PLANTAR FASCIITIS NEWS
The Case for Options to Surgery
A lot of orthopedic surgeries are not actually necessary, suggests Dr. Howard Luks, Associate Professor of Orthopedic Surgery at New York Medical College and Chief of Sports Medicine and Arthroscopy at Westchester Medical Center, in an editorial published July 23, 2013.
We’ve touched on this in a number of our Bobbing for Answers Web pages. On the Plantar Fasciitis Surgery page, for example, we take note of the University Foot & Ankle Institute’s comment that the need for plantar fasciitis related surgery is “exceptionally rare;” and we have noted how reluctant are orthopedic surgeons to go the surgery route without first exhausting the possibilities of self-cure and minimally invasive treatments.
In our Rotator Cuff Solutions pages, we’ve taken note of similar reservations about surgery. On our Rotator Cuff News & Tips page, for example (where we have also referenced Dr. Luks’ cautionary view of the topic), we’ve noted one study under the heading “Surgery Not Necessary?” Described in an article in The Journal of Musculo-Skeletal Medicine, the study indicated that “three out of four (75% 117 patients studied) patients with massive rotator cuff tears were able to forego surgery in favor of “conservative measures…The results were significantly better than those for the 30 patients who ultimately required surgery.”
“Many patients are under the unfortunate impression that if something is torn it must be fixed,” according to Dr. Luks. “Nearly all patients who are informed that they have a torn meniscus or a torn rotator cuff will immediately conclude that they need surgery to repair the problem.”
So writes Dr. Howard Luks in a July 22, 2013 commentary on the Rheumatology Network, “When Not to Fix: Thoughts of an Orthopaedic Surgeon.” However, writes Dr. Luks, “Patients who are informed fully about the various risks and benefits of surgical and nonsurgical measures generally tend to opt for less-invasive procedures.”
For example, according to Dr. Luks, “It has been estimated that anywhere from 15% to 20% of knee replacements and arthroscopy for various orthopedic conditions are unnecessary. I suspect that actually this number may be higher; however, the data is lacking.”
“One driving force that is emerging in our high-tech, low-touch approach to healthcare is our tendency to rely far too much on technology such as MRI findings, and too little on our physical exam findings and on the story our patient is telling us” writes Dr. Luks.
“Are we treating these patients?” he asks. “Or are we treating their MRI findings?
New (4/13) Plantar Fasciitis Treatment Study
While a lot of people swear by Platelet-Rich-Plasma (PRP) therapy for plantar fasciitis, the medical community, being a scientific bunch, wants proof, and they’re working on it.
Results of a study, presented April 19 at the annual meeting of the American Medical Society for Sports Medicine in San Diego showed significant improvement for both PRP therapy and corticosteroid therapy, better known to the average person as steroid shots.
It was not a conclusive study, with a small number of subjects, and more of a pilot study for more to come, but both PRP and cortisone showed significant improvement in plantar fasciitis outcomes after 32 weeks, based on standard patient questionnaires.
Both involved a single injection. Cortisone is well-known for the hazards of getting multiple injections in the same tissue, but does PRP have a similar hazard?
“That’s a great question, and we don’t know the answer,” says lead study author 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. “The few studies done on PRP did not seem to show any worsening (of the integrity of the plantar fascia tissue). We think it’s pretty safe, but we don’t know the whole story yet.”
PRP has well-document healing effects, and studies have shown promise, but they are studies too small to be definitive. In one study of nine plantar fasciitis patients, for example, PRP results showed “complete resolution” in seven of them after one year. Everybody seems to be awaiting results of a large-scale study now going on in the Netherlands, and word has it that study will be reporting later this year.
The University of Wisconsin group now has another study underway based not on the subjective basis of patient questionnaires but ultrasound imaging of the plantar fascia tissue over time. This should determine whether single cortisone and PRP injections show improvement in the actual collagen tissues of the plantar fascia – ligament thickness, blood flow and extent to which the tissue is organized or disorganized.
“Our initial hypothesis was that cortisone would have no effect but PRP would on tissue healing,” says Dr. Wilson. “That will be interesting to analyze the tissue results compared to the questionnaire-based portion. We have been surprised at the preliminary analysis to see how well corticosteroid did over time. Another possibility is that eight months is not long enough to follow these people to detect the difference (between cortisone and PRP). One trend was that the PRP group showed slow but continuous improvement over time. The corticosteroid group, on the other hand, showed a high rate of improvement in two months, and then their improvement seemed to plateau. If we followed it for a year or more, maybe we would see that the steroid effect wears off.”
Dr. Wilson plans to get a larger, longer-scale study under way later this year comparing cortisone and PRP, and meanwhile who isn’t excited about that big definitive study from the Netherlands on the value of PRP. I know I am.
More Cause for Worry About Steroid Injections
At least that’s the title of a 4/16/13 communication from the Journal of Musculoskeltal Medicine. According to a summary at the start of the article, “There ‘continues to be reason for concern’ about the sterility of injectable steroids and other supposedly sterile products from compounding pharmacies, according to the Food and Drug Administration (FDA), after inspections at 31 such firms over the past seven weeks. Prompted by the recent outbreak of contaminated steroid injections, the inspections have shown widespread evidence of lax efforts to assure sterility within these facilities.” Eeewww, sick!
Save on Doctor Bills?
Do patients with a musculoskeletal condition — INCLUDING PLANTAR FASCIITIS — really benefit from seeing a primary care doctor rather than going straight to a physical therapist (PT)? A new statistical study suggests not.
Any physical therapist worth a hoot should be able to diagnose plantar fasciitis. What’s more, for an introduction to the proper use of plantar-fasciitis-specific stretching exercises – as well as advice on orthotics and footwear – a physical therapist is one of your best places to start on the road to the “self-cure” which the medical establishment says works for 90% or more of those with plantar fasciitis.