of you flew to Chicago, the Achilles tendinopathy and plantar fasciitis talks. I'm a foot and ankle surgeon. As most of you know, foot and ankle is anatomically and financially at the bottom of orthopedics. Adam Anz, actually, was here earlier. He was my chief resident when I was an intern. So when we were on- That's why he's flying private. Yeah, yeah. When I was an intern, we would go and tell people that he's the chief. I'm just an Indian. It's not going to get any better, OK? All right, so I know most of you don't really take care of much Achilles tendinopathy or plantar fasciitis. So we're just going to go over some real basics and then a little bit of the contemporary literature. And I'm on call today, so I've got to get back to downtown in a second. But there's basically two types of Achilles tendinopathy. You may remember from residency, there's insertional Achilles tendinopathy. This is often associated with calcaneal enthesophytes and Haglund's deformities. It occurs at the insertion of the Achilles into the calcaneus, as the name states. Non-insertional or mid-substance occurs about 3 to 5 centimeters above this at a watershed area. So the diagnosis is usually made clinically. Sometimes we get an MRI if we think that it's germane. A lot of times, you can walk into the room, and you take a look at this person's heel from the side, and you can see a big bump, and you already know what they're there for. They have pain at the mid-substance of the Achilles. The first few steps in the morning are very painful. And the pain gets better, usually, as the day goes on, as they stretch it out. They have start-up pain if they've been sitting down for a while. And then the differential includes calcaneal stress fractures, posterior ankle impingement syndromes, osteogonim, and also peritonitis, or sometimes people get adhesions around the periton. A lot of these slides are going to look very similar to the plantar fasciitis one, because the treatments are very similar. So anti-inflammatories, if you want to go on the immobilization end, you can do a BOOT or a CAST. But we try to keep people moving. We do a lot of eccentric training, night splints, physical therapy. There's also a randomized control trial that shows evidence that nitroglycerin patches are very helpful for this to incite blood flow. As far as operative management goes, we can do open debridement and calcaneoplasty. If it's an insertional achilotendinopathy, that procedure has a 90% to 95% success rate. If it's mid-substance and open debridements of more than 80% to 90% range, you can do an endoscopic debridement. Also, you can use a 10X harmonic scalpel as well. This is a picture of when I was looking at PRP stuff. It reminded me of one of my patients that we gave it to. And she asked if we could use some of the extra to inject her face. We did not do that. So a meta-analysis of four randomized trials. You know, in foot and ankle, it's such a heterogeneous diagnoses that we have that we don't have very big numbers for a lot of things, unfortunately, although plantar fasciitis is something that we see every single day. So patients in these different studies were randomized to either PRP with eccentric training or just a saline injection eccentric training. And it was found that this did not improve the patient-reported outcome measures that were used in these studies, tendon thickness, or Doppler activity within the achilotendinopathy. There was a randomized trial with 60 men that was using people with chronic achilotendinopathy for more than three months. They were followed for six months after. And they were randomized to high-volume injection, PRP versus sham procedure, where just a small amount of saline was injected underneath the skin. And what they found is that the HVI and PRP, in combination with eccentric training, worked better than just the sham procedure and that the HVI early on was able to, oops, excuse me, I don't know how to go back here. I think I'm missing a slide. Okay. Was more effective in the short term, which is basically the first two time points, five to 10 weeks. As far as orthobiologics, it's all pretty much limited to PRP in the Achilles. There is this one study that was published this past year looking at stromal vascular fraction. Patients were randomized to this versus PRP. Again, a very small study. Found that both were safe and effective and that SVF may have been able to provide results a little bit faster. And here we see at 15 to 30 days that there's a little bit of improvement as compared to PRP. But overall, in the six-month follow-up point, they were pretty similar. So low-level evidence supporting role of PRP and even less supporting SVF in pain reduction and function in Achilles teninopathy, but higher power studies are warranted. We're going to go ahead and just go straight to the plantar fasciitis talk. It's very similar to this one. Even though you may not have a whole lot of patients that show up with these things, probably everyone in the room is going to have plantar fasciitis at some point in their life. So this is a picture. I tried to include pictures of what I feel like when people come in with plantar fasciitis to my clinic. All right, so in contradistinction to the itis and its names, this is not a primarily inflammatory condition. We have histologic studies that shows this is a degenerative condition, like Dr. Cole referred to, that occurs at the origin of the plantar fascia, as theorized to be due to micro tears and aberrant fascularity. This is me listening to the HPI. Pain at the origin of the plantar fascia, the medial heel. Same thing as Achilles teninopathy. First few steps in the morning, very painful when they get out of bed, and then it gets better. They have start-up pain. The differential includes the different types of Achilles teninopathy, which can often be coexistent with it. Baxter's, nerve entrapment, tarsal tunnel syndrome, a stress fracture, and then in older people, central heel pad syndrome due to fat pad atrophy. Non-operative management is essentially similar to that for Achilles teninopathy, except nitroglycerin patches don't have a role for this. Corticosteroids are given a lot by orthopedic surgeons and podiatrists. The large reviews of this in the Cochrane Database systematic review showed that there's actually very low quality evidence that corticosteroids reduce heel pain in the long run, and that overall, they have pretty much just a short-term effect. Operative management, things took a dark turn here when I have to operate on them. So there's a partial plantar fasciotomy, plus or minus tarsal tunnel release, complete fasciotomy, endoscopic plantar fasciotomy against the Tenex ultrasound probe. The plantar fascia releases, plus or minus the tarsal tunnel release, the best study you'll find is in the 80% success range. There are ones that show even like 40% or less, so it's not something that we really enjoy doing. There are some very small case series on the Tenex probe that show about 90% success rate, but they're not very well-done studies, unfortunately. All right, so then we got to 2014, and I apologize for the large number of animated GIFs that you're about to see. It seemed like a good idea at two in the morning. It was the first RCT in foot and ankle for, it wasn't the first one, but it was probably the largest one at the time. 40 patients, they were randomized to three cc of PRP versus 40 milligrams of Depamedrol, and they used the AOFAS study. So the AOFAS study is a, excuse me, AOFAS score is a legacy score within foot and ankle surgery. It's the most commonly used study, study prom, and unfortunately, it's not validated, but it's like the best that we have, so we just kind of stick with it, and it's starting to be phased out in more contemporary research, but in 2014, this was what was used. What we found was that Depamedrol did not really show any improvement at two years, but that the PRP cohort did, and we were really excited about it, but then there was a lot of other studies that came out afterwards. So in 2017, there was a meta-analysis of 10 studies that showed no difference in pain or function between PRP and corticosteroid injections in plantar fasciitis patients at six months and a year. There was a meta-analysis also in 2017 of nine RCTs, and a lot of these meta-analyses have a fair amount of overlap, showing a decreased VAS score at six months. A lot of the studies also ended at six months, even though these people continue to get pain, and they can have pain even years later. No difference in the FADI, which is a validated score, but then you see the AOFS pop up over there again, and then last meta-analysis of 15 RCTs showed again a slight decrease in pain at six months post-injection as compared to corticosteroids. So there's low-level evidence of supporting role for PRP and pain reduction as compared to steroid injections in plantar fasciitis, but hopefully we're gonna be working on some more high-powered studies, and I hope I kept you awake. Thank you. I know you're kinda odd man out, so before you leave, come here. So just tell me what you do for, what's your treatment algorithm for Achilles? Okay, what do you do based on what you know, and what is it for plantar fasciitis? So for plantar fasciitis, we try all the conservative management, but the primary thing that we do is stretching. So we will, I mean, we will stretch, work on stretching and physical therapy until they're like blue in the face. If after six months to a year, they are not better, 85, 90% of these will get better within a year, but it's a long haul. And if at six months to a year, they continue to have symptoms that are interfering with them doing the things that they enjoy in life, then we offer them PRP injection, and some people will take us up on it. Another thing that we offer them is the Tenex ultrasound probe. With Achilles teninopathy, these people with mid-substance Achilles teninopathy, they oftentimes don't need surgery. We rarely actually have to operate on that. We'll do stretching again until they're blue in the face, and nitroglycerin patches, which work exceptionally well for mid-substance Achilles teninopathy. If they don't get better with that, then we engage in the shared decision-making process as far as whether we're gonna do something minimal, like the Tenex procedure, or whether we're gonna do an open debridement. As far as insertional Achilles teninopathy, there's actually not much role for nitroglycerin patches. We try stretching, we'll actually try the opposite, which is booting or even casting to calm them down. If it doesn't get better with that, then we do a posterior midline incision, excise the posterior aspect of the calcaneus, including the Hagglund's deformity and calcaneal enthesophyte, and then debride the Achilles tendin. If they want a biologic in there, we'll give it to them, but we don't mandate it, and that does pretty well. Thank you.

Achilles tendinopathy

plantar fasciitis

diagnosis

treatment options

operative management