Platelet rich plasma has been advocated for the treatment of plantar fasciitis but there are few good quality clinical trials to support its use. We report a pilot double blind randomised controlled trial of platelet rich plasma versus normal saline. Methods. Patients with more than 6 months of MRI proven plantar fasciitis who had failed conservative management were invited to participate in this study. Patients were block randomised to either platelet rich plasma injection (intervention) or equivalent volume of normal saline (control). The techniques used for the injection and rehabilitation were standardised for both groups. The patient and independent assessor were blinded. Visual analogue scale for pain (VAS) and painDETECT were recorded pre-op and at 6 months. Results. Twenty-eight patients (19 females, mean age 50 years) were recruited, with 14 randomised to each arm. At 6 month follow-up, 8 patients (28.6%) were lost to follow-up. There was a significant change in VAS score from baseline to follow-up in both intervention (mean change 37.2, p = 0.008) and control (mean change 42.2, p = 0.003) groups. However there was no difference between the arms in terms of the change in VAS score from baseline to follow-up (p = 0.183). There was no correlation between pre-op PainDETECT score and change in VAS. Conclusion. This pilot study has failed to show a significant benefit of platelet rich plasma compared to saline injection, although both treatments have shown a significant improvement in symptoms. This may be due to the needling effect of injections. A larger study is required to demonstrate a meaningful change. Loss to follow in this patient group should be considered

Introduction. Whilst most cases of plantar fasciitis can be resolved with existing conservative established treatment options, a few intractable cases can be difficult to resolve. New biologic treatments have been proposed for a variety of soft tissue tendon problems. We evaluated the results of PRP in the treatment of recalcitrant chronic cases of plantar fasciitis. Methods. Patients with plantar fasciitis that had not responded to a minimum of 8 months standard conservative management (eccentric stretching, physiotherapy, cortisone injection, night splints) were offered PRP therapy. The injection into the tender spot at the proximal plantar fascial insertion was performed in theatre as a day case. Roles Maudsley (RM) scores, Visual analogue scores (VAS) for pain, AOFAS scores and ‘would have injection again’ were collated pre-operatively, at three and six months. Results. Prospective data was collected on 39 patients (44 heels – 15 males, 24 females; mean age 51 years, range 25–79 years). No complications were noted. At six months review RM score improved from 3.8 to 2.5 (p<0.001), VAS improved from 7.7 to 4.2 (p<0.001) and AOFAS improved from 61 to 82 (p<0.001). 21 patients had complete relief of symptoms on 3 months review. 25 patients were very satisfied with the clinical improvement and would have the injection again. Whilst there was a slight improvement in scores from 3 to 6 months, this was not significant. 3 patients with bilateral injections on the same sitting did not improve, though 2 patients with bilateral injections on separate sittings did improve. Conclusion. In this series of chronic intractable cases, PRP injection produced a 64% satisfaction rate from patients. The procedure was safe with no reported complications. The authors feel PRP for plantar fasciitis may have some role in treatment and merits further study with a prospective randomised trial

Background. Previous studies have individually shown extracorporeal shockwave therapy (ESWT) to be beneficial for mid-substance Achilles tendinopathy, insertional Achilles tendinopathy or plantar fasciitis. The purpose of this pragmatic study was to determine the efficacy of ESWT in managing the three main causes of refractory heel pain in our routine clinical practice. Methods. 236 patients (261 feet) aged between 25 – 81 years (mean age 50.4) were treated in our NHS institute with ESWT between April 2014 and May 2016. They all underwent a clinical and radiological assessment (ultrasonography +/− magnetic resonance imaging) to determine the primary cause of heel pain. Patients were subsequently categorized into three groups, mid-substance Achilles tendinopathy (55 cases), insertional Achilles tendinopathy (55 cases) or plantar fasciitis (151 cases). If their symptoms were recalcitrant to compliant first line management for 6 months, they were prescribed three consecutive ESWT sessions at weekly intervals. All outcome measures (foot & ankle pain score, EQ-5D) were recorded at baseline and 3-month follow-up (mean 18.3 weeks, range 11.4 to 41). Results. Complete data sets were obtained for 41% of the ESWT treatments (107/261). EQ-5D scores showed a statistically significant improvement between baseline and follow-up in all three-treatment groups; mid-substance Achilles tendinopathy 0.681 to 0.734, insertional Achilles tendinopathy 0.687 to 0.742 and plantar fasciitis 0.684 to 0.731 (p< 0.05). The foot & ankle pain scores grouped for all causes of heel pain also showed a statistically significant reduction from 6.78 at baseline to 5.36 at follow-up (p< 0.05). Conclusion. Overall our results showed that ESWT is an effective tool for the management of all refractory heel pain in an NHS foot & ankle clinical practice

Background. Plantar fasciitis is a frequently chronic and disabling cause of foot pain in adults. This prospective study aims to evaluate the analgesic effect of ultrasound guided dry needling in patients with chronic plantar fasciitis, refractory to conservative treatment. Method and Materials. Patients undergoing dry needling for plantar fasciitis, followed by perifascial injection between Jan ′09 and Feb ′10 were identified. Pain scores were recorded on a visual analogue scale from 0 (no pain) to 10 (worst pain possible) before the procedure, 2 weeks and 6 weeks post procedure. Patients were also contacted in April to assess their current pain level. Responses were graded as excellent (> 75% pain score improvement), good (50-74%), fair (25-49%) and poor (<25% relief). Any complications or need for any further intervention were recorded. Results. 55 feet (46 patients) were identified. All patients had had no relief with previous treatment. 24 feet who had calf tightness had undergone a gastrocnemius muscle lengthening. All patients had radiological confirmation of diagnosis prior to undergoing the procedure. At 2 weeks: 1 foot lost to follow-up. 43/54 feet had excellent or good pain relief. At 6 weeks: 5 feet (4 patients) were lost to follow up. 37 feet (28 patients) reported excellent or good pain relief. 11/13 feet patients with fair to poor response underwent a repeat procedure. Redo-Procedure. Using the same outcome measures, 8/11 and 9/11 feet had excellent or good response at 2 and 6 weeks respectively. Long-term follow-up:. 42 feet (34 patients) were contacted. 13 feet (12 patients) lost to follow-up. Follow-up duration from 2 to 13 months. Mean F/U = 7 months. 23 feet (5 redos) had excellent or good outcome 19 feet (6 redos) had fair or poor outcome. If symptoms reoccurred, average duration of total analgesic effect was 3 months. Conclusion. 80% and 74% of patients had excellent or good outcome at 2 and 6 weeks respectively. After an average of 7 months follow-up, 55% patients had excellent or good results. In those patients in whom symptoms recurred, the average duration of total analgesic effect was 3 months. We believe that ultrasound guided dry needling is an effective treatment method for plantar fasciitis

Background. We compared platelet rich plasma (PRP) injection to cortisone (40mg triamcinolone) injection in the treatment of chronic plantar fasciitis resistant to traditional nonoperative management. The aims were to compare early and long term efficacy of PRP to that of Steroid (3, 6 and 12 months after injection). Methods. 60 heels with intractable plantar fasciitis with failed conservative treatment were randomized to either PRP or Steroid injection. All patients were assessed with Roles-Maudsley (RM) Score, Visual Analogue Score (VAS) for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) score. Data was collected prospectively on the cohort, pre-treatment, at 3, 6 and 12 months post injection. The mean scores of the two groups were compared using Student t test. Results. Pre-injection, the two groups were well matched with no statistically significant difference in the values. At 3 months, all three outcome scores in both groups had significantly improved from their pretreatment level with no significant difference between the groups (PRP: RM 3.7 to 2.0, VAS 8.3 to 3.5, AOFAS 58 to 84; Steroid: RM 3.6 to 1.9, VAS 8.3 to 2.8, AOFAS 57 to 86). At 6 months, improvement was maintained in both groups with no significant difference between groups (PRP: RM 2.1, VAS 3.7, AOFAS 89; Steroid: RM 2.2, VAS 3.3, and AOFAS 84). At 12 months, all outcome measures were significantly better for the PRP group as response in the steroid group had deteriorated (PRP: RM 1.9, VAS 3.3 and AOFAS 89; Steroid: RM 2.6, VAS 5.1 and AOFAS 77: p = 0.008, 0.02 and 0.002 respectively). Conclusions. PRP is better for the treatment of chronic plantar fasciitis as compared to steroid. It shows no statistical difference in effectiveness early on, but unlike steroid, its effectiveness does not wear off with time, making it more durable

Heel pain is very prevalent. Pain, especially after a period of rest, is the main symptom. Reduced ability to walk long distances and inability to participate in exercise and sport are other complaints. Plantar heel pain is most commonly caused by plantar fasciitis. Whilst only the recalcitrant cases reach secondary care, this can still be a significant workload. In the Royal Surrey County Hospital, Guildford, we see approximately 200 cases of recalcitrant heel pain each year. The vast majority of cases never come to hospital and are managed in primary care (1500/yr in podiatry alone). Effective primary treatments should reduce the number of long-term sufferers. Recalcitrant cases of plantar fasciitis often have atypical symptoms. Radiological imaging is extremely useful in clarifying the diagnosis. Ultrasound is our preferred modality. There is a spectrum of pathology that affects the plantar fascia, and this is less well classified than for the achilles tendon, where the distinction between insertional tendinopathy and tendinopathy of the main body of the tendon is helpful in guiding treatment. The evidence for many forms of treatment for plantar fasciitis is weak. Currently, the use of formal calf stretching programs is widely considered to be the best first-line treatment. There are additional benefits with stretches to the fascia itself. The mechanism by which these stretches help is not well established. Calf contracture is, however, associated with a variety of clinical problems in the foot and ankle. This is especially true for isolated gastrocnemius contracture. There is also laboratory evidence that increased plantar fascia strain is seen with increased calf muscle tension. Surgery to release a gastrocnemius contracture improves biomechanics and has been used in refractory cases of heel pain with good effect. Radial extracorporeal shock wave lithotripsy is the latest version of this non-invasive treatment. Results in our centre are encouraging. For selected cases of atypical plantar fasciopathy injection treatments are effective

Introduction. Injections are used to treat a wide variety of pathologies. Our aim was to evaluate the efficacy and safety of foot and ankle injections in our clinic. Materials and methods. We performed a retrospective review of notes and a telephone questionnaire audit into the clinical outcome of all patients who underwent an injection of the foot or ankle in a year. All procedures were performed in an out-patient setting by a consultant musculoskeletal radiologist using either ultrasound or X-ray guidance, with a minimum of two year follow-up. According to the pathology treated, the type of injection included depomedrone, hyaluronic acid and high volume saline injections. Results. Overall 410/446 (92%) patients reported a significant improvement in symptoms and 227 (62%) reported complete resolution of their pain, with 127 (28%) remaining asymptomatic at two year follow-up. The mode time of recurrence of pain was three months. 59 (13%) underwent a further injection and 102 (23%) underwent operative intervention within the follow-up period. There were no reported infections. Complications occurred in two percent of patients, including steroid flare, pain and plantar plate ruptures. Conclusion. Injections are a safe and effective option for treating a variety of foot and ankle conditions and reduce the need for surgery. They are particularly effective for the treatment of ankle soft tissue impingement. They appear ineffective in providing significant improvement in pain for longer than three months in conditions such as plantar fasciitis and hallux rigidus

Introduction:. Plantar Fasciitis is an extremely common and challenging problem that presents itself to foot and ankle practitioners. Many different treatment modalities are available for this condition, with little proven benefit. ECSWT was approved for use by the FDA for the treatment of chronic proximal plantar fasciitis in 2002 and NICE published guidance in 2009 recommending its use in refractory cases. Methods:. Patients who diagnosed with ultrasound scan, and for whom other treatments were unsuccessful, underwent treatment on an outpatient basis. They had three 4–5 minute sessions, once a week. A Spectrum machine was used delivering 10 Hz waves in 500 preset pulses at 2 bar pressure, followed by 2000 preset pulses at 2.5 bar pressure. Pre- and 3 month post-treatment pain levels were recorded using a 10 point Visual Analogue Scale. Results:. 210 courses of treatment have been performed on 181 feet belonging to 135 patients. 46 patients have had treatment to both feet. 121 treatments have paired pre and postoperative VAS scores. 79 had a reduced score post treatment (65.2%), 17 had an increased score (14%), and 24 had a score which remained unchanged (19.8%). 65.8% subjectively felt they had improved. Overall there was an average reduction in VAS score from 7 to 4.975, a reduction of 2.025 points (p=0.000000000151). Discussion:. The majority of patients show a benefit in terms of an overall reduction in pain score, though it is not clear how many patients would have improved spontaneously in that time. However, there is further work to do in terms of a more detailed evaluation of the effect on foot function: anecdotally the treatment may significantly improve start up pain. We would also like to see if we can establish a benefit for the therapy earlier in the disease process

Introduction:. The dorsal closing wedge calcaneal osteotomy has been described for the treatment of insertional pathology of the tendo-achilles. The aim of this study was to evaluate the efficacy of the technique using outcome measures. Method:. This was a prospective case series. Patients were included if they had tendo-achilles insertional pathology (calcific tendonitis, bursitis or Haglund's deformity). A short extended lateral approach was used and a 1 cm dorsally based closing wedge osteotomy of the calcaneus performed. Fixation was with 2 staples. Patients were scored pre-operatively and at 6 and 12 months post-operatively using the VISA-A and AOFAS ankle-hindfoot scores. Results were analysed with the paired student t-test. Results:. Twenty five feet in 23 patients were enrolled in the study February 2011 – May 2013. 22 patients underwent the osteotomy (9 males and 14 females). Average age was 47.2 years (range 19–62 years). 12 feet have been followed up for 1 year, 6 for 6 months, 5 less than 6 months. Average VISA-A improvement was 27.87 points (−13–71) at 6 months p=0.001 and 38 (−13–81) at 12 months p=0.001. Average AOFAS improvement was 11 points (−8–31) at 6 months p=0.005 and 11 (−18–42) at 12 months p=0.04. 82.3% of patients would have the procedure again. Complications included minor wound problems (3), sural nerve symptoms (1) and plantar fasciitis (3). All complications have resolved. Conclusion:. The results of this study show that the use of the Zadek osteotomy of the calcaneus can provide consistent symptomatic relief from insertional Achilles pathology by altering the biomechanics of the tendon without disrupting the bursa. There is a small risk of minor complications, which should be included in the consent process

ECSWT has been on the medical horizon for last 30 years mainly in urology for urolithiasis and has found a parallel use in orthopaedics for various chronic soft tissue conditions like Tendoachilles tendinoses and plantar fasciitis etc. ECSWT acts a piezoelectric device releasing acoustic energy and causing micro-trauma activating cytokine mediated response stimulating local angiogenesis and tissue repair. Methodology. 56 patients were recruited for the trial after ethics approval was achieved. The diagnosis was confirmed with ultrasound scan and measuring the width of the swelling and the local hypervascularity. The cohort of the patients was randomised in groups for physiotherapy [n=23] and shockwave therapy [n= 23]. The patient groups with shockwave therapy received a 3-week treatment with typical 2000 impulses per session once a week and physiotherapy group was subjected to eccentric loading exercises. Patients were assessed at 12 week with AOFAS, VISA-A scores and repeat ultrasound scan. Results. The average age of the average age was 51 years [36- 73 years] Mean duration of symptoms prior to treatment was 25 months (range 6-60 months). AOFAS scores increased in both groups: from 64□86 in the ECSWT group and 72□79 in the physiotherapy group. VISA-A scores also increased in both groups from 39□73 in the ECSWT group and from 36□56 in the physiotherapy group. Scores were significantly higher in the ECWST group post treatment. The ultrasound scan findings suggested the tendon girth receding from 10.9 mm□9.9 mm in physiotherapy group while 9.8 mm□8.7 mm in the ECSWT group with hypervascularity decreasing from marked to mild in both groups. Statistical significance was established using SPSS 16 p < 0.001in post treatment group. Conclusion. Clinically significant improvement was found in the patients treated with ECSWT as compared to the physiotherapy sessions while radiological evidence showed parallel improvement in both the groups

Aims

To evaluate the donor site morbidity and tendon morphology after harvesting whole length, full-thickness peroneus longus tendon (PLT) proximal to the lateral malleolus for ligament reconstructions or tendon transfer.

Aims

Gastrocnemius tightness predisposes to musculoskeletal pathology and may require surgical treatment. However, it is not clear what proportion of patients with foot and ankle pathology have clinically significant gastrocnemius tightness. The aim of this study was to compare the prevalence and degree of gastrocnemius tightness in a control group of patients with a group of patients with foot and ankle pathology.

There are few data available regarding the association between hallux valgus and pain or functional limitation. We determined the prevalence of hallux valgus in a rural Korean population aged between 40 and 69 years, and its association with pain and function. A total of 563 subjects was examined using the foot health status questionnaire, the Short Form-36 questionnaire and weight-bearing anteroposterior radiographs.

Hallux valgus was present in 364 subjects (64.7%). It did not significantly correlate with age and was more common in women. Of the 364 subjects, 48 (13.2%) had moderate or greater deformity, defined as a hallux valgus angle > 25°. This was significantly associated with pain, worse function and worse foot health. The putative risk factors associated with painful hallux valgus were female gender, low educational attainment and the presence of pain in the knee.