July 2016 Journal Club

[SLCpod]

Journal club overview:
- An article will be selected and posted each month. Please PM me an article you are interested in and I will select one. Please keep them as recent as possible.
- The person who suggested the article will give a BRIEF overview of the article
- We will discuss how we can use what we learned in practice and perhaps share some clinical experiences (remember not to disclose specific patient information)

This is open to DPM's, students and pre-pods!! All are invited.

Jounral: Journal of Foot and Ankle Surgery

Article: Endoscopic Debridement for Treatment of Chronic Plantar Fasciitis: An Innovative Technique and Prospective Study of 46 Consecutive Patients

Authors: James M. Cottom, DPM, FACFAS, Jared M. Maker, DPM, Phillip Richardson, DPM, Joseph S. Baker, DPM, AACFAS

Link: http://www.sciencedirect.com/science/journal/10672516
-Students at podiatry schools and major universities should have access to the article through PubMed and ClinicalKey.

I selected this article because I thought it could generate a lot of discussion about one of the most common issues we deal with. Maybe some of the pre-pods or 1st/2nd year students can list a few conservative treatments that are offered for Plantar Fasciitis (there is a list in the paper).

The article discusses the outcome of 46 patients who received an endoscopic debridement of the plantar fascia due to chronic plantar fasciitis after failed conservative treatment. Surgical technique was replicated as much as possible for all of the procedures preformed which included a debridement of the plantar fascia at the insertion into the calcaneus and the surrounding inflammatory tissue. If a spur was present it was excised. PRP was also used as an adjunct to the procedure. All patients were allowed to weight bear in a boot after three days and began physical therapy after 3 weeks.

The AOFAS and VAS scores were used in the assessment of patient outcomes. The authors found that their technique was effective in the treatment of chronic plantar fasciitis.

There are some things I liked and didn't like about the article. I'll elaborate more after some of you share your thoughts.

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[dtrack22]

I'll read and add another response or add to this one, but the very first thing that jumps out at me is the bias this paper will have given the author...

 

[ldsrmdude]

But @dtrack22 I looked at the paper and it said there were no disclosures, doesn't that mean the paper is not biased?

 

[dtrack22]

But @dtrack22 I looked at the paper and it said there were no disclosures, doesn't that mean the paper is not biased?

The king of scoping for dollars certainly has bias (using Arthrex products or not). Like I said, I will read and post my thoughts in the near future.

 

[ldsrmdude]

OK, a few thoughts since nobody else is commenting on it. As far as bias is concerned, although my previous comment was tongue-in-cheek, other than the fact that the author loves to scope, I don't know that there is much more bias than any other paper.

A few big picture comments. After I read a paper, I ask myself if this will change how I practice. This paper won't, for a few reasons. First, I still feel more comfortable with an open procedure than endoscopic. Especially with a procedure like a plantar fasciotomy, I would probably spend as much time establishing my portals as I would with the entire plantar fasciotomy I do through a small incision. To follow with that thought, I am not sure releasing the fascia is a big enough deal that I would feel the need to complicate things.

Another reason this paper won't change my practice is because all of the patients received PRP injections, which alone has been shown to have some effect on plantar fasciitis. It would be tough to prove that the improvement in symptoms wasn't just from the PRP/immobilization.

Just a few thoughts. I look forward to others

 

[AttackNME]

I don't have access to the full article, only the abstract, but I would like to add some big picture thoughts. It makes sense to debride hypertrophied and chronically inflamed ligaments rather than to simply release them, but in the heel it seems to make an exception since from years of experience podiatrists have found success with the plantar release procedure. If someone wants to do things different than "standard of practice", one would be wise to publish at least a case series to show to future patients and skeptical colleagues that this new procedure is at the very least safe. Whether or not it can produce inferior or superior results would be the next step requiring a larger sample size. The abstract doesn't really tell us anything other than the reason why this new procedure was created. Can someone summarize the complications associated with the procedure in Cottom's article and (if someone has even more time and access to look this up) compare this with the complications (and its incidence) with the traditional release?

 

[ldsrmdude]

I don't have access to the full article, only the abstract, but I would like to add some big picture thoughts. It makes sense to debride hypertrophied and chronically inflamed ligaments rather than to simply release them, but in the heel it seems to make an exception since from years of experience podiatrists have found success with the plantar release procedure. If someone wants to do things different than "standard of practice", one would be wise to publish at least a case series to show to future patients and skeptical colleagues that this new procedure is at the very least safe. Whether or not it can produce inferior or superior results would be the next step requiring a larger sample size. The abstract doesn't really tell us anything other than the reason why this new procedure was created. Can someone summarize the complications associated with the procedure in Cottom's article and (if someone has even more time and access to look this up) compare this with the complications (and its incidence) with the traditional release?

I can post the complications they reported really quick but I won't have the time until later to compare it to historical data. They had 13% with parasthesias that all resolved in the follow-up period and 6.5% with wound healing complications that required antibiotics and local wound care. I'd guess the overall complication rate (~20%) is similar to traditional fasciotomy, but with different specific complications.

Another point to add to my previous post is that almost 20% had a gastrocnemius recession at the time of the procedure. Again, another procedure that has been used alone to treat plantar fasciitis.

I think another point of discussion is their choice to resect the calcaneal spur and whether it was needed

 

[dyk343]

I've done way more plantar fasciotomies as a resident then I would like to admit to. It takes me about 5 min to do it open and about 10 min with the scope. I do favor the scope because I can see everything I am releasing. I can see that I am only cutting the medial band and maybe part of the central band. I dont have tons of follow up aftwerwards though. That's the problem with my residency training. Perform the procedure and they're gone. The attendings who use the scope say the post op pain and swelling is much less with the scope.

I don't know how quick I will be to offer a plantar fasciotomy when I'm done. The plantar fascia is a very important structure. I'm not a big fan of removing the functionality of important structures. I would try Topaz, ECSWT, Dry needling, ultrasound, PRP etc, etc before I release the fascial band.

 

[ldsrmdude]

I've done way more plantar fasciotomies as a resident then I would like to admit to. It takes me about 5 min to do it open and about 10 min with the scope. I do favor the scope because I can see everything I am releasing. I can see that I am only cutting the medial band and maybe part of the central band. I dont have tons of follow up aftwerwards though. That's the problem with my residency training. Perform the procedure and they're gone. The attendings who use the scope say the post op pain and swelling is much less with the scope.

I don't know how quick I will be to offer a plantar fasciotomy when I'm done. The plantar fascia is a very important structure. I'm not a big fan of removing the functionality of important structures. I would try Topaz, ECSWT, Dry needling, ultrasound, PRP etc, etc before I release the fascial band.

I think we all did more plantar fasciotomies as residents than we want to admit And you've pointed out a flaw in a lot of surgical training, the lack of consistent follow-up. It is unfortunate, but the way most residencies are set up, it is essentially impossible to follow-up all of your cases, especially long-term.

I agree with your hesitancy to offer a plantar fasciotomy quickly. I see several cases of heel pain in a day and I've had 1 patient go on to surgery that I just did a few weeks ago. Part may be because I really go out of my way to look for other causes of heel pain. I certainly don't think that there is any magic treating heel pain conservatively. I use a pretty simple formula. Initial visit a patient gets stretching, anti-inflammatory, some advice about shoes, and rarely an injection of a corticosteroid. I expect somewhere around 25-50% improvement when they come back in a month. If so, then we continue with the same, maybe add a night splint or the injection if they feel they're not improving fast enough. If they haven't hit the level of improvement we expect, then I offer the injection, night splint, or physical therapy. I like PT for this and get pretty good results. If we're still not making enough progress at around 2-3 months, we go for immobilization. Like I said, nothing too crazy. This has worked pretty well. I bring this up because the group of 46 patients they had with a single surgeon is quite a few. I imagine he has referrals coming from outside for treatment because to have 46 patients through your office that fail conservative treatment seems like a lot. Or maybe I'm just not aggressive enough with surgery for this...

 

[heybrother]

http://painmedicine.oxfordjournals.org/content/early/2016/07/10/pm.pnw164

I think we need to be skeptical about the association of what we do and the perceived outcomes.

 

[AttackNME]

From my observation, even surgery with horrific complications can make patients happy as long as the physician is good with the patient. Does this count as a success or failure? Depends on what you consider as a good result. Musculoskeletal pain is incredibly complex and I don't think we fully understand it, which is why there are so many ways to treat the same thing. But back to the journal article our moderator has selected... Seems this new procedure is pretty safe. If one day I'm adept enough at this technique it would be easier to get patients to buy into a fascia debridement than having to convince them to buy into a fascia release.

 

[SLCpod]

Thank you all for your comments. When I first read the article I expected there to be a debate about the validity of the study. A healthy debate is always good. I did not agree with the outcomes from the article as there were variables that weren't eliminated such as the PRP injections. After reading the comments I did some studying in regards to different surgical techniques used for a plantar fasciotomy release. When it is my turn to make a decision about which technique to preform I will be better prepared. Thank you all for sharing your pearls.

I listened to the podcast below and liked some of the comments made.

Evaluation of Plantar Fasciitis Treatment
Moderator: Stephen M. Schroeder, DPM
Panelists: Mary E. Crawford, DPM; G. Dock Dockery, DPM; Daniel J. Hatch, DPM; Gary P. Jolly, DPM
Release Date: September 2009
Run Time: 57min 38sec
http://www.acfasdistancelearning.co...Evaluation of Plantar Fasciitis Treatment.mp3

 

[dyk343]

I think we all did more plantar fasciotomies as residents than we want to admit And you've pointed out a flaw in a lot of surgical training, the lack of consistent follow-up. It is unfortunate, but the way most residencies are set up, it is essentially impossible to follow-up all of your cases, especially long-term.

I agree with your hesitancy to offer a plantar fasciotomy quickly. I see several cases of heel pain in a day and I've had 1 patient go on to surgery that I just did a few weeks ago. Part may be because I really go out of my way to look for other causes of heel pain. I certainly don't think that there is any magic treating heel pain conservatively. I use a pretty simple formula. Initial visit a patient gets stretching, anti-inflammatory, some advice about shoes, and rarely an injection of a corticosteroid. I expect somewhere around 25-50% improvement when they come back in a month. If so, then we continue with the same, maybe add a night splint or the injection if they feel they're not improving fast enough. If they haven't hit the level of improvement we expect, then I offer the injection, night splint, or physical therapy. I like PT for this and get pretty good results. If we're still not making enough progress at around 2-3 months, we go for immobilization. Like I said, nothing too crazy. This has worked pretty well. I bring this up because the group of 46 patients they had with a single surgeon is quite a few. I imagine he has referrals coming from outside for treatment because to have 46 patients through your office that fail conservative treatment seems like a lot. Or maybe I'm just not aggressive enough with surgery for this...

The thing about night splints that never made sense to me is when patients sleep they more than likely contract their leg at their knee releasing the gastroc muscle. If the equinus is soleus mediated they will work fine, but most of the time the gastrocnemius muscle is in play. They need to make one that crosses the knee joint (maybe they do and I don't know about it).

I got rid of my plantar fasciitis in <1 week with aggressive icing, Ibuprofen, and (correctly) stretching. Patient's should be adducting their forefoot when stretching to lock the MTJ. Otherwise they're probably just stretching the STJ.

 

[ldsrmdude]

The thing about night splints that never made sense to me is when patients sleep they more than likely contract their leg at their knee releasing the gastroc muscle. If the equinus is soleus mediated they will work fine, but most of the time the gastrocnemius muscle is in play. They need to make one that crosses the knee joint (maybe they do and I don't know about it).

I got rid of my plantar fasciitis in <1 week with aggressive icing, Ibuprofen, and (correctly) stretching. Patient's should be adducting their forefoot when stretching to lock the MTJ. Otherwise they're probably just stretching the STJ.

Interesting point. I would assume that most people spend at least some time with the knee extended and maybe that is enough to help. Or maybe it is the combination of a little bit of gastroc stretch and a lot of soleus that helps. I'm not sure.

Good point about the stretching. I demonstrate the stretches to the patients in the office and will reinforce it at a follow-up appointment if they aren't making improvements

 

[dyk343]

Interesting point. I would assume that most people spend at least some time with the knee extended and maybe that is enough to help. Or maybe it is the combination of a little bit of gastroc stretch and a lot of soleus that helps. I'm not sure.

Good point about the stretching. I demonstrate the stretches to the patients in the office and will reinforce it at a follow-up appointment if they aren't making improvements

Do you get good results with night splints?

Plantar fascia specific stretching? http://jbjs.org/content/88/8/1775

Also, what if there is no equinus deformity? I see it all the time in the setting of P fasciitis. Does it make sense to stretch the Triceps surae?

Should we be worrying about stretching the triceps surae even in the presence of equinus?

My sense is yes - A plantarflexed overloaded forefoot causes retrograde pressure through the plantar fascia and causes heel pain. Reduce equinus and reduce the forefoot pressure which reduces heel pain. The studies that have been published on achilles stretching show an improvement in 2-4 degree range of motion after I believe 1 month of stretching. Which really isn't much. I also don't think they made statistical significance if my memory serves me right.

I have no faith in the idea that the fibers of the Achilles tendon are continuous with the plantar fascia causing pain. I'm sure the fibers are continuous but they also insert into the Calc. Its more of an insertion lever arm than a continuous band of pain IMO.

 

[ldsrmdude]

Do you get good results with night splints?

Plantar fascia specific stretching? http://jbjs.org/content/88/8/1775

Also, what if there is no equinus deformity? I see it all the time in the setting of P fasciitis. Does it make sense to stretch the Triceps surae?

Should we be worrying about stretching the triceps surae even in the presence of equinus?

My sense is yes - A plantarflexed overloaded forefoot causes retrograde pressure through the plantar fascia and causes heel pain. Reduce equinus and reduce the forefoot pressure which reduces heel pain. The studies that have been published on achilles stretching show an improvement in 2-4 degree range of motion after I believe 1 month of stretching. Which really isn't much. I also don't think they made statistical significance if my memory serves me right.

I have no faith in the idea that the fibers of the Achilles tendon are continuous with the plantar fascia causing pain. I'm sure the fibers are continuous but they also insert into the Calc. Its more of an insertion lever arm than a continuous band of pain IMO.

Good points. I see decent results with night splints. It's not a first-line treatment for me. Some people use it more than me for reimbursement reasons.

I have all my patients do both plantar fascia and Achilles stretching, regardless of the presence or absence of equinus. The Digiovanni articles (one of which you quoted) as well as the chapter he wrote for plantar fasciitis in Coughlin and Mann helped shape my treatment protocol on this.

I agree with you about the fibers of the Achilles. It doesn't make sense to me to think of it as a "continuous band of pain." Like you, I view it as more of a lever arm issue. It is interesting that a lot of patients have both insertional Achilles tendinitis and plantar fasciitis concomitantly.