Search Results
Background: Human amniotic membrane contains growth factors and cytokines, which promote epithelial cell migration and proliferation, stimulate metabolic processes leading to collagen synthesis, and attract fibroblasts, while also reducing pain and inflammation. Randomized studies have shown that micronized dehydrated human amnion chorion membrane (mdHACM) allograft injection is an effective treatment for plantar fasciitis. Our objective is to present our experience with using mdHACM injection as a treatment for Achilles tendinopathy and report short term treatment outcomes. Methods: Included in this retrospective case series were patients diagnosed with Achilles tendinopathy treated with mdHACM by a single physician were identified from an electronic medical record system. Included for analysis were those with at least 2 follow up visits within 45 days of mdHACM injection. Outcomes examined included change in reported level of pain during the 45-day observation period and adverse events associated with treatment. Results: Follow-up data were available for 32 mdHACM-treated patients and abstracted from the electronic medical record. At treatment initiation 97% of patients reported severe (66%) or moderate (31%) pain. At first follow-up visit (mean 8.1 {plus minus} 2.7 days after injection), 84% (27/32) had reported improvement in pain levels, although 37% of patients continued to report severe (6%) or moderate (31%) pain. At the second follow-up visit (mean 23.1 {plus minus} 6.2 days after injection), no patients reported severe pain and one reported moderate pain. Within 45 days of mdHACM injection complete resolution of symptoms was reported by 66% of treated patients (n=21) with the remaining 34% reporting improvement but not complete resolution (n=11) of their symptoms. Two patients reported calf or quadricep pain or tightness post-injection. Conclusions: In a single practice mdHACM injection reduced or eliminated pain in all patients where follow-up data was available.
Letters to the Editor
Effectiveness of Extracorporeal Shockwave Treatment in 353 Patients with Chronic Plantar Fasciitis
Background
The definition of equinus varies from less than 0° to less than 25° of dorsiflexion with the foot at 90° to the leg. Despite its pervasive nature and broad association with many lower-extremity conditions, the prevalence of ankle equinus is unclear. Furthermore, there are few data to suggest whether equinus is predominantly a bilateral finding or isolated to the affected limb only.
Methods
We conducted a prospective cohort study examining consecutive patients attending a single foot and ankle specialty practice. Participation involved an assessment of ankle joint range of motion by a single rater with more than 25 years of clinical experience. We defined ankle equinus as ankle joint dorsiflexion range of motion less than or equal to 0° and severe equinus as less than or equal to –5°. Patients who had previously experienced an Achilles tendon rupture, undergone posterior group lengthening (ie, Achilles tendon or gastrocnemius muscle lengthening), or had conservative or surgical treatment of equinus previously were excluded.
Results
Of 249 included patients, 61% were female and 79% nondiabetic. The prevalence of ankle equinus was 73% [183 of 249], and nearly all of these patients had bilateral restriction of ankle joint range of motion (prevalence of bilateral ankle equinus was 98.4% [180 of 183] among those with equinus). We also found that ankle equinus was more common in patients with diabetes, higher body mass indexes (BMIs), or overuse symptoms.
Conclusions
The prevalence of ankle equinus in this sample was higher than previously reported, and nearly all of these patients had bilateral involvement. These data suggest that many people attending foot/ankle specialty clinics will have ankle equinus, and select groups (diabetes, increased BMI, overuse symptoms) are increasingly likely.
Letters to the Editor
Effectiveness of Extracorporeal Shockwave Treatment in 353 Patients with Chronic Plantar Fasciitis
We report the case of a 40-year-old female patient presenting with resistant heel pain attributable to plantar fascia rupture. She was treated with ultrasound-guided platelet-rich plasma injection, and her pain was decreased. Additionally, ultrasound was useful for diagnosis, intervention and follow-up of the patient.
Ultrasound-guided Plantar Fascia Release Technique
A Retrospective Study of 46 Feet
Background: Ultrasound-guided plantar fascia release offers the surgeon clear visualization of anatomy at the surgical site. This technique uses small arthroscopic dissecting instruments through a 0.5-cm incision, allowing the surgeon to avoid the larger and more tissue-disruptive incision that is traditionally used for plantar heel spur resection and plantar fascia releases.
Methods: Forty-one patients (46 feet) were selected for the study. The mean patient age was 47 years. Twenty-nine were considered obese with a body mass index greater than 30 kg/m2. Patients were functionally and subjectively evaluated 4 weeks after surgery using the American Orthopedic Foot and Ankle Society Ankle and Hindfoot Rating Scale.
Results: Results from the study show a significant improvement (P = .05 confidence level) 4 weeks postoperatively for the 41 patients (46 feet), compared to their preoperative condition. The mean pretest score was 33.6 (range 10–52); this score improved to 88.0 (range 50–100), 4 weeks postoperatively. There were no postoperative infections or complications.
Conclusions: The ultrasound-guided plantar fascia release technique is a practical surgical procedure for the relief of chronic plantar fascia pain because the surgeon is able to clearly visualize the plantar fascia by ultrasound. In addition, there is minimal disruption to surrounding tissue because small instruments are passed through a small 0.5-cm incision. The traditional open method of heel spur surgery, in contrast, uses a larger skin incision of 3 to 5 cm, followed by larger instruments to dissect to the plantar fascia. (J Am Podiatr Med Assoc 99(3): 183–190, 2009)
Efficacy of Taping for the Treatment of Plantar Fasciosis
A Systematic Review of Controlled Trials
Background: The proximal insertional disorder of the plantar fascia is plantar fasciosis. Although plantar fasciosis is frequently seen by different health-care providers, indistinctness of etiology and pathogenesis is still present. A variety of interventions are seen in clinical practice. Taping constructions are frequently used for the treatment of plantar fasciosis. However, a systematic review assessing the efficacy of this therapy modality is not available.
Methods: To assess the efficacy of a taping construction as an intervention or as part of an intervention in patients with plantar fasciosis on pain and disability, controlled trials were searched for in CINAHL, EMBASE, MEDLINE, Cochrane CENTRAL, and PEDro using a specific search strategy. The Physiotherapy Evidence Database scale was used to judge methodological quality. Clinical relevance was assessed with five specific questions. A best-evidence synthesis consisting of five levels of evidence was applied for qualitative analysis.
Results: Five controlled trials met the inclusion criteria. Three trials with high methodological quality and of clinical relevance contributed to the best-evidence synthesis. The findings were strong evidence of pain improvement at 1-week follow-up, inconclusive results for change in level of disability in the short term, and indicative findings that the addition of taping on stretching exercises has a surplus value.
Conclusions: There is limited evidence that taping can reduce pain in the short term in patients with plantar fasciosis. The effect on disability is inconclusive. (J Am Podiatr Med Assoc 100(1): 41–51, 2010)
Background: Although there are studies showing that extracorporeal shockwave therapy (ESWT) and instrument-assisted soft-tissue mobilization methods are effective in chronic plantar heel pain (CPHP) treatment, there is a need for studies comparing these techniques. We compared the effectiveness of ESWT versus instrument-assisted soft-tissue mobilization using Graston Technique (GT) instruments in addition to stretching exercises (SEs) in CPHP.
Methods: Sixty-nine patients were randomly assigned to three groups: ESWT+SEs (group 1), GT+SEs (group 2), and SEs only (control group) (ratio, 1:1:1). The SEs, twice daily for 8 weeks, were standard for all. Group 1 received low-intensity ESWT; in group 2, GT was the selected method. Visual analog scales (for initial step and activity pain), the Foot Function Index (FFI), the 12-item Short-Form Health Survey (SF-12), and the Tampa Scale for Kinesiophobia were used pretreatment, posttreatment, and at 8-week and 6-month follow-up.
Results: Visual analog scale and FFI scores improved posttreatment and during follow-up in all groups (P < .001). Although effect sizes were greater in groups 1 and 2 than in the control group in initial step pain posttreatment and at 8-week follow-up, group 2 had the highest effect size at 6 months. Mean SF-12 scores in groups 1 and 2 improved on the posttreatment assessment. Furthermore, group 2 showed significant improvements in FFI scores compared with the other groups at 6-month follow-up (F = 6.33; P = .003).
Conclusions: Although ESWT+SEs and GT+SEs seem to have similar effects on initial step pain posttreatment and at 8-week follow-up, GT+SEs was found most effective for improving functional status at 6 months in the management of CPHP.
Use of Primary Corticosteroid Injection in the Management of Plantar Fasciopathy
Is It Time to Challenge Existing Practice?
Plantar fasciopathy (PF) is characterized by degeneration of the fascia at the calcaneal enthesis. It is a common cause of foot pain, accounting for 90% of clinical presentations of heel pathology. In 2009–2010, 9.3 million working days were lost in England due to musculoskeletal disorders, with 2.4 million of those attributable to lower-limb disorders, averaging 16.3 lost working days per case. Numerous studies have attempted to establish the short- and long-term clinical efficacy of corticosteroid injections in the management of PF. Earlier studies have not informed clinical practice. As the research base has developed, evidence has emerged supporting clinical efficacy. With diverse opinions surrounding the etiology and efficacy debate, there does not seem to be a consensus of opinion on a common treatment pathway. For example, in England, the National Institute for Clinical Health and Excellence does not publish strategic guidance for clinical practice. Herein, we review and evaluate core literature that examines the clinical efficacy of corticosteroid injection as a treatment for PF. Outcome measures were wide ranging but largely yielded results supportive of the short- and long-term benefits of this modality. The analysis also looked to establish, where possible, “proof of concept.” This article provides evidence supporting the clinical efficacy of corticosteroid injections, in particular those guided by imaging technology. The evidence challenges existing orthodoxy, which marginalizes this treatment as a secondary option. This challenge is supported by recently revised guidelines published by the American College of Foot and Ankle Surgeons advocating corticosteroid injection as a primary treatment option. (J Am Podiatr Med Assoc 103(5): 418–429, 2013)
