May-09

Can Peppering Augment Injections For Plantar Fasciitis?

By Brian McCurdy, Senior Editor

   A new study in the Journal of the American Podiatric Medical Association (JAPMA) concludes that a peppering injection technique can boost the effect of corticosteroids and provide greater pain relief.

   The prospective, randomized, multicenter study consisted of 100 patients divided into four groups of equal sizes. Patients in group A received a 2 mL injection of autologous blood. Group B received 2 mL of lidocaine along with peppering injections. Group C received 2 mL of the corticosteroid triamcinolone (Kenalog, Bristol Myers-Squibb). Group D received 2 mL of triamcinolone plus peppering. Follow-up occurred at three weeks and six months after injection.

   Researchers determined that at three weeks post-injection, the combination of corticosteroid injections with a peppering technique (Group D) facilitated the lowest pain level out of the four patient groups. At six months post-injection, the Group D patients had “significantly lower” pain levels than those groups that had autologous blood or local anesthetic injections alone. The authors conclude that corticosteroid injection with peppering can be a first alternative in plantar fasciitis for patients in whom other conservative methods have failed.

   How does peppering work? The study authors would insert the needle, inject, withdraw without emerging from the skin, slightly redirect the needle and reinsert the needle. According to the JAPMA article, the authors would feel a “cracking” sensation during the injection and would continue the injections “until this sensation was lost.” They hypothesize that the peppering technique may create new channels through the degenerative myxoid tissue in which bleeding occurs.

What Is The Verdict On Peppering?

   Patrick Nunan, DPM, a Fellow and Past President of the American Academy of Podiatric Sports Medicine, says corticosteroids are relatively inexpensive and easy to use. The main advantage of corticosteroid injections is that they break the pain cycle of plantar fasciitis, according to Charles Peebles, DPM, a Fellow of the American College of Foot and Ankle Surgeons. If functional support, stretching and night splints do not work, Dr. Peebles says corticosteroids can reduce inflammation and assist with healing.

   Dr. Peebles does not think peppering would benefit standard corticosteroid injections. However, Dr. Nunan says several studies have shown the use of a peppering technique can decrease plantar fasciitis pain whether one uses the technique with radiofrequency devices, autogenous blood preparations or corticosteroids. Dr. Nunan does acknowledge that the use of radiofrequency devices or autogenous blood preparations “requires special equipment and may require conscious sedation from an anesthesiologist.”

   Stephen Barrett, DPM, notes that the peppering technique is essentially microdebridement of the plantar fascia, which stimulates the tissue cascade of healing. In his experience in using autologous platelet concentrate to treat severe cases of plantar fasciosis, Dr. Barrett says increased peppering (or what he prefers to call debridement) facilitates better clinical outcomes.

   Drs. Nunan and Barrett express concern about the peppering technique described by the study authors and suggest that high-resolution diagnostic ultrasound would be helpful in guiding injections.

   Dr. Barrett, an Adjunct Associate Professor in the Arizona Podiatric Medical Program at Midwestern University College of Health Sciences, has used diagnostic ultrasound to document definable objective changes both in thickness and signal intensity of the plantar fascia. He says his technique has evolved to the point where he can administer any of the injections painlessly.

Is Radiofrequency Nerve Ablation A Better Option Than ESWT?

By Lauren Grant, Editorial Assistant

   In recent years, physicians have considered extracorporeal shockwave therapy (ESWT) for plantar fasciopathy when they have exhausted conservative care modalities and prior to exploring surgical options. However, a recent study suggests that radiofrequency nerve ablation (RFNA) may have advantages over ESWT in treating plantar fasciopathy.

   The retrospective study, which was presented as a poster at the American College of Foot and Ankle Surgeons Annual Scientific Meeting, involved 24 patients with 36 feet affected by plantar fasciopathy. Researchers performed RFNA for these patients via the NeuroTherm NT-250 radiofrequency generator (NeuroTherm) and compared the results to those reported in a recent meta-analysis of 17 ESWT studies.

   The study authors found that 88.9 percent of RFNA patients demonstrated improvement in comparison to 75 percent of patients who had improvement after being treated with ESWT. The study also found faster response times with RFNA (one week) in comparison to ESWT patients, who reportedly may not notice a measurable improvement for up to 12 weeks in many cases.

    “Radiofrequency nerve ablation provides pinpoint accuracy directed at the source of pain. The risk is very minimal,” says Adam Landsman, DPM, PhD, the lead author of the study. “(The NeuroTherm device) we use measures the impedance between the probe and the nerve, and gives a very strong indication about how close you are to the target nerve. Once you have located the nerve, the device is pre-programmed to deliver the appropriate amount of heat to disrupt the nerve signal and pain source (without) damaging the adjacent tissues.”

   While pain management specialists and neurologists have used RFNA over the past 10 years, the technology has recently become more accessible to the point where it is an office-based procedure for podiatrists.

    “Placement of the probe is not much more difficult than giving an injection in this area but the relief lasts much longer than steroids and without the side effects normally experienced with injections,” notes Dr. Landsman, an Assistant Professor of Surgery at Harvard University.

   In addition to the efficacy of RFNA and minimal learning curve, Dr. Landsman says the cost-effectiveness of RFNA may lead to a more prominent role for the device in the armamentarium for plantar fasciopathy.

    “Reimbursement codes are already available and the cost of the (NeuroTherm device) is less than one-tenth that of an ESWT device,” points out Dr. Landsman. “In fact, with practice, you can perform RFNA in 10 minutes. Eventually, I think you will find physicians adopting this technology earlier in the treatment course rather than waiting for other methods to fail.”

Study: Ertapenem Is Effective Empiric Agent For Community-Acquired Infections

   A recent study in the Journal of Foot and Ankle Surgery concludes that ertapenem (Invanz, Merck) is an effective empiric antibiotic for patients with community-acquired lower extremity infections.

   The study was a retrospective review of 230 patients who had been treated for lower extremity infections with ertapenem. Researchers noted that 159 patients had diabetes and 85 were diagnosed with osteomyelitis. Of the 157 patients who had culture and sensitivity results, the study identified polymicrobial infections in 114 patients with an average of 2.46 organisms isolated per patient.

   Patients received a mean duration of 5.77 days of ertapenem therapy with 17 patients undergoing outpatient parenteral antibiotic therapy. The study noted a success rate of 79.13 percent.

   Ertapenem has good activity against a broad spectrum of mixed aerobic/anaerobic organisms, according to Matthew Nielsen, DPM, the lead author of the study. Dr. Nielsen says these organisms include Staphylococcus aureus, Streptococci, Enterobacteriacea, Peptostreptococcus and Bacteroides fragilis. He notes that the antibiotic does not cover the anaerobic bacteria Clostridium difficile and Lactobacillus and, in general, does not have reliable activity against Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus (MRSA), Enterococcus and Acinetobacter species.

   Dr. Nielsen notes that due to ertapenem’s once-a-day dosing and broad spectrum, it has the potential for outpatient parenteral antimicrobial therapy (OPAT). Using the carbapenem in OPAT may reduce healthcare costs by shortening hospital stay and decreasing the risk of nosocomial infection, says Dr. Nielsen, a second-year resident in the Department of Foot and Ankle Surgery at Western Pennsylvania Hospital in Pittsburgh.
—B.M.

In Brief

   Dr. Comfort was recently awarded the American Podiatric Medical Association’s (APMA) Seal of Acceptance for its line of men’s and women’s diabetic footwear, athletic shoes, heat-moldable elite inserts and Gel Plus inserts.