Advanced treatments for plantar fasciitis.

Four advanced treatments for "difficult" cases of plantar fasciitis or plantar fasciosis are offered by San Antonio Podiatrist, Dr. Ed Davis.

1) The Topaz Procedure:  This procedure is a minimally invasive procedure for plantar fasciitis that involves use of a small wand made by Arthrocare.  It employs radiofrequency utilized by the surgeon to debride or thin the fascia at the heel, that is, remove the diseased tissue causing the heel pain.  The procedure is performed via tiny "puncture" holes made in the skin at the bottom of the heel that require no sutures and leave no scarring.  Patients can walk on the area the next day.  http://www.topazprocedure.com/

2) ESWT or extracorporeal shockwave therapy:  This procedure is a non-invasive and involves the use of a machine that generates sonic pressure waves to induce remodeling or repair of the diseased fascial tissue at the heel.  It is also effective for achilles tendon problems.  The procedure is performed in the office without the need for anesthesia and patients can return to activity the same day.  Dr. Davis owns and uses the Swiss Dolorclast which is a third generation ESWT machine manufactured by EMS:  http://www.ems-company.com/en/medical/products/swiss%20dolorclast/swiss%20dolorclast%20classic/

3) MLS Laser Therapy:  MLS laser is a modality in which is supplied by Cutting Edge Lasers, http://med.celasers.com/.    The laser works by employing two synchronized wavelengths of light which treat damaged tissue at the cellular level to stimulate healing, reduce inflammation and pain.  I was introduced to this modality about a year ago but had difficulty understanding and accepting the concept behind this.  CE Lasers initially sold to the veterinary market in the US despite fairly widespread use of the products in Europe.  There is no placebo effect with animals.  I talked to several veterinarians using the CE Laser before becoming convinced of its efficacy.

4) Platelet rich plasma (PRP):   Platelet rich plasma has become a popular and somewhat glamorous new treatment modality used by professional athletes for injuries. PRP is a concentrate of whole blood of the patient in which the the platelets are concentrated in a small portion.  The platelet concentrate is then reinjected into the injured area.  Platelets are involved in the clotting mechanism so bruising and swelling can be decreased.  Platelets contain growth factors so, in concentrated form, the amount of growth factors can be increased in an injured area.  Results in the press and literature have been mixed but there is a reason for this in my opinion.  PRP is often used as a primary treatment or sole treatment. There may be a benefit to do so but the underlying cause of tendon and ligament pathologies must first be addressed otherwise lasting relief may not occur.  I use PRP as an adjunctive treatment; for example, I will inject PRP into the plantar fascia after performing the Topaz procedure.  I use the same strategy with the CE Laser, utilizing it in conjunction with ESWT.

For more information see our heel pain website:  http://www.heelpain.pro/


Treatment Triad for Plantar Fasciitis

Treatment Triad

I coined the term "treatment triad" for plantar fasciitis a few years back to better describe the disease process and its treatment. 

Acute plantar fasciitis is basically a sprain of the fascia, it is an inflammatory condition. It thus can be treated successfully with anti-inflammatories -- oral or injections or cortisone plus the use of soft heel pads or OTC inserts (acute PF can sometimes progress to chronic PF but lets leave that out for simplicity's sake for now).

Plantar fasciitis that persists or becomes chronic does so for one of two reasons....
...abnormal or excessive strain persists on the fascia. This may be due to work conditions, poor shoegear, poor body mechanics: subtalar joint overpronation, midtarsal joint oversupination, tight achille-gastrosoleus.

...tissue quality deteriorates. This can occur due to chronic inflammation which leads to tissue damage, genetic factors leading to poor connective tissue quality or a combination of both.

LEG #1 = inflammation,  LEG #2 = abnormal biomechanics,  LEG #3 = poor tissue quality(degeneration of the tissue due to long term chronic inflammation)

The 3 "legs" of the triad thus have different "height" at different times.

Initially the first leg, "inflammation" is by far the predominant process. As such expect modalities such as cortisone shots to work reasonably well in the first few weeks or few months, then gradually decrease in effectiveness with time. As time goes on and if plantar fasciitis persists, the second leg must be focused on. The body can and does repair itself and if that is not happening then one must remove impediments, ie. find and remove the biomechanical problems preventing that from occurring. Look carefully at the second leg from 6 weeks to 6 months. Inflammation and tissue damage occurring for extended periods of time (say greater than 6 months) will compromise the body's ability to repair tissue. The tissue becomes badly scarred and devascularized. This is the point where the third leg predominates -- tissue quality.

Problematic biomechanics is best treated by a practitioner trained in that area.  There are many who dabble in the area of biomechanics, from shoe fitters to retail stores, etc.  Expertise in biomechanics is derived from years of study. Biomechanical issues are addrressed by changes in shoegear, prescription foot orthotics, manual therapy/physical therapy.  Dr. Larry Huppin of Seattle provides a good overview of custom orthotics on his web site: http://www.footankle.com/custom-orthotics.htm

 

How is the third leg treated. The term "plantar fasciosis" is a relatively new term that specifically defines this degneration of the fascia. Such degeneration can easily be diagnosed by use of diagnostic ultrasound or sonography. It is important that the presence or absence of fasciosis be established early on so that treatment can be adequately targeted.  Surgical release of the plantar fascia was used at this stage but carries a potentially long recovery period as well as what I would consider an unacceptably high complication rate. It has been supplanted by less invasive, safer and more effective treatments to include ESWT (extracorporeal shockwave therapy) and more recently, the Topaz procedure, http://www.topazprocedure.com/, which is also known as a partial fasciectomy via coblation.  Coblation is a term meaning "cold ablation" and is a trademark of the Arthrocare Corp.

Now, one caveat, plantar fasciitis often waxes and wanes in the early stages for a number of patients so the "stages"  or "legs" I am discussing be affixed to firm time periods. For example, a patient can low grade chronic plantar fasciitis for years, change jobs to one that requires more standing and develops a bout of acute plantar fasciitis superimposed on the chronic process.


Heel pain - getting the proper diagnosis

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I see many patients with heel pain in my practice as a San Antonio podiatrist, who have had the problem for months, if not years but have never had a well defined treatment plan.
Such treatment plan starts with an accurate diagnosis. Plantar fasciitis, inflammation of the ligament which supports that arch and originates on the heel bone is the most common cause of heel pain.  Other causes may include:...stress fractures of the heel bone (calcaneus), Baxter's neuritis - a nerve entrapment of a small nerve branch beneath the heel bone, plantar fasciosis - degenerative process of the plantar fascia, rheumatologic entities such as Reiter's syndrome, rheumatoid arthritis, gout, psoriatic arthritis, irritable bowel syndrome, ankylosing spondylitis; chronic pain syndrome due to overuse of steroids (cortisone shots), plantar fascial tears, plantar fibromatosis, infections, tumors, cysts....Ed Davis, DPM, FACFAS http://www.southexaspodiatrist.com/