Additional treatment methods for plantar fasciitis
Let's say that you've had painful plantar fasciitis for at least 4 months that has failed to respond to traditional conservative care. You've tried stretching, you've used heel lifts and you've had in-office physical therapy to include ultrasound and electric stimulation. You've tried a night splint and have used your Rx orthotics religiously. You've tried two cortisone shots and have been on an oral anti-inflammatory medication for several months. You've read a lot on the Internet and have a good understanding regarding the causes of plantar fasciitis. But you're not a fan of surgery. What can you do? How can you treat plantar fasciitis without surgery? There are actually a lot of options that are used as alternatives to surgery. The problem with the alternatives though is that they are not consistently reliable. Sure, surgery has its risks, but an endoscopic plantar fasciotomy has a successful and reliable outcome. What about the 'other' treatments. What are some of the alternatives?
First, let's talk a little bit about why these alternative methods are used. Some providers believe that the fascia simply shouldn't be cut. Their belief is that once the fascia is cut it causes irreparable harm to the biomechanical function of the foot. I can understand this logic. From my perspective as a surgeon, I've seen my fair share of complications following endoscopic plantar fasciotomy (EPF). Lateral column syndrome is what I consider to be the most unpredictable complication of EPF surgery. Lateral column syndrome is pain the occurs as the patient begins to get active again following fasciotomy. The pain of lateral column syndrome is much like a stress fracture. In fact, that is how I describe this complication to my surgery patients. So in part, the 'save the fascia' approach to chronic plantar fasciitis is understandable. Lateral column syndrome is not a common complication and occurs in up to 10% of endoscopic plantar fasciotomy patients. Lateral column syndrome resolves with several months of care.
Another consideration is the difference between plantar fasciitis and plantar fasciosis. The suffice 'itis' denotes an acute, inflamed condition. The suffice 'osis' denotes a 'condition of' where pain is still present but without the inflammatory component. An interesting study was performed that sampled the tissue of the plantar fascia where the tissue was evaluated under a microscope to determine the number of inflammatory cells that were present. What these researchers found was that over several months, the cell structure of tissue in the plantar fascia changed from acutely inflamed to showing fewer and fewer inflammatory cells. The theory then is that in time (over months), plantar fasciitis changes from an inflamed condition to a non-inflammatory condition. What these researchers recommended was to use treatment methods that re-initiated inflammation in the fascia. By doing so, the body could then heal the condition as an acute condition. I think it's an interesting theory, quite honestly. And there's a number of ways to go about 'jumpstarting' the inflammation. My impression is that the 'other methods' are primary used to spare the fascia and to restart the inflammatory component of plantar fasciitis.
ESWT - Extracorporeal shock wave therapy is a sound wave that is used to treat plantar fasciitis. Although there is no consensus as to how shock wave therapy works, I believe it to work by restarting the inflammatory component of fasciitis. Shock wave therapy employs a pulsed ultrasound wave. The shock wave therapy is performed under sedation at a surgery center or hospital. Think of the shock wave as a punch, just like you took your fist and punched the heel, except that the ultrasound has the capacity to penetrate deep into tissue. I trained some time ago in pulsed shock wave therapy and have used it on just a handful of patients. The literature cites a success rate of about 60%.
Platelet Rich Plasma (PRP) - Platelet-rich plasma is interesting in that it uses your own plasma to heal plantar fasciosis. Serum is the liquid portion of your blood. To use PRP, 50cc of your blood is drawn and placed in a centrifuge to spin off the cellular component of your blood. The plasma is rich in platelets that contain human growth factor. The plasma is then injected into the heel in the area of the plantar fasciosis. PRP has been around for years but has failed to gain traction with providers. PRP is not covered by insurance so it is typically a cash out of pocket procedure. PRP has many applications including wound care and surgical closure. Success rates vary and to date, the use of PRP is not consistently accepted as a reliable procedure in the treatment of plantar fasciitis and plantar fasciosis.
Rolfing - Rolfing is deep tissue massage that is used to restart the inflammatory phase of plantar fasciosis. Rolfing is a common practice in massage therapy and chiropractic offices. I've not tried it in my practice - it sounded painful. Rolfing is a manual massage method often performed with a knuckle of the finger.
Topaz surgery - Topaz surgery was popular for a few years but I've not seen it used very often as of late. Topaz employs a method called radiofrequency ablation. The Topaz technique uses a wand about the size of a piece of spaghetti. The wand is inserted percutaneously and when activated creates a small thermal burn at the site of treatment. Again, this is a method of reinitiating the inflammatory component of plantar fasciitis. And by doing so, you're calling on the chemical and cellular components of the body to heal plantar fasciitis.
Needling or stippling - needling is used to jump-start inflammation. The plantar heel is anesthetized with local anesthetic and a hypodermic needle is used to pierce the fascia. This pierced fascia reinitiates the inflammatory process, changing the condition from plantar fasciosis to the acute form, plantar fasciitis.
Tenex FAST - Tenex is a relatively new technique that uses ultrasound-guided, ultrasonic debridement of the fascia. FAST stands for focused aspiration of scar tissue. Tenex FAST is used to treat tennis elbow, shoulder pain, osteoarthritis of the knee and ankle, along with plantar fasciitis. When we specifically speak of treating plantar fasciitis with the Tenex method, I think it's debatable whether the true action of the Tenex procedure is actually removal of scar tissue or re-initiation of the acute (fasciitis) stage of the condition from the dormant condition of fasciosis. To date, the success rate of the Tenex FAST procedure has not been published in the literature.
Heel pads with bars of varying density - one of the products that we sell on the site has gained very little attention but I think it's one of those sleeper products used to treat plantar fasciitis and plantar fasciosis. It's called The Plantar Fasciitis Reliever. The Plantar Fasciitis Reliever uses three interchangeable bars of varying densities to 'massage' the plantar heel. Honestly, I think the bars work to re-stimulate inflammation just like Rolfing. Although it's not a particularly popular product, I think it's an innovative approach to the treatment of plantar fasciitis.
I'm sure that there are more methods that are being used to treat plantar fasciitis and plantar fasciosis that I'm not aware of. I think the interesting thing about this though is that any time you see multiple treatment methods what you're actually seeing is a lack of consensus among providers. If one method of treatment was universally reliable, we would all be doing the same thing. But in the treatment of plantar fasciitis, that's not the case. As I've mentioned in previous posts, it's important to speak with your doctor and see what their opinion is about these different methods. Each has its pros and cons and it's important to see what your doctor feels is best for your case.
Additional topics in the blog series include -
Plantar fasciitis | History
Plantar fasciitis | Causes and contributing factors
Plantar fasciitis | Differential diagnosis of heel pain
Plantar fasciitis | Conservative methods of care
Plantar fasciitis | Surgical treatment
Plantar fasciitis | Surgical complications