rss

facebooktwittergoogle_plusredditpinterestlinkedintumblrmail

Plantar fasciitis – is Laser Phototherapy a good option?

By Jan Tunér

 

Plantar fasciitis affects nearly 1 million people annually in the United States. Traditional non-operative management is successful in about 90% of patients, usually within 10 months. Chronic plantar fasciitis develops in about 10% of patients and is a difficult clinical problem to treat. Laser phototherapy is a good option for these patients, but still not widely used. How effective is LPT for plantar fasciitis and what is the scientific evidence?

The first study was published in 1998, and the outcome was negative. Basford [1] treated 32 patients with plantar fasciitis during 12 sessions. The origin of the plantar fascia was given 1 J of 830 nm laser (30 mW) and the medial border of the fascia was swept with a total dose of 2 J. With today’s knowledge about dosage, the negative outcome is what can be expected. 1 J at the origin is very low and sweeping with a total of 2 J does not produce much of an effect. WALT recommendation is a minimum of 4 J per point and 2-3 points, so at least 8 J per session.

Three years later, Hronková [2] published a study where irradiated the place of maximum pain with a 200 mW, 870 nm , energy density 9 J/cm2, 10 sessions every other day. Sixty-one patients had this therapy while fifty-two patients had a non-active placebo laser. In the laser group, 64% had a complete remission of pain, 26% experienced an improvement, and in 10% this therapy brought no effect at all. In the placebo group, 18% reported a full remission of pain, 42% reported an improvement and 40% felt no effect. In a separate study, ultrasound was used for 60 patients - 1 W/cm2 applied for 5 minutes, 10 applications. All in all 50% of the patients had a complete remission of pain, 16.6% were improved and 33.3% reported no effect. Eight of the patients who had not experienced any effect from ultrasound were given LPT, no earlier than two weeks after ending the ultrasound treatment. Six of these patients evaluated their treatment as successful while the additional LPT had no effect in two patients.

The two studies above used GaAlAs wavelengths. Kiritsi [3] used GaAs (904 nm) to investigate the effect of LPT on plantar fasciitis documented by the ultrasonographic appearance of the aponeurosis and by patients’ pain scores. Thirty individuals with diagnosis of unilateral plantar fasciitis were enrolled in a randomised, double-blind, placebo-controlled trial, but 25 participants completed the therapeutic protocol. The contralateral asymptomatic fascia was used as control. After enrolment, symptomatic individuals were randomly assigned to receive LPT, or identical placebo, for 6 weeks. Ultrasonography was performed at baseline and after completion of therapy. The subjective subcalcaneal pain was recorded at baseline and after treatment on a visual analogue scale (VAS). After LPT, plantar fascia thickness in both groups showed significant change over the experimental period and there was a difference (before treatment and after treatment) in plantar fascia thickness between the two groups. However, plantar fascia thickness was insignificant (mean 3.627 +/- 0.977 mm) when compared with that in the placebo group (mean 4.380 +/- 1.0042 mm). Pain estimation on the visual analogue scale had improved significantly in all test situations (after night rest, daily activities) after LPT when compared with that of the placebo group. Additionally, when the difference in pain scores was compared between the two groups, the change was statistically significant. In summary, while ultrasound imaging is able to depict the morphologic changes related to plantar fasciitis, 904 nm laser may contribute to healing and pain reduction in plantar fasciitis.

The most recent study on plantar fasciitis is by Jastifer [4] and of particular interest. What is so interesting is not shown in the abstract, though. The PubMed abstract says that thirty patients were administered LPT and completed 12 months of follow-up. Patients were treated twice a week for 3 weeks for a total of 6 treatments and were evaluated at baseline, 2 weeks post procedure, and 6 and 12 months post procedure. Patients completed the Visual Analog Scale (VAS) and Foot Function Index (FFI) at study follow-up periods. Patients demonstrated a mean improvement in heel pain VAS from 67.8 out of 100 at baseline to 6.9 out of 100 at the 12-month follow-up period. Total FFI score improved from a mean of 106.2 at baseline to 32.3 at 12 months post procedure.

And here is the interesting part: The laser was irradiating the heel area in non-contact mode from three sides with 630 nm, 17 mW, during 10 minutes per session, delivering a total energy of about 30 J per session. One would expect the red 630 nm light to be ineffective for this type of condition, but the explanation is probably the long irradiation time. It is well documented that low energies during long time is more effective for reduction of inflammation that high energies during short time [5]. And in spite of the fact that the laser light hardly reached the actual foci of inflammation, a long time of irradiation can produce a systemic effect. This is nothing new. In the 90s, defocused CO2 lasers were used for biostimulation, and the 10600 nm wavelength has extremely poor penetration. So it was all a matter of systemic effects.

The laser used was from the Erchonia company. In the Annals we have criticized this company several times for the homeopathic doses recommended and the vastly exaggerated claims of penetration of 630 nm. So we are happy to give credit to a study that finally makes sense and provides interesting information. Red laser may not be ideal, but the study shows that it can be used if applied during long time.

Summing up, the scientific documentation is scant, but suggests that LPT could be a non-invasive option for plantar fasciitis. And as always: no side effects, no needles and no knives.

 

  1. Basford J R, Malanga G A, Krause D A, Harmsen W S. A randomized controlled evaluation of low-intensity laser therapy: plantar fasciitis. Arch Phys Med Rehab. 1998; 79 (3): 249-254.
  2. Hronková H, Navrátil L, Krymplová J, Knizek J. Possibilities of the analgesic therapy of ultrasound and non-invasive laser on plantar fasciitis. Laser Partner. No 21. May 2001. www.laserpartner.org.
  3. Kiritsi O, Tsitas K, Malliaropoulos N, Mikroulis G. Ultrasonographic evaluation of plantar fasciitis after low-level laser therapy: results of a double-blind, randomized, placebo controlled trial. Lasers Med Sci. 2010; 25 (2): 275-281.
  4. Jastifer J R, Catena F, Doty J F, Stevens F, Coughlin M J. Low-Level Laser Therapy for the Treatment of Chronic Plantar Fasciitis: A Prospective Study. Foot Ankle Int. 2014 [Epub ahead of print].
  5. Castano A P, Dai T, Yaroslavsky I, Cohen R, Apruzzese W A, Smotrich M H, Hamblin M R. Low-level laser therapy for zymosan-induced arthritis in rats: Importance of illumination time. Lasers Surg Med. 2007; 39 (6): 543-550.