Healing Heels

Plantar fasciitis is hard to escape these days. The most common cause of heel pain, it is easily the most common type of musculoskeletal sports injury I see in the office. Whether you’re Peyton Manning, an ultra marathoner, or a weekend warrior, it seems to affect people of all age groups, activity levels, gender, race, size and shape. It can be a quite debilitating injury with long delays in returning to your activity of choice. It can many times be stubborn and resistant to many conventional treatments. First line treatments often include targeted stretching and strengthening exercises, rest, icing, support for the fascia (in terms of strappings or orthotics), and many times we will add anti-inflammatory measures such as oral medications, topical medications, or steroid injections. Many times, these methods go a long way in relieving symptoms. Previously, when these treatment methods failed, the final resort would be surgery. However, more advanced pre-surgical treatments have become available including extra corporeal shock waver therapy, MLS laser therapy, PRP injections, and the FAST procedure.

Briefly and simply stated, the plantar fascia is a structure on the bottom (plantar surface) of the foot which originates on the heel bone, and runs along the arch of the foot, eventually splitting and sending slips to all five toes. The purpose of the plantar fascia is to help maintain the arch of the foot. Fascia is a tough tissue with some elasticity (picture a tendon rolled flat into a sheet). There are three main bands of the plantar fascia, and it Picture 1seems to be the medial band (and sometimes the medial portion of the central band) closer to the inside of the foot which causes all the problems. Leading theories believe that the fascia undergoes a series of micro traumas resulting in small tears, usually close to its bony origin (aka enthesis). Due to a notoriously poor blood supply, these tears usually heal with fibrous (scar) tissue which is denser and less elastic than the fascia is meant to me, and leads to pain in the heel. This pain usually starts as pain after periods of res, especially in the morning, but as the condition becomes more chronic, pain can occur throughout the day with increased activity.

Extra corporeal Shockwave therapy: So the name may sound a bit medieval, but this is a non-invasive therapy used for treating various musculoskeletal conditions and has been studied to have a positive benefit for plantar fasciitis. There are two forms of ECSWT, high energy and low energy. The high energy machine is used less often these days, and typically needed a local anesthetic block to avoid discomfort. Most practitioners will use low energy therapy in their office, also known as EPAT (or extracorporeal pulse activation technology). Essentially, the machine has a hand held device which creates an acoustic pressure wave which stimulates local metabolism, increased blood flow and anti- inflammatory factors. I often explain to patients that it’s sort of like tricking the body into thinking there is an injury somewhere that the body is then forced to try and heal, and helps incorporates the body’s own healing response. Patients usually undergo 3-5 treatments about a week apart. There are no real side effects (although there can be some discomfort during or after treatment), and there are typically no activity restrictions.

Picture 2MLS Laser: Cold lasers or pain lasers have been in use for a while. New pain lasers (class IV lasers) are now used to treat a variety of musculoskeletal conditions. Essentially, the MLS laser uses specific wavelengths of light that have strong anti-inflammatory and pain reducing effect on tissues that are exposed to the laser. Painful conditions accompanied by swelling or inflammation benefit the most. Photons of laser energy penetrate deeply into tissues and accelerate cellular reproduction and growth (it is believed the laser increases the amount of ATP available to cells, essentially the cellular “energy currency”). The goal is to decrease inflammation and increase healing time. The laser has no known negative side effects, although patients are asked to wear protective eyewear during the treatment. Typically, patients will have 6-10 laser therapy sessions.

Picture 3Protein Rich Plasma (PRP) Therapy: This minimally invasive treatment method has gained a lot of traction in sports medicine in recent years. Again, tissues like the plantar fascia and many tendons and ligaments, have a poor blood supply. In PRP therapy, your own blood is drawn, and then placed in a centrifuge. The centrifuge separates the blood into several component layers, one of which is the PRP layer which contains an aggregate of healing factors. The PRP is then placed in n syringe and is injected back into an area of poor blood supply, in an effort to ramp up the body’s natural healing mechanism. The procedure can be done in the office or operating room. Most patients will wear a Cam walker for some time after the procedure (typically 2-3 weeks)

Picture 4The Fast procedure from Tenex Health: The last minimally invasive technique to discuss is one of the newest, the Fast procedure. Again, due to a poor blood supply, as the micro-tears in the fascia heal, they leave behind thickened, fibrous, scar tissue. Using ultrasound imaging, we are able to identify the exact area of diseased (thickened) tissue. A micro-incision is then made, and a specialized probe is inserted through the incision, and uses ultrasonic energy to precisely break down and remove only diseased tissue without disturbing healthy tissue. This selectivity is a huge benefit of the procedure, along with the minimal incision and recovery time. Most patients will wear a protective boot for several weeks after the procedure.

Picture 5So, if you’re suffering from a stubborn case of plantar fasciitis, that has not responded to more conventional treatments, don’t feel discourage. There are several advances in technology that will put you back to your desired activity quicker than you think.

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