Scientific News in Foot Pain (Part 2):

Non-Insertional Achilles Tendinopathy Treated with Gastrocnemius Lengthening

Tendinitis of the Achilles tendon is one of the most frequent problems that I see. It can be located either directly above the back of the heel or behind the ankle. When it is behind the ankle, it is often a bulbous lump. Sometimes people are concerned that it may be cancer, but tumors in this area are very rare. When it is near the heel (insertional Achilles tendinitis), it can rub on the counter of the shoe.

Prolonged nonoperative treatment including physical therapy, immobilization, weight relief, and strengthening exercises for two months or more are generally recommended prior to any consideration of surgery. Surgical treatment involves removing the scarred and degenerated tendon and repairing it. The recuperation can be painful and prolonged. The success rate is generally quoted at between 70 and 90%.

Dr. Duthon and her associates (Duthon VB et al.  Noninsertional Achilles tendinopathy treated with gastrocnemius lengthening. Foot Ankle Int. 2011 Apr;32(4):375-9) have reviewed the success of gastrocnemius tendon lengthening in treatment of non-insertional Achilles tendinitis after two years. This surgery involves cutting a portion of the tendon/muscle area in the midcalf.  Lengthening of the tendon in this area is easier to recover from and is usually less painful.  It relieves some of the tension around the inflamed area.  Of the 14 patients (three whom had both of the tendons done in this manner), all but one was satisfied with the results, and 11 of the 14 were able to resume their previous sporting activities. MRIs taken of the area showed a decrease in the signal hyper intensity, suggesting that some healing had occurred.

I find this study interesting not only because it demonstrates a easier, more effective, less direct surgical treatment for Achilles tendinitis, but also because it seems to suggest that loosening the gastrocnemius muscle complex aids in the healing of Achilles tendinitis. Because of this, I am more convinced that stretching exercises along with eccentric muscle/tendon conditioning directed at loosening the gastrocnemius muscle nonoperatively can be effective if treatment is continued over a long period of time.

–Brett Fink, MD.  Co-author of The Whole Foot Book:  A Comprehensive Guide to Taking Care of your Feet

Scientific News in Foot Pain (Part 3):

Association between Plantar Fasciitis and Isolated Contracture of the Gastrocnemius

My book, The Whole Foot Book, is focused on the nonoperative treatment of foot pain. One of my main tenets is that many common chronic foot pains are caused and can be treated by correcting overloading of the forefoot. Many studies have shown an association of limited ankle dorsal flexion or gastrocnemius contracture and plantar fasciitis and other foot problems. In fact, they have shown that surgical loosening of a portion of the gastrocnemius is effective at relieving the pain. This is mentioned not so much to advocate it as a panacea for the treatment of foot problems, as there are many serious consequences to gastrocnemius lengthening, but to illustrate that directing treatment towards the underlying stiffness in the Achilles and hamstring muscles is a powerful tool in curing plantar fasciitis.

Dr. Patel and Dr. DiGiovanni (Patel A, DiGiovanni B. Association between plantar fasciitis and isolated contracture of the gastrocnemius. Foot Ankle Int. 2011 Jan;32(1):5-8.) examined people with plantar fasciitis. They found that 83% of people with plantar fasciitis had some form of limited ankle dorsal flexion or stiffness. Many of these were felt to be due to contracture of the gastrocnemius/Achilles muscles and tendons.

Other researchers have noted this in the past. One researcher, Dr. Labovitz et al. (Foot Ankle Spec, Jun 2011, 4(3), p 141-144), commented that, in addition to gastrocnemius tightness, patients with hamstring tightness were about 8.7 times as likely to experience plantar fasciitis. This helps doctors design rehabilitative treatments that are likely to help people with plantar fasciitis.

–Brett Fink, MD.  Co-author of The Whole Foot Book:  A Comprehensive Guide to Taking Care of your Feet

I’ve written several times previously regarding the use of platelet rich plasma in the treatment of musculoskeletal problems, primarily commenting on its uses in the foot and ankle (See also my recent article in J Musculoskeletal Medicine on Plantar Fasciitis, and upcoming comment on PRP in Achilles Tendinitis). A recent new article appeared in the AAOS (American Academy of Orthopedic Surgeons) newsmagazine AAOS Now. It describes a presentation done by Dr. Raymond Monto, M.D. at the 2012 AAOS annual meeting entitled “PRP is more effective than cortisone for chronic severe plantar fasciitis”. Unfortunately, while I was at the meeting, I did not get the opportunity to see this presentation.

According to the article, Dr. Monto reported on 40 patients randomized into treatment with cortisone injection or PRP. He followed these patients for a year. Initial function scores were approximately 44 initially. At three months, those in the PRP group were at 95 while those in the cortisone group had function scores of 81. At the conclusion of the trial, the PRP group continued to have scores that were 94, while those in the cortisone group had scores around 58. It should be noted that Dr. Monto disclosed an association to Exactech, Inc., a company that, among other products, does sell equipment that makes PRP. No mention in this article was made regarding whether the patients were blinded to their treatment.

While this study is encouraging, it should be noted once again that several other studies have failed to definitely show an improvement in other forms of connective tissue damage, such as recently Achilles tendinitis. This study has many limitations and caution should be used until it is confirmed by other larger studies. PRP continues to be poorly covered by most insurances.

The need for the slow incorporation of this new product into general treatment is highlighted by another article in the same issue of AAOS Now which discussed the disappointing results of BMP (bone morphogenic protein) in operations used to make bones fuse. The large industry-sponsored trials used to evaluate the substance showed it to have no bad effects, but this did not prove true with further study. They stated that “shortfalls, including poor design and reporting bias in peer review/publications, ‘may have promoted widespread, poorly considered on-and off-label use, eventual life-threatening complications, and deaths.’” The history of medicine is littered with these stories.

In medicine, what seems a logical, safe, easy, and common-sense approach to a problem may in the end be ineffective and possibly even dangerous.  Safe, non-operative methods of treating plantar fasciitis exist.  Stay persistent and consistent and often it will pay off.  Avoid the temptation to resort to unproven methods such as platelet-rich plasma (PRP).

–Brett Fink, MD.  Co-author of The Whole Foot Book:  A Comprehensive Guide to Taking Care of your Feet

Scientific News in Foot Pain (Part 1):

Alcohol Sclerosing Therapy Is Not an Effective Treatment

for Interdigital Neuroma

Morton’s neuroma is a commonly diagnosed pain in the front of the foot. This pain is characteristically between the third and fourth toe in the ball of the foot. It is usually worse with walking and with tighter shoes.  Often, a click is noted in this area and numbness or tingling is in the toes. It can be quite painful.

Injections with alcohol are commonly prescribed. As you can imagine if you have ever put alcohol on an open wound, injections of alcohol into your tissue are quite painful. A recent study done by Dr. Espinosa in Zürich, Switzerland (Espinosa N et al.  Alcohol sclerosing therapy is not an effective treatment for interdigital neuroma.  Foot Ankle Int. 2011 Jun;32(6):576-80.)

recently reported on 32 patients who had been treated with alcohol injections around the painful neuroma. The patients had been injected with alcohol several times over a year treatment period in the irritated area in their forefoot. Of the 32 patients, 25 showed no significant reduction of symptoms or underwent surgery for the Morton’s neuroma. Three of these patients developed transient intolerable pain from the injection, but no major complications or otherwise noted.

While there are several other reasonable nonoperative and operative treatments for Morton’s neuroma, sclerosing injections with alcohol are of questionable benefit. Phenol is also sometimes used.  This substance is even more toxic than alcohol.  While it is also questionable whether it gives any long-term benefit, I have found injection with steroid or cortisone to give often remarkable symptomatic relief over the short term. This along with a stretching program focusing on hamstring and Achilles tendon contractures and the use of shoe pads is a reasonable initial nonoperative step.

–Brett Fink, MD.  Co-author of The Whole Foot Book:  A Comprehensive Guide to Taking Care of your Feet