ESWT for the Treatment of Plantar Fasciitis: A Nine-Year Follow-Up

ESWT for the Treatment of Plantar Fasciitis: A Nine-Year Follow-Up

Kelly A. Malinoski, DPM, Lowell Weil Jr., DPM, Lowell Scott Weil, Sr., DPM

Anthony Borrelli, DPM, Wendy Benton-Weil, DPM

WEIL FOOT AND ANKLE INSTITUTE, DES PLAINES, IL www.weil4feet.com

Introduction

Extracorporeal Shockwave Therapy (ESWT) is a well-accepted treatment alternative, world wide, for the treatment of chronic and recalcitrant tendonopathies and plantar fasciitis. Early and mid-term study results indicate success with a variety of orthopedic disorders, including plantar fasciitis. While several short-term studies support ESWT for the treatment of plantar faciitis1,2, there are only a few mid-term studies that have evaluated the benefit of ESWT on function and pain five years post-treatment. These studies demonstrate favorable results including improved function and pain .3,4

Objective

To determine the long term benefit (9 years) and safety of ESWT on patient reported measures of function, pain, patient satisfaction, and level of improvement and time necessary to resume regular activities. Safety measures evaluated whether there was any history of long-term weakness, lateral column pain, or plantar fascial rupture that could be attributed to the ESWT intervention.

Methods

Study Design

The number of patients with plantar fasciitis treated with ESWT in 2001-2002 was identified using retrospective chart review (N=197).

Data Collection

A 10-item paper pencil retrospective survey was mailed to each patient and was used to document level of function, pain, patient satisfaction, level of improvement, time necessary to resume regular activities, and complications.

Statistical Analysis

Descriptive statistics were used to examine the distribution for all key variables. For categorical variables (i.e., level of satisfaction, level of function, and etc..), frequency counts were calculated. For continuous variables (i.e., level of improvement, level of pain), measures of central tendency and dispersion were calculated. Additional analyses included cross tabulation and correlations of key variables to further understand the data. SAS version 9.1 was used for all analyses.

Results

Of the 197 patients identified for inclusion in the study, 75 patients returned the survey (38.1%).

SATISFACTION

65 patients (87.84%) reported moderate to high satisfaction with ESWT.
Of those patients, 58 reported high satisfaction. For those patients, the percentage of improvement in heel pain was 96.4% (SD=6.16) with an average pain rating of 0.77 (SD=1.10) after the procedure.

ACTIVITY

Of the 63 patients (87.50%) able to return to regular activities after ESWT, the amount of time was 3.44 weeks and average pain rating after the procedure was 1.21.

PAIN

There was a significant negative correlation between percentage of improvement in heel pain and average pain rating after the procedure (r=-0.801, p < 0.001).


18 patients (24.3%) were able to discontinue comfort maintenance (i.e., stretching, icing and etc..) after ESWT. For those patients, percentage of improvement in heel pain was 95.8% (SD=7.72) with an average pain rating of 0.67 (SD=1.19) after the procedure. For the remaining 56 patients who continued maintenance, the percentage of improvement in heel pain was 79.7% (SD=32.60) with an average pain rating of 2.07 (SD=2.77).

FUNCTION

Of the 66 patients (91.67%) who reported better functioning after ESWT, the percentage of improvement in heel pain was 91.09% (SD=17.38)

COMPLICATIONS

There were no long-term complications such as continued lateral column pain, neuropraxia, nerve injury, or plantar fascial rupture reported.

Table 1. Descriptive Statistics
Domain	Outcome	N=74 Patients
Satisfaction	Level of satisfaction with ESWT n (%)	65 (87.84)
Pain	Average percent improvement in heel pain (0-100%; Mean ± SD) Average heel pain rating following ESWT (0-10; Mean ± SD)	83.61 ± 29.40 1.73 ± 2.55
Function	Level of functioning following ESWT n (%)	66 (91.67)
Activity	Ability to return to regular activities n (%) Average time (weeks) necessary to return to regular activities (Mean ± SD)	4.50 ± 12.74

Conclusions

ESWT has been shown to be highly effective in treating numerous musculoskeletal conditions, including chronic plantar fasciitis, in patients as early as three months following treatment. To date, there have been no studies evaluating these patients beyond five years.

We have evaluated a limited number of patients, retrospectively, who were an average of nine-years post-ESWT treatment of plantar fasciitis. Our early results have continued to be beneficial and satisfying to the great majority of patients responding to our request for evaluation.

This leads us to a conclusion that ESWT is equivalent to open surgery for the treatment of chronic plantar fasciitis, and that the results of this treatment appears to be void of some of the complications such as chronic lateral column pain and neuropraxia that are seen with surgical intervention.

In short and long-term studies, the clinical benefit of ESWT for plantar fasciitis across the dimensions of pain, function, patient satisfaction and activity has been consistently positive.

The results of this study combined with the results that have been reported in the world literature over the past five years are significant and greater in number than similar studies evaluating surgery for plantar fasciitis. The results seem to be equivalent, with faster recovery and no complications from ESWT.

It is our opinion that ESWT can no longer be considered as an investigational treatment and should be made compensable by insurance to the public at large.

We are aware of the limitation of this study because of the limited number of responses (75, 38.1%) drawn from our index number of (197)

References

1. Gerdesmeyer L, Frey C, Vester J, Maier M, Weil L Jr, Weil L Sr, et al. Radial extracorporeal shock wave therapy is safe and effective in the treatment of chronic recalcitrant plantar fasciitis: results of a confirmatory randomized placebo-controlled multicenter study. Am J Sports Med. Nov 2008;36(11):2100-9.
2. Lowell Scott Weil Jr. DPM, Thomas S. Roukis DPM, Lowell Scott Weil Sr. DPM, and Anthony H. Borrelli DPM, Extracorporeal shock wave therapy for the treatment of chronic plantar fasciitis: indications, protocol, intermediate results, and a comparison of results to plantar fasciotomy. Journal of Foot and Ankle Surgery. 41(3): 166-72.
3. Ogden, John A, MD, et al. Electrohydraulic High-Energy Shockwave Treatment for Chronic Plantar Fasciitis. The Journal of Bone and Joint Surgery (American) 86:2216- 2228 (2004)
4. Wang, Chin-Jeng, MD, et al. Long-Term Results of Extracorporeal Shockwave Treatment for Plantar Fasciitis. The American Journal of Sports Medicine. April 2006. 34: 592-596.
5. Benton-Weil, W, Weil, Jr, LS, Weil, Sr, LS, Borrelli AH, Percutaneous plantar fasciotomy, :a minimally invasive procedure for recalcitrant plantar fasciitis. J. Foot Ankle Surg. 37(4):269-272, 1998

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Retrospective Comparison of Patients Undergoing Formal Physical Therapy Versus No Physical Therapy Following Bunion Correction

Retrospective Comparison of Patients Undergoing Formal Physical Therapy

Versus No Physical Therapy Following Bunion Correction

Kelly A. Malinoski, DPM, Lowell Weil Jr., DPM, Lowell Scott Weil, Sr., DPM

Anthony Borrelli, DPM, Wendy Benton-Weil, DPM


WEIL FOOT AND ANKLE INSTITUTE, DES PLAINES, IL www.weil4feet.com

Introduction

Physical therapy (PT), following bunion correction, is theorized to recover range of motion of the first metatarso-phalangeal joint (MTP). PT can also aid in decreasing the recovery period from hallux valgus surgery, which is particularly advantageous to the active patient.1 Physical therapists frequently use manual therapy procedures as part of comprehensive rehabilitation programs to help patients regain joint mobility and function.2

Few investigations include both subjective and objective measurements of the effectiveness of physical therapy treatments in reconstructive foot surgery, particularly following hallux valgus correction.

We hypothesize that patients receiving formal physical therapy will yield functional benefits and an improved return of 1st MTP range of motion, as well as an increased patient satisfaction as compared to those who did not receive a formal physical therapy program, post operatively. This study evaluates the effectiveness and differentiates whether a regimented course of physical therapy following bunion correction enhances the results of the surgical correction.

Methods

Study Design

Patients with a history of receiving Scarf bunionectomies by three surgeons at the Weil Foot & Ankle Institute were identified using retrospective chart review and (N=55) recruited to participate in this retrospective, post-operative follow-up study. All three surgeons used virtually the same technique in performing the Scarf Bunion Procedure.

Two of the surgeons used a standard, formal physical therapy program beginning at one week post-operative. The third surgeon did not use physical therapy post operatively.

Data Collection

Patients were administered five subjective instruments during their follow-up clinical office visit. Instruments were completed before any clinical assessment to avoid biasing patient’s responses. Several instruments include objective clinician rating, which were completed during the course of the office visit. Retrospective chart review was used to obtain pre-operative pain ratings as well as the number of post operative physical therapy sessions attended.

Instrumentation

1. The 8-item American Orthopedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal Scale: a patient-reported measure of pain combined with a clinician rating of function and alignment.
2. The 3-item AOFAS Hallux MPJ Scale: a patient-reported measure of pain and function.
3. The 10-item Weil Satisfaction Survey: a newly developed patient-reported measure of function, pain, patient satisfaction, level of improvement and time necessary to resume regular activities.
4. The 5-item American College of Foot and Ankle Surgery First Metatarsophalangeal Joint and First Ray: a patient-reported measure of pain, cosmesis, and functional capacities with clinician ratings of radiography and function.
5. The 23-item Foot Function Index: a patient-reported visual analog scale (VAS) of pain severity, activity difficulty, and limitation frequency.

Statistical Analysis

Descriptive statistics were used to examine the distribution for all key variables. For categorical variables (i.e., level of satisfaction, level of function, and etc..), frequency counts were calculated. For continuous variables (i.e., level of improvement, level of pain), measures of central tendency and dispersion were calculated. Change in level of pain was assessed using a paired samples t-test. The sub-analyses by physical therapy participation was assessed using Independent Samples t-test. Additional analyses included cross tabulation and correlations of key variables to further understand the data. SAS version 9.1 was used for all analyses.

Overall Results

Patient Demographics

The study included 55 patients (79 feet; average age 57, range 16-78 years) with right (n=16), left (n=15), or bilateral (n=24) Scarf Bunionectomies. 44 patients (80.0%; 65 feet) participated in a formal, regimented physical therapy program and 11 (20%; 14 feet) were not given a post operative, PT program.

Patient Satisfaction

48 out of 55 patients (87.3%) were moderately to extremely satisfied with the results of the Scarf Bunionectomy procedure.

Function and Daily Activities

49 out of 55 patients (89.1%) were able to return to their routine daily activities at an average of 11.6 weeks (SD=10.2, range=1-48 weeks). 48 out of 55 patients (87.3%) reported similar or improved post-operative functioning. On the AOFAS Hallux MPJ, 89.4% of patients indicated “no limitations” in daily activities.

Pain

Patients reported a 87.1% (SD=21.8) improvement in pain post-operatively. There was a significant reduction in patient reported pain rating (t=6.280, df=30, p= < 0.0001). The average change in pain rating (0-10) was a 3.2 point decline (FIGURE 1: SD=2.9). Pre-operatively, patients reported an average pain score (0-10) of 5.3 (SD=2.3, range=2-10). Post-operatively, patients reported an average pain score (0-10) of 2.1 (SD=2.1, range 0-4). On the patient report AOFAS Hallux MPJ, 75% of patients indicated “none” to “mild, occasional” pain.

Physical Therapy Results

Results indicate that patients who participated in physical therapy reported significantly higher foot function and fewer activity limitations as measured by the Foot Function Index (see Table 1: Foot Function Index), than the patients who had no physical therapy program. These results were confirmed by the patient reported measure of functional capacity as well as the clinical (objective) rating of foot function on the ACFAS (SEE TABLE 1: ACFAS).

Dorsiflexion was categorically measured on the ACFAS as well as clinically rated during the office visit. For 65.0% of patients who participated in physical therapy, the range of motion was 60 degrees or greater (39 feet, mean=66.4, SD=20.2). Only 45.5% of patients who did not participate in physical therapy had a similar range of motion (5 feet, mean=60.7, SD=25.8).

Plantarflexion was categorically measured on the ACFAS. For 98.4% of patients who participated in physical therapy, the range of motion was 0 degrees or greater (63 feet). The same was true for 91.7% of patients who did not participate in physical therapy (11 feet).

Conclusions

The application of continuous passive motion to joints immediately after joint surgery stimulates the regeneration of articular tissue, eliminates adhesions, prevents joint stiffness, reduces pain, and is well tolerated by patients.³
Although the idea of post-operative physical therapy is supported and recommended by podiatric and orthopedic surgeons, the literature is weak in identifying the benefit of physical therapy after reconstructive bunion correction.

Patients who underwent regimented physical therapy post-Scarf Bunionectomies at the Weil Foot & Ankle Institute presented higher satisfaction rates, and scored better in the Foot Function Index and ACFAS total scores, versus those patients who did not complete physical therapy. These patients were also shown to function better and at a higher level of capacity with less limitation (TABLE 1). It is imperative to note that the correlation, while positive, between AOFAS and ACFAS scores is considered marginally moderate (r=0.409). Similarly, it was expected that the correlation between the Foot Function Index and ACFAS and AOFAS would be low, but the direction negative, given that one is patient-reported while the other two are clinically rated. This assumption was true for the ACFAS (r=-0.072); however, for the AOFAS, the correlation was positive (r=0.007). This indicates that the ACFAS may be more sensitive for discriminating between patient groups in observational studies.

Formal physical therapy following bunion correction yields favorable clinical and functional results, including an increased level of patient satisfaction, and is shown to provide continual long-term benefits after the post-operative course.

References

1. Saxena, A., O’Brien, T. Postoperative Physical Therapy for Podiatric Surgery. JAPMA. 1992, Aug. 8. 2(8): 417-23.
2. Deyle, Gail D., MPT et al. Effectiveness of Manual Physical Therapy and Exercise of the Knee:
   A Randomized, Controlled Trial. Annals of Internal Medicine. Vol. 132 (3), 1 Feb. 2000. 173-8.
3. The Podiatric Application of Continuous Passive Motion: A Preliminary Report. JAPMA
   Dec. 1991; 81(12): 631-7.

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Correction of 2nd MTP Instability Utilizing a Weil Osteotomy and Dorsal Approach Plantar Plate Repair – A New Technique & Early Results

Correction of 2nd MTP Instability Utilizing a Weil Osteotomy and Dorsal

Approach Plantar Plate Repair – A New Technique & Early Results

Kelly A. Malinoski, DPM, Lowell Weil Jr., DPM, Lowell Scott Weil, Sr., DPM


WEIL FOOT AND ANKLE INSTITUTE, DES PLAINES, IL www.weil4feet.com

Introduction

The plantar plate is the principal sagittal plane stabilizer of the metatarsal-phalangeal joint (MTP) and any compromise to the integrity of the plate can lead to wearing and rupture of this joint. Plantar plate tears often contribute to metatarsalgia, leading to chronic instability, subluxations, and dislocations. A plantar plate rupture can be either acute, due to a hyperextension injury, or chronic in nature, secondary to chronic metatarsal overload. Primary repair of a plantar plate tear has been performed for years, although the etiology of a non-traumatic, isolated primary plantar plate injury has not been clearly understood.1,2,3 The traditional repair of the plate from a plantar approach is both difficult and does not address the underlying etiology of those cases caused by chronic pathology: an elongated or sub-located lesser metatarsal.

We present a new technique and early results that incorporate a Weil Metatarsal Osteotomy and primary repair of the plantar plate through a DORSAL approach. We have utilized this technique for over two years with promising early results. This unique surgical technique addresses and allows for correction of both the metatarsal deformity and plantar plate pathology through one, minimally invasive, surgical approach.

Surgical Technique

• A curvi-linear incision is made overlying the 2nd MTPJ exposing the metatarsal head and base of the proximal phalanx.
• A Weil metatarsal osteotomy is performed and the capital fragment is retrograded under the distal one third of the metatarsal, and is held in temporary position with a smooth .045 wire. This allows for exposure to the plantar plate and flexor tendon, when visible. The redundant dorsal bone surface is resected about 3-4 mm and smoothed to normal anatomical contour (FIG. 3).
• The plantar plate is visualized and noted to be torn (in this case) and/or attenuated (in other cases) at the insertion in the base of the proximal phalanx. The plantar plate is fully mobilized distally and freed of any residual attachments. (FIG. 4).
• Using the Smart Stitch System*, #2 Magnum wire is used to grab and fixate the plantar plate proximally with a mattress suture (FIG. 5, 6, 7).
• Two drill holes are then made with .062 threaded k-wires in the base of the proximal phalanx; one dorsal-medial to central and the other dorsal-lateral to central (FIG. 8). Using monofilament wire through the bone tunnels, the sutures securing the plantar plate are passed from the plantar to the dorsal surface of the base of the proximal phalanx.
• The temporary pin fixating the Weil osteotomy is removed and the 2nd metatarsal head is reduced, properly aligned to create corrected positioning and fixated with a 2.4mm threaded head screw or two .062 threaded k-wires (FIG. 9, 11).
• The suture on the dorsal surface of the proximal phalanx is now tied dorsally with the digit held in plantarflexion, and the 2nd MTP is reduced and stabilized
  (FIG. 10, 11, 12).

*Arthrocare Opus

Function and Daily Activities

11 out of 13 patients (84.6%) reported similar or improved post-operative functioning. All patients were able to return to their routine daily activities at an average of 14.7 weeks (SD=7.4, range=4-24 weeks).

Pain

Patients reported a 71.9% (SD=36.4) improvement in pain post-operatively. There was a significant reduction in patient report pain rating (t=6.824, df=13, p=< 0.0001). The average change in pain rating (0-10) was a 4.9 point decline (SD=2.7, range 2-8 reduction). Pre-operatively, patients reported an average pain score (0-10) of 6.7 (SD=1.7, range=2-9). Post-operatively, patients reported an average pain score (0-10) of 1.6 (SD=1.4, range 0-4).

Conclusions

Metatarsophalangeal joint instability/dislocation can be a very difficult problem for patients and surgeons. Until recently, repair of the plantar plate was limited to soft tissue correction without addressing the bony etiology of the deformity.

Through a dorsal approach, a Weil Osteotomy is performed and the plantar plate tear is visualized and primarily repaired, advanced, and strongly anchored into bone using a shoulder arthroscopy knotless system, addressing and correcting the true etiology of plantar plate pathology.

Despite the small sample size, this procedure has been shown to yield consistent and favorable early results across the domains of patient satisfaction, pain, function and daily activities, as well as ACFAS & AOFAS Scoring Scales

References

1. R.B. Johnston III, J. Smith and T. Daniels, The plantar plate of the lesser toes: an anatomical study in human cadavers, Foot Ankle Int 15 (1994), pp. 276–282.
2. Blitz, DPM, et al. Plantar Plate Repair of the Second Metatarsal Phalangeal Joint: Technique and Tips. Journal of Foot & Ankle Surgery. Vol. 43, Issue 4. 266-270.
3. Bouché DPM, FACFAS, Heit DPM, FACFAS Combined Plantar Plate and Hammertoe Repair with Flexor Digitorum Longus Tendon Transfer for Chronic, Severe, Saggital Plane Instability of the Lesser MPJ’s: Preliminary Observations. Journal of Foot & Ankle Surgery. Vol. 47, Issue 2, 2008. 125-37.

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