- Email: [email protected]
Percutaneous Ultrasonic Fasciotomy for Refractory Plantar Fasciopathy After Failure of a Partial Endoscopic Release Procedure
PM R XXX (2015) 1-4
www.pmrjournal.org
Case Presentation
Percutaneous Ultrasonic Fasciotomy for Refractory Plantar Fasciopathy After Failure of a Partial Endoscopic Release Procedure Adam M. Pourcho, DO, Mederic M. Hall, MD
Abstract Plantar fasciopathy is a painful, degenerative condition of the plantar fascia that affects 2 million people annually and has an estimated 10% lifetime prevalence. When both nonoperative and operative management fails, patients have limited therapeutic options. We present a case of an active 47-year-old male runner who was successfully treated with songraphically guided percutaneous ultrasonic fasciotomy after undergoing a prolonged course of nonoperative management and an endoscopic plantar fascia release procedure. Percutaneous ultrasonic fasciotomy may be considered in patients with chronic, refractory plantar fasciopathy, including those for whom a prior operative release procedure has failed.
Introduction Plantar fasciopathy is the most common cause of posterior heel pain, accounting for more than 1 million physician visits annually [1]. Identified risk factors include increasing age, high body mass index, prolonged walking or standing, excessive pes cavus or pes planus alignment, and Achilles tendon tightness [1]. Histologically, plantar fasciopathy typically begins as an acute inflammatory process affecting the central band of the plantar aponeurosis at or near its medial calcaneal origin [1]. Patients often report dull, aching, posterior heel pain that is associated with the first few steps in the morning and prolonged standing or walking and is relieved by rest [1]. If the condition fails to resolve, the acute inflammatory process is gradually replaced by chronic degenerative changes histologically characterized by microtears, disorganized tissue, and hypercellularity, often accompanied by enthesopathy [1]. During this phase, symptoms may become more localized to the heel and interfere with all aspects of daily life [1]. It is at this point that many patients seek medical treatment. Plantar fasciopathy commonly responds to activity modification, weight loss, orthotics, stretching, ankle and foot intrinsic muscle strengthening, immobilization,
night splints, oral and topical anti-inflammatory medications, judicious use of injections (eg, corticosteroids and platelet-rich plasma [PRP]), and/or extracorporeal shockwave therapy [2,3]. For refractory cases, endoscopic or open operative release of the plantar fascia has provided benefit for some patients, with reported success rates of 67.7%-82.3% [2,3]. Unfortunately, patients who do not respond to operative intervention have limited therapeutic options. We present a case of a 47-year-old man who was successfully treated with sonographically guided percutaneous ultrasonic fasciotomy for persistent symptoms of plantar fasciopathy after a failed endoscopic release procedure. This case represents the first report describing the use of this novel technique after a failed endoscopic release procedure. Case Report A 47-year-old man presented to the senior author’s sports medicine clinic with persistent right heel pain. Eleven months prior to his initial presentation, he had been treated with endoscopic partial plantar fascia release for chronic plantar fasciopathy. He reported that his pain had begun insidiously 2 years prior to his operative release procedure and had been associated
1934-1482/$ - see front matter ª 2015 by the American Academy of Physical Medicine and Rehabilitation http://dx.doi.org/10.1016/j.pmrj.2015.04.004
2
Percutaneous Ultrasonic Fasciotomy for Plantar Fasciopathy
with the first few steps in the morning, as well as prolonged standing and running. He eventually presented to his primary physician and was diagnosed with “plantar fasciitis.” Radiographs demonstrated a plantar calcaneal spur, mild hindfoot valgus, and minimal pes planus. He was treated with activity modification, a night splint, orthotics, physical therapy (plantar fascia and Achilles tendon stretching and ankleeintrinsic foot strengthening), a walking boot, cold laser therapy, and nonguided cortisone injections. Because these interventions provided only modest, temporary symptom relief, he elected to undergo an endoscopic plantar fascia release procedure. After the procedure, the patient reported only 1-2 months of symptom relief, followed by a gradual return to his preoperative status without meaningful change in the character of his pain. Because he was experiencing persistent, functionally limiting symptoms, he sought another opinion at the senior author’s clinic. At initial presentation, the patient reported right posterior and posteromedial heel pain extending slightly distal along the medial longitudinal arch that increased with his initial steps in the morning, with prolonged standing, and with any running activity. His American Orthopaedic Foot and Ankle Society Hind Foot score was 68/100 [4]. Physical examination revealed marked palpatory tenderness at the plantar fascia origin that extended 2 cm distally; limited tibiotalar dorsiflexion with partial pain reproduction; and mild pes planus. The remainder of the examination was normal, including the Tinel sign over the operative site and tarsal tunnel region. Standing radiographs demonstrated pes planus, a large plantar calcaneal spur, and small, punctate plantar fascia calcifications just distal to the calcaneal tubercle (Figure 1A). Sonography revealed diffuse central band plantar fascia thickening and a large area of midsubstance heterogeneity approximately 1-2 cm from the calcaneus, presumed to represent the region of prior endoscopic release (Figure 1B). As suggested on the radiograph, punctate calcifications were sonographically visualized within this region. The maximal site of tenderness correlated to this region. The remainder of the sonographic evaluation, including Doppler examination and assessment of Baxter’s nerve, was unremarkable. The clinical and imaging findings were consistent with chronic, refractory plantar fasciopathy accompanied by postoperative changes. After a discussion of various treatment options, the patient elected to proceed with percutaneous ultrasonic fasciotomy. Percutaneous ultrasonic tenotomy/fasciotomy is a novel sonographically guided technique in which a small handpiece is used to fragment and remove diseased tissues, thus promoting soft tissue healing and symptom reduction. Percutaneous ultrasonic tenotomy/ fasciotomy is currently performed using the TX1 device (Tenex Health, Lake Forest, CA). Prior to the procedure, a sonographically guided tibial nerve block was
performed for regional anesthesia. Thereafter, a number 11 blade was used to make a small, horizontally oriented stab incision, creating a tract down to the plantar fascia from a medial approach. A tibial nerve block was performed because of the senior author’s anecdotal experience of improved patient comfort during and after procedures about the plantar heel with use of this nerve block. However, the procedure can be successfully performed with local anesthetic only, and our current experience suggests that either method is a viable option. The TX1 working tip was then introduced, using real-time sonographic guidance through the incision and into the area of plantar fasciopathy. The working tip was activated via a foot pedal, resulting in small-amplitude, high-frequency tip oscillations that fragmented the tissue. Tissue fragments were then removed via a continuous inflow-outflow irrigation system connected to the TX1 tabletop console. Using precise sonographic guidance and orthogonal long- and short-axis imaging of the plantar fascia, the senior author treated all the affected areas with a total energy time of 2 minutes and 51 seconds (Figure 2A-C). The patient wore a walking boot for 5 days while removing the boot to apply ice and perform range of motion exercises and gentle plantar fascia and Achilles tendon stretching 3-4 times per day. He was allowed to wean out of use of the boot as tolerated during the next 2 weeks. At 3-week follow-up, he had successfully weaned out of the walking boot, and his incision was well healed. He received instructions regarding a home exercise program consisting of intrinsic foot and ankle group strengthening exercises, plantar fascia and Achilles tendon stretching, and soft tissue mobilization of the plantar fascia. At 8 weeks follow-up, his American Orthopaedic Foot and Ankle Society Hind Foot score had improved from 68/100 to 87/100, and he had returned to work and resumed most of his activities of daily living. His home exercise program was advanced, and he was allowed to return to activities as tolerated. At 6 months, he had returned to running with only minimal intermittent soreness, reported that he was “very satisfied” with his outcome, and indicated that he would have the procedure again or recommend it to a friend or family member. Discussion Although plantar fasciopathy is the most common cause of posterior heel pain, approximately 5%-10% of patients do not respond to nonoperative interventions and are therefore considered candidates for endoscopic or open plantar fascia release [1]. Unfortunately, surgery can be associated with nerve injury, wound complications, and fat pad irritation [3]. Furthermore, therapeutic options are limited in patients who do not improve after surgery. Percutaneous ultrasonic tenotomy/fasciotomy is a novel technique available since 2011 that allows precise removal of diseased tissues
A.M. Pourcho, M.M. Hall / PM R XXX (2015) 1-4
3
Figure 1. A standing lateral radiograph of the right foot with sonographic correlation. (A) A standing lateral radiograph of the right foot and ankle (note: the image has been inverted for orientation purposes) demonstrates pes planus, a plantar calcaneal enthesophyte (open arrowhead), and punctate calcification (solid arrowhead) within the plantar fascia (PF) at the prior operative site. A 12-5 MHz linear array transducer was placed on the plantar aspect of the foot to create the sonographic field of view (dotted rectangle) seen in image B. (B) A correlative sonographic anatomic long-axis (LAX) view of the plantar foot, with the plantar skin at the top of the image, distal (DIST) to the right and proximal to the left, demonstrating the origin of the PF, deep to the plantar fat pad (FP), with diffuse PF thickening of the central band represented by thickening and hypoechoic heterogeneity in the mid substance of the PF. Also seen in this area of presumed partial endoscopic release were several punctate calcifications (solid arrowheads).
using ultrasound guidance [5,6]. This technology is similar to phacoemulsification used in cataracts surgery and was adapted for use in tendons, fascia, and other soft tissues [7]. This technique is generally indicated for the treatment of chronic tendinopathy or fasciopathy that is refractory to nonoperative management. Two previous studies have reported statistically significant improvements in a total of 39 patients with refractory lateral or medial elbow tendinopathy at 1-year followup [5,6]. No complications occurred in either study. The current case is the first to report successful treatment of chronic plantar fasciopathy using percutaneous ultrasonic fasciotomy after a failed endoscopic plantar fascia release. Our patient experienced minimal postprocedural soreness and eventually progressed to full daily, work, and sporting activities despite the failure of extensive nonoperative treatment prior to undergoing our procedure.
A few aspects of our case warrant further discussion. First, we recognize that it is possible that our patient spontaneously improved after the procedure. However, given that the patient had symptoms for more than 2 years, underwent extensive nonoperative treatment, and had a prior operative intervention, in our opinion, the percutaneous ultrasonic fasciotomy likely contributed significantly to the patient’s improvement. Second, we did not obtain structural follow-up of the patient’s plantar fascia. Although this lack of follow-up might be considered a limitation of this report, we do not routinely obtain follow-up imaging on patients after successful treatment. Lastly, a PRP plantar fascial injection could have been considered. However, given the postoperative calcific and scar tissue deposition in the presented case, debridement with aspiration using the TX1 device was believed to be a better clinical approach. Furthermore, other than comparing the added
Figure 2. Anatomic short-axis (SAX) view of the plantar fascia (PF) and sonographically guided percutaneous fasciotomy (PF). (A) Plantar view of a right (RT) foot demonstrating transducer position (black rectangle) for an SAX view of the PF. (B) A correlative sonographic SAX view of the right PF with the plantar skin at the top of the image and lateral (LAT) to the right of image, demonstrating a thickened PF with hypoechoic heterogeneity consistent with diffuse plantar fasciopathy with intrafascial punctate calcification (solid arrowhead). The abductor hallucis (AH) muscle is also viewed medial to the PF. (C) SAX view of the right PF being treated with sonographically guided percutaneous ultrasonic fasciotomy with the TX1 device (arrows).
4
Percutaneous Ultrasonic Fasciotomy for Plantar Fasciopathy
cost to the patient, currently no head-to-head comparison trials of percutaneous ultrasonic fasciotomy, PRP, or a combination of both treatment options have been performed. Future randomized controlled trials comparing these 2 treatment approaches by themselves or in combination are needed to better understand the potential benefits and differences. Conclusion Percutaneous ultrasonic fasciotomy may be considered in patients with chronic, refractory plantar fasciopathy, including those for whom prior endoscopic partial plantar fascia release has failed. References 1. Rosenbaum A, DiPreta JM, Misener D. Plantar heel pain. Med Clin North Am 2014;98:339-352.
2. Saxena A, Fournier M, Gerdesmeyer L, Gollwitzer H. Comparison between extracorporeal shockwave therapy, placebo ESWT and endoscopic plantar fasciotomy for the treatment of chronic plantar heel pain in the athlete. Muscles Ligaments Tendons J 2013;2: 312-316. 3. Lundeen R, Aziz S, Burks J, Rose J. Endoscopic plantar fasciotomy: A retrospective analysis of results in 53 patients. J Foot Ankle Surg 2000;39:208-217. 4. Madeley N, Wing K, Topliss C, Penner M, Glazebrook M, Younger A. Responsiveness and validity of the SF-36, Ankle Osteoarthritis Scale, AOFAS Ankle Hindfoot Score, and Foot Function Index in end stage ankle arthritis. Foot Ankle Int 2012; 33:57-63. 5. Koh J, Mohan P, Howe T, et al. Fasciotomy and surgical tenotomy for recalcitrant lateral elbow tendinopathy: Early clinical experience with a novel device for minimally invasive percutaneous microresection. Am J Sports Med 2013;41:636-644. 6. Barnes D, Beckley J, Smith J. Percutaneous ultrasonic tenotomy for chronic elbow tendinosis: A prospective study. J Shoulder Elbow Surg 2015;24:67-73. 7. Barnes D. Ultrasonic energy in tendon treatment. Oper Tech Orthop 2013;23:78-83.
Disclosure A.M.P. Department of Physical Medicine and Rehabilitation, Swedish Spine, Sports, and Musculoskeletal Center, Swedish Medical Group, Seattle, WA Disclosure: nothing to disclose M.M.H. Departments of Orthopaedics & Rehabilitation and Family Medicine, University of Iowa Sports Medicine Center, University of Iowa Hospitals & Clinics, 2701 Prairie Meadow Dr, Iowa City, IA 52242. Address correspondence to: M.M.H.; e-mail: [email protected] Disclosures outside this publication: nonfinancial support, Tenex Health
Submitted for publication December 22, 2014; accepted April 3, 2015.
www.pmrjournal.org
Case Presentation
Percutaneous Ultrasonic Fasciotomy for Refractory Plantar Fasciopathy After Failure of a Partial Endoscopic Release Procedure Adam M. Pourcho, DO, Mederic M. Hall, MD
Abstract Plantar fasciopathy is a painful, degenerative condition of the plantar fascia that affects 2 million people annually and has an estimated 10% lifetime prevalence. When both nonoperative and operative management fails, patients have limited therapeutic options. We present a case of an active 47-year-old male runner who was successfully treated with songraphically guided percutaneous ultrasonic fasciotomy after undergoing a prolonged course of nonoperative management and an endoscopic plantar fascia release procedure. Percutaneous ultrasonic fasciotomy may be considered in patients with chronic, refractory plantar fasciopathy, including those for whom a prior operative release procedure has failed.
Introduction Plantar fasciopathy is the most common cause of posterior heel pain, accounting for more than 1 million physician visits annually [1]. Identified risk factors include increasing age, high body mass index, prolonged walking or standing, excessive pes cavus or pes planus alignment, and Achilles tendon tightness [1]. Histologically, plantar fasciopathy typically begins as an acute inflammatory process affecting the central band of the plantar aponeurosis at or near its medial calcaneal origin [1]. Patients often report dull, aching, posterior heel pain that is associated with the first few steps in the morning and prolonged standing or walking and is relieved by rest [1]. If the condition fails to resolve, the acute inflammatory process is gradually replaced by chronic degenerative changes histologically characterized by microtears, disorganized tissue, and hypercellularity, often accompanied by enthesopathy [1]. During this phase, symptoms may become more localized to the heel and interfere with all aspects of daily life [1]. It is at this point that many patients seek medical treatment. Plantar fasciopathy commonly responds to activity modification, weight loss, orthotics, stretching, ankle and foot intrinsic muscle strengthening, immobilization,
night splints, oral and topical anti-inflammatory medications, judicious use of injections (eg, corticosteroids and platelet-rich plasma [PRP]), and/or extracorporeal shockwave therapy [2,3]. For refractory cases, endoscopic or open operative release of the plantar fascia has provided benefit for some patients, with reported success rates of 67.7%-82.3% [2,3]. Unfortunately, patients who do not respond to operative intervention have limited therapeutic options. We present a case of a 47-year-old man who was successfully treated with sonographically guided percutaneous ultrasonic fasciotomy for persistent symptoms of plantar fasciopathy after a failed endoscopic release procedure. This case represents the first report describing the use of this novel technique after a failed endoscopic release procedure. Case Report A 47-year-old man presented to the senior author’s sports medicine clinic with persistent right heel pain. Eleven months prior to his initial presentation, he had been treated with endoscopic partial plantar fascia release for chronic plantar fasciopathy. He reported that his pain had begun insidiously 2 years prior to his operative release procedure and had been associated
1934-1482/$ - see front matter ª 2015 by the American Academy of Physical Medicine and Rehabilitation http://dx.doi.org/10.1016/j.pmrj.2015.04.004
2
Percutaneous Ultrasonic Fasciotomy for Plantar Fasciopathy
with the first few steps in the morning, as well as prolonged standing and running. He eventually presented to his primary physician and was diagnosed with “plantar fasciitis.” Radiographs demonstrated a plantar calcaneal spur, mild hindfoot valgus, and minimal pes planus. He was treated with activity modification, a night splint, orthotics, physical therapy (plantar fascia and Achilles tendon stretching and ankleeintrinsic foot strengthening), a walking boot, cold laser therapy, and nonguided cortisone injections. Because these interventions provided only modest, temporary symptom relief, he elected to undergo an endoscopic plantar fascia release procedure. After the procedure, the patient reported only 1-2 months of symptom relief, followed by a gradual return to his preoperative status without meaningful change in the character of his pain. Because he was experiencing persistent, functionally limiting symptoms, he sought another opinion at the senior author’s clinic. At initial presentation, the patient reported right posterior and posteromedial heel pain extending slightly distal along the medial longitudinal arch that increased with his initial steps in the morning, with prolonged standing, and with any running activity. His American Orthopaedic Foot and Ankle Society Hind Foot score was 68/100 [4]. Physical examination revealed marked palpatory tenderness at the plantar fascia origin that extended 2 cm distally; limited tibiotalar dorsiflexion with partial pain reproduction; and mild pes planus. The remainder of the examination was normal, including the Tinel sign over the operative site and tarsal tunnel region. Standing radiographs demonstrated pes planus, a large plantar calcaneal spur, and small, punctate plantar fascia calcifications just distal to the calcaneal tubercle (Figure 1A). Sonography revealed diffuse central band plantar fascia thickening and a large area of midsubstance heterogeneity approximately 1-2 cm from the calcaneus, presumed to represent the region of prior endoscopic release (Figure 1B). As suggested on the radiograph, punctate calcifications were sonographically visualized within this region. The maximal site of tenderness correlated to this region. The remainder of the sonographic evaluation, including Doppler examination and assessment of Baxter’s nerve, was unremarkable. The clinical and imaging findings were consistent with chronic, refractory plantar fasciopathy accompanied by postoperative changes. After a discussion of various treatment options, the patient elected to proceed with percutaneous ultrasonic fasciotomy. Percutaneous ultrasonic tenotomy/fasciotomy is a novel sonographically guided technique in which a small handpiece is used to fragment and remove diseased tissues, thus promoting soft tissue healing and symptom reduction. Percutaneous ultrasonic tenotomy/ fasciotomy is currently performed using the TX1 device (Tenex Health, Lake Forest, CA). Prior to the procedure, a sonographically guided tibial nerve block was
performed for regional anesthesia. Thereafter, a number 11 blade was used to make a small, horizontally oriented stab incision, creating a tract down to the plantar fascia from a medial approach. A tibial nerve block was performed because of the senior author’s anecdotal experience of improved patient comfort during and after procedures about the plantar heel with use of this nerve block. However, the procedure can be successfully performed with local anesthetic only, and our current experience suggests that either method is a viable option. The TX1 working tip was then introduced, using real-time sonographic guidance through the incision and into the area of plantar fasciopathy. The working tip was activated via a foot pedal, resulting in small-amplitude, high-frequency tip oscillations that fragmented the tissue. Tissue fragments were then removed via a continuous inflow-outflow irrigation system connected to the TX1 tabletop console. Using precise sonographic guidance and orthogonal long- and short-axis imaging of the plantar fascia, the senior author treated all the affected areas with a total energy time of 2 minutes and 51 seconds (Figure 2A-C). The patient wore a walking boot for 5 days while removing the boot to apply ice and perform range of motion exercises and gentle plantar fascia and Achilles tendon stretching 3-4 times per day. He was allowed to wean out of use of the boot as tolerated during the next 2 weeks. At 3-week follow-up, he had successfully weaned out of the walking boot, and his incision was well healed. He received instructions regarding a home exercise program consisting of intrinsic foot and ankle group strengthening exercises, plantar fascia and Achilles tendon stretching, and soft tissue mobilization of the plantar fascia. At 8 weeks follow-up, his American Orthopaedic Foot and Ankle Society Hind Foot score had improved from 68/100 to 87/100, and he had returned to work and resumed most of his activities of daily living. His home exercise program was advanced, and he was allowed to return to activities as tolerated. At 6 months, he had returned to running with only minimal intermittent soreness, reported that he was “very satisfied” with his outcome, and indicated that he would have the procedure again or recommend it to a friend or family member. Discussion Although plantar fasciopathy is the most common cause of posterior heel pain, approximately 5%-10% of patients do not respond to nonoperative interventions and are therefore considered candidates for endoscopic or open plantar fascia release [1]. Unfortunately, surgery can be associated with nerve injury, wound complications, and fat pad irritation [3]. Furthermore, therapeutic options are limited in patients who do not improve after surgery. Percutaneous ultrasonic tenotomy/fasciotomy is a novel technique available since 2011 that allows precise removal of diseased tissues
A.M. Pourcho, M.M. Hall / PM R XXX (2015) 1-4
3
Figure 1. A standing lateral radiograph of the right foot with sonographic correlation. (A) A standing lateral radiograph of the right foot and ankle (note: the image has been inverted for orientation purposes) demonstrates pes planus, a plantar calcaneal enthesophyte (open arrowhead), and punctate calcification (solid arrowhead) within the plantar fascia (PF) at the prior operative site. A 12-5 MHz linear array transducer was placed on the plantar aspect of the foot to create the sonographic field of view (dotted rectangle) seen in image B. (B) A correlative sonographic anatomic long-axis (LAX) view of the plantar foot, with the plantar skin at the top of the image, distal (DIST) to the right and proximal to the left, demonstrating the origin of the PF, deep to the plantar fat pad (FP), with diffuse PF thickening of the central band represented by thickening and hypoechoic heterogeneity in the mid substance of the PF. Also seen in this area of presumed partial endoscopic release were several punctate calcifications (solid arrowheads).
using ultrasound guidance [5,6]. This technology is similar to phacoemulsification used in cataracts surgery and was adapted for use in tendons, fascia, and other soft tissues [7]. This technique is generally indicated for the treatment of chronic tendinopathy or fasciopathy that is refractory to nonoperative management. Two previous studies have reported statistically significant improvements in a total of 39 patients with refractory lateral or medial elbow tendinopathy at 1-year followup [5,6]. No complications occurred in either study. The current case is the first to report successful treatment of chronic plantar fasciopathy using percutaneous ultrasonic fasciotomy after a failed endoscopic plantar fascia release. Our patient experienced minimal postprocedural soreness and eventually progressed to full daily, work, and sporting activities despite the failure of extensive nonoperative treatment prior to undergoing our procedure.
A few aspects of our case warrant further discussion. First, we recognize that it is possible that our patient spontaneously improved after the procedure. However, given that the patient had symptoms for more than 2 years, underwent extensive nonoperative treatment, and had a prior operative intervention, in our opinion, the percutaneous ultrasonic fasciotomy likely contributed significantly to the patient’s improvement. Second, we did not obtain structural follow-up of the patient’s plantar fascia. Although this lack of follow-up might be considered a limitation of this report, we do not routinely obtain follow-up imaging on patients after successful treatment. Lastly, a PRP plantar fascial injection could have been considered. However, given the postoperative calcific and scar tissue deposition in the presented case, debridement with aspiration using the TX1 device was believed to be a better clinical approach. Furthermore, other than comparing the added
Figure 2. Anatomic short-axis (SAX) view of the plantar fascia (PF) and sonographically guided percutaneous fasciotomy (PF). (A) Plantar view of a right (RT) foot demonstrating transducer position (black rectangle) for an SAX view of the PF. (B) A correlative sonographic SAX view of the right PF with the plantar skin at the top of the image and lateral (LAT) to the right of image, demonstrating a thickened PF with hypoechoic heterogeneity consistent with diffuse plantar fasciopathy with intrafascial punctate calcification (solid arrowhead). The abductor hallucis (AH) muscle is also viewed medial to the PF. (C) SAX view of the right PF being treated with sonographically guided percutaneous ultrasonic fasciotomy with the TX1 device (arrows).
4
Percutaneous Ultrasonic Fasciotomy for Plantar Fasciopathy
cost to the patient, currently no head-to-head comparison trials of percutaneous ultrasonic fasciotomy, PRP, or a combination of both treatment options have been performed. Future randomized controlled trials comparing these 2 treatment approaches by themselves or in combination are needed to better understand the potential benefits and differences. Conclusion Percutaneous ultrasonic fasciotomy may be considered in patients with chronic, refractory plantar fasciopathy, including those for whom prior endoscopic partial plantar fascia release has failed. References 1. Rosenbaum A, DiPreta JM, Misener D. Plantar heel pain. Med Clin North Am 2014;98:339-352.
2. Saxena A, Fournier M, Gerdesmeyer L, Gollwitzer H. Comparison between extracorporeal shockwave therapy, placebo ESWT and endoscopic plantar fasciotomy for the treatment of chronic plantar heel pain in the athlete. Muscles Ligaments Tendons J 2013;2: 312-316. 3. Lundeen R, Aziz S, Burks J, Rose J. Endoscopic plantar fasciotomy: A retrospective analysis of results in 53 patients. J Foot Ankle Surg 2000;39:208-217. 4. Madeley N, Wing K, Topliss C, Penner M, Glazebrook M, Younger A. Responsiveness and validity of the SF-36, Ankle Osteoarthritis Scale, AOFAS Ankle Hindfoot Score, and Foot Function Index in end stage ankle arthritis. Foot Ankle Int 2012; 33:57-63. 5. Koh J, Mohan P, Howe T, et al. Fasciotomy and surgical tenotomy for recalcitrant lateral elbow tendinopathy: Early clinical experience with a novel device for minimally invasive percutaneous microresection. Am J Sports Med 2013;41:636-644. 6. Barnes D, Beckley J, Smith J. Percutaneous ultrasonic tenotomy for chronic elbow tendinosis: A prospective study. J Shoulder Elbow Surg 2015;24:67-73. 7. Barnes D. Ultrasonic energy in tendon treatment. Oper Tech Orthop 2013;23:78-83.
Disclosure A.M.P. Department of Physical Medicine and Rehabilitation, Swedish Spine, Sports, and Musculoskeletal Center, Swedish Medical Group, Seattle, WA Disclosure: nothing to disclose M.M.H. Departments of Orthopaedics & Rehabilitation and Family Medicine, University of Iowa Sports Medicine Center, University of Iowa Hospitals & Clinics, 2701 Prairie Meadow Dr, Iowa City, IA 52242. Address correspondence to: M.M.H.; e-mail: [email protected] Disclosures outside this publication: nonfinancial support, Tenex Health
Submitted for publication December 22, 2014; accepted April 3, 2015.