Pain on the back or bottom of the heel caused by a condition known as tendinopathy is a common problem among people who are trying to lead an active lifestyle. The Achilles tendon and the plantar fascia are tendon type tissues that each play a key role in maintaining balance while walking and standing and are commonly afflicted with this condition. The pain in these areas often emerges from overuse following repetitive strain or after a recent increase in activity. Most people who have heel pain from tendinopathy will experience relief with the use of stretching, supportive shoes, anti-inflammatory therapy and shoe inserts. However, if the condition is not addressed, the acute inflammatory process continues as the body attempts to repair the damaged tendon. Eventually, this healing process ceases as the tendon becomes riddled with scar tissue.
Chronic tendinopathy in these areas can severely impair your ability to function in your daily life. Often described as tendinosis or fasciosis, this recalcitrant condition may persist for more than 6 months and is not relieved with the use of anti-inflammatory medicine or corticosteroid injection. This chronic, degenerative process manifests as thickened fibrous tissue within the tendon or fascia. Blood flow decreases to the diseased area and the normal healing process is halted. If conservative options fail to alleviate the symptoms of chronic tendinopathy, novel therapy that involves restarting the healing process should be the next option considered. Since healing is a normal response to injury, restarting the healing process in chronic tendinopathy could involve either introducing a controlled injury to the fibrotic/scarred tissue or directly implanting the necessary growth factors. There are several therapies currently available for treating pain due to chronic tendinopathy.
New Approaches to Treating Chronic Tendinopathy
TENEX FAST - Focused Aspiration of Scar Tissue
The TENEX FAST system provides a novel way of directly accessing the diseased portion of tendon, using ultrasonic energy to break the fibrous tissue within the Achilles tendon or plantar fascia. This minimally invasive approach uses a handheld device with a micro tip. Using ultrasound imaging as a guide, the handheld micro tip is brought to the area of injury through a small incision in the skin. With the use of a foot pedal, ultrasonic energy is emitted through the micro tip to emulsify the scarred portions of tendon. The micro tip is also equipped with a saline delivery system to flush and aspirate/remove the debrided fibrous tissue. This process has been termed phacoemulsification and essentially cleans the scar tissue in a focused manner, leaving behind healthy tendon. (1) Prior to the procedure, local anesthetic is injected near the affected area to control pain during the procedure.
For procedures involving the plantar fascia, one can bear weight on the affected limb with a CAM boot and cane for assistance for 2 weeks. For Achilles, a CAM boot and crutches for guarded weight bearing is used. After the procedure, the doctor will determine when transition out of the CAM boot to supportive shoe gear and careful return to normal activities is appropriate. Any discomfort experienced following the procedure can be controlled with pain medication as prescribed by the doctor.
Platelet-Rich Plasma Injection
Platelet Rich Plasma, or PRP, is an orthobiologic substance that is used to alleviate pain caused by chronic tendinopathy. As mentioned previously, the diseased portion of the tendon has decreased blood flow and is unable to heal. PRP functions by directly stimulating the healing process in this area through the use of growth factors and inflammatory molecules from the patient’s own body. Prior to the procedure, blood is drawn from the patient. It is then spun in a centrifuge to separate the platelet-rich plasma from the rest of the blood. (Because a centrifuge or spinning machine is used in this procedure, PRP is sometime commonly known as, “Blood Spinning”) The platelet rich plasma is then drawn out of the processed vial and injected into the affected area. This procedure has now directly implanted growth factors into the site of injury. These growth factors help recruit other cells from the body which are involved in healing of the injured soft tissue.
During the procedure, ultrasound imaging is used to visually inspect the tendon or fascia and find the specific region of injury. Once the area of injury is located local anesthetic is used to numb the area of interest and the PRP is injected. In order to stimulate the process of healing, many small injections will be peppered into the diseased tissue to introduce a form of micro trauma and encourage the body to recruit inflammatory cells. Doing this essentially restarts the healing process in the previously scarred tendon. Following the injection, anti-inflammatory medications and icing should be avoided in order to allow the inflammatory healing process to work. A short leg-walking CAM boot is worn following the injection. Avoid walking without the boot on the affected limb for 2 week. After 2 weeks, patient can transition to supportive shoe gear.
Amniovo – Amniotic Membrane Injection
Amniovo is a form of dehydrated human amniotic membrane and is another way to introduce growth factors to the site of injury in chronic tendinopathy. Although amniotic membrane tissue is known to possess healing potential, there would be risks involved with direct implantation of untreated, fresh amniotic membrane. In order to avert these risks, the amniotic membrane used in this process is taken from screened and tested donors, it is then purified using the PURION process. This purification process allows for the dehydrated amniotic membrane to be safely implanted to the affected site without the risk of disease transmission and allows for the graft to be stored for up to 5 years. Once purified, the product is in powder form and is suspended in saline solution to use as an injection. Through the direct implantation of growth factors, injection with Amniovo helps the tendon’s diseased tissue heal. In fact, in a study using dehydrated amniotic membrane injection compared to a control injection of local anesthetic and saline the amniotic membrane injection was shown to be more effective at relieving pain from chronic plantar fasciosis. (2)
Once again, ultrasound-imaging guidance is used to identify the diseased portion of tendon or fascia. An anesthetic injection is first used to numb the affected area and Amniovo is then injected.
Following the injection, a walking boot is used for 2 weeks in order to protect the involved site. Two weeks after the injection the patient can transition to supportive shoe gear.
Chronic tendinopathy is an issue that plagues many people who are attempting to engage in an active lifestyle. Because the condition may not respond to anti-inflammatory therapies, many patients are frustrated, especially if they would like to avoid surgery. Novel therapies that combat this chronic, degenerative process have emerged that help restart the healing process in the diseased tissue. If you have had heel pain from chronic tendinopathy that has stopped you from leading the daily lifestyle you would like to, speak with your doctor to see which therapeutic option would best suit your needs and help you get back on your feet.
1) Barnes, D. Ultransonic Energy in Tendon Treatment. Operative Techniques in Orthopaedics. 2013
2) Zelen, C; Poka, A; Andrews, J. Prospective, Randomized, Blinded, Comparative Study of Injectable Micronized Dehydrated Amniotic/Chorionic Membrane Allograft for Plantar Fasciitis—A Feasibility Study. Foot and Ankle International. 2013