One of the most common symptoms that a podiatrist will hear from their patients is that they are suffering from heel pain. This is often a chronic heel pain, that is unrelenting and not responsive to conservative treatment. Several things can cause this heel pain, including stress fractures of the calcaneus (heel bone), entrapment of a nerve running into the heel, or fractures of a heel spur. Most commonly, however, the complaint is related to plantar fasciitis.
Plantar fasciitis is a term used to describe a painful and inflamed plantar fascia, which is a thick, fibrous band of tissue running along the bottom of the foot. This band of tissue attaches to the calcaneus, which is typically where the pain is located. Pain is often worse in the morning with the first steps out of bed, or after long periods of rest, such as sitting at a desk. After the first few steps, the pain may decrease, but will get worse throughout the day with a lot of activity or standing. These are very typical symptoms of plantar fasciitis.
Because of its chronic nature, plantar fasciitis may also be referred to as plantar fasciosis, indicating the chronicity of the problem. When viewed under a microscope, the plantar fascia will show signs of degeneration and a lack of acute inflammatory cells, which is more consistent with a chronic tendinosis than with an acute inflammatory reaction. The plantar fascia will appear thickened as well. These findings all indicate that the condition is non-inflammatory, and is chronic in nature.
The exact etiology of plantar fasciitis has been the subject of debate for some time. Most evidence points towards increased traction at the calcaneus as being the cause of the pain. This increased traction has been associated with obesity, a difference in limb length, increased pronation of the foot, and many other things that increase the stress on the plantar fascia. Some believe that plantar fasciitis is partially due to periostitis of the calcaneus. The periosteum is a structure that surrounds bones and supplies blood to the bone. When this tissue becomes inflamed, regardless of the cause, it is termed periostitis.
Conservative therapy for plantar fasciitis revolves around trying to relieve the symptoms while at the same time decreasing the stress on the plantar fascia. This usually involves any combination of the following:
· Rest
· Ice
· Stretching
· Orthotics
· Physical Therapy
· Non-steroidal anti-inflammatory drugs (NSAIDs)
· Heel cups
· Night splints
· Taping
· Steroid Injections
· Advanced conservative therapies such as platelet-rich plasma injections and extracorporeal shockwave therapy
Generally speaking, conservative measures are exhausted before surgical intervention is attempted. Surgical intervention today typically involves releasing part of the plantar fascia to relieve the tension on the structure. For a long time, the only option surgically was to make a small incision into the foot and release the plantar fascia. With technological advances, new options have popped up.
One option that has become popular among foot and ankle surgeons over the past few years has been the use of Topaz to address plantar fasciitis. The Topaz procedure involves the use of radiofrequency microdebridement of the plantar fascia. The Topaz equipment is a small, pen-like device that delivers a small amount of radiofrequency to the tissues, which helps to remove some of the thickened, diseased tissue that results from chronic plantar fasciitis.
The device works by stimulating angiogenesis in the chronically diseased plantar fascia. This means that it stimulates the growth of new blood vessels. The formation of new blood vessels allows for inflammatory cells to reach the poorly vascularized plantar fascia. These inflammatory cells essentially “restart” the process from the beginning, allowing the tissues in the plantar fascia to reorganize and decrease the amount of scar tissue in the structure.
The Topaz procedure is designed to be as minimally invasive as possible. Generally, the plantar fascia can be microdebrided through small holes made in the skin with a small pin. The Topaz radiofrequency device can then be inserted into the small holes, and the plantar fascia can thus be reached without opening up the foot. These small holes created surgically are small enough to heal without the use of stitches. A small bandage can be placed onto the skin in the surgical area, and the patients can walk on the foot in a protective shoe within a few days.
Short-term and intermediate-term results of Topaz microdebridement for plantar fasciitis have shown good results, with a high percentage of success. Complications involved with open procedures are effectively eliminated from the post-operative course. Because of the avoidance of open surgery, Topaz is becoming a viable option among foot and ankle surgeons. The device has also gained acceptance for use in Achilles tendonitis.
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