Study: Radial ESWT Superior To Corticosteroids For Plantar Fasciitis

The longer duration of action of radial extracorporeal shockwave therapy (ESWT) makes it superior to corticosteroid injections for chronic plantar fasciitis, according to a recent study.

Authors of the randomized study, published in the Journal of the American Podiatric Medical Association, focused on 72 patients with unilateral plantar fasciitis, who received either radial ESWT once a week for three weeks or corticosteroid ultrasound-guided injection consisting of one 1 mL dose of betamethasone sodium plus 0.5 mL of prilocaine. Researchers found the radial shockwave patients experienced “significant improvements” in measures such as Visual Analog Scale scores, Foot Function Index scores, heel tenderness and plantar fascia thickness, and maintained those improvements at follow-up exams. In comparison, the study notes the patients in the corticosteroid group saw improvements in the same measures but did not maintain the improvements during follow-up at one, three and six months.

Extracorporeal shockwave addresses the root cause of plantar fasciitis, not just the pain, according to Nicholas Romansky, DPM, FACFAS, a Diplomate of the American Board of Foot and Ankle Surgery. As he notes, the rationale is treating pain at the insertion and connective tissue, restoring the extensibility of the tissue, and relieving stress on the fascia. He adds that ESWT increases neovascularization.

Lowell Weil Jr., DPM, FACFAS, cites several advantages of radial ESWT, saying it is non-invasive, treatment can occur in the office, patients can bear weight immediately and there is no disruption of activities of daily life. In addition, he notes radial shockwave can provide improvements as quickly as the first treatment, offers long-term improvement and has evidence-based medicine showing its results are comparable to surgery without any complications.

Brian Fullem, DPM, says ESWT has proven to work more effectively than any other treatment studied for plantar fasciitis. He notes a disadvantage that patients may take up to 12 weeks to see results because the main beneficial effect of the treatment is the development of new blood vessels, which takes time to happen.   

In contrast, corticosteroids have a disadvantage in that one can only give the injections three time per year per location, says Dr. Romansky, who is in private practice in Pennsylvania. He notes corticosteroids can damage tissue, which can outweigh the good they can do for chronic heel pain.

Dr. Weil says corticosteroids can provide immediate relief but cautions that people who get immediate relief will be unlikely to change the things that caused the problem to begin with and thereby create a more long-term, chronic problem. Although corticosteroids do produce “very good short-term pain relief,” the injections do not have lasting effects, according to Dr. Fullem, a Fellow of the American Academy of Podiatric Sports Medicine, who is in private practice in Clearwater, Fla.

If Dr. Fullem has an athletic patient with a competition coming up, he would be more inclined to try a cortisone injection. If someone has plantar fasciitis for longer than three months and has tried different therapies that have been ineffective, then he would encourage the patient to consider ESWT.

“I rarely use cortisone any longer and have utilized placenta-derived injections,” says Dr. Weil, the CEO of the Weil Foot, Ankle and Orthopedic Institute. “The future of treating these kinds of conditions is through regenerative medicine. Cortisone is damaging, not regenerative. Just because cortisone can provide pain relief doesn’t mean it’s good for the patient.”

How Effective Is Radiofrequency Microdebridement For Achilles Tendinosis?

By Brian McCurdy, Managing Editor

For Achilles tendinosis, a new study in the Journal of Foot and Ankle Surgery says radiofrequency microdebridement is no more effective than surgical decompression.

Authors compared radiofrequency microdebridement with the Topaz Microdebrider Wand (Smith and Nephew) and traditional surgical decompression in 16 patients with Achilles tendinosis. The study notes that six months following treatment, both groups showed improvement in the Victorian Institute of Sports Assessment–Achilles and Visual Analog Scale scores. The authors note they have stopped using Topaz to treat Achilles tendinosis.

Bob Baravarian, DPM, FACFAS, notes radiofrequency microdebridement breaks up the scar tissue, causes neovascularization and also destroys the small nerve fibers that cause pain. There is no real disadvantage to Topaz treatment except that large amounts of scar tissue are hard to treat with microdebridement, says Dr. Baravarian, an Assistant Clinical Professor at the UCLA School of Medicine and the Director of the University Foot and Ankle Institute in Los Angeles.

Dr. Baravarian emphasizes that radiofrequency microdebridement also breaks up the nerve fibers in the area that cause pain and one can perform radiofrequency microdebridement percutaneously with less risk of scar tissue and infection.

When patients have less than 50 percent of the tendon affected by tendinosis, Dr. Baravarian prefers percutaneous debridement with radiofrequency. If more than 50 percent of circumference is involved, he will do open microdebridement as it may require a flexor tendon transfer.

Study Examines Quality Of Life And Function After Transtibial Amputation

By Brian McCurdy, Managing Editor

Following transtibial amputation, 75 percent of patients with diabetes related good quality of life and function scores, according to a study in the International Journal of Lower Extremity Wounds.

Researchers evaluated 81 patients with at least one year of follow-up after a transtibial amputation. The median Short Form Survey (SF-36) physical component score results for patients improved from 26.2 to 36.6 after surgery. In addition, the median mental component score on the SF-36 improved from 43.7 to 56.1 following surgery, authors note. The study authors also noted improvements in Foot and Ankle Ability Measure scores for activities of daily living and sports.

How does transtibial amputation compare with other forms of amputation in regard to quality of life? Study coauthor Javier La Fontaine, DPM, says the quality of life of patients with transtibial amputation is very similar to that of patients with other forms of amputation as long as the patients have a good potential for rehabilitation and acquire a prosthesis. Otherwise, he says quality of life decreases and mortality rates increase in the transtibial amputee.

Dr. La Fontaine cites three instances in which the transtibial amputation is indicated: when healing can only occur at that level, when infection has invaded the lower extremity and/or when the potential for ambulation/functionality is better with the transtibial amputation than the current foot pathology being treated.

It is important to differentiate between patient satisfaction and quality of life, notes Dr. La Fontaine, a Professor in the Department of Plastic Surgery at the University of Texas Southwestern Medical Center.
Often, he says patients are not satisfied with the outcome being discussed but they do not understand that how much better or worse they are can be dependent on the decision they are making. For example, Dr. La Fontaine says often patients would rather keep a dry, gangrenous toe than have a transtibial amputation, rehabilitate, get fitted for prosthesis and move on with their daily activities.