Between Self-Cure and Surgery
Plantar fasciitis doctors call them “the in-between patients,” that small percentage of people who cannot self-cure but may not be bad enough for surgery, or just don’t want surgery. Oh, there is a variety of in-betweener treatments more aggressive than self-cure, “minimally invasive” treatments short of surgery. But do they work? And if so, how well?
“The difference, at least in our business, is that we don’t have a great treatment for the in-betweener patients,” says Dr. W. Hodges Davis, a Charlotte, North Carolina Foot and Ankle Surgeon and 2012-2013 President of the Outreach and Education Fund of the American Orthopaedic Foot & Ankle Society. “I mean those patients who stretch but are still disabled. That’s where we don’t have a good option.”
Not great treatments, perhaps, but some minimally invasive treatments show promising results and/or are getting a lot of attention, including these (which are detailed under separate subsections below):
- Shock wave therapy
- Platelet-rich plasma
- Therapeutic ultrasound
- Botulism toxin injections
For that 5-10% of plantar fasciitis suffers for whom “conservative treatment” such as “self-cure” through stretching, orthotics, etc., does not fix the problem within 6-12 months, doctors may suggest some of these treatments as alternatives to surgery or at least as intervening stages of treatment to try first.
Studies of some show success rates worth of consideration, but none of them is a sure cure.
“The fact that we have so many different treatments for plantar fasciitis is probably a testimony to the fact that not any one thing works all that well,” says Dr. John Wilson, a faculty member in the University of Wisconsin School of Medicine and Public Health, and a team physician for the University of Wisconsin Athletic Department.
Among comments commonly heard from doctors about plantar fasciitis is that “there is so much we don’t know,” or “we really don’t know” the answer to this or that.
One problem with evaluating treatments is that plantar fasciitis often improves spontaneously, according to Indianapolis orthopedic surgeon Dr. Brett Fink in his February 2012 article, “Management of Plantar Fasciitis Evolving,”in The Journal of Musculoskeletal Medicine.
“Therefore, large, well-controlled trials are necessary before new therapies should be adopted as standard practice.”
Shock wave therapy
ESWT, or extra corporeal shockwave therapy, is really sound wave therapy. “The machine used for managing musculoskeletal disorders with extracorporeal shock wave therapy (ESWT) – the application of high-intensity pulses of ultrasonic energy – was modified from designs that were used successfully to break up kidney stones,” according to “Management of Plantar Fasciitis Evolving.”
“The FDA approved ESWT in 2000 for the treatment of patients with plantar fasciitis who did not improve with conservative therapy. The initial results of controlled studies indicated that such treatment is moderately effective and has few adverse effects…The results achieved with this procedure probably vary greatly with the devise used and the amount of energy delivered.”
“ESWT generates pulses of high-pressure sound that travel through the skin,” according to “Managing plantar fasciitis and other heel pain,” a 2009 article in The Journal of Musculoskeletal Medicine. “For reasons that are not fully understood, soft tissue and bone that are subjected to these pulses become less painful…The benefit of the high-energy ESWT waves may be the result of growth of new blood vessels (neovascularization) in small cavities created by the pulses. Alternatively, the pulses may damage the deep sensory nerves, resulting in decreased pain.”
Researchers have found, according to the article, that “ESWT significantly reduces the symptoms associated with chronic plantar fasciitis and that the results compare favorably with those achieved with surgical intervention…Typically, ESWT is performed as a single treatment; maximum improvement is achieved after 3 months.”
ESWT has good research behind it with promising results, probably the most promising research among the minimally invasive non-treatments for plantar fasciitis,” says Dr. Mark Vann, assistant professor of orthopedic surgery at the Baylor College of Medicine in Houston, Texas. “Unfortunately, none of it is conclusive.”
Platelet-rich plasma (PRP) injections are injections of PRP spun down from your own blood, “separated from whole blood after it has been centrifuged, according to according to the February 2012 article, “Management of Plantar Fasciitis Evolving.”
The idea is that PRP contains growth factors and other elements essential in healing.
There “have been no good published studies to support the use of PRP” in plantar fasciitis treatment, says the article, but “its use in the community seems to be increasing. Some of the demand may be fueled by reports of high-profile athletes with various musculoskeletal injuries having received successful treatment with PRP. This treatment can be quite expensive and often is not covered by insurances.”
One group that is bonkers for PRP is professional athletes, a realm where the cost of PRP is dwarfed by the cost of having a player out of commission. Some athletes and sports medicine professional are convinced of PRP’s value, and more on that in the article, “Plantar Fasciitis in the NBA,” also appearing as “Plantar Fasciitis in Basketball” on our plantar-fasciitis-only Web site.
Meanwhile, at least one large scale study is underway in Europe now to get better data on how well PRP works.
Radiofrequency microtenotomy causes less “mechanical disruption” of the tissues than does plantar fasciotomy” (surgery), according to Dr. Fink in his article, “Management of Plantar Fasciitis Evolving.”
“This may reduce the possibility of midfoot pain…which complicates plantar fasciotomy post-operatively,” he writes. However, “Studies comparing the results of this procedure with those of more conventional surgical fasciotomy procedures are necessary before it can be recommended as an alternative. None are currently available.”
There’s a good You Tube video of microtenotomy being done:
It shows the ArthroCare Corporation’s Microdebrider being inserted through the skin to the plantar fascia, where radio-frequency waves “dissolve inflamed scar tissue,” creating a new injury that is “allowed to heal under controlled circumstances…in time, new healthy tissue develops in the plantar fascia.”
“Ultrasound delivers heat, that’s all it does,” says Dr. Jeffrey Johnson, Professor of Orthopaedic Surgery at WashingtonUniversity in St. Louis. “If you can deliver heat, maybe it increases blood flow into that region, into a deeper tissue area that needs to be healed. By heating tissues, the idea is that it dilates blood vessels and brings new blood flow. “
Heating the tissues results “in an increase in tissue temperature and metabolism, tissue softening and an increase in circulation,” according to a 2006 article in the Journal of the Canadian Chiropractic Association. But the authors referenced one study comparing ultrasound to sham ultrasound in eight sessions over four weeks. “The authors concluded that this treatment was no more effective than placebo,” although the size, extent and follow-up of the study comprised “ a less than ideal study design.”
The article concluded that therapeutic ultrasound was among those therapies that “have been shown to be ineffective in the treatment of plantar fasciitis.”
“A theory of why people don’t heal a partial tear of the plantar fascia is that there is not good blood supply,” says Dr. Davis. “Shock wave therapy will help that, but ultrasound doesn’t even in theory do that.”
Botulism Toxin Injection
Botulism toxin injection has been “used for musculoskeletal disorders, including…plantar fasciitis, according to an article published in the Journal of Musculoskeletal Medicine in February 2012, “Management of Plantar Fasciitis Evolving.”
“Injection into the plantar fascia has been shown to provide significant pain relief,” according to Dr. Fink. The mechanism of the pain relief is at this point not clear, he writes, and “Because the studies evaluating botulism toxin injection have been small and uncontrolled, endorsement awaits validation from larger, higher-quality investigations.”