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Pulsed vs. Thermal Radiofrequency for Management of Chronic Refractory Plantar Fasciitis

Plantar Fasciitis:

Plantar fasciitis is like, but painful condition affecting the heels. It often is the most symptomatic with the first steps taken in the morning. It usually presents with pain around the medial or inside aspect of the calcaneus (heel bone). Often there is tenderness along the soft tissue extending from the heel to the mid-arch or beyond.  In 20 to 30% of patients, the problem occurs on both sides (bilateral).

Plantar Fasciitis Treatments:

There are many treatments for this condition. Usually, conservative treatment is successful. This may include rest while minimizing running and jumping activities until the condition resolves. Other conservative treatment such as physical therapy, shoe inserts, he heel cups, and ice massage have been successfully used. When conservative options fail, medications such as non-steroidal anti-inflammatory drugs may be helpful. Extracorporeal shockwave therapy may also help. For cases that are persistent, injection of corticosteroids may be the next reasonable step. For the small number of cases that failed to improve with the above conservative options, a surgical procedure called a plantar fasciotomy may be considered. The surgery may be performed either open or through an endoscope.

Thermal Radiofrequency Lesioning (TRF)

Another option which has been used is radiofrequency lesion of the nerve that provides sensory function to the plantar fascia. The name of this nerve is the medial calcaneal nerve. Traditionally, conventional radiofrequency lesion involves heating up the tissue around the nerve until the nerve is lesion or cauterized. This lesion and prevents the pain signals from the plantar fascia from traveling back up the nerve and eventually being interpreted by the brain is pain.

Thermal radiofrequency lesioning has been used for decades by interventional pain specialists to treat various sorts of musculoskeletal pain such as pain from the lumbar, cervical, and thoracic facet joints. It has also been used to treat sacroiliac joint pain and more recently pain in the knees and hip joints.

Pulsed Radiofrequency (PRF)

In recent years, there has been some research that has indicated that it may not be the heat lesion that is responsible for the majority of pain relief. Instead, it may be the electric field that interferes with the nerve function at the cellular and subcellular level. Using this information, a newer technique called pulsed radiofrequency has been used. Pulsed radiofrequency is a nondestructive or minimally disruptive treatment that does not heed the tissue up as high as conventional radiofrequency and gives the tissue a chance to cool down slightly between "pulses" of heat. The advantages of this technique include decreased risk of prolonged neuritis, decreased risk of neuroma formation, and usually a decrease period of increased pain following the procedure.

Obviously, if the pulsed radiofrequency treatment is able to give equivalent results as the conventional radiofrequency treatment with greater safety and shorter recovery time, this could be preferable in many respects.

TRF vs. PRF for Chronic Plantar Fasciitis

In a recent study published in Pain Physician, researchers from the Orthopedic Clinic and Rehabilitation Clinic of Assiut University Hospital in Egypt performed a prospective nonrandomized comparative study between these two treatment methods. In this study, 20 patients with bilateral plantar fasciitis for more than six months were treated with both pulsed radiofrequency and conventional radiofrequency. For each patient, one  symptomatic heel received one type of treatment and the other remedial received the alternate type of treatment. In essence, each patient served as their own control group.

This study revealed several interesting findings between the two methods. Generally, it is assumed that conventional radiofrequency treatment, while having significantly more discomfort for a few weeks following the treatment, should last significantly longer than pulsed radiofrequency treatment. However, in this study, both treatment methods resulted in very similar pain relief at 24 weeks. What was different however is that the pulsed radiofrequency group had significantly greater comfort at the one and three week marks.

Overall, effective analgesia was achieved in both groups. However, the patients had significantly better pain scale and satisfaction scores in the pulsed radio frequency group in the first and third weeks. These findings were highly statistically significant with P-values of <0.001.  Prior to treatment, the Numerical Verbal Ratings Scale upon waking (NVRS) scores for both groups were 8.7/10.  At the 24 week mark, the NVRS scores for both groups were below 2/10. While there was a very slightly lower score for the conventional radiofrequency technique at the 24 week mark, the results were not statistically significant. At the 24 week mark, the NVRS score for conventional radio frequency was 1.9/10 and a score for the pulsed radiofrequency group was 2.05/10. Similar minimal differences were saying with prolonged walking scores of 1.80/10 and 1.85/10 respectively. The patient satisfaction scores improved from 2.35 at the start of the study to 8.40 at the 24 week mark in the pulsed radiofrequency group and from 2.45 to 8.45 in the conventional (thermal) radio frequency group.

Authors Conclusions:

The authors concluded that:

"PRF to the medial calcaneal nerve is a safe and effective method for treatment

of chronic plantar fasciitis pain. The onset of effective analgesia can be achieved more rapidly

with PRF compared to TRF on the same nerve. Further randomized trials are needed to confirm

the therapeutic effect and optimizing the dose of RF needed."

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About the Author

Dr. John B. Adams is board certified in Pain Management by the American Board of Medical Specialties and the American Board of Interventional Pain Physicians. With almost 2 decades of experience, he offers patients access to state-of-the-art pain management, emphasizing a multidisciplinary approach to pain management utilizing precision injections, neuromodulation technology, physical therapy, behavioral medicine and judicious use of medications including help with patients titrating off opiates (narcotic pain medications).

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