF-based microsurgical techniques to treat tendinosis.  The initial work was drawn on research in patients with CHF treated with RF-based transmyocardial revascularization or TMR.  TMR causes angiogenic healing and it was extrapolated in the application of chronic tendinosis and possible use in plantar fasciosis.  Plasma RF based healing was tested in vivo by biochemical and histologic analysis.  Clinical trials using plasma RF based microtenotomy has demonstated success in treatment of chonic tendinosis.  It is reported that patients had a much faster recovery period and the procedure is less invasive than conventional tendon surgery.

 

Podiatrists have been studying the affects of microdebridement in Achilles tendonitis, peroneal tendonitis and plantar fasciosis.  Microdebridement using coblation works by replacing the extreme heat of a laser with standard radiofrequency that gently heats the tissues.  This causes molecular degeneration.  Using a conduction medium, a sufficiently high voltage difference between the probe causes dislocation of molecular bonds within tissue.  This causes a dissociative process confined to the surface layers of the target tissue, in essence, causing microdebridement.  This promotes angiogenesis and a healing cascade. 

 

Coblation technique is not new and has been used for cosmetic surgery, otolaryngolgical, spine, cardiac, neurosurgical, gynecological and urological surgeries.  The application for the modality in podiatry surgery looks very promising.  The technique is similar to an endoscopic plantar fasciotomy, although the incision is slightly bigger to accommodate the probe.  However, there is no need for complete fasciotomy, which can be a draw back in the EPF procedure.  There have been a few reports of dorsal midtarsal joint pain from loss of the Windlass effect after plantar fasciotomy.  Other complications have included lateral column pain and nerve entrapments.  Draw-backs seen in this procedure includes a longer down time.  The company recommends immobilization for three weeks with progression to a night splint and CAM walking in six to eight weeks.  Inflammatory postoperative swelling will decrease in three weeks.  Sometimes, fascial nodules have been reported that can disappear, usually in twenty weeks.  To see a video example of the procedure performed on Patellar tendinosis, click here. 

 

There continues to be a place for conservative care in the treatment of acute plantar fasciits and chronic plantar fasciosis.  Every case is individual and unique.  Guidelines continue to present and add to our understanding of this frustrating condition that affects so many people.  This will be another surgical treatment alternative in the treatment of plantar fasciosis. 

 

References 

Arthrocare Corporation – News Release   ArthroCare’s Topaz ™ Named Among Podiatry Today’s Annual ‘Top Ten Innovations’ List, 2005.

 

  Tasto, James P. et al  Radiofrequency Microdebridement:  A Novel Treatment Option for Tendinopathies.  Online PDF article

 

  Clinical Trials: Plantar Fasciosis Treament Using Coblation.  Verified by ArthroCare Corporation, Oct 2006. 

 

Baxter, Donald E., Pfeffer, Glenn B.  Treatment of Chronic Heel Pain by Surgical Release of the First Branch of the Lateral Plantar Nerve.  Clinical Orthopedic and Related Research, Number 279, June, 1992.

 

 

 

© Al Kline DPM, 2006