Tag Archives: plantar fasciitis

Case study: Schwannoma of the tibial nerve in a patient with a history of neurofibromas

Posted on September 30, 2019 | Comments Off on Case study: Schwannoma of the tibial nerve in a patient with a history of neurofibromas

by Zachary T. Ritter, DPM, MS, FACFAS1*, Amy Kruger, DPM2

The Foot and Ankle Online Journal 12 (3): 6

A schwannoma is a common benign tumor of the peripheral nerve sheath.  Schwannomas are rarely found in the foot and typically do not elicit any painful symptoms. We report the case of a large schwannoma eliciting tarsal tunnel like symptoms in a patient with a previous history of neurofibromatosis within the spine. The patient had previously undergone lumbar laminectomy for neurofibromas of the lumbar spine that went on to develop pain in the right foot.  She then underwent extensive workup of this persistent right foot pain. She was treated for plantar fasciitis for several years, until presenting to our clinic. At that time, EMG findings showed tibial neuropathy and medial plantar nerve degeneration; accompanied by MRI findings consistent with a schwannoma of the tibial nerve. The patient underwent surgical excision of the mass. The pathology report revealed an encapsulated biphasic tumor composed of compact hypercellular areas and mixed hypocellular areas with foci of hyalinization with no malignant features measuring 3.7 x 2.5 x 2.0 cm, consistent with a diagnosis of schwannoma.  The patient had an uneventful postoperative course. At one year follow up, she was pain free but had persistent neuropathic changes to the distal forefoot. Currently, there are few reports in the literature of schwannomas arising the tibial nerve eliciting the symptoms of tarsal tunnel syndrome. The incidence of such a schwannoma in association of a patient with a history of neurofibromas is even more rare.

Keywords: neuroma, schwannoma, neurofibromatosis, plantar fasciitis

ISSN 1941-6806
doi: 10.3827/faoj.2018.1203.0006

1 – Chief of Podiatric Surgery. UPMC Susquehanna. Williamsport, PA.
2 – PGY-3. St. Luke’s University Hospital. Bethlehem, PA.
* – Corresponding author: ztritter@msn.com

A schwannoma is a benign soft tissue tumor of the peripheral nerve sheath. These slow-growing tumors can be difficult to distinguish from other benign tumors based on clinical findings [1]. The principal diagnosis is made histologically by by identifying the principle cellular elements—Schwann cells. This tumor was first described in the thorax [2], and is typically found in the head, neck, and flexor surfaces of the extremities [3]. The most common nerve affected is the eighth cranial nerve; however, the spinal roots as well as the sympathetic, vagus , ulnar, and peroneal nerves are commonly affected as well [3,4]. This tumor is rarely found in the tibial nerve in the region of the tarsal tunnel [5-9]. Finally it is highly uncommon to find this tumor in association with a neurofibroma, with only one report of a schwannoma of the posterior nerve accompanied by a neurofibroma in the tarsal tunnel itself [10]. There are currently no other reports of a patient with a schwannoma eliciting secondary tarsal tunnel syndrome in a patient with a history of symptomatic neurofibromas elsewhere in the literature.

We report a case of a large schwannoma of the tibial nerve located in the tarsal tunnel in a patient with a previous history of neurofibromas in the spine.

Case Report

A 69-year-old female presented to UPMC Susquehanna Foot and Ankle Clinic in July 2015 with right-sided plantar fascial pain accompanied by plantar foot numbness and tingling.  On clinical exam, her foot was neutrally positioned and demonstrated no clinically palpable abnormality. She did have a positive Tinel and Valleix sign. There was mild tenderness along the plantar fascial ligament origin. The patient had been treated by an outside physician for over 5 years with plantar fasciitis.  She had tried various conservative treatment methods including custom orthotics, physical therapy, and a series of corticosteroid injections, all of which provided only temporary relief. She additionally had a history of a prior lumbar laminectomy secondary to pain, after which she began to notice increasing right foot pain and paresthesias.  Her previous spine MRI (June 2014) revealed extramedullary enhancing masses and nerve sheath tumors leading to a diagnosis of neurofibromas.

During her first visit to our clinic in July 2015, an EMG from the previous month was reviewed.  On EMG, there was evidence of tibial neuropathy and degenerative changes of the medial plantar nerve leading to a diagnosis of tarsal tunnel syndrome.  After her first visit, the patient was recommended an additional course of physical therapy, given a script for new custom orthotics, and prescribed a nonsteroidal anti-inflammatory drug, meloxicam (Mobic). Following this course of treatment, the patient’s symptoms did not improve (Figure 1). An MRI was then ordered of the area which revealed a well-encapsulated oval lesion measuring 4.2 x 2.2 x 2.1 cm, appearing hypointense on T1 and hyperintense on T2 consistent with a diagnosis of schwannoma (Figure 2). 

At this point, surgical excision of the mass was recommended to the patient. An oncology referral was discussed, but deferred until after the procedure in the event that surgical pathology findings did not indicate malignancy. She underwent surgical excision of the mass and decompression of the tarsal tunnel in October 2015. 

Figure 1 Preoperative lateral weight bearing radiograph.

Figure 2 Preoperative MRI T1 and T2 images.

The patient was brought into the operating room and placed on the table in a supine position and general anesthesia was administered. Local anesthesia was then administered to the area utilizing a 1:1 mixture of 1% lidocaine plain and 0.5% bupivacaine plain.  A pneumatic calf tourniquet was applied and inflated.  

Attention was then directed to the medial hindfoot, where a curvilinear incision was made just posterior to the medial malleolus and extended to the medial aspect of the glabrous junction at the level of the porta pedis. The incision was then deepened over the tarsal canal. The flexor retinaculum was then identified and released. Extensive tortuous veins were noted within the tarsal tunnel and were gently mobilized. 

Figure 3 Intraoperative image of the soft tissue mass.

 

Figure 4 Intraoperative specimen of the soft tissue mass after removal from tarsal tunnel.

The tibial nerve was then identified and the proximal portion was mobilized. The dissection was then carried distally exposing a large, swollen tibial nerve just proximal to its bifurcation into the medial and lateral plantar nerves.  

A longitudinal incision was then made in the epineurium and the marginal nerve fibers were mobilized  and retracted in an extra capsular fashion. The tumor was then fully exposed. The plane of the tumor capsule was gently dissected from the epineural layers and the tumor was then separated without significant damage to the surrounding nerve fascicles, though there were several small fascicles noted to be entering the tumor at the distal and proximal poles (Figure 3). These fascicles were isolates in an effort to minimize nerve damage, but due to local ingrowth they were impossible to separate from the tumor and were transected.  

Once the tumor was completely removed, the area was thoroughly flushed with sterile saline solution.  The remaining tibial nerve at the level of the lesion was examined and found to demonstrate significant degenerative changes. As there was no obvious tissue to repair, an amniotic graft was then wrapped around the degenerative portion of the nerve in order to promote healing and prevent adhesions.

The incision was then closed in a layered fashion utilizing monocryl suture for the subcutaneous tissues and nylon suture for skin closure. The operative site was then infiltrated with an additional 10 cc of 1:1 mixture of 1% lidocaine plain 0.5% bupivacaine plain.   The incision was then dressed with xeroform and covered with a dry sterile dressing. A modified Jones compression dressing was then applied. The tourniquet was then deflated and a prompt hyperemic response was noted to all digits. 

The pathology report revealed an encapsulated biphasic tumor composed of compact hypercellular areas and mixed hypocellular areas with foci of hyalinization with no malignant features measuring 3.7 x 2.5 x 2.0 cm, consistent with a diagnosis of schwannoma (Figure 4).

The patient was permitted to immediately weight bear postoperatively in a surgical boot. At two weeks postoperative, she underwent suture removal and was transitioned to a street shoe as tolerated. She was followed until one year postoperatively, and found to have no functional limitations, but did continue to notice sensory changes in the plantar foot. 

Discussion

Schwannomas are benign, encapsulated peripheral nerve sheath tumors. They are commonly described throughout the literature by a variety of names: neurilemoma, neuroschwannoma, peripheral glioma, perifibroma, and schwannoma [11,12]. Typically these tumors are found elsewhere in the body (trunk, head, neck, upper extremities) and even more rarely in the lower extremities [2-3, 13].  The foot is noted only to be affected in approximately 10% of cases [3]. There are even fewer noted in the literature to be associated with the tibial nerve and eliciting tarsal tunnel syndromes [5-9].  

Neurofibromas are not typically found in with the foot and ankle.  In a study by Bakotic and Borkowski of primary soft tissue neoplasms of the foot, schwannomas and neurofibromas were noted to account for only 5.4% and 2.7% of all benign soft tissue tumors, and 2.0% and 1.0% of all total neoplasms respectively in the foot and ankle [14].  It is rarely reported to find these two types of tumors in association with one another, with only one report of a schwannoma associated with a neurofibroma in the tarsal tunnel [10]. 

There are currently no other reports of a patient with a schwannoma eliciting secondary tarsal tunnel syndrome and a history of spinal neurofibromas. Currently the recommended treatment for schwannomas of the foot and ankle is open surgical resection [15]. Fortunately, surgical resection has positive results with minimal morbidity and recurrence if resected entirely [16,17]. It is recommended to remove the lesion in total with great care not to damage the nerve through excessive violation of the nerve sheath or compromising the marginal neural fibers. 

We report a case of successful excision of a schwannoma of the tibial nerve located within the tarsal tunnel, eliciting symptoms leading to a diagnosis of tarsal tunnel secondary to tumor. The patient did have a significant medical history of painful neurofibromas of the lumbar spine confirmed on MRI with a subsequent lumbar laminectomy. While the patient did have EMG findings positive for tibial neuropathy and degeneration of the medial plantar nerve, we cannot effectively determine whether the patient’s symptoms were solely related to compression from the longstanding mass within the tarsal tunnel or if they were possibly exacerbated by the patient’s history of lumbar neurofibromas with subsequent surgical intervention. 

The patient’s postoperative course was uneventful.  She did regain some hindfoot and midfoot sensation, while completely eliminating her preoperative pain.  However, parasthesias persisted within the forefoot. 

References

  1. Graviet S, Sinclair G, Kajani N. Ancient schwannoma of the foot. J Foot Ankle Surg. 1995;34(1):46-50.
  2. Ackerman LV, Taylor FH. Neurogenous tumors within the thorax; a clinicopathological evaluation of forty-eight cases. Cancer. 1951;4(4):669-91.
  3. Odom RD, Overbeek TD, Murdoch DP, Hosch JC. Neurilemoma of the medial plantar nerve: a case report and literature review. J Foot Ankle Surg. 2001;40(2):105-9.
  4. Weiss S, Goldblum J, Folpe AL. Schwannoma. In: Enzinger and Weiss’s Soft Tissue Tumors, ed 5, Elsevier Mosby, Maryland Heights MO, 2008, pp. 853-862
  5. Hallahan K, Vinokur J, Demski S, Faulkner-jones B, Giurini J. Tarsal tunnel syndrome secondary to schwannoma of the posterior tibial nerve. J Foot Ankle Surg. 2014;53(1):79-82.
  6. Grossman MR, Mandracchia VJ, Urbas WM, Mandracchia DM. Neurilemmoma of the posterior tibial nerve with an uncommon case presentation. J Foot Surg. 1992;31(3):219-24.
  7. Mangrulkar VH, Brunetti VA, Gould ES, Howell N. Unusually large pedal schwannoma. J Foot Ankle Surg. 2007;46(5):398-402.
  8. Judd T, Jones T, Thornberry L. Schwannoma of the posterior tibial nerve: case study. J Am Podiatr Med Assoc. 2014;104(5):539-43.
  9. Nawabi DH, Sinisi M. Schwannoma of the posterior tibial nerve: the problem of delay in diagnosis. J Bone Joint Surg Br. 2007;89(6):814-6.
  10. Tladi MJ, Saragas NP, Ferrao PN, Strydom A. Schwannoma and neurofibroma of the posterior tibial nerve presenting as tarsal tunnel syndrome: review of the literature with two case reports. Foot (Edinb). 2017;32:22-26.
  11. White NB. Neurilemomas of the extremities. J Bone Joint Surg Am 49:1605-1610, 1967.
  12. Spiegel PV, Cullivan T, Reiman HM. Neurilemoma of the lower extremity. Foot Ankle 6:194-8, 1986.
  13. Jacobson JM, Felder JM, Pedroso F, Steinberg JS. Plexiform schwannoma of the foot: a review of the literature and case report. J Foot Ankle Surg. 2011;50(1):68-73.
  14. Bakotic BW, Borkowski P. Primary soft-tissue neoplasms of the foot: the clinicopathologic features of 401 cases. J Foot Ankle Surg. 2001;40(1):28-35.
  15. Kellner CP, Sussman E, Bar-david T, Winfree CJ. Schwannomas of the foot and ankle: a technical report. J Foot Ankle Surg. 2014;53(4):505-10.
  16. Carvajal JA, Cuartas E, Qadir R, Levi AD, Temple HT. Peripheral nerve sheath tumors of the foot and ankle. Foot Ankle Int. 2011;32(2):163-7.
  17. Kim DH, Ryu S, Tiel RL, Kline DG. Surgical management and results of 135 tibial nerve lesions at the Louisiana State University Health Sciences Center. Neurosurgery. 2003;53(5):1114-24.

Comments Off on Case study: Schwannoma of the tibial nerve in a patient with a history of neurofibromas

Posted in Uncategorized

Tagged , , ,

Prospective study of plantar fascia thickness correlated to efficacy of conservative treatment for plantar fasciitis using ultrasonography

Posted on August 31, 2016 | Comments Off on Prospective study of plantar fascia thickness correlated to efficacy of conservative treatment for plantar fasciitis using ultrasonography

by Gerald Kuwada, DPM, NMD1*pdflrg

The Foot and Ankle Online Journal 9 (3): 9

The thickness of the plantar fascia is measured using ultrasonography and has been correlated to either success or failure of conservative treatment depending on how thick the fascia is. The research hypothesis is that the thicker the plantar fascia in a patient diagnosed with plantar fasciitis, the higher the incidence of treatment failure. One hundred thirty six patients from our 4 clinics and 7 podiatric physicians made the clinical diagnosis of plantar fasciitis. The patients were divided into 2 groups for this study. Group 1 included all the patients that had a successful outcome with conservative treatment. Group 2 included all the patients who failed to improve after extensive conservative treatment. The mean for Group 1 plantar fascia thickness was .522 mm. Group 2 included 11.7% of feet and the mean plantar fascia thickness was 1.006mm. The range of plantar fascia thickness was .3mm to .97mm for Group 1. The range of plantar fascia thickness for Group 2 was .67mm to 1.22mm. Based on this study, 1.006 mm was measured to be the mean for Group 2 and may be a useful predictor of treatment outcomes.

Keywords: plantar fascia thickness, plantar fasciitis, ultrasonography, conservative treatment

ISSN 1941-6806
doi: 10.3827/faoj.2016.0903.0009

1 – FASA Family Wellness, Tumwater, WA
* – Corresponding author: drgeraldkuwada@hotmail.com

The thickness of the plantar fascia is measured using ultrasonography and has been correlated to either success or failure of conservative treatment depending on how thick the fascia is [1-13]. The research hypothesis is that the thicker the plantar fascia in a patient diagnosed with plantar fasciitis, the higher the incidence of treatment failure. Conservative treatment in this study includes injection therapy, physical therapy modalities like icing, stretching, prefabricated arch supports, massaging, over the counter anti-inflammatory medications, and orthotics. The null hypothesis states that no matter what the thickness of the plantar fascia it has no effect on success or failure of conservative treatment.

What are some of the etiologies of plantar fascia thickness? It has been suspected that inflammation of the fascia occurs. Other etiologies include degenerative changes to the fascia, micro-tearing and scarification of the fascia [14]. Since using ultrasonography, this has been a recent concept in treating plantar fasciitis. In the past, we had no idea there was a thickness issue. According to more recent studies, there is a possible correlation between the thickness of the plantar fascia and the success of conservative treatment [15]. A study published by this author in 1980 found a 90% success rate with conservative treatment and a 10% failure rate. Most of the patient’s in the 10% group elected to proceed with open fascial release to get complete pain relief [16]. Yet, several authors found that a plantar fascia thickness of greater than 4mm was considered thick [15].

Methods

One hundred thirty six patients from our 4 clinics and 7 podiatric physicians made the clinical diagnosis of plantar fasciitis. Each patient had their plantar fascia measured using ultrasonography and the thicknesses were recorded. There were a total of 197 feet with the diagnosis of plantar fasciitis. The success or failure of conservative treatment was recorded for all 136 patients. The feet were divided into 2 groups for this study. Group 1 included all the patients that had a successful outcome with conservative treatment. Group 2 included all the patients who failed to improve after extensive conservative treatment. There was no time limit regarding conservative treatment time. Thus, some patients took several months to complete their conservative treatment, whereas others took much longer. A majority of these patients in Group 2 eventually had endoscopic plantar fasciotomy or open fascial releases performed to eliminate their heel pain. The mean thickness of the plantar fascia was calculated for both groups. Using a T test 2 tailed type with a p value of .001 and 95% confidence intervals was calculated.

Results

The statistical analysis demonstrated that the two groups were significantly different at a p-value of .0001. Group 1 included 88.3% of feet (174/197). The mean for Group 1 plantar fascia thickness was .522 mm. Group 2 included 11.7% of feet and the mean plantar fascia thickness was 1.006mm. The range of plantar fascia thickness was .3mm to .97mm for Group 1. The range of plantar fascia thickness for Group 2 was .67mm to 1.22mm. Thus, the null hypothesis is rejected and our research hypothesis was accepted.

Discussion

This study corroborates the conclusion of several other studies supporting the concept that the plantar fascia thickness is important and may predict patient  conservative treatment outcomes [1-13]. However, the 4mm thickness or greater was not considered significantly thick in this study. Many of the patients in Group 2 had EPF or open fascial release performed. All the patients had no residual heel pain after their surgical sites healed. Others have reported that the plantar fascia in some patients will be thinner after corticosteroid injections [15]. The author plans on doing a study on this topic to determine if this is true or not. Will the thickness also play a role in determining whether the plantar fascia will thin after corticosteroid injections? Will the BMI also be a predictor of outcomes based on thickness of the plantar fascia?

One of the concerns of this study was the inability to control the accuracy of the various podiatric physician measurements of the plantar fascia. There is a steep learning curve in accurately measuring the plantar fascia thickness. This was not tested by having each physician measure the same plantar fascia of a dozen patients and determine accuracy of each podiatric physician.

It has been suggested that diabetes mellitus has a high correlation with increased plantar fascial thickening [15]. This study did not examine this relationship.

Lastly, despite the thickness of the plantar fascia, the patient diagnosed with plantar fasciitis needs to undergo conservative treatment to fulfill the standard of care. How extensive the care is will be determined by the podiatric physician and the patient. Furthermore, there will be exceptions to the findings and conclusions of this study. A patient may be within range of Group 1 yet fail improving after receiving conservative treatment.  Contrarily, a patient within Group 2 range completely  becomes asymptomatic after completing conservative treatment. This is plausible even though it did not occur in this study. Based on this study, 1.006 mm was measured to be the mean for Group 2 and may be a useful predictor of treatment outcomes.

References

  1. Tsai WC, Chiu MF, Wang CL, Tang FT, Wong, MK. Ultrasound evaluation of plantar fasciitis. Scand J Rheumatol. 2000; 29(4): 255-259. Doi: 10: 1080/030097400750041415.
  2. Wearing SC, Smeathers, Sullivan PM, Yates B, Urry SR, Dubois P. Plantar fasciitis: are pain and fascial thickness associated with arch shape and loading? Phys. Ther. 2007:87(8):1002-1008.
  3. Genc H, Saracoglu M, Nacir G, Erdem HR, Kacar M. Long term ultrasonographic follow-up of plantar fasciitis patients treated with steroid injection. Joint Bone Spine. 2005;72(1):61-65. Doi:10.1016/j.jbspin.2004.03006.
  4. Ozdemir H, Yilmaz E, Murat A, Karakurt L, Poyraz AK, Ogur E. Sonographic evaluation of plantar fasciitis and relation to body mass index. Eur J Radiol. 2005:54(3):443-447/ doi: 10.1016/j ejrad 2004.09.004.
  5. Sabir N, Demirlenk S, Yagei B, Karabulut N, Cubukcu S. Clinical utility of sonography in diagnosing plantar fasciitis. J Ultrasound Med. 2005;24(8):1041-1048.
  6. Wall KR, Harkness MA, Crawford A. Ultrasound diagnosis of plantar fasciitis. Foot Ankle. 1993;14(8):465-470.
  7. Akfirat M, Sen C, Gunes T. Ultrasonographic appearance of the plantar fasciitis. Clin Imaging. 2003;27(5):353-357. DOI: 10.1016/S0899-7071(02)00591-0.
  8. Cardinal E, Chhem RK, Beauregard CG, Aubin B, Pelletier M. Plantar fasciitis: sonographic evaluation. Radiology. 1996;201(1):257-259.
  9. Gibbon WW, Long G. Ultrasound of the plantar aponeurosis (fascia) Skeletal Radiol. 1999;28(1):21-26. Doi: 10.1007/s002560050467.
  10. Vohra PK, Kincaid BR, Japour CJ, Sobel E. Ultrasonographic evaluation of plantar fascia bands. A retrospective study of 211 symptomatic feet. J Am Podiatr Med Assoc. 2002;92(8):444-449.
  11. Hall RL, Erickson SJ, Shereff MJ, Johnson JE, Kneeland JB. Magnetic resonance imaging in the evaluation of heel pain. Orthopedics. 1996; 19(3):225-229.
  12. Kamel M, Kotob H. High frequency ultrasonographic findings in plantar fasciitis and assessment of local steroid injection. J Rheumatol. 2000;27(9):2139-2141.
  13. Karabay N, Toros T, Hurel C. Ultrasonographic evaluation in plantar fasciitis. J Foot Ankle Surg. 2007;46(6):442-446. doi: 10.1053/j.jfas.2007.08.006.
  14. Walther M, Radke S, Kirschner S, Ettl V, Gohlke F. Power Doppler findings in plantar fasciitis. Ultrasound Med Biol. 2004;30(4):435-440. Doi: 10.1016/j.ultrasmedbio.2004.01.006. PubMed Cross Ref
  15. Buchbinder R. Plantar Fasciitis. N Engl J Med 2004:350:2159-66.
  16. McMillan AM, Landorf KB, Barrett JT, Menz HB, Bird AR. Diagnostic Imaging for chronic plantar heel pain: a systematic review and meta-analysis. J Foot Ankle Res. 2009; 2: 32 published online 2009 Nov 13. Doi: 10.1186/1757-1146-2-32.
  17. Kuwada GT, Gormley J. A Retrospective Analysis of calcaneal spur removal and complete fascial release. J Foot Ankle Surg. 1980; 19: 218-222.

Comments Off on Prospective study of plantar fascia thickness correlated to efficacy of conservative treatment for plantar fasciitis using ultrasonography

Tagged , , ,

Post-surgical plantar fasciitis

Posted on June 30, 2014 | Comments Off on Post-surgical plantar fasciitis

by Priya P. Sundararajan , DPM¹pdflrg

The Foot and Ankle Online Journal 7 (2): 4

Current evidence suggest that plantar fasciitis is multi-factorial in etiology. The following report introduces an extended post-surgical nonweightbearing period (6-10 weeks) as a previously unknown cause of plantar fasciitis. Through a univariate statistical analysis, the present study compares the presence of heel pain in twenty patients who remained nonweightbearing for 2-6 weeks (group 1) and twenty patients who remained nonweightbearing for 6-10 weeks in the post-surgical period (group 2). Results indicate a statistically significant correlation (p<0.05) between patients who endured an extended postoperative nonweightbearing period (group 2) and the presence of plantar fascial symptoms in the immediate weightbearing period. Findings of the present study suggest that a stretching regimen should be initiated prior to ambulation for patients remaining nonweightbearing greater than six weeks post-surgery.

Key Words: Plantar fasciitis, postoperative, nonweightbearing, heel pain, surgery, fascia

ISSN 1941-6806
doi: 10.3827/faoj.2014.0702.0004

Address correspondence to: Priya Sundarararjan DPM,
Wilmington Veterans Affairs Hospital, 1601 Kirkwood Highway, Wilmington, DE 19805

¹ Director of Podiatric Surgical Services, Wilmington Veterans Hospital 302-994-2511 Email: Priya.Sundararajan@va.gov

Plantar fasciitis is one of the most common pedal pathologies requisitioning medical evaluation and treatment, which translates to over one million outpatient visits annually in the United States [1]. Though the pain associated with plantar fasciitis can be debilitating, the syndrome is characterized as self-limiting since approximately 90% of symptomatic patients find relief through conservative measures [2,3]. Plantar fasciitis is the result of multi-factorial etiologies from increased body mass index to ankle equinus [1,4]. The following retrospective analysis introduces the extended post-surgical nonweightbearing period as a previously unknown cause of plantar fasciitis.

Methods

A retrospective review of forty patients who underwent surgery between August 2010 and August 2011 was conducted. These patients remained nonweightbearing between 2 and 10 weeks in the postoperative period. Twenty patients who were completely offloaded between 2 and 6 weeks post surgery were consecutively enrolled in the study as group 1. Similarly, twenty patients who remained completely nonweightbearing between 6 and 10 weeks after surgery were consecutively enlisted as group 2. The six-week mark was considered the divide as most reconstructive surgeries involve offloading for more than 6 weeks. Additionally, all patients remained nonweightbearing between 2 and 10 weeks; thus 6 weeks is the mean week. Exclusion criteria included any prior complaint or treatment of plantar heel pain or any surgery involving the plantar fascia. Patients who bore weight in the heel or forefoot without a two-week nonweightbearing period were also excluded from the study.

All patients were questioned as to the areas of discomfort in the beginning two weeks of the post-surgical weightbearing (WB) period. Specifically, each patient was questioned as to the presence or absence of heel pain. The heel was anatomically defined as the area underlying the calcaneal tuberosity. The presence of postoperative heel pain during the initial weightbearing period was recorded and statistically evaluated with a univariate analysis. If the patient related to having heel pain when first bearing weight, they were instructed to perform at least 15 minutes of calf stretching exercises daily. Patients were monitored until complete resolution of symptoms.

Results

Twenty patients in each group yielded usable results. A description of groups 1 and 2 are depicted in Tables 1 and 2, respectively. A statistically significant difference (p=0.0002) in the presence of heel pain in the early weightbearing period was found between patients who remained nonweightbearing between 2 and 6 weeks (group 1) and those who remained nonweightbearing between 6 and 10 weeks (group 2). Noting that the presence and resolution of symptoms are “yes” and “no” questions, the mean was calculated by assigning “yes” to 1 and “no” to 0. In group 1, 15% of patients reported heel pain during the first two weeks of bearing weight on the operated limb (Table 1). Of these patients, 100% reported total resolution of symptoms within the first six weeks of the weightbearing period with conservative calf stretching exercises. In group 2, 70% of patients reported heel pain during the first two weeks of bearing weight on the operated limb (Table 2). All patients who reported heel pain in both groups related complete relief of symptoms to the heel of the operated extremity within six weeks using conservative modalities, primarily through regimented stretching exercises. However, one patient in group 2 (patient 15) who reported significant relief without total resolution of symptoms was additionally fitted with custom-molded orthotics. With a stretching exercise protocol and orthoses, the patient found complete resolution within 6 weeks of bearing weight.

Discussion

Plantar fasciitis is a complex pathology involving the ligament-bone interface at the inferior aspect of the calcaneal tuberosity [3]. As a primary supporter of the plantar arch, the plantar fascia minimizes transverse plane motion between the calcaneus and metatarsals [3]. Vertical forces from the body travel down the body and exert pressure flattening the medial longitudinal arch [5]. Subjected to significant traction as weight is transferred from the rearfoot to the forefoot, the plantar fascia accommodates the transfer with minimal disruption to the plantar arch [6]. Biomechanical studies simulating total fascial release demonstrate extensive arch deformation in stance and over 200% increase in stresses to the long plantar ligament [7]. Rapid fascial elongation occurs before midstance, hence patients with plantar fasciitis present with sharp pains between heel strike and midstance [6]. Furthermore, research has shown that with 90N of force, the plantar fascia will stretch 4% with the failure point being the clamps [8]. Such research confirms the integrity of the plantar fascia and indicates the majority of the pathology occurs at the fascial-calcaneal interface.

Factors

As demonstrated in the present study, post-static dyskinesia is a hallmark of plantar fasciitis [3]. Frequently, patients give a history of sharp pain with insidious onset when first bearing weight after recumbent periods. Typically patients complain of maximal pain with initial ambulation in the morning. Plantar fasciitis is caused by bearing weight after a state of relative inactivity [9]. In the static nonweightbearing state, the plantar fascia is void of tension and thus rests in a contracted state [9]. In the immediate weightbearing period following recumbency, the plantar fascia undergoes a rapid elongation up to 4%, thus the patient experiences sharp, stabbing pains with initial weightbearing [6,8]. When extrapolating the recumbent state from a few hours to several weeks, the fascia is in a state completely void of weightbearing tension. Consequently, patients applying pressure to the heel of a limb which has not carried weight for a significant period of time will likely exhibit symptoms of plantar fasciitis as demonstrated by the current study.

fasciitis1

Table 1 Heel pain in patients remaining nonweightbearing between 2 and 6 weeks (Group 1).

Previous research has demonstrated an increased incidence of plantar fasciitis in individuals experiencing weight gain in the cases of pregnancy or obesity [10]. The mechanical overload causes excessive strain to the arch supporting capacity of the plantar fascia resulting in microtears in the plantar fascia [3]. Histopathological analysis of fascial specimens in chronically symptomatic patients reveal fibroblastic proliferation and granulomatous tissue signifying the cyclic degeneration and limited inflammatory response sustained at the fascial origin [11]. MRI and ultrasound reviews indicate that the dorsal-plantar thickness of plantar fascia in symptomatic patients can increase to 10 mm in thickness, whereas normal plantar fascia is approximately 3 mm [12,13,14]. Though patients in the present study did not exhibit chronicity in their fascial symptoms, the weight gain generally associated with the post-surgical nonweightbearing period may have exacerbated plantar fascial symptoms demonstrated in the early ambulatory stage.

In addition to an elevated body mass index, studies have reported patients with limited ankle flexion to have an increased incidence of plantar fasciitis [10]. Patients with ankle equinus are unable to fully utilize the entire length of the plantar fascia since the heel is bearing less than its proportional weight [10]. Similarly, in the nonweightbearing state the ankle usually rests in some degree of plantarflexion, thus allowing the plantar fascia to contract [9]. When patients begin ambulation after an extended nonweightbearing period, they may experience an incapacitating plantar fascial pain as demonstrated by the current study. All patients exhibited acute manifestations of fasciitis; hence, time to resolution of symptoms was abbreviated in the present study compared to clinical patients demonstrating chronic symptoms. With persistence of plantar fasciitis, pain becomes recalcitrant throughout the day and night [15]. Research correlates the presence of rest pain and night pain with a high failure rate of conservative treatment and serves as an indication for surgical intervention [15].

fasciitis2

Table 2 Heel pain in patients remaining nonweightbearing between 6 and 10 weeks (Group 2).

Treatment

Preliminary treatment protocols for acute plantar fasciitis involve regimented stretching exercises. Plantar fasciitis has earned the reputation of being a self-limiting condition since most patients achieve resolution of symptoms with conservative treatment alone as supported by the present study [2,16]. Stretching protocols often focus on either the posterior compartment of the leg or the plantar fascia itself. Prospective studies demonstrate that regular stretching of either focal point decreases overall pain and pain experienced with initial ambulation [17]. Fascial stretching exercises involve dorsiflexion of the hallux and lesser digits which passively tensions the plantar fascia [3]. Calf stretching exercises work by actively tensing the gastrosoleal complex as well as the plantar fascia [4]. Over 80% of patients with plantar fasciitis demonstrate a concomitant equinus; consequently, equinus is characterized as an etiologic factor of plantar fasciitis [4]. Research has shown that calf stretching exercises result in increased ankle dorsiflexion which directly increases fascial stretch [18,19]. The effectiveness of calf stretching exercises alone is evident in the present study. Furthermore, one case in the current study supported the effectiveness of combining calf stretching exercises with custom molded arch supports as demonstrated by previous research [20].

Conclusion

To the author’s knowledge, the following statistical analysis is the first to introduce an extended post-surgical nonweightbearing period (6-10 weeks) as an etiology of plantar fasciitis. The data presented suggests a statistically significant correlation between the length of postoperative nonweightbearing period and the presence of plantar fascial symptoms in the early ambulatory stage. The lack of fascial tension in the recumbent state, post-surgical weight gain, and ankle plantarflexion may be factors which intensify plantar fasciitis. These compounding factors deserve further research to clarify their significance in post-surgical plantar fasciitis. The clinical implication of the present research suggests that practitioners should implement stretching protocols prior to initiating ambulation. Accordingly, surgeons may facilitate a smoother transition to return to activity by preventatively countering plantar fascial symptoms. The current study is limited in its capacity to determine the full nature of post-surgical plantar fasciitis by its inability to accurately access patient compliance to the nonweightbearing regimen and patient adherence to the prescribed stretching program. By correlating post-surgical plantar fasciitis in terms of ranges, the current study obviates the need to determine exact patient compliance to the nonweightbearing timeline. Moreover, the minute p-value (p=0.0002) indicates a strong correlation between a nonweightbearing postoperative period greater than six weeks and plantar fascial symptoms. In conclusion, the current study presents a new etiology and clinical scenario associated with plantar fasciitis which surgeons and practitioners may preventatively treat by implementing stretching protocols prior to ambulation for patients with a lengthened post-surgical nonweightbearing period.

References

  1. Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int. 2004;25 (5): 303-10. – Pubmed
  2. Wolgin M, Cook C, Graham C et-al. Conservative treatment of plantar heel pain: long-term follow-up. Foot Ankle Int. 1994;15 (3): 97-102. – Pubmed
  3. League AC. Current concepts review: plantar fasciitis. Foot Ankle Int. 2008;29 (3): 358-66. – Pubmed
  4. Patel A, Digiovanni B. Association between plantar fasciitis and isolated contracture of the gastrocnemius. Foot Ankle Int. 2011;32 (1): 5-8.  – Pubmed
  5. Bolgla LA, Malone TR. Plantar fasciitis and the windlass mechanism: a biomechanical link to clinical practice. J Athl Train. 2004;39 (1): 77-82.  – Pubmed
  6. Gefen A. The in vivo elastic properties of the plantar fascia during the contact phase of walking. Foot Ankle Int. 2003;24 (3): 238-44. – Pubmed
  7. Gefen A. Stress analysis of the standing foot following surgical plantar fascia release. J Biomech. 2002;35 (5): 629-37. – Pubmed
  8. Wright DG, Rennels DC. A study of the elastic properties of plantar fascia. J Bone Joint Surg Am. 1964;46 : 482-92.  – Pubmed
  9. Cole C, Seto C, Gazewood J. Plantar fasciitis: evidence-based review of diagnosis and therapy. Am Fam Physician. 2005;72 (11): 2237-42.  – Pubmed
  10. Riddle DL, Pulisic M, Pidcoe P et-al. Risk factors for Plantar fasciitis: a matched case-control study. J Bone Joint Surg Am. 2003;85-A (5): 872-7.  – Pubmed
  11. Singh D, Angel J, Bentley G et-al. Fortnightly review. Plantar fasciitis. BMJ. 1997;315 (7101): 172-5.  – Pubmed
  12. Berkowitz JF, Kier R, Rudicel S. Plantar fasciitis: MR imaging. Radiology. 1991;179 (3): 665-7. – Pubmed
  13. Grasel RP, Schweitzer ME, Kovalovich AM et-al. MR imaging of plantar fasciitis: edema, tears, and occult marrow abnormalities correlated with outcome. AJR Am J Roentgenol. 1999;173 (3): 699-701. – Pubmed
  14. Kier R. Magnetic resonance imaging of plantar fasciitis and other causes of heel pain. Magn Reson Imaging Clin N Am. 1994;2 (1): 97-107. – Pubmed
  15. Haake M, Buch M, Schoellner C et-al. Extracorporeal shock wave therapy for plantar fasciitis: randomised controlled multicentre trial. BMJ. 2003;327 (7406): 75. – Pubmed
  16. Davis PF, Severud E, Baxter DE. Painful heel syndrome: results of nonoperative treatment. Foot Ankle Int. 1994;15 (10): 531-5. – Pubmed
  17. Digiovanni BF, Nawoczenski DA, Lintal ME et-al. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg Am. 2003;85-A (7): 1270-7.  – Pubmed
  18. Flanigan RM, Nawoczenski DA, Chen L et-al. The influence of foot position on stretching of the plantar fascia. Foot Ankle Int. 2007;28 (7): 815-22.  – Pubmed
  19. Radford JA, Burns J, Buchbinder R et-al. Does stretching increase ankle dorsiflexion range of motion? A systematic review. Br J Sports Med. 2006;40 (10): 870-5. – Pubmed
  20. Pfeffer G, Bacchetti P, Deland J et-al. Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot Ankle Int. 1999;20 (4): 214-21. – Pubmed

Comments Off on Post-surgical plantar fasciitis

Tagged , , , , ,

Evaluation of the results of autologous blood injection in the treatment of refractory heel pain

Posted on October 1, 2013 | Comments Off on Evaluation of the results of autologous blood injection in the treatment of refractory heel pain

By Muzamil Ahmad Baba1, B. A Mir2, M. A Halwai3, Arshad Bashir2, Shakir Rashid1, Omar Khursheed1, Qazi Manaan1pdflrg

The Foot and Ankle Online Journal 6 (10): 2

Background: Plantar heel pain is one of the most common problems of the foot treated by health care professionals. As the precise etiological diagnosis of a painful heel still remains unknown, this entity remains enigmatic and frustrating to both the physician and the patient. The present study was done to assess the efficacy of autologous blood injection in the treatment of refractory heel pain.
Methodology: Fifty patients (average age of 46.7 years), 18 (36%) males and 32 (64%) females with refractory heel pain of more than 6 months duration underwent autologous blood injection. Patients were clinically evaluated and reviewed with visual analogue scale (VAS) pain scores pre-procedure and post procedure at 6 weeks followed by a final follow up at 6 months.
Results: Our study showed a significant reduction in VAS scores which reduced from a mean score of 8 (range 6-10) to a mean score of 4 (range 2-9) at 6 weeks and 2(range 0-9) at 6 months.
Conclusion: Autologous blood injection can be used as a treatment modality in patients with heel pain.

Key words: Autologous blood, heel pain, plantar fasciitis

Accepted: September, 2013
Published: October, 2013

ISSN 1941-6806
doi: 10.3827/faoj.2013.0610.002

Address correspondence to: Muzamil Ahmad Baba (MS), Post graduate department of orthopaedics Govt. Hospital for Bone and Joint Surgery Barzullah, Srinagar Kashmir, 190005. Mobile 9086181281. Email: muzamilbaba79@yahoo.com

1Orthopaedic Resident, Post graduate department of Orthopaedics Govt. Hospital for Bone and joint surgery Srinagar Kashmir.
2Associate professor, Govt. Hospital for Bone and joint surgery Srinagar Kashmir.
3Professor and Head, , Govt. Hospital for Bone and joint surgery Srinagar Kashmir.

In 1922, Stiell stated that painful heel appears to be a condition which is seldom efficiently treated, for the simple reason that the causation is not exactly diagnosed.[1]

It was 40 years later that Lapidus and Guidotti, in their article “Painful heel”, stated that the name painful heel is used deliberately in preference to any other more precise etiological diagnosis, since the cause of this definitive clinical entity still remains unknown. This entity of painful heel still remains enigmatic and often frustrating to both the doctor and the patient.[2]

The exact cause of painful heel is uncertain. It is known that the degenerative changes with increasing age are the most constant findings in the elastic adipose tissue of the heel pad.[3- 5]

Aging also brings about a gradual reduction in collagen and water content as well as in elastic fibrous tissue. Woolnough called the entity “tennis heel”, and postulated that repeated traction with aging and repeated trauma, produces microscopic tears and cystic degeneration in the origin of the plantar fascia and the flexor digitorum brevis immediately beneath the plantar fascia.[4] Other theories include the windlass mechanism and the neurogenic causes.[5]

As the etiology of plantar fasciitis is unclear, diagnosis is usually based on clinical signs including: plantar heel pain when weight-bearing after a period of rest, pain that eases with initial activity, but then increases with further use as the day progresses, and pain on palpation.[6] The various treatment options for this condition includes rest, massage, stretching, ultrasound, extra-corporeal shock wave therapy, cold/ heat therapy, orthotics, anti-inflammatory medications, injection of corticosteroids and surgery in refractory cases.[7, 8]

The findings of existing clinical trials provide some support for the use of corticosteroid injection in the short term management of plantar fasciitis.9 However; a recent systematic review concluded that the effectiveness of this treatment has not been sufficiently established, indicating that further research is required. Local steroid injections can provide good short-term relief of symptoms, but are associated with complications such as the rupture of plantar fascia and fat pad atrophy.[10, 11]

Treatment with autologous blood injections acts by providing various cellular and humoral mediators like growth factors which result in healing and relief of pain without any risk of plantar fascia rupture and fat pad atrophy.[12] As autologous blood injection in heel pain is the least studied, we carried out this study to find out the efficacy of this form of treatment in cases of refractory heel pain in which other treatment modalities had failed thus acting as their own controls.

Material and Methods

In our study, 50 patients with refractory heel pain were included following informed consent and institutional review board approval. Inclusion criteria included all patients with unilateral symptoms of at least 6 months with failure to conservative treatment including stretching, orthotics, local steroid injections or other conservative treatment modalities. Exclusion criteria included patients with symptoms of less than 6 months duration, current skin or soft tissue infection at the site, systemic inflammatory diseases, patients with bilateral involvement and patients who had received a steroid injection or other intervention within 3 months period.

A record of the patient’s pain using a visual analogue scale (VAS) was obtained prior to the procedure using a range of 0 to 10, with 0 representing no pain and 10 the worst pain ever experienced. Two millimeters of autologous blood was drawn from the antecubital fossa of the patient. The heel along with the foot was prepared and draped and 2 ml of 2% lignocaine was infiltrated along the surface followed by insertion of a 23 G needle at the most tender point and the blood was slowly injected into the site of maximum pain. Patients were advised to follow up at 2 and 6 weeks and a final follow up at 6 months. All injections were performed by two senior orthopaedic surgeons. The VAS was recorded prior to the procedure and recorded again at 6 weeks and 6 months post injection follow-up.

Results

Between May 2010 to June 2012, 54 patients were included in the study having met the inclusion criteria. Out of these, 4 patients were lost to follow-up while 50 patients completed the study and were followed for a period of 6 months following the injection. There were 32 (64%) females and 18 (32%) males in our study. The age of the patients ranged from 26 to 63 with an average age of 46.7 years. The mean period of symptoms was 11 months (range 6 to 28 months).

Gender Side Age (years) Duration of symptoms (months)
Male= 18 (36%) Right= 17 (34%) <30= 2 (4%) 6 – 12= 11 (22%)
Female = 32 (64%) Left= 33 (66%) 30 – 50= 39 (78%) 12 – 18= 33 (66%)
>50= 9 (18%) 18 – 36= 6 ( 12%)

Table 1: Distribution of patients on basis of gender, age, laterality and duration of symptoms.

Visual analogue scale (VAS) score NO. OF PATIENTS (Total=50)
Pre procedure At 6 weeks At 6 months
0 – 3 0 12 (24%) 41 (82%)
4 -7 11 (22%) 33 (66%) 4 (8%)
8 – 10 39 (78%) 5 (10%) 5 (10%)

Table 2: The VAS scores prior to the treatment and at 6 weeks and final follow up at 6 months.

The left side was more frequently involved 33 (66%) as compared to 17 (34%) on right side. (Table 1)

In our patients, the median VAS pain score at pre procedure was 8 (range 6-10) which decreased to a mean of 4 (range 2- 9) at 6 weeks and a mean score of 2 (range 0 – 8) at 6 months. Statistical analysis revealed a significant decrease in the score (p<.001). (Table 2)

Out of 50 cases, 4 (8%) patients showed an initial improvement but had a recurrence of symptoms with minimal or no change in VAS scores at 6 months. Five (10%) of the cases failed to respond to the treatment. Statistically significant improvement was seen in rest of the 41 (82%) cases both at 6 weeks and 6 months follow-up. Among complications 11 (22%) patients reported an initial temporary increase in pain which resolved within 2 – 3 days, with 3 (6%) patients requiring shot term use of narcotics. There was no infection, neurovascular damage, plantar fascia rupture in our study group.

Discussion

Plantar heel pain is one of the most common foot complaints presenting to a healthcare professional.[13] Reliable incidence data is lacking in many countries including our country. In USA, its incidence has been estimated to be around 10% and accounts for over one million medical visits every year.[13, 14]

A clear etiology still remains unknown, but plantar fasciitis is reported as the most common cause and the terms are frequently used interchangeably in the literature. Conservative treatment is used for this condition in majority of the cases and surgery being used in cases with failed conservative treatment. Surgery carries the risk of nerve injury, infection, rupture of the plantar fascia, and failure to improve the pain.[15] Corticosteroid injections have been shown to be effective in improving symptoms however it has been associated with various complications such as rupture of plantar fascia, calcaneal osteomyelitis and fat pad atrophy.[10, 11]

No such complication occurred in our series. In our study 41 (82%) of the patients had an excellent outcome with only 5 (10%) patients showing no relief and 4 (8%) cases showing a recurrence at final follow up.

In a study of autologous blood injections in plantar fasciitis by Frontera, 80% cases responded to the treatment.[12] Other treatment options like extra-corporeal shock wave therapy (ESWT) have been tried recently, however there is contradictory evidence and recommendations for the efficacy of extracorporeal shockwave therapy (ESWT), as a treatment modality for plantar fasciitis.[16]

The introduction of autologous blood into an area of inflammation will initiate the inflammatory cascade and promote healing in an otherwise degenerative process such as tendinosis or fasciosis. Barrett, et al.[17] also reported on the use of injectable Autologous Platelet Concentrate (APC+) for the treatment of plantar fasciosis. The hypothesis was that by injecting APC+ into recalcitrant, symptomatic plantar fascia was thought to cause a reparative effect leading to a resolution of symptoms. He termed this technique plantar fasciorraphy. His study included 9 patients who enrolled in the study. Of the 9 patients enrolled, 6 patients reported complete relief of symptoms post injection. At one year post study, 7 (77.8%) of the 9 patients had complete relief of symptoms.

Conclusion

Autologous blood injection appears to be a viable and effective treatment in chronic heel pain. It appears to be safe, cost effective and effective form of treatment even in cases who do not respond to other treatment modalities.

References

1. Stiell WF. Painful heel. Practitioner 1922 108: 345.
2. Lapidus PW, Guidotti FP. Painful heel: report of 323 patients with 364 painful heels. Clin Orthop 1965 39: 178-186. [PubMed]
3. Canale TS, Beaty HJ, Murphy AG. Disorder of tendons and fascia. Campbell’s Orthopaedics. 11th ed. Philadelphia USA; 2008. P. 4815-4818.
4. Woolnough J. Tennis heel. Med J Aus 1954 2: 857-861. [PubMed]
5.  Lemont H, Ammirati K, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. JAPMA 2003 93: 234-237. [PubMed]
6.  Schepsis A, Leach R, Gorzyca J. Plantar fasciitis: etiology, treatment, surgical results, and review of the literature. Clin Orthop1991 266: 185-196. [PubMed]
7.  Crawford F, Thomson C. Interventions for treating plantar heel pain. Cochrane Database Syst Rev 2003 3: CD 000416. [PubMed]
8.  Landorf K, Menz H. Plantar heel pain and fasciitis. Clin Evid 2008 2: 1111. [PubMed]
9.  Tatli ZY, Kapasi S. The real risks of steroid injection for plantar fasciitis with a review of conservative therapies. Curr Rev Musculosketel Med 2009 2: 3-9. [PubMed]
10.  Sellman JR. Plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int 1994 15: 376-81. [PubMed]
11.  Acevedo JI, Beskin JL. Complications of plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int 1998 19: 91-97. [PubMed]
12.  Frontera RW, Silver KJ, Rizzo DT. Autologus blood injection in plantar fascitis. Essential Phy Med Rehab 2008 472-473.
13.  Dunn JE, Link CL, Felson DT, Crincoli MG, Keysor JJ, McKinlay JB. Prevalence of foot and ankle conditions in a multiethnic community sample of older adults. Am J Epidemiol 2004 159: 491-498. [PubMed]
14.   Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int 2004 25:303-310. [PubMed]
15.  Kauffman J.  (2006-09-21). Plantar Fascitis. MedlinePlus Medical Encyclopedia. National Institutes of Health.
16.  Rompe JD, Furia J, Weil L, Maffulli N. Shock wave therapy for chronic plantar fasciopathy. Br  Med Bull 2007 81-82: 183-208. [PubMed]
17.  Barrett S, Erredge S. Growth factors for chronic plantar fasciitis. Podiatry Today 2004 17: 37-42.

Comments Off on Evaluation of the results of autologous blood injection in the treatment of refractory heel pain

Tagged , ,