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EXPERTS DISCUSS NONSURGICAL AND SURGICAL TREATMENTS
For many people in the United States, taking those first few steps when they get out of bed in the morning causes excruciating heel pain. The culprit—plantar fasciitis—is an overuse injury that affects the band of tissue (fascia) that supports the arch and extends from the heel to the toes.
Yesterday, a panel of experts discussed the pros and cons of surgical and nonsurgical treatments for the condition. Steven Ross, MD, clinical professor in the department of orthopaedic surgery at the University of California, Irvine, and president of the American Orthopaedic Foot & Ankle Society, served as moderator.
A widespread problem
“More than 2 million Americans receive treatment for proximal plantar fasciitis every year,” said Troy S. Watson, MD, director of the Foot and Ankle Institute at the Desert Orthopaedic Center. One in 10 people will develop heel pain in their lifetime, said Dr. Watson, and approximately 1 percent of visits to orthopaedic surgeons are for heel pain.
The condition is more likely to affect patients who are female, overweight, or who have a job that requires a lot of walking or standing on hard surfaces. People who walk or run for exercise, especially those with tight calf muscles that limit how far the ankle can be flexed, and patients with very flatfeet or very high arches are also more prone to developing this degenerative disease. Pinpointing exactly what triggers the onset of the condition is difficult.
“The true cause of heel pain is not really known,” said Dr. Watson. “The main theories that have been discussed in the literature involve microtrauma and compression neuropathies.” Dr. Watson also noted that heel spurs, atrophy of the fat pad, and a tight Achilles tendon may contribute to the problem to a lesser extent. “It could also be a combination of all these factors,” he added.
Currently, physicians treat plantar fasciitis patients with several nonsurgical methods, including foot and toe exercises, massage techniques, stretching, and cortisone injections.
Approximately 90 percent of plantar fasciitis patients improve with exercises or other nonsurgical treatments over a 9-month span. According to Benedict DiGiovanni, MD, director of orthopaedic medical student education and associate professor of orthopaedics at the University of Rochester, the other 10 percent of patients develop chronic plantar fasciitis, which often causes disabling symptoms.
Study finds benefits of plantar fascia–specific stretches
Dr. Giovanni presented the results of a prospective, randomized, clinical trial that compared the results of two different nonsurgical treatment protocols for chronic heel pain. In the study, 101 patients whose heel pain had lasted 9 months or more received educational videos and handouts, non-steroidal anti-inflammatory drugs, and over-the-counter shoe inserts. One group performed non-weight-bearing, plantar fascia–specific stretches three times per day that involved dorsiflexion of the toes and ankle; patients palpated the plantar fascia with the hand to ensure it was stretched firmly. These patients were instructed to stretch before the first step in the morning and before standing after inactivity. The other group performed traditional, weight bearing Achilles tendon stretches three times per day.
The study’s 2-year follow-up results showed marked improvement for all patients who performed the plantar fascia stretching exercises, with an especially high rate of improvement for those in the original group treated with the Achilles tendon stretching program.
Extracorporeal shockwave therapy
John G. Anderson, MD, associate clinical professor at Michigan State University, explained that extracorporeal shockwave therapy (ESWT) is an option for treating recalcitrant plantar fasciitis.
“ESWT involves strong pressure waves that are generated in an elastic media, penetrate the body, and reflect, refract, and scatter, releasing energy at the interfaces,” said Dr. Anderson. “It creates a zone of microscopic tissue disruption that stimulates new tissue formation.”
“Because it’s noninvasive,” continued Dr. Anderson, “ESWT is advantageous when compared with open surgery. It’s very easy to apply, and has very minimal morbidity; however, the cost is very high and it’s not widely available. In addition, there haven’t been many long-term studies of ESWT, and it doesn’t address the primary pathology.”
When other treatments fail, said Dr. Anderson, gastrocnemius recession should be considered.
He referenced a prospective study of 29 consecutive patients (34 feet) who had symptoms for 18 months and had failed conservative treatment. These patients, all of whom underwent gastrocnemius recession, had been diagnosed with conditions such as heel pain, Achilles tendinitis, arch pain, and metatarsalgia.
“After lengthening their gastrocnemius muscle, we found a dramatic improvement in their pain scores and a satisfaction rate of 93 percent,” said Dr. Anderson.
“We feel that gastrocnemius equinus contracture is a progressive deformity that leads to a multitude of problems in the foot and ankle,” continued Dr. Anderson. “We believe that plantar fasciitis is an example of a condition where the structural alignment of the foot is quite normal, but the foot hurts, which is an early symptom of an arch that’s trying to collapse. Potentially, gastrocnemius recession may have the benefit of delaying progression of the collapse cascade.”
Further studies,proper diagnoses needed
“Certainly, a lot more research needs to be done in this area, but we do believe that the gastrocnemius contracture contributes to some of these symptoms,” said Dr. Anderson, adding that not all heel pain is due to a tight gastrocnemius muscle or to plantar fasciitis itself. “It’s important that patients understand that they need a thorough physical exam performed by a qualified orthopaedic surgeon to sort through all these issues and identify why their heel hurts,” he said.
Originally published by www.aaos.org, March 8, 2017