Surgery Section - Radiofrequency Lesioning for the Treatment of Plantar Fasciitis

IMPORTANT REMINDER

This Medical Policy has been developed through consideration of medical necessity, generally accepted standards of medical practice, and review of medical literature and government approval status.

Benefit determinations should be based in all cases on the applicable contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control.

The purpose of medical policy is to provide a guide to coverage. Medical Policy is not intended to dictate to providers how to practice medicine. Providers are expected to exercise their medical judgment in providing the most appropriate care.

Description

Plantar fasciitis is a very common ailment characterized by deep pain in the plantar aspect of the heel, particularly on arising from bed. While the pain may subside with activity, in some patients the pain may persist, interrupting activities of daily living. On physical examination, firm pressure will elicit a tender spot over the medial tubercle of the calcaneus. The exact etiology of plantar fasciitis is unclear, although repetitive injury is suspected. Heel spurs are a common associated finding, although it has never been proved that heel spurs are the cause of the pain. It should be noted that asymptomatic heel spurs can be found in up to 10% of the population.

Conservative therapy of plantar fasciitis is successful in the vast majority of cases. Rest or minimization of running or jumping is the cornerstone of therapy. Heel cups are sometimes helpful in alleviating symptoms, presumably by padding the heel and absorbing the impact of walking. Nonsteroidal anti-inflammatory drugs are also helpful in acute cases. If the above measures are ineffective, a local injection of steroids may be effective. Improvement is frustratingly slow and gradual, taking up to a year in some cases. For refractory cases, either open or endoscopic plantar fasciotomy may be considered.

Radiofrequency lesioning has been proposed as another method to treat plantar fasciitis that is refractory to medical management.  With this technique, an electrode is placed into the tissue at the painful site and an electric current is delivered, generating heat that destroys the sensory nerve fibers beneath the skin.

Policy/Criteria

Radiofrequency lesioning for the treatment of plantar fasciitis is considered investigational.

Scientific Background

The most clinically relevant outcomes of therapy for plantar fasciitis are improvements in pain and/or function. Both of these outcomes can be influenced by nonspecific effects, placebo response, natural history of the disease, and regression to the mean; therefore, they need to be evaluated in randomized, controlled trials that maintain satisfactory blinding of the treatment assignment.  Pain outcomes require quantifiable pre- and post-treatment measures, which are most commonly measured with a visual analogue scale (VAS). Collectively, the pain measurement literature cautions against using only statistical significance of difference in mean change in scores to determine clinical significance. More meaningful to patients and clinicians is the correlation of improvement in pain scores with improvement in function and quality of life. Thus, quantifiable pre- and post-treatment measures of functional status are also necessary.

A search of the MEDLINE database through June 23, 2008 identified only one published study in which radiofrequency lesioning was investigated. (1)  This was a retrospective analysis of 39 patients who received radiofrequency lesioning as an alternative to surgical intervention.  No information was provided on patient selection criteria for this study, nor were pre-treatment measures of either pain or function reported.  The length of preoperative symptoms varied from 2 to 12 months, with 24 of 39 patients (62%) experiencing symptoms less than 6 months prior to receiving radiofrequency lesioning.  All patients received cortisone injections following the procedure, thus introducing a co-intervention.  Postoperative follow-up varied from 16 to 28 months; there were no post-operative measures of pain or function reported.  No other published clinical trials were identified in the literature search.

It is not possible to reach scientific conclusions concerning the effects of radiofrequency lesioning on plantar fasciitis based on this single published study.  Several serious flaws confound the reported results, namely:

References

1. Sollitto RJ, Plotkin EL, Klein PG, Mullin P.  Early clinical results of the use of radiofrequency lesioning in the treatment of plantar fasciitis.  J Foot Ankle Surg 1997;36(3):215-9
   

Cross References

Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions, Regence Medical Policy Manual, Medicine, Policy No. 90

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