Dry Needling for Plantar Fasciitis

A fast, minimally invasive technique appears to provide long-term relief from plantar-fasciitis pain. Plantar fasciitis is the most common cause of foot pain in the United States, accounting for 11-15 percent of all foot-pain treatment and affecting about 1 million Americans per year. Sometimes called "flip-flop disease," it presents with pain that ranges from mild twinges to excruciating, stabbing pain on the underside of the heel and sometimes along the arch of the foot. The pain is worst in the morning and tends to fade throughout the day. Caused by inflammation of the plantar fascia, the condition most commonly results from abnormal pronation, though shoes with poor arch support are also a common culprit. Its presentation and severity correlate strongly with obesity, and it is also commonly associated with weight gain, sedentary lifestyles, and careers that involve standing on hard surfaces. In athletes, increases in running mileage or foot injuries during high-energy activities can spawn plantar fasciitis. It can result in a heel spur on the calcaneus, though the spur is the result of the underlying condition and does not itself cause pain, according to Andrew L. Chen, MD, in the National Institutes of Health (NIH) online encyclopedia, Medline Plus. In the April 15, 1999, edition of American Family Physician , Steven M. Barrett, DPM, and Robert O'Malley, DPM, give a more technical explanation of pronatory problems that can lead to the condition: "A patient with a flexible rearfoot varus may...on weight-bearing, display significant pronation. The talus will plantarflex and adduct as the patient stands, while the calcaneus everts. This pronation significantly increases tension on the plantar fascia." They also contend that other conditions, including tibia vara, ankle equinus, and rearfoot varus, irritate the fascia. Current Treatment Approaches Multiple methods of approaching the problem already exist, from stretching to surgery. Barrett and O'Malley say that many sufferers attempt to treat the symptoms at home for years before seeking professional treatment. The most common home remedies include stretching, nonsteroidal anti-inflammatory drugs (NSAIDs), and night splints. According to Barrett, night splints are an excellent bet, with at least one study showing that 83 percent of patients experienced some relief after using them. Ultrasound-guided puncturing of the heel periosteum and the insertion of the plantar fascia, supplemented with a steroid injection, can eliminate plantar fasciitis. People who do see a practitioner for the condition may be treated with therapeutic shoes, orthotics, or physical therapy. However, Alan Mozes, writing for HealthDay Reporter on December 1, 2008, says that these treatments may take up to a year to produce benefits and don't help everyone. If first-line treatments fail, three to six weeks in a short leg cast is "very often successful" in reducing pain and inflammation, Chen says. He continues that steroid injections also provide lasting relief to some patients with intractable fascia pain. In worst-case scenarios, patients may undergo surgery to detach the fascia from the heel bone and can expect a good chance of success from doing so. However, both steroid injections and surgery carry the risk of intense pain and fascia rupture, and surgery carries the additional risk of infection and nerve injury. A newer, noninvasive treatment, extracorporeal shockwave therapy (ESWT), shows significant promise. Researchers led by Lowell Scott Weil Jr., DPM, reported in the November 1, 2003, Journal of Foot and Ankle Surgery (JFAS) an 82-percent success rate for ESWT on patients whose symptoms had not responded to other noninvasive treatments. Unfortunately, ESWT is painful, can take up to three months to take full effect, and can be relatively expensive. According to a survey of practitioners, it costs between $500 to $3,000 per treatment, and generally requires two to three treatments. [Editor's note: For more information about shockwave therapy, visit www.oandp.com/edge/issues/articles/2008-11_05.asp ] Sharp New Treatment Now, many of these treatments may become obsolete. A highly promising, fast, minimally invasive, and inexpensive new treatment has been developed by researchers at the department of experimental medicine at the University of Genoa, Italy. In a preliminary study that included 44 patients, a research team led by Luca M. Sconfienza, MD, used a combination of dry-needling- repeated puncturing of tissue with an empty hypodermic needle-and ultrasound-guided steroid injections to achieve a 95 percent success rate in completely resolving plantar fasciitis symptoms, relief that has so far lasted for more than eight months since the procedure. In a December 1, 2008, presentation at the annual meeting of the Radiological Society of North America, Sconfienza described the method. The study, presented in a talk titled "What's New in the Treatment of Plantar Fasciitis: A Percutaneous Ultrasound (US)-Guided Approach" included 39 female and five male plantar fasciitis patients who had proven "unresponsive to medical therapy." They ranged in age from 35 to 80. For each patient, radiologists first applied a local anesthetic to the affected heel area and then used ultrasound to guide the empty anesthetic needle in puncturing the periosteum and the insertion of the plantar fascia multiple times, inducing minor bleeding in the tissues. Then, still using ultrasound guidance, a steroid concentration of 1mL of triamcinolone acetonide at 40 mg/mL was injected into the perifascial tissues to reduce inflammation and pain. The entire procedure took about 15 minutes. Following the procedure, patients experienced some tenderness in the foot, and soft-arch orthotics were inserted into the patients' shoes to reduce pressure on the heel area. Sconfienza told the Radiological Society, "It's a very good [method] because we allow nature to work for us. The dry needling performed on plantar fascia and on periostium produces a local hyperaemia that can be compared to a surgical debridement." The hyperemia recruits platelets to heal the normally circulation-poor tissue, while injecting the steroid into the perifascial soft tissue, rather than directly into the fascia-especially with the use of ultrasound guidance-reduces inflammation and eliminates the risk of fascia rupture. Sconfienza continued by saying that 39 of the 44 patients experienced "complete resolution of symptoms within two or three weeks. In just three patients we had initial worsening of the symptoms [for] two or three days and then a complete recovery in about two or three weeks. We had just two nonresponders." Sconfienza stressed, "In cases of mild plantar fasciitis, patients should first try noninvasive solutions...but when pain becomes annoying and affects the activities of daily living, dry-needling with steroid injection is a viable option." Levon Nazarian, MD, professor of radiology and vice-chair of education at Thomas Jefferson Medical College, Philadelphia, Pennsylvania, commented on the technique in an interview with Medscape Radiology . Nazarian already uses dry-needling by itself to treat plantar fasciitis in his patients, and commented, "In my practice, I use [dry needling alone] to break up the scar tissue at the heel.... In my experience, it is about 90 percent effective." He continued, "I think it is sufficient to use the needle alone to break up the [plantar fascia] band. I'm not 100 percent sure adding corticosteroids is necessary.... Adding cortisone further shrinks the scar tissue by reducing inflammation.... Cortisone alone would relieve symptoms in a certain percentage of patients. And then there are some patients who, no matter what you do, don't get better." He concluded, "The bottom line is that this is a promising treatment approach for plantar fasciitis, but doing both techniques together muddies the waters a bit." Sconfienza himself considers the technique ripe for further study-his initial results were derived from a single study with a small sample size and no control group. He said, however, that comparing his team's results with current therapies demonstrated its promise. Further, Sconfienza estimated the cost of the therapy to be a fraction of what ESTW or surgery cost, which is sure to appeal to insurance companies and patients who pay out of pocket. Morgan Stanfield can be reached at linkEmail('morgan','opedge.com');

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