Hi everyone.
We're going to talk today about treatment for chronic plantar fasciitis pain.
Now, first of all, this isn't the primary treatment or the initial treatment.
You should first go to our website, do a search for "plantar fasciitis guide," and you'll
find a lot of, actually, easy home treatments you can start with and other treatments that
are available.
But this is for that plantar fasciitis that's just not getting better.
Now, first thing we have to look at is the plantar fascia itself.
It is this thick ligament running on the bottom of the foot, inserts in here into the heel
bone.
Now, where it inserts is usually about 4 millimeters thick.
Now, when this starts to hurt, normally it starts with a condition called "plantar fasciitis,"
that means inflammation of the plantar fascia.
But over time, usually over a month or so, that devolves into a condition called "plantar
fasciosis," where you start to see thickening of this plantar fascia, some little tears
in it.
Almost think of it as scarring.
And if you were to measure it on ultrasound, where that normal fascia's about 4 millimeters
thick, anything above about 6 millimeters thick is considered plantar fasciosis.
And that's a much more difficult problem to treat, in that that plantar fascia is simply
no longer healing.
That healing process has stalled and we need to do something to stimulate that healing.
Now, there are a couple different ways to accomplish that.
The first one is called "shockwave therapy," that's using this machine over here.
Second one is a process called "dry needling."
I'll go over both of those, including advantages and disadvantages.
Now, first one is shockwave.
Now, this is called "extracorporeal" or outside the body shockwave therapy.
In this handle is a little bullet that goes back and forth and that creates pressure waves
that come out the head here.
That is applied to the heel and only takes about 6-7 minutes, and you do it 3 times,
1 session 3 weeks in a row.
Physiologically, what happens when you send shockwaves through that plantar fascia, is
two things occur.
Number 1 is something called "neovascularization," formation of new blood vessels, second is
something called "growth factor release."
These are proteins that help stimulate a healing process.
Basically you're taking a non-healing situation and turning it into an acute healing situation.
Shockwave has excellent studies behind it, many Level 1 studies, which is the highest
level of medical evidence on treating plantar fasciosis.
It works usually about 70%-80% of the time, and I'll go over advantages and disadvantages
of both these in a second.
The second treatment is something called "dry needling."
And what we do there is we first numb this up and we put a local anesthetic in, and then
under ultrasound, we take an injection needle and we poke that plantar fascia multiple times.
That causes some bleeding into the fascia that brings in blood cells, and those blood
cells have proteins that, again, help stimulate a healing process.
So many times you're making a choice between which of these you might want to do in order
to get that tissue to heal.
Now, the advantage of shockwave therapy is it, by far, has the best studies behind it.
There is more Level 1 evidence of shockwave to cure plantar fasciosis than any other treatment
out there.
So that's Number 1.
Number 2, it's, for the most part, painless, and Number 3, there is literally no complication.
Nobody's ever worse for having done shockwave therapy.
Number 4, there's no real downtime.
The physiologic effect of shockwave is not affected by whether or not you're active.
So those are the upsides of it.
The downsides are it's slow, it takes about 4 months to see the benefit of shockwave therapy
and it's not covered by insurance.
Most areas of the country you'll face somewhere between about $400 and $600 total for those
shockwave sessions.
Now, the advantage of dry needling is that it's a covered service, it's just considered
an injection under ultrasound.
There's a code we can use for it, and there's not for shockwave, and so most insurances
do cover it.
The downside to it is, the research isn't nearly as compelling, there's far fewer studies,
and those studies aren't as well done.
There is also a little bit of downtime.
We are traumatizing that fascia a little bit, we may be weakening it by perforating it with
the needle, and so we usually want you in a walking boot for a week or two with it.
It's not absolutely necessary, but there is some slight increase in the risk of a rupture
of the plantar fascia.
There's no right or wrong here.
Most people will start with shockwave simply because it does have the best studies behind
it, but other people will start with dry needling because it is a covered service and they'll
do that first, but you can go either way.
People that start with dry needling may later go to shockwave if that fails.
And I've actually had a couple patients where they started with shockwave and that did not
work, and they later went onto dry needling and it worked out just fine.
So there's obviously no right or wrong way to go, just advantages and disadvantages.
If you have any other questions, go to the website.
You can do a search for either the "plantar fasciitis guide" or "chronic heel pain."
Both of those will give you the information that you need.