Study Assesses Laser Treatment For Plantar Fasciitis

Lasers may number among the effective treatments for chronic plantar fasciitis, suggests a recent study in the Journal of Foot and Ankle Surgery.

The randomized, double-blind study concerned 37 patients with chronic plantar fasciitis who were treated with low-level 635 nm lasers and 32 who had placebo treatments. Patients received treatments twice a week over a three-week period. At the final follow-up visit at eight weeks after treatment, the study notes the laser patients demonstrated a mean improvement in heel pain with a Visual Analog Scale score of 29.6 in comparison with a mean improvement of 5.4 in the placebo patients.

In addition to being non-invasive, low-level laser therapy is a form of regenerative medicine as the modality’s mitochondrial stimulation initiates a low-grade inflammatory cascade of events that can stimulate revascularization of the thickened fascial tissue, according to study co-author Kerry Zang, DPM, FACFAS. He notes lasers work synergistically with other forms of regenerative medical therapies.

As Dr. Zang notes, lasers are preferential to cortisone injections, which act as suppressants and temporarily stop the pain but also stop any inflammatory healing response, putting the plantar fascia at risk for further degeneration or rupture.  

For the past eight to 10 years, Lisa M. Schoene, DPM, ATC, has been using class III and class IV lasers for acute and chronic musculoskeletal conditions including plantar fasciitis. Dr. Zang notes the mechanism of action for class IV lasers is heat and true low-level lasers function by initiating biostimulation, producing no heat.

Low-level lasers are effective in treating both acute plantar fasciitis and degenerative fasciopathy, according to Dr. Zang, who is in private practice at the Arizona Institute of Footcare Physicians. He says six to eight treatments are necessary for chronic plantar fasciitis while three to four treatments are necessary for acute plantar fasciitis if treatment begins six to eight weeks after the onset of symptoms. He says lasers are cost-effective in comparison with other non-surgical modalities.

“I would use low-level laser therapy as a first-line therapy,” says Dr. Zang, a consultant for Erchonia Corp. “It can be used as a stand-alone treatment or in conjunction with other regenerative medical therapies. It is the only non-invasive treatment available that will stimulate an internal response.”  

Dr. Schoene notes the importance of patients with plantar fasciitis combining many treatments, including strapping, stretching and night splints. She advises patients not to run, jump or go barefoot. She also encourages patients to wear a higher heel profile to reduce the discomfort associated with the injury to the plantar fascia.

If one of Dr. Schoene’s patients comes back after one visit and is not at least 70 percent better, she will add a splint, ultrasound, laser treatment and possibly deep tissue massage. After a second visit with less than 70 percent improvement, if diagnostic ultrasound determines any tearing or loss of echotexture and increased thickening, she will perform deep tissue therapeutic massage, needling with a Traumeel (MediNatura) injection and will continue laser therapy.    

“This protocol takes chronically damaged, thickened or torn tissue, and creates an ‘uptick’ in the inflammatory cascade via the controlled irritation to the tissue to get it to become microscopically ‘acutely’ inflamed so the immune system can now jump in and turn on the inflammatory cascade to start the repair process,” says Dr. Schoene, a Fellow of the American College of Foot and Ankle Surgeons and the American Academy of Podiatric Sports Medicine.

Study Looks At Relationship Between Metatarsus Primus Elevatus And Hallux Limitus

By Brian McCurdy, Managing Editor

A study presented as a poster at the American Podiatric Medical Association Annual Scientific Meeting postulates a new twist on the long-established connection between metatarsus primus elevatus and hallux limitus.  

The poster consisted of a chart review of 20 patients who had modified Valenti arthroplasties. The authors note that increased first MPJ dorsiflexion after surgery facilitated a decrease in metatarsus primus elevatus in measurements of first and second metatarsal head elevation, the Seiberg index, first through fifth metatarsal head distance, and first and second metatarsal sagittal angle. The poster authors concluded that metatarsus primus elevatus was significantly reduced after first MPJ decompression with a non-implant arthroplasty.

Poster co-author John Grady, DPM, stresses that the results of this study should prompt DPMs to reevaluate the relationship of metatarsus primus elevatus to hallux limitus.

“While there is statistical evidence of a strong relationship between the two, the truth is that hallux limitus may be the cause of as well as the result of metatarsus primus elevatus. It is currently mostly believed that metatarsus primus elevatus is the primary biomechanical cause of hallux limitus,” says Dr. Grady, the Director of Podiatric Surgical Residency at the Jesse Brown Veterans Affairs Medical Center in Chicago.
Metatarsus primus elevatus can lead to increasing lateral loading, says Dr. Grady. He says this can contribute to decreasing push-off power and shock absorption as well as resulting knee, hip and lower back rotational problems that can lead to arthritic development or progression.

One can combat metatarsus primus elevatus with techniques such as peroneus longus strengthening, tibialis anterior stretching, orthotic control, and the mobilizing non-implant arthroplasty, which Dr. Grady employs when recalcitrant symptomatic hallux limitus is the cause. As he emphasizes, the important thing is to evaluate the patient to determine and address the correct cause.

New Bone Graft Gets FDA Approval For Ankle And Hindfoot Fusions

By Brian McCurdy, Managing Editor

Augment Bone Graft (Wright Medical) recently received approval from the Food and Drug Administration (FDA).

The company notes that for ankle and/or hindfoot fusions, Augment is a safe and effective alternative to autografts. Augment has recombinant human platelet-derived growth factor, which initiates a cellular response with upregulation for cellular bone growth including osteoblasts, according to Peter Blume, DPM. He adds that the product’s beta-tricalcium phosphate provides the scaffold for new bone growth.  

There are several advantages of the Augment bone graft over autografts, according Dr. Blume. He notes Augment does not require harvesting of the graft and therefore does not create a secondary defect such as with iliac crest graft, tibial graft or calcaneal bone graft.

“This product should provide additional stimulation for bone growth, especially in foot and ankle fusion type procedures,” says Dr. Blume, an Assistant Clinical Professor of Surgery in the Department of Surgery and an Assistant Clinical Professor of Orthopaedics and Rehabilitation in the Department of Orthopaedics, Section of Podiatric Surgery at the Yale University School of Medicine in New Haven, Ct.

The most common pathologies that could benefit from Augment would include but are not limited to revisional arthrodesis procedures, non-union repair, and hindfoot and ankle arthrodesis in the immunocompromised patient, according to Dr. Blume.

Dr. Blume adds that postoperatively, he has found patients who have had reconstructive procedures with Augment had comparable radiographic findings of fusion in comparison to those who had autografts.