Jack Hutter DPM, C.ped, FACFAS, FAPWCA, Diplomate, ABPFAS
Jack Hutter DPM, C.ped, FACFAS, FAPWCA, Diplomate, ABPFAS Laser therapies Chemical treatment of verruca plantaris Minimally invasive surgical of heel pain caused by plantar fascitis Treatment of plantar fibromatosis Laser antimicrobial therapy Multiwave Locked System laser Light Amplification by Stimulated Emission of Radiation UV- C 100 – 280 nm UV- B 280 – 315 nm UV- A 315 – 400 nm VIS 400 – 560 nm IR – A 560 – 1400 nm IR- B 1400 – 3000 nm IR- C 3000 – 10,600 nm IR – A 870 and 930 nm non thermal photoinactivation ( Noveon) IR – A 532 – 595 nm thermal ablation leading to disintegration and vaporization ( Cutera Genesis Plus) UV – C 254 nm pigment specific photoablation, mutagenic interaction on genetic material Specific intracellular chromophores in tissue absorb radiation, providing varying degrees of filtration of emissions Therapeutic window refers to wavelengths from 600 to 1200 nm Less chromophores in this range allows for greatest tissue penetration of emission Thermal injury to treated and adjacent tissues Mutagenic effects through genetic material alteration Ocular damage Respiratory effects ( vapor plume from 1 gm of ablated tissue equals roughly 5 cigarettes ) UV - C 100 – 280 nm ( 254 nm ) antibacterial and antifungal through genetic alteration wound decolonization (includes MRSA ), treatment of onychomycosis Keraderm VIS 400 – 560 nm (532 nm) pulsed Nd:YAG laser pigment specific tissue ablation Antifungal,verruca plantaris ablation Pinpointe, Patholase, Cutera Genesis Plus ND:YAG PHOTO/THERMAL ABLATION 400 PULSES 12 -16 J/CM2, 3 HZ, 5MM SPOT SIZE, DURATION 3 MS IR - A 560 – 1400 nm ( dual wavelength 870 nm and 930 nm laser specific non-thermal photo inactivation of fungal and bacterial pathogens, not harmful to normal cells wound antisepsis including MRSA Potentiating antibiotic efficacy (Ciprofloxacin, erythromycin, tetracycline ) Two separate wavelengths emitted simultaneously One emission is continuous, providing antiinflammatory and anti-edemic effects The other emission is pulsed and provides analgesic effects Effective in tendonitis, sprains, DJD and arthridities, effusions, bursitis, contusions, venous ulcerations, burns, fascitis, trauma, wound healing 5% fluorouracil cream ( 5 FU, Efudex ) Interferes with the synthesis of DNA and RNA Effect most marked on those cells that grow more rapidly and take up fluorouracil at a more rapid rate Treatment may take at least two months Contraindicated during pregnancy and if breast feeding Especially applicable in cases of large or many lesions Not to be used on inflamed or open skin Avoid contact with eyes and mucous membranes Occlusion increases absorption Integument includes ulceration, pruritis, contact dermatitis, scarring, UV light photosensitivity Infrequently GI, CNS, hematologic events Scalpel debridement every three weeks Patient applies 5 FU cream under tape occlusion to verruca daily, morning and evening Every other evening patient applies mediplast 40% salicylic acid patch over verruca, instead of 5 FU, to be left on overnight Removal of mediplast the next morning provides a chemical debridement effect Caution patient to discontinue treatment if any blistering, ulceration or break in skin develops Topical Treatment Options Topaz Minimally Invasive Microdebridement Plantar fascia bands originate at plantar tubercles, extending proximally to blend with the achilles tendon, distally to blend with the flexor tendons under the MTPJ’s and distally to the toes The greatest amount of linear stretch through the plantar fascia is medial plantar, with fascitis most frequently presenting as inflammation of the medial fascia band attachment to the calcaneus Acute trauma causing an excessive stretch through the plantar fascia ( sudden dorsiflexion of the toes or hyperextension of the foot on the ankle ) Chronic sub- acute trauma to the fascia attachment at the calcaneus, often related to biomechanical abnormality and resulting in calcaneal hypertrophy within the plantar fascia Longitudinal arch structure Ankle, forefoot equinus Body weight Barefoot ambulation Joint inflammatory disease Poor or inappropriate shoe gear Ambulatory surface (hard vs. soft, incline, ladder, steps ) Often can contribute to development of heel pain Incline contributes to excessive pronation and abduction and greater plantar fascia stretching Increased speed adds to mechanical stresses on the plantar fascia Running on the treadmill creates greater heel strike and accentuated pronation Especially problematic if the patient has significant equinus Pain on the bottom of the heel, sometimes referred to arch Mininal pain off weight bearing More constant pain in chronic cases Painful when driving Often no history of trauma, gradual onset Worse when ambulating barefoot Pain on palpation at the origin of the plantar fascia from the calcaneus Minimal pain at the body of the calcaneus, Negative Tinel sign No erythema or local temperature increase No overlying skin or subcutaneous lesions X-ray may show heel spur MRI if suspect fascia tear SHORT TERM TREATMENT (RESOLUTION PHASE ) Medications Support Plantar fascia and achilles tendon stretching at least b.i.d Limit ambulating barefoot LONG TERM TREATMENT (MAINTENANCE PHASE ) Continue stretching routine Avoid barefoot ambulation May need to alter activities to avoid reoccurrence Cornerstone in treatment is orthotic control Medications – Oral or topical NSAID, oral or injected steroid Support – taping, in shoe padding, Powerstep, BFO Stretching and massage – passive, plantar fascia and achilles tendon, anterior or posterior night splint, b.i.d, tennis ball, frozen juice can Limit walking barefoot – croc, birkies, ortha heel Rest – alter walking activities i.e.. Reduce mileage, speed and frequency of workout, change to nonloading force workout ( bike, elliptical ) Passive stretching morning and evening and before and after workout Get in the habit of limiting barefoot ambulation Alter workout routine Appropriate shoe gear and orthotics Shoe design Topical options Minimally invasive microdebridement Multiwave Locked System laser Well known technology to podiatry and pedorthics Traditionally found in many running shoes and orthopedic shoes Seems to be a new trend in walking shoes First developed by MBX Newer siblings Easy Spirit, Sketcher ,New Balance, Avon, Curves, Apex MBX Rocker Shoe - Arguably the prototype of the current influx of similar style shoes POSITIVES More efficient gait Unloading of heel and forefoot Increased shock absorption NEGATIVES More heel and toe spring, could be too drastic for patients with balance problems Negative heel effect from heel spring can be intolerable for patients with significant ankle equinus Rigid orthotics can be uncomfortable due to increased pressure at arch VOLTAREN GEL Topical version of oral NSAID Voltaren ( diclofenac sodium ) Indicated for tendonitis, also being used for plantar fascitis 16 gm total per day ( 2-4 gm bid or tid ) Minimal systemic absorption, but should not be used concurrent with oral NSAID FLECTOR PATCH Diclofenac sodium embedded in an adhesive patch for topical absorption Similar indications as Voltaren gel Apply q12h Awkward in plantar fascitis as is difficult to maintain in position during ambulation Minimal systemic effect Topaz microdebridement Indicated for treatment of chronic plantar fascitis ( 6 - 8 months of failed conservative care ) Thermographic studies show that the plantar fascia in the chronic state of fascitis is hypovascular, making it unresponsive to treatment Acute state of fascitis is hypervascular Microdebridement allows for plantar fascia revascularization Increased local vascular perfusion allows for plantar fascia repair, 1 – 3 months of recovery, minimal complications Bipolar plasma mediated radiofrequency coablation 68,000 cases Minimal tissue damage, few reported complications Indicated for debridement of soft tissue within the shoulder, elbow, knee, foot, ankle Single application Outpatient or office procedure, local anesthesia Two different techniques, open and percutaneous Partial tear of the plantar fascia Acute trauma Neurogenic disease History of keloids In extremely severe cases the chronic inflammation of the plantar fascia may be too extensive for success, requiring an open fasciotomy Patient must be off any anti-inflammatory one week prior to surgery and two weeks after PERCUTANEOUS Palpate to locate area of maximum symptoms Administer local anesthesia Sterile prep Using sterile technique mark a grid pattern of penetration points directly over the symptomatic area on the plantar surface with a sterile marker One at a time at each grid point percutaneously produce a guide hole using a.062 in. K-wire down to the plantar fascia followed by the Topaz wand Penetration depths should vary between 1,3,and 5 mm, 12 – 16 holes OPEN Location of symptoms, anesthesia and prep same as percutaneous Linear skin incision Dissect to plantar fascia Produce grid pattern with the Topaz wand into the plantar fascia Same penetration depths and number of holes, Flush and standard closure GRID PATTERN FOR PERCUTANEOUS MICRODEBRIDEMENT GRID PATTERN FOR OPEN MICRODEBRIDEMENT 0.62 K-WIRE GUIDE HOLES THROUGH THE PLANTAR FASCIA FOLLOW GUIDE HOLES WITH TOPAZ MICRODEBRIDEMENT WAND First three weeks crutch ambulation, immobilize with splint or cast Week 4 – 8, passive and active range of motion exercises and Night splint-Cam walker as appropriate 2 -3 months, no sports or heavy lifting, routine at home or work is okay at surgeon discretion Post op recommendations taken from Topaz literature Plantar fibromatosis is a fibrotic tissue disorder of the plantar aponeurosis characterized by excess collagen formation and fibrosis Fibromatosis may be palpable as single or multiple firm nodules, or can be nonpalpable with generalized fascia thickening Sometimes bilateral MRI confirms diagnosis and rules out sarcoma Traditional treatment includes unloading, injections or surgery A new option in treatment is Transdermal Verapamil Gel Ten times more often in males Caucasians of northern European descent tend to be more affected 25% in middle age to elderly Increased incidence in diabetes mellitus and seizure disorders Trauma to the plantar aponeurosis causing overproduction of collagen/fibrotic tissue Reduction in normal tissue elasticity and local prominence contributes to pain on ambulation Genetic predisposition to fibromatosis and other fibrotic tissue disorders May have concurrent Dupuytren’s contracture Beta blocking agents, antiseizure medications, glucosamine/chondroitin, large doses of vitamin C can promote the production of excess collagen Local steroid injections usually fail as the density of the fibromatosis does not allow adequate medication dispersion Multiple injections may worsen the condition due to trauma Nonpalpable fibrosis is indiscernible, thereby making injection therapy ineffective Surgical removal has a 57% rate of reoccurrence, but may need consideration in cases of larger lesion Orthotics are used to manage pain symptoms but will not resolve the problem Transdermal Verapamil Gel offers resolution with less risk of complications Verapamil is a calcium channel blocker The flow of calcium into fibroblasts through calcium channels in the cell membrane is required for the production of excess collagen that forms the plantar fibroma By blocking the calcium channels Verapamil slows or stops collagen production in fibroma growth Calcium channel blockage also causes increased fibroblast collagenase production which allows for fibroma collagen reduction Apply to the entire plantar aponeurosis, treating both palpable and non-palpable fibromatosis Fibrosis reduction works cumulatively, adequate concentration levels need to be built up and maintained for sustained collagenase activity No systemic or localized adverse effects have been reported Standard treatment time is 6 – 12 months Beta blockers used to treat hypertension and cardiac arrythmia can cause tissue fibrosis, may reduce effectiveness of Verapamil Oral Verapamil can interfere with the metabolism and elimination of statin drugs, digoxin/cyclosporin, with risk of toxic levels – Transdermal Verapamil has minimal systemic absorption, but patient should be advised about this possible adverse effect Nicotene impedes the skin’s ability to absorb topical medications Do not apply under occlusion Wash and dry bottom of affected foot Apply two 0.5 ml doses twice per day using the dosimeter included with the medication Each application is to the entire bottom of the foot Massage the medication into the skin for approximately 1 – 2 minutes, wait 5 minutes, then continue to rub into the skin for another 1 – 2 minutes Repeat the application process The application procedures should be repeated morning and evening every day In Severe Cases of Plantar Fibromatosis, Surgical Intervention May Be Necessary……….. Surgery in Plantar Fibromatosis Dissecting the Lesion Distal fascia band Onychomycosis Keraderm, Pinpointe , Patholase, and Noveon laser systems Wound care/antisepsis Patholase, Pinpointe, and Noveon laser systems Antibiotic potentiation Noveon laser systems Plantar fascitis MLS laser systems, Topaz Arthrocare Sports Medicine, MBX shoes,Voltaren gel, Flector Patch King Pharmaceuticals Plantar fibromatosis Pd labs transdermal verapamil Verruca plantaris Efudex ICN Pharmaceuticals, Pinpointe, Patholase
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