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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
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
Light Amplification by Stimulated Emission of Radiation
IR – A 870 and 930 nm non thermal photoinactivation ( Noveon)
IR – A 532 – 595 nm thermal ablation leading to disintegration and vaporization ( CuteraGenesis 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 VIS
100 – 280 nm ( 254 nm )
antibacterial and antifungal through genetic alteration
wound decolonization (includes MRSA ), treatment of onychomycosis
Keraderm
400 – 560 nm (532 nm)
pulsed Nd:YAG laser
pigment specific tissue ablation
Antifungal,verrucaplantaris ablation
Pinpointe, Patholase, Cutera Genesis Plus
ND:YAG PHOTO/THERMALABLATION
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 anti-inflammatory 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 mediplast40% 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 )
LONG TERM TREATMENT (MAINTENANCE PHASE )
Medications
Support
Plantar fascia and achilles tendon stretching at least b.i.d
Limit ambulating barefoot
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 non-loading 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 NEGATIVES
More efficient gait
Unloading of heel and forefoot
Increased shock absorption
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 FLECTOR PATCH
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
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 OPEN
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
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 PERCUTANEOUSMICRODEBRIDEMENT
GRID PATTERN FOR OPEN MICRODEBRIDEMENT
0.62 K-WIRE GUIDE HOLES THROUGH THE PLANTAR FASCIA
FOLLOW GUIDE HOLES WITH TOPAZ MICRODEBRIDEMENTWAND
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 collagenaseactivity
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,Voltarengel, Flector Patch King Pharmaceuticals
Plantar fibromatosis Pd labs transdermalverapamil
Verruca plantaris Efudex ICN Pharmaceuticals, Pinpointe, Patholase