Extrinsic Padding
Over the counter there are many forms of extrinsic padding such as Dr Scholl’s double pillow cushion inserts or Spenco insoles. When the patient is compliant with wearing these assists, they may provide some relief. The downfall of this approach: Many times the cause of the fat pad atrophy is due to a hammer toe or bunion deformity. Their shoe does not have enough room to accommodate their deformity and extra padding. Ultimately they may develop unrelated blisters or lesions due to extra shoe pressure. In addition, although high-heels are not recommended, women will wear them and they are not friendly to extra padding.
Orthotic Management
Orthotics are custom made devices which may pocket out and cushion the prominent bone and are helpful. The downfall of this approach: Orthotics are bulky and do not fit in all shoes. Orthotics may range between $300-600 and are rarely covered by insurance. When in the shower, patients are barefoot and complain of pain and pressure. Although there is an attempt to pocket out for the diabetic bone prominence and pre-ulcerative lesion, the orthotic can have only so much extrinsic thickness to offload the area before it leads to other irritations that are not felt by the patient due to their neuropathy. If the diabetic patient is not compliant for even one night with their orthotic/diabetic shoes for a special occasion, that is enough irritation on a bone prominence to cause an ulceration and infection. Intrinsic management through fat pad restoration may help avoid these complications.
Atrophic Plantar Fat Pad Augmentation With Acellular Dermal Graft
In 2008 a case study was reported by Thomas M. Rocchio, DPM. The GRAFTJACKET acellular dermal matrix was applied to help close a two year long standing plantar calcaneal ulcer. The ulceration partially closed with the GRAFTJACKET matrix and partially through secondary intention and wound healing over a ten week treatment course post GRAFTJACKET application. This acellular graft was chosen to minimize an inflammatory immune response while serving as a collagen network to promote cell migration, in-growth and proliferation. The acellular dermis used had about a 2 mm thickness. The author made a full thickness skin incision and then through blunt and sharp dissection created a pocket deep to the subcutaneous tissue which was equal in size to preoperative fat pad atrophy measurements. After re-hydration of the graft, the author used a “parachute technique” to implant the graft. Non-absorbable traction sutures were used at the two deep corners of the graft. Loops of suture 3mm in distance from one another were at the deep designated corners of the graft, this way knots were not used to secure the suture in the graft. The sutures were then driven out through the skin from inside the pocket with both needles exiting the corners 3mm distance apart. The traction sutures ultimately pulled the graft material into the pocket in proper position. Once positioned properly the sutures at each corner were tied together externally on the surface of the skin. With this “parachute technique” no foreign suture material remained in the patient upon suture removal. Dr. Rochhio has published a case series, but no controlled trials. It’s safety and efficacy remain to be determined. Acellular dermis may lead to increased tissue thickness, but this may not be the same type of cushioning and thickness that fat can provide. Fat grafting does not require incisions to be made on the foot.
Injectable Materials Such As Silicone
Injected liquid silicone has been found to increase plantar tissue thickness and decrease plantar pressure over at least a one year period. It also has been found to stimulate some proliferation of surrounding collagen fibers. However, after two years, the cushioning ability of silicone was noted to diminish and peak plantar pressures increased. It is believed that injections of silicone might therefore be necessary on a yearly basis. Another contraindication noted to injected liquid silicone is the fluid is difficult to maintain in the needed fat pad position. It has been noted that silicone tends to migrate similar to the pathological migration of the plantar fat pad. Although the migration was asymptomatic, microscopic droplets were identified in groin lymph nodes.
Other Injectables
Some doctors will offer injections of fillers commonly used for the face, such as Restylane, Radiesse, or Sculptra. While these fillers often are effective in the face, their use in the foot is not FDA approved, nor are there any clinical trials demonstrating their long term efficacy. They are also expensive, and do not last a long time.
Restoration Of The Plantar Fat Pad With Fat Grafting
In 1994, a subjective study was performed by Edward L. Chairman, DPM, FACFAS. This is the only study discussing fat grafting to the plantar foot in the literature. Fifty patients were subjectively interviewed 9-28 months post-operatively for fat pad fat grafting. Many of the patients had bone surgery performed in conjunction with the fat pad fat grafting. 48 patients reported less pain and 2 patients required additional procedures due to fat transplant re-absorption post-operatively. The author felt these failures were due to insufficient fat transfer initially, and the patients admitted to post-operative trauma to their foot. The technique for fat grafting involved fat from the calf, and the exact processing technique is not well described. No objective data about foot pressures or tissue thickness was presented. It is hard to say if the patients got better due to the bone surgery or the fat grafting.
Our clinical trials have demonstrated that fat injections into the foot can decrease pain and improve quality of life. We have also shown that patients that did not get the fat grafting actually get worse over time, so if anything, fat injections actually prevent from worsening over time. Fat cells are harvested through liposuction of one’s belly or thighs. It is processed in a special way to best maintain the integrity of the fat cell and even the stem cell that matures into a fat cell. We use proven methods to purify the fat that is harvested before transfer. By increasing the cushion under the painful area of the foot through autologous fat grafting, shock absorption to the area on ambulation improves and pressure to the foot on stance and ambulation decreases ultimately relieving foot pain.
Our novel procedure for fat injections for chronic plantar fasciitis is also proving to be a very effective, minimally invasive technique. Patients that have failed 6 months of conservative treatment or other surgical plantar fascia release methods are candidates for the procedure.
Learn more about our treatment for chronic plantar fasciitis in our podcast! inside.upmc.com/plantar-fasciitis-treatment/
We have now demonstrated success in fat grafting to the feet and our 1-year clinical data was published in Plastic & Reconstructive Surgery!
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