Study Compares Foot Orthoses Versus Corticosteroid Injection For Plantar Heel Pain

A recent study in the Journal of Orthopaedic and Sports Physical Therapy asserts that corticosteroid injection is more effective than arch-contouring foot orthoses for plantar heel pain at week four but orthotics are more effective at week 12. Additionally, the study authors also note that patients themselves may not notice a significant difference between the two treatment options.

In the randomized study, which involved 103 patients ranging between 21 and 72 years of age, participants received either full-length prefabricated orthoses that contoured the arch or a corticosteroid injection via ultrasound guidance. Researchers assessed foot pain scales via a Foot Health Status Questionnaire at four and 12 weeks post-treatment. Regardless of treatment group, researchers provided all patients with instructions for plantar fascia and calf stretching.

When using a visual analog scale (VAS), 18 percent of patients in the corticosteroid injection group reported symptom improvement at week four. At weeks eight and 12, 15 and 16 percent of those with foot orthoses reported overall improvement respectively.

The authors note future research should evaluate additive effects of these treatments as well as effectiveness after twelve weeks in a multicenter study. However, they advocate for educating patients with plantar heel pain that the effects of corticosteroid injection are meant to be a shorter-term solution. Additionally, patients should be aware that “appropriately contoured” foot orthoses are more effective long-term.

Paul Langer, DPM, relates the importance of getting patients to focus on the long-term. He notes that he typically starts treatment with footwear recommendations, if necessary, semi-rigid over-the-counter insoles, low-dye taping and stretching exercises. Then he will have patients follow up with him in two to four weeks if they do not have reduced pain. At this time, Dr. Langer, who is affiliated with Twin Cities Orthopedics in Minnesota, discusses corticosteroid injections as well as physical therapy, shockwave therapy and night splints.

In her practice, Alicia Canzanese, DPM, ATC, AACFAS, commonly utilizes corticosteroid injections in the acute stage of plantar heel pain. However, she maintains that a home therapy program, biomechanical examination, footwear and orthoses all play important roles.

Dr. Canzanese, who is in private practice in Glenside, Pa., feels the type of device may have had an impact on the study. Karen Langone, DPM, concurs and maintains that the lack of inclusion of true custom orthoses in the study is problematic.

“The design of this study is flawed and is emblematic of many orthotic effectiveness studies,” notes Dr. Langone, a Past President of the American Academy of Podiatric Sports Medicine and First Vice President of the American Association for Women Podiatrists.

Dr. Langer cites a 2011 study by Ferber and Benson in the Journal Of Foot And Ankle Research, who found that semi-rigid insoles relieved plantar fascial strain by 25 to 35 percent, and were more effective if contoured to the arch.

“I emphasize that gel, foam, or other soft insoles cannot relieve strain on the plantar fascia,” adds Dr. Langer, a Fellow of the American Academy of Podiatric Sports Medicine.

Dr. Langer and Dr. Canzanese both feel the study reinforces but does not change their current treatment protocols. Additionally, Dr. Langone relates that this study will not change her current treatment algorithm as she feels the study did not elaborate on a comprehensive treatment plan. Specifically, she points out the lack of detailed discussion of orthotic corrections, foot type, mobility, symptoms or weight of the patients.

“To me, the importance of this study is that it presents good data to use to educate our patients about their options,” comments Dr. Langer. Dr. Canzanese elaborates that a multifaceted approach is best: “Podiatrists can use the results of this study to help validate the use of multiple modalities to best treat heel pain.”  

Poll Says TUSPM Has Best Reputation Among Podiatry Colleges

By Jennifer J. Spector, DPM, Associate Editor

The Temple University School of Podiatric Medicine (TUSPM) came out on top in a recent Podiatry Today online poll asking which podiatry college has the best academic reputation.

The Temple University School of Podiatric Medicine garnered 29 percent of votes cast, followed by the Des Moines University College of Podiatric Medicine and Surgery, and the Dr. William M. Scholl College of Podiatric Medicine at the Rosalind Franklin University of Medicine and Science.

Andrew Meyr, DPM, cautions the poll’s sample size is small (n=209) and could be at risk for bias. “Education is not a competitive enterprise as all of the schools have relative strengths and weaknesses,” notes Dr. Meyr, an Associate Professor in the Department of Podiatric Surgery at TUSPM.

John Mattiacci, DPM, the Dean of TUSPM, agrees. “I believe every school and college does their best to maintain high academic standards given its constraints and resources,” notes Dr. Mattiacci.

“Students will get good training anywhere as long as they put in the appropriate effort and time,” adds Rami Basatneh, DPM, a recent graduate of TUSPM and a current resident at Detroit Medical Center. Dr. Basatneh also notes he felt very well prepared for podiatric clinical medicine during his externships.

That said, Dr. Basatneh, Mattiacci and Meyr all feel the Foot and Ankle Institute, TUSPM’s outpatient clinic, is a standout program. One of the highlights is the quantity and variety of pathology that students see, according to Dr. Meyr and Dr. Basatneh. Dr. Meyr also cites “the hands-on experience that we offer in the clinic, on rotation and in workshops.” Dr. Mattiacci adds that TUSPM has the largest full-time faculty and clinical operation among the podiatry colleges.

Dr. Mattiacci contends that recruitment of quality, motivated candidates with a genuine dedication to becoming a podiatrist is currently a universal challenge for the podiatry colleges.

Dr. Meyr provides additional feedback on the students’ role in the success at all of the podiatry colleges. “As teachers, we can only open the door, as the (Chinese) proverb says. It takes the students to walk through on their own,” notes Dr. Meyr.  

Study Evaluates Sesamoid Malalignment In Hallux Valgus

By Jennifer J. Spector, DPM, Associate Editor

M

easuring sesamoid rotation on MRI provides accurate assessment of the severity of hallux valgus and is a better indicator of sesamoid displacement than standard AP radiographs, according to a recent study in the British Journal of Radiology.

In the study, 56 patients had an X-ray and MRI on the same foot within three months. The study authors assessed non-rotational sesamoid displacement on both studies and examined the sesamoid rotation angle on MRI. They subsequently correlated these findings with the hallux valgus angle and morphologic characteristics of the hallux-sesamoid complex. The study cites poor inter-rater reliability for both modalities for lateral sesamoid displacement and tibial sesamoid position. However, the study authors noted better reliability for sesamoid rotation on MRI and qualitative features.

The sesamoid rotation angle correlated with the hallux valgus angle in the study while lateral sesamoid displacement and tibial sesamoid position lacked significant correlation. Lastly, no statistically significant correlation was seen between any sesamoid displacement measure and morphologic changes.

Mark Prissel, DPM, who is in private practice at Orthopedic Foot and Ankle Center in Westerville, OH, notes that hallux valgus is increasingly appreciated as a truly multiplanar deformity. With MRI being a non-weightbearing study, Dr. Prissel says he does not routinely use it to evaluate sesamoid rotation. However, he cites dorsoplantar, oblique, lateral and sesamoid axial radiographic views and weightbearing computed tomography (CT) as being valid in applicable cases.

Dr. Prissel stresses the importance of the complexities of the hallux valgus deformity.

“As the body of literature on the subtleties of hallux valgus increases, surgeons can develop better outcome-based treatment algorithms and focus on correcting each aspect of the deformity,” says Dr. Prissel, a Fellow of the American College of Foot and Ankle Surgeons.