Etodolac

* EVIDENCE-BASED ANSWER

Mechanical therapies--such as taping, tension night splinting, and rigid arch support--are the most effective treatment for plantar fasciitis (strength of recommendation: A, based on randomized controlled trials). If limited or no improvement is observed after 6 months of mechanical therapy, extracorporeal shock wave therapy (Orthotripsy) is the next treatment of choice (strength of recommendation [SOR]: A, based on meta-analysis of randomized controlled trials). When mechanical therapies and extracorporeal shock wave therapy have failed for more than 1 year, surgical treatment may be considered (SOR: C, based on a case-series study).

* EVIDENCE SUMMARY

In a prospective, observer-blinded study, 103 subjects were randomized to 1 of 3 treatment categories: anti-inflammatory (etodolac plus corticosteroid injections); accommodative (viscoelastic heel cup); or mechanical (low-dye tapping for 1 month followed by rigid custom orthosis for 2 months). (1) After 3 months of treatment, 70% of patients in the mechanical treatment group rated their functional outcome as excellent, compared with only 33% of the anti-inflammatory group and 30% of the accommodative group (P=.005). Additionally, the mechanically treated group was less likely to terminate treatment early because of treatment failure (P<.001).

Several of the same researchers then went a step further to find out which specific mechanical treatment is best. They found no statistically significant difference among treatment with tension night splinting (Figure 1), custom rigid orthosis, and over-the-counter arch supports. (2) A retrospective study of 237 subjects also concluded that mechanical treatment is better than anti-inflammatory or accommodative treatments. (3)

[FIGURE 1 OMITTED]

Another prospective, observer-blinded study randomized 116 patients to 1 of 2 groups for 3 months. (4) The first group of patients were treated with a nonsteroidal anti-inflammatory drug (piroxicam) and Achilles tendon stretching 3 times a day. The second group received the same treatment but also wore plastic tension night splints in 5 [degrees] of dorsiflexion. After 3 months, in an intention-to-treat analysis, no statistically significant difference was detected in subjective pain between the 2 groups. In this study, patient compliance with the tension night splinting was poor, and this likely affected the outcome.

From 1993-1995 an observer-blinded randomized controlled trial of 112 patients compared standard with sham extracorporeal shock wave therapy. (5) The main outcome measure was patient satisfaction on a 4-step score at 6 months and 5 years. At 6 months, the treatment group had a significantly better 4-step score than the placebo group (P<.0001). In fact, 51% of treatment-group patients were pain-free, while none of the 48 placebo-group patients were pain-free. After 5 years, the 4-step score only demonstrated a trend in favor of the treatment group (P<.071) because of a high rate of good results from subsequent surgery in the placebo group. Thirteen percent of the treatment-group patients had undergone a heel operation, compared with 58% of placebo-group patients.

A controlled and observer-blinded study of 302 patients with plantar fasciitis compared standard extracorporeal shock wave therapy with sham treatment. (6) The treated patients had significantly lower pain scores (as measured on a visual analog scale) than the placebo group (1.9 vs 4.7). Three months post-treatment, half as many treated patients were taking pain medication when compared with placebo patients. After 1 year of follow-up, 94% of the treatment group patients were still pain-free, with a pain score of <2.

One randomized controlled study of 166 patients found no evidence to support a beneficial effect on pain, function, and quality of life of extracorporeal shock wave therapy over a sham treatment. (7) Of note, this study enrolled patients who had a minimum of 6 weeks of symptoms. All recommendations in the US are to reserve extracorporeal shock wave therapy for patients with more than 6 months of symptoms.

A meta-analysis of 8 published studies involving 840 patients whose condition was not improved after conservative therapy for at least 6 months showed that up to 88% of patients experienced good to excellent outcomes with extracorporeal shock wave therapy and were satisfied with the result. (6)

As for surgical treatment, in a prospective study of 43 patients with 47 painful heels followed for an average of 31 months, only 49% of the patients were satisfied with their outcome. (8) Patient expectations should be considered in preoperative counseling. In contrast to surgery, either open or endoscopic, extracorporeal shock wave therapy does not require the patient avoid weight-bearing or a prolonged time for return to work.

* RECOMMENDATIONS FROM OTHERS

Figure 2 has been modified from a clinical practice guideline on the treatment of plantar fasciitis published by the American College of Foot and Ankle Surgeons. (9)

[FIGURE 2 OMITTED]

What is a Clinical Inquiry?

Clinical Inquiries answer real questions that family physicians submit to the Family Practice Inquiries Network (FPIN), a national, not-for-profit consortium of family practice departments, residency programs, academic health sciences libraries, primary care practice-based research networks, and individuals with particular expertise.

Questions chosen for Clinical Inquiries are those considered most important, according to results of web-based voting by family physicians across the U.S.

Answers are developed by a specific method:

* First, extensive literature searches are conducted by medical librarians.

* Clinicians then review the evidence and write the answers, which are then peer reviewed.

* Finally, a practicing family physician writes a commentary.

* CLINICAL COMMENTARY

Keys to treatment: Avoid overuse, stabilize, be patient

Plantar fasciitis (heel pain syndrome) is one of the most common disorders of the foot and ankle and is notoriously difficult to treat. Patients are commonly symptomatic for months, leading to frustration, poor compliance, and general dissatisfaction.

From a pathophysiologic perspective, plantar fasciitis is a form of overuse syndrome. When approached in this manner, it makes intuitive (and now scientific) sense that stabilization of the proximal fascial enthesis at the point of its insertion to the calcaneus is the key to clinical resolution of symptoms. Activity modification, mechanical therapy, and patience are the essential elements for treating plantar fasciitis.

Mark B. Stephens, MD, MS, Uniformed Services University of the Health Sciences, Bethesda, Md

REFERENCES

(1.) Lynch DM, Goforth WP, Martin JE, Odom RD, Preece CK, Kotter MW. Conservative treatment of plantar fasciitis. A prospective study. J Am Podiatr Med Assoc 1998; 88:375-380.

(2.) Martin RL, Irrgang JJ, Conti SF. Outcome study of subjects with insertional plantar fasciitis. Foot Ankle Int 1998; 19:803-811.

(3.) Probe RA, Baca M, Adams R, Preece C. Night splint treatment for plantar fasciitis. A prospective randomized study. Clin Orthop 1999; 368:190-195.

(4.) Martin JE, Hosch JC, Goforth WP, Murff RT, Lynch DM, Odom RD. Mechanical treatment of plantar fasciitis: A prospective study. J Am Podiatr Med Assoc 2001; 91:55-62.

(5.) Rompe JD, Schoellner C, Nafe B. Evaluation of low-energy extracorporeal shock-wave application for treatment of chronic plantar fasciitis. J Bone Joint Surg Am 2002; 84-A:335-341.

(6.) 0gden JA, Alvarez R, Levitt R, Cross GL, Marlow M. Shock wave therapy for chronic proximal plantar fasciitis. Clin Orthop 2001; 387:47-59.

(7.) Buchbinder R, Ptasznik R, Gordon J, Buchanan J, Prabaharan V, Forbes A. Ultrasound-guided extracorporeal shock wave therapy for plantar fasciitis: a randomized controlled trial. JAMA 2002; 288:1364-1372.

(8.) Davies MS, Weiss GA, Saxby TS. Plantar fasciitis: how successful is surgical intervention? Foot Ankle Int 1999; 20:803-807.

(9.) The diagnosis and treatment of heel pain. J Foot Ankle Surg 2001; 40:329-340.

Teresa S. Stadler, MD, Scott & White Hospital, Texas A & M University, Temple, Tex; E. Diane Johnson, MLS, J. Otto Lottes Health Sciences Library, University of Missouri-Columbia

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