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Emerging Therapies for Heel Pain – What Works? Jason R

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Emerging Therapies for Heel Pain – What Works? Jason R Emerging Therapies for Heel Pain – What Works? Jason R. Miller, DPM, FACFAS, FAPWCA Director- Pennsylvania Intensive Lower Extremity Fellowship Residency Director- Phoenixville Hospital PMSR/RRA Associate Professor- Adjunct Department of Surgery- Temple University School of Podiatric Medicine Premier Orthopaedics and Sports Medicine, Malvern PA Musculoskeletal-Plantar Fasciosis • Widely called plantar fasciitis, but fasciosis is more appropriate 1 • Histopathology of PF of 50 patients who underwent surgery • Findings: fragmentation and degeneration of PF without inflammation • Corticosteroid injections? Lemont et al. say NO. • Over a lifetime, 10% of the general population will experience PF or plantar heel pain 2 • Peak age of incidence: 40-60 y.o • Risk factors: excessive running (or sudden increase), occupational (prolonged standing), pes planus, ankle equnius, and obesity. 1. Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc 2003; 93: 234-237 2. Ajimsha MS, Binsu D, Chithra S. Effectiveness of myofascial release in management of plantar feel pain: a randomized control trial. Foot (Edinburg, Scotland) 2014;24(2):66-71. Other Plantar Fascia related pathology • Plantar fascia rupture • Hx of chronic PF, pes planus • Acute pain and ecchymosis • Plantar fibromatosis • non-malignant thickening of PF 1. Al Kline. Plantar fascial rupture in the foot: a case report. The Foot and Ankle Online Journal 2009;2(5):4. Musculoskeletal-Fat pad atrophy • Heel fat pad absorbs about 20- 25% of the contact force at heel strike. • Risk factors: over age 40, obesity, excessive heel injections • Thinning of calcaneal fat pad • Less shock absorbency with loss of water/collagen/elastic tissue 1. Morag E, Lemmon DR, Cavangh PR. What role does plantar soft tissue stiffness play in determining peak pressure under the heel? Gait Posture . 1997;5:164 . PF vs FPA • Retrospectively studied 113 PF subjects, 37 FPA subjects, and 23 with both • Most common characteristics of each are compared below Plantar Fasciosis Fat Pad Atrophy -Post-static dyskinesia -No PSD. Night pain -Relief after walking -Pain after long walk/standing -Unilateral -Bilateral -Often medial calcaneal tenderness -Often plantar-central tenderness 1. Yi TI, Lee GE, Seo IS, Huh WS, Yoon TH, Kim BR. Clinical characteristics of the causes of plantar heel pain. Ann Rehabil Med 2011;35:507-513. MSK • Stress fracture • Tuning fork? • Lateral squeeze • Enthesopathy fracture • Sever’s disease • Child with heel pain, do NOT assume PF • OM MSK • FHL tenosynovitis 1 • Dancers and long distance runners • Cavus foot • Uncompensated poor shock absorption • Pronatory compensation increase tensile stretch on PF 1. Romano N, Fischetti A, Migone S, Barbieri F, Pizzorni C, Garlaschi G, Cimmino MA. Plantar pain is not always fasciitis. Reumatismo 2017; 69 (4): 189-190. Metabolic and Arthritic • Psoriatic arthritis 1 • About 25% of patients with skin manifestations had arthritic symptoms • Among those with PA, 54% reported heel pain. • Ankylosing spondylitis • Younger males with low back pain (SI fusion, bamboo spine) • Enthesopathy of medial calcaneal tubercle 1. Bezza,A, Niamane,R, et al. Involvement of the foot in patients with psoriatic arthritis. Joint Bone Spine, 2004;71(6):546-9. Metabolic and Arthritic • Reactive arthritis 1 • Heel pain is 2 nd most common presenting symptom (44% in study group). “Lover’s Heel” • Tetrad: conjunctivitis, urethritis, arthritis and mucocutaneous lesions (Keratoderma blennorrhagicum ) • Inflammatory bowel disease 2 • Crohn’s and Ulcerative Colitis • Pain in heel and joints (especially knee) often present before GI symptoms 1. Prakash,S, Bansal,R, et al. Immunological studies in seronegative spondyloarthropathies. British Journal Rheumatology, 1983, 22(3) 2. Veys,EM, Mielants,H. Enteropathic arthritis. Current Opinion Rheumatology. 1993,5(4):454-60. Metabolic and Arthritic • Rheumatoid arthritis 1 • Joints are affected most in foot, but 21% of study patients had daily heel pain. • Rheumatoid nodules in calcaneus heel pain • Juvenile rheumatoid arthritis 2 • 319 patients (7-12 y.o). 95% had limp, and 95% had heel pain • Limp alone quick diagnosis of JRA • Limp with heel pain took 2x as long to make diagnosis • SLE: heel pain in immediate post-pubescent females 1. Thomas, WH. Rheumatoid arthritis of the ankle and foot. In: R.R. Cooper (Ed.)AAOS Instructional course lectures. Vol.28. CV Mosby, St. Louis; 1979:325- 336. 2. Shiff, NJ, Lix,LM, et al. Chronic inflammatory arthritis prevalence estimates for children and adolescents in three Canadian provinces. Rheumatol Int. 2015 Feb;35(2):345-350. Other Metabolic and Arthritic Causes • Gout • CPPD (pseduogout) • Hyperparathryoidism (Brown tumor) • Hemochromatosis • CREST • Osteoporosis • Paget’s disease of bone • Diffuse idiopathic skeletal hyperostosis Neurological • Tarsal tunnel syndrome • Tibial nerve entrapment: post-op scarring, varicosities, soft tissue masses, overpronation • Medial plantar nerve entrapment • Neuro heel pain: Tinel’s. Burning/radiating. Pain at rest. • Baxter’s neuritis • 1st branch of lateral plantar nerve • Pain worsens with ambulation • EMG demonstrates obstructive signal • Nerve to Abductor digiti minimi • Can the patient abduct his/her 5 th toe? Neurological • Lumbar Radiculopathy • L4-S1 (foraminal stenosis, disc herniation) • Straight leg raise + • Piriformis syndrome • Sciatic nerve impingement at piriformis muscle Peripheral neuropathies • Toxins (Lead, Arsenic, Mercury) • DM • HIV • Alcohol • Endocrine (hypothyroid) • Nutritional (Vit B12, B6) • Gullian-Barre • Recurrence of GB • Amylodosis • Porphyria • Infection (Syphilis, TB, Leprosy, Lyme disease) • Sarcoidosis • Tumor/Trauma Vascular • Isolated heel pain secondary to arterial infarct is RARE Bone Tumors: benign • Unicameral bone cyst • Fallen fragment sign, painful pathological fracture • Aneursymal bone cyst • Generally painful • Intraosseous lipoma • Osteochondroma • Osteoid Osteoma • Pain at night, relieved by aspirin • Osteoblastoma • “large osteoid osteoma” pain not relieved by aspirin Bone Tumors • Osteosarcoma • Children, and adults with Paget’s • Chondrosarcoma • Adults over 40 • Ewing’s Sarcoma Standard Conservative Treatment Options • PT/Soft tissue mobilization • Iontophoresis • Orthotics • Steroid injection • Low Dye taping • Cam boot • Night splints Newer Alternative Treatment Options • Platelet-rich plasma (PRP) • Centrifuged concentrate platelet levels induce cell growth and tissue healing • Extracorporeal shock wave therapy (EPAT) FDA 2005 • Shock waves Controlled microtrauma stimulate healing & micro- vascularization • Dry Needle Technique (MTrP) • Needle (without steroid) at myofascial trigger point. • Low-level laser therapy (LLLT) • Visible or invisible laser at body surface enhance mitochondrial activity cell and microvascular proliferation alleviate degeneration • External Radiotherapy • Safe, low doses of ionizing radiation (x-ray, Co-60) reduce inflammation pain relief • Amnion/Stem Cell injections Surgical Treatment Options • Open plantar fasciectomy • Endoscopic plantar fasciotomy • Percutaneous radiofrequency microdebridement therapy • Ultra-sound guided Percutaneous ultrasonic microdebridement ESWT/Focused Shock Wave/Radial Shock Wave Meta Analysis • 9 studies involving 935 patients were included. • ESWT had higher improvement rates than the placebo group (OR 2.58, 95% confidence interval [CI] 1.97–3.39, P < .00001). • ESWT had markedly lower standardized mean difference than placebo, with heterogeneity observed (standardized mean difference 1.01, 95% CI −0.01 to 2.03, P = .05, I2 = 96%, P < .00001). • FSW and RSW therapies had greater therapeutic success in pain relief than the placebo group (OR 2.17, 95% CI 1.49–3.16, P < .0001; OR 4.63, 95% CI 1.30– 16.46, P = .02), but significant heterogeneity was observed in RSW therapy versus placebo ( I2 = 81%, P = .005) Sun et al, Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis A meta-analysis of RCTs Medicine (Baltimore) . 2017 Apr; 96(15): e6621. Dry Needling (MTrP) • Dry needling showed statistically significant 1 reduction in plantar heel pain (VAS) vs sham needling (placebo in blinded study) at 12 week f/u • 1 treatment per week, 6 weeks. • Compared to steroid injections 2. N= 66 • Steroid injections reduced pain more rapidly (first 3 weeks) • Dry needling reduced pain in long term (1 year follow-up) 1. Cotchett MP, Muneanu SE, Landorf KB. Effectiveness of trigger point dry needling for plantar heel pain: a randomized control trail. Physical therapy 2014;94(8):1083-1094 2. Rastegar S, Mahdavi SB, Hoseinzadeh B, Badiei S. Comparison of dry needling and steroid injection in the treatment of plantar fasciitis: a single-blinded randomized control trial. International Orthopaedics (SICOT) 2018;42:109-116. Dry Needling Meta Analysis • Extensive literature search yielded 1,941 articles, of which only seven RCTs met the inclusion criteria and were included in the meta- analysis. • The pooled results showed that MTrP needling significantly reduced the VAS score (WMD =−15.50, 95% CI: −19.48, −11.53; P<0.001) compared with control • Similar success rate for pain with control (risk ratio [RR] =1.15, 95% CI: 0.87, 1.51; P=0.320). • Moreover, MTrP needling was associated with a similar incidence of adverse events with control (RR =1.89, 95% CI: 0.38, 9.39; P=0.438) Chunhui et al Effectiveness of trigger point dry needling for plantar heel pain:
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