Description of Condition:
The plantar fascia is a thick fibrous tissue on the bottom of the foot which protects sensitive structures such as nerves, vessels, muscles and tendons and is also responsible for maintaining the arch of the foot. When the plantar fascia becomes aggravated or inflamed, plantar fasciitis develops. In many cases, plantar fasciitis is called “heel spur syndrome.” Many people think that heel spurs are the cause of their foot pain, but the pain is actually caused by the inflammation or irritation of the plantar fascia. If untreated, plantar fasciitis can lead to a heel spur.
Symptoms:
The symptoms of plantar fasciitis may vary among different patients. Its onset is insidious and it is not associated with a specific incident or trauma. In many cases, the patient suffers from a dull intermittent pain that eventually progresses into a sharp persistent pain. The pain usually is the worst in the morning with the first steps out of bed or after long periods of sitting. The pain is aggravated by continuous weight bearing and becomes progressively more severe over time.
Incidence and Causes:
Plantar fasciitis affects over two million Americans each year and as much as 10% of the population over the course of a lifetime. Plantar fasciitis is caused by a number of factors and is a common sports injury among runners, walkers, and athletes. In fact, it is the most common diagnosis for pain in the inferior aspect of the heel and accounts for 10% of running injuries. Studies have shown a direct relationship between plantar fasciitis and obesity, occupations requiring prolonged standing or walking on hard surfaces and athletic related overuse injuries. In addition, pes planus (flat foot), pes cavus (high arched foot), and inadequate dorsiflexion (tight Achilles tendon) have been recognized as predisposing factors to developing plantar fasciitis.
Anatomy:
The band of tissue that stretches along the bottom of the foot is known as the plantar fascia. The plantar  fascia runs from the front of the heel bone (calcaneus) to the ball of the foot.
During normal gait progression, the fascia alternately goes through states of relaxation and tension. The above mentioned factors cause an overstress on the insertion of the plantar fascia, which in some cases radiates toward the midfoot and toes. Irritation and microtears of the plantar fascia are considered to be the beginning of the pathological process. The tissue then becomes inflamed. Once started, the symptoms often progress rapidly because it is difficult to rest the foot. A bony heel spur may be observed on X-ray; however, it often does not correlate with the symptoms. In contrast, corresponding symptoms may occur without the bony heel spur being observed.
Patient Selection:
The Dornier Epos Ultra is a non-surgical alternative for the treatment of chronic plantar fasciitis for patients with symptoms of plantar fasciitis for six months or more and a history of unsuccessful conservative therapy.
Examination:
On examination, the patient typically has a point of maximal plantar tenderness on the medial calcaneal tuberosity. Ultrasonography of the heel can confirm the diagnosis and can help exclude other entities, especially fascia rupture. Ultrasonographic diagnostic criteria include thickening, hypoechogenicity, and alterations in the normal fibrillary pattern of the plantar fascia
Treatment Description:
The Epos Ultra delivers high-energy shock waves to the area of pain to increase blood flow and stimulate healing of the affected foot.
The therapy head of the Epos Ultra uses a magnetic current impulse to generate shock waves. Shock waves are a type of sound wave. A pulse of electrical energy causes strong magnetic fields, which produce forces that vibrate and create a pressure wave or shock wave. The shock waves travel through the water in the shock wave source (coupling cushion) mounted to the therapy head, where they are precisely focused by a lens to the target tissue without any energy loss or damage to the body tissue.
Before treatment begins, the patient will be given a local anesthetic. Using ultrasound guidance, the source of the pain will be located. Ultrasound gel will be applied to the foot and the therapy head. Treatment then begins and lasts approximately 20-25 minutes. The ultrasound is used throughout the treatment to assist with the targeting of the shock waves.
Post-Procedure Protocol:
After the shock wave treatment is complete, the foot is assessed for any side effects or complications. Side effects that may be related to the ESWT treatment may include:
- Pain or swelling for a brief period following treatment
- Localized numbness, tingling or decreased sensation in the foot or at the site of shock wave delivery; and/or
- Minor bruising or small purplish spots on the skin on the foot or at the treatment site
Instruction on what steps should be taken to ensure the best possible results should be given to the patient. He or she may need to limit athletic activities for several weeks after the treatment to ensure that there is no further injury to the foot. Questionnaires (e.g. VAS and Roles & Maudsley) may be used to assess pain levels before and after treatment.
Alternative Treatment Options:
During the early stages of plantar fasciitis, one or more of the following alternative measures may be utilized to relieve symptoms:
- Rest
- Physical therapy
- Heel cushions
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Corticosteroid injections
- Taping
- Orthotics
- Shoe modifications
- Nightsplinting
- Casting
If these treatment options are not effective (and other specific criteria is met), shock wave therapy or surgery may be recommended. One benefit of shock wave therapy over surgery is that it is conducted in an out-patient setting. This means that the treatment is performed at a doctor’s office or clinic and an overnight stay in the hospital is not required. Another significant benefit of shock wave therapy versus surgery is the recovery time is significantly lower, as are the side effects.
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