Study Compares Four Treatments For Chronic Plantar Fasciitis

Comparing extracorporeal shockwave therapy (ESWT), platelet-rich plasma (PRP), local corticosteroid injection and prolotherapy for chronic plantar fasciitis, a recent study concludes that the effects of each treatment vary in duration.

The randomized study, recently published in the Journal of Foot and Ankle Surgery, focused on 158 patients with plantar fasciitis and a heel spur who received either ESWT, prolotherapy, PRP, or a local corticosteroid injection. The authors note corticosteroid injections were more effective in the first three months but lost their efficacy by the end of the 36-month follow-up period. Shockwave was effective for pain in the first six months. The study notes prolotherapy and PRP showed their efficacy within three to 12 months. The authors noted that at 36 months, there was no difference in efficacy among the four treatments they studied.

Nicholas Romansky, DPM, FACFAS, emphasizes that no one treatment is most effective for heel pain as heel pain can have different etiologies such as a plantar fascia tear, Baxter’s nerve entrapment or fat pad atrophy.

Dr. Romansky has used ESWT for chronic and acute heel pain with “very good” results, citing the treatment’s non-invasive nature. However, he notes the results of shockwave can take up to six to 12 weeks to be apparent. Tim Dutra, DPM, has found ESWT treatment to be 80 to 90 percent effective for patients with chronic plantar fasciitis.

Dr. Romansky has had minimal results with PRP and prolotherapy (the latter of which he has an MD perform). He has selectively used corticosteroids with good results. However, a disadvantage is that PRP, prolotherapy and corticosteroids are all invasive treatments with limited efficacy, according to Dr. Romansky, who is in private practice in Media and Phoenixville, Pa. Although he thinks both prolotherapy and PRP injections have potential, Dr. Dutra calls for evidence-based studies to improve patient access to those therapies as well as improvements in reimbursement.

Dr. Dutra notes recent research has not really proven the efficacy of corticosteroid injections, which he reserves for more chronic cases. He says he usually provides no more than one or two injections to the affected area.

For patients with plantar fasciitis, the most effective treatment is addressing the pain and the cause, according to Dr. Dutra, an Assistant Professor and Clinical Investigator at the California School of Podiatric Medicine at Samuel Merritt University.

“Obviously the key is treating the acute phase before it becomes chronic,” notes Dr. Dutra. “Then other treatment options become more realistic.”

Dr. Dutra’s standard approach to treatment is ice, NSAIDs, low Dye strapping, shoe modification (motion control or stability shoe), and modified activity with support based on response to symptoms. He finds that if patients do not respond positively to taping, shoe recommendations and modified activity, the heel pain is not purely plantar fasciitis. Custom functional orthotics have worked for effective long-term treatment and preventing recurrence of heel pain, says Dr. Dutra. He has recommended slow and gradual stretching after patients attained relief from the acute pain.

As Dr. Romansky emphasizes, ESWT, corticosteroids, PRP and prolotherapy are not primary treatments for heel pain but should be adjunctive. He says podiatric physicians should undertake more biomechanics-related, comprehensive care for heel pain. Dr. Romansky says that more multifaceted approach is something that sets DPMs apart from orthopedists as foot and ankle specialists.

In Memory Of Paul Scherer, DPM

By Brian McCurdy, Managing Editor

Podiatric friends and colleagues are mourning the recent death of Paul R. Scherer, DPM.

Dr. Scherer, the founder and CEO of ProLab Orthotics/USA in Napa, Calif., had been active in podiatry for over 40 years, which included a long tenure at the California College of Podiatric Medicine (CCPM) that culminated in the position of Chairman of the Department of Applied Biomechanics. He was also a frequent lecturer and published extensively in numerous journals.

Kevin A. Kirby, DPM, had known Dr. Scherer since he was a student at CCPM in 1979 and Dr. Scherer was the Vice President and Academic Dean.

“Paul Scherer always had very intelligent and logical arguments, and was a great wealth of knowledge, As one of his students and residents, I greatly appreciated that,” says Dr. Kirby, an Adjunct Associate Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Calif.

“Paul was passionate about biomechanics and had a desire to educate every podiatric physician about the importance of biomechanics in private practice,” recalls Alona Kashaninan, DPM, who is in private practice in Los Angeles. “Paul taught us all to evaluate the surgical, diabetic and pediatric patient by assessing the structural as well as functional mechanics of the associated pathology.”

Dr. Kirby also recalls Dr. Scherer’s work as the Scientific Chairman of the Prescription Foot Orthotic Lab Association (PFOLA) Annual International Conference on Foot Biomechanics and Orthotic Therapy from 1998 to 2007. Dr. Kirby had spoken at PFOLA and noted that Dr. Scherer’s leadership made the conference “‘the’ seminar that nearly all of my international podiatric biomechanics colleagues and researcher friends would be looking forward to every year.”

“Paul was among the first in our profession to emphasize the need for evidence-based use of orthoses,” notes the American Board of Podiatric Medicine. “He maintained an unwavering commitment to a standard of excellence in the products generated by his laboratory, supported by the best available evidence regarding the nature and method by which foot and lower extremity orthoses deliver their benefits.”

Dr. Kashanian praises Dr. Scherer’s role as a physician, professor, businessman and humanitarian. Dr. Scherer also gave his students and residents a passion for the doctor-patient relationship, she notes.

“(Dr. Scherer) was a podiatric physician who demonstrated compassion to all of his clinical patients,” says Dr. Kashanian. “He was charitable with his time and financial resources to young podiatric physicians seeking his advice. He was an ultimate optimist about our medical profession and he shaped many lives with his positivity about life and work.”

Is Arthroscopic Repair Effective For Chronic Ankle Instability?

By Brian McCurdy, Managing Editor

For patients with chronic ankle instability, arthroscopic repair and reconstruction offer potential, according to a recent study.

The study, published in Orthopaedics & Traumatology: Surgery & Research, included 286 patients with chronic ankle instability. Of those, 115 had arthroscopic ligament repair and 171 had arthroscopic ligament reconstruction. At a mean follow-up of 9.6 months, patients related an overall satisfaction of 8.5 out of 10. In addition, the study notes patients’ American Orthopaedic Foot and Ankle Scores (AOFAS) and Karlsson scores improved from 62.1 to 89.2 after ligament repair and from 55 to 87.1 after ligament reconstruction. The authors advocate further evaluation to better determine indications for repair in comparison with reconstruction.

Physicians can treat 90 percent of lateral ankle instability non-surgically with exercises (physical therapy), bracing and orthoses, emphasizes Amol Saxena, DPM. The best conservative treatment for chronic ankle instability includes balance and proprioception exercises combined with a multi-ligament supportive brace, according to Bob Baravarian, DPM, FACFAS, an Assistant Clinical Professor at the UCLA School of Medicine. For surgical treatment, he recommends a modified Broström primary ankle ligament repair.

Dr. Saxena cites research indicating that when stabilizing the lateral ankle, surgeons should keep the diagnostic arthroscopy relatively short, noting that distending the soft tissue “does not make sense.” He also performs a modified Broström procedure using local tissue usually with one anchor in the distal anterior fibula.

Dr. Saxena supports ankle arthroscopy as long as the arthroscopic portion is not significantly long (usually 20 minutes but up to 40 minutes if a chondral defect needs microfracture). At a panel discussion at the American Academy of Podiatric Sports Medicine Annual Meeting, Dr. Saxena notes there was consensus that most patients with lateral ankle instability do not need arthroscopy unless they have a loose body or chondral defect.

An arthroscopic approach is not necessarily more effective than an open procedure and is associated with more nerve injury, notes Dr. Saxena, who is affiliated with the Department of Sports Medicine at the Palo Alto Medical Foundation. Dr. Baravarian performs arthroscopic repair adjunctively on all his ligament repair cases but doesn’t recommend arthroscopy as a primary repair, saying it does not address the instability in any way.