Heel Pain Season: What Is Your Strategy When Conservative Care Fails?

In my last DPM Blog (see https://tinyurl.com/qgh9azu ), I talked about the conservative regimen we employ at the Weil Foot & Ankle Institute that is evidence-based and provides consistent outcomes. However, no matter how diligent the physician and the patient are with a conservative plan, some people will not resolve their heel pain and it becomes necessary to consider other causes of the pain or more advanced treatments.

As I noted in the last posting, we have a relatively strict protocol that we follow institutionally. We follow that protocol for three or four months and find that 80 to 90 percent of people will respond with that protocol and in that time frame. The 80 to 90 percent are the easy ones. The other 10 to 20 percent are often your nightmares.

When I was first started practice nearly 20 years ago, the expanse of conservative methods I previously highlighted were not as available and failures were more numerous with fewer options. In the 1990s, endoscopic plantar fascia (EPF) release became in vogue and it seemed that everyone with any complaint of heel pain was getting EPF.

While EPF was successful for many patients, multiple studies found residual problems with lateral column pain and peroneal pain postoperatively.^1-3 Additionally, many inexperienced surgeons were performing the procedure and releasing excessive amounts of plantar fascia. It was not uncommon to hear about substantial nerve damage following EPF. As a result, I never performed many plantar fascia releases as it seemed wrong to release an important structure and destabilize the foot. I also had the unenviable situation of seeing patients for second opinions who had not had relief or became worse following their plantar fascia releases.

So what does all this mean and how does this relate to what patients need today?

It has been my policy to consider plantar fascia sparing treatments for chronic and residual heel pain.

What About ESWT and PRP?

My mainstay for chronic plantar fasciopathy has been extracorporeal shockwave treatment (ESWT) since 2000. I had previously been exposed to ESWT in 1996 during my fellowship in Europe and saw the amazing results it delivered. Since then, we have performed thousands of ESWT treatments and consistently achieve results approaching 90 percent success. Initially, ESWT was extremely costly due to the expensive technology. Unfortunately, a few physicians abused the system and were billing and getting reimbursements in the $10,000 to $15,000 range per treatment and ESWT got a bad name with insurance providers. Since around 2004, few insurance companies reimburse for ESWT and it has become a cash-only alternative. However, there are now many different companies that market ESWT/extracorporeal pulse activation treatment (EPAT) technology and the units are much more affordable. 

There are different ways that one can utilize ESWT and the differences are commonly known as high-energy and low-energy ESWT. I will save a more thorough discussion about ESWT for a later post but research has shown that there is really no difference in outcomes for plantar fascia treatment between high-energy and low-energy ESWT. Shockwave therapy has 10 times more prospective, placebo-controlled studies than all surgical procedures for heel pain combined. Some results of these studies do not show great superiority but a large majority of the studies show substantial success with ESWT.⁴

Platelet rich plasma (PRP) has become a hot topic for treatment of soft tissue problems in the orthopedic community, let alone the foot and ankle. The principles behind PRP are not entirely different than those of ESWT: irritate the tissue and increase growth factors to the area to help heal the chronic damage and scar tissue. Platelet rich plasma is relatively easy with a simple blood draw and centrifuge to separate the blood products followed by an injection into the pathologic area.

Like ESWT, PRP is not covered by insurance and patients have to pay cash for the procedure. There seems to be a wide regional difference for the cost of PRP. I have heard of ranges from $250 to $2,500 per injection despite there being no difference in the procedure. Evidence has not clearly defined PRP as having success and studies have very mixed results. Anecdotally, I have seen success with PRP but rarely use it in isolation. I will typically add it to an ESWT procedure and we have an ongoing study showing that the results of combined ESWT/PRP are superior to the use of either in isolation.

This combination is something I have utilized on multiple professional, collegiate and Olympic athletes with success. There is virtually no risk with these procedures and there is return to regular activities immediately after the procedures.

When You Are Considering Surgery For The Patient

When surgery is necessary, I have been using percutaneous microfasciotomy with Topaz (Arthrocare) for the last seven or eight years. Animal studies have shown the benefits of utilizing Coblation procedures to stimulate healing to chronic damaged and scarred soft tissue structures like tendons and fascia.⁵ With the minimally invasive nature of this procedure, disability following Topaz is minimal with patients returning to their athletic shoes two days after surgery and full recovery within six to 12 weeks.

We performed a study looking at 6,715 patients with Blue Cross/Blue Shield of Illinois who were diagnosed with plantar fasciitis in our institution from 2002 to 2014 to determine the costs of their entire care. In the study, 305 of the patients were treated with ESWT and 100 were treated with either surgical release or Topaz. There was no difference in the success of treatment between the two groups. However, the cost of care was much different. When looking at the cost of care for physician/surgeon, facility, anesthesia and follow-up care, ESWT was less expensive than surgery by an average of $760.88/patient. This did not account for lost wages, interference of daily life or additional medical care such as physical therapy.

Considering A Possible Neurologic Component For Heel Pain

Over the last decade, I have come to appreciate that a substantial amount of heel pain has a neurologic component. In the past, I have missed the diagnosis or been fooled by changes in symptoms that I did not pick up. I have been trying to understand why ESWT worked in almost 90 percent of patients but failed in 10 percent.

Talking to colleagues Peter Bregman, DPM, and Steven Barrett, DPM, made me start to appreciate the neurologic contributions to heel pain. I have become much more diligent in my assessment of possible nerve issues that may cause heel pain and make sure to do a proper work up. This includes ordering nerve conduction studies and referring patients to back and nerve specialists. Then I will treat the patient appropriately with oral medications, topical medications, nerve blocks and surgery if necessary. Ten years ago, I performed one tarsal tunnel release a year. Now I perform two per month and my results are consistently good. Not all patients make a full, pain free recovery but a substantial amount of patients get relief that is life changing.

Final Notes

In my experience, heel pain can be relatively simple and straightforward for most patients with 80 to 90 percent successful results with appropriate conservative care. However, you must have a thoughtful strategy to approach those patients who do not respond to conservative care. I would encourage you to consider plantar fascia sparing procedures that yield results comparable to surgery and ultimately do so at less risk, less disability and less expense. 

Do not forget that other problems can create heel pain and that heel pain can change from plantar fasciitis to something else during the course of treatment. Be sure that you ask the right questions and perform the right examination at each visit to ensure you are implementing the right treatments.

Combining a strong diagnostic workup with an evidence-based regimen for conservative care and other treatment options for chronic heel pain can provide you and your patients with a more gratifying approach to the treatment of the most common complaint we see in our practices. Reassess your treatment for heel pain and you may find small changes can make huge differences.

References

1. Barrett SL, Day AV, et al. Endoscopic plantar fasciotomy: a multi-surgeon prospective analysis of 652 cases. J Foot Ankle Surg 1995; 34(4):400-406.

2. Barrett SL, Day AV. Endoscopic plantar fasciotomy for chronic plantar fasciitis/heel spur syndrome: surgical technique – early clinical results. J Foot Surg 1991; 30(6):568-570.
3. Barrett SL, Day SV. Endoscopic plantar fasciotomy: Two portal endoscopic surgical techniques – clinical results of 65 procedures. J Foot Ankle Surg 1993; 32(3):248-256.

4. Armstrong DG, Lavery LA. Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trial. Lancet 2005; 366(9498):1704-10.

5. Takahashi N, Tasto JP, Ritter M, et al. Pain relief through an antinociceptive effect after radiofrequency application. Am J Sports Med. 2007; 35(5):805-10.