Plantar Ulcers and Neuropathic Arthropathies: Associated Diseases, Polyneuropathy Correlates, and Risk Covariates.

OBJECTIVE: To evaluate the associated diseases, polyneuropathy correlates, and risk covariates of neuropathic plantar ulcers (PUs) and neuropathic arthropathies (NAs). DESIGN: The authors conducted a retrospective, observational study over 3.5 years of 69 patients with neuropathy, NA, or PU seen in a wound clinic who also had a comprehensive neurologic evaluation and neurophysiologic testing. Comparisons were made to a population representative cohort of patients with diabetes mellitus (DM; n = 259). RESULTS: Of the 69 wound clinic patients, 32 had PUs, 14 had NAs, and 23 had both. Of the 61 adequately assessed patients, 37 (61%) had DM, 22 (36%) had no known associated disease, and 2 (3%) had hereditary sensory and autonomic neuropathy. Of the 37 patients with DM, 35 had distal polyneuropathy, and 2 did not. In 22 patients with chronic idiopathic axonal polyneuropathy, 20 had distal polyneuropathy. CONCLUSIONS: Although DM was the disease most commonly associated with PUs and NAs, chronic hyperglycemia may not have been the major underlying risk factor. The major risk covariates are sensation loss from polyneuropathy, old age, obesity, repetitive foot injury, and inadequate foot care or treatment. Physicians and other healthcare providers can help by identifying patients at risk and instituting measures such as adequate foot care to decrease these risks.

Diagnostic and Therapeutic Ultrasound on Venous and Arterial Ulcers: A Focused Review.

GENERAL PURPOSE: To provide information about the use of ultrasound for diagnostic and therapeutic treatment of venous and arterial ulcers. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After completing this continuing education activity, you should be able to: ABSTRACT: To review the diagnostic and therapeutic use of ultrasound on venous and arterial ulcers. METHODS: PubMed was searched for peer-reviewed articles using the search terms "ultrasound for venous ulcers" and "ultrasound for arterial ulcers." The search yielded 282 articles on ultrasound for venous ulcers and 455 articles for ultrasound on arterial ulcers. Data from 36 articles were selected and included after abstract review. RESULTS: Ultrasound is an established diagnostic modality for venous and arterial disease and is indicated for wound debridement. Recent evidence continues to support its superiority over standard of care in healing venous ulcers, but findings conflict in terms of the effectiveness of low-frequency ultrasound over high-frequency ultrasound. There are currently no standardized treatment protocols for ultrasound. CONCLUSIONS: Diagnostic ultrasound is used to assess venous and arterial disease and guide appropriate treatment for ulcers. Therapeutic low-frequency ultrasound is used to debride the wound bed, as an adjunctive topical wound treatment with standard of care, and to guide the application of other advanced therapies to chronic wounds. Better trial designs and consistent data are needed to support the effectiveness of ultrasound therapy on venous and arterial ulcers.

Expert Recommendations for the Use of Hypochlorous Solution: Science and Clinical Application.

Wound complications such as infection continue to in ict enormous nancial and patient quality-of-life burdens.The traditional practice of using antiseptics and antibiotics to prevent and/or treat infections has been questioned with increasing concerns about the cytoxitity of antiseptics and proliferation of antibiotic resistant bacteria. Solutions of sodium hypochlorite (NaOCl), commonly known as Dakin's solution, have been used in wound care for 100 years. In the last 15 years, more advanced hypochlorous acid (HOCl) solutions, based on electrochemistry, have emerged as safe and viable wound-cleansing agents and infection treatment adjunct therapies. After developing a literature-based summary of available evidence, a consensus panel of wound care researchers and practitioners met to review the evidence for 1) the antimicrobial effectiveness of HOCl based on in vitro studies, 2) the safety of HOCl solutions, and 3) the effectiveness of HOCl acid in treating different types of infected wounds in various settings and to develop recommendations for its use and application to prevent wound infection and treat infected wounds in the context of accepted wound care algorithms. Each participant gave a short presentation; this was followed by a moderated roundtable discussion with consensus-making regarding conclusions. Based on in vitro studies, the antimicrobial activity of HOCl appears to be comparable to other antiseptics but without cytotoxicity; there is more clinical evidence about its safety and effectiveness. With regard to the resolution of infection and improvement in wound healing by adjunct HOCl use, strong evidence was found for use in diabetic foot wounds; moderate evidence for use in septic surgical wounds; low evidence for venous leg ulcers, wounds of mixed etiology, or chronic wounds; and no evidence for burn wounds.The panel recommended HOCl should be used in addition to tissue management, infection, moisture imbalance, edge of the wound (the TIME algorithm) and aggressive debridement.The panel also recommended intralesional use of HOCl or other methods that ensure the wound is covered with the solution for 15 minutes after debridement. More controlled clinical studies are needed to determine the safety and ef cacy of HOCl in wound types with limited outcomes data and to evaluate outcomes of various application methods.

Dual-energy CT for the diagnosis of gout: an accuracy and diagnostic yield study.

OBJECTIVES: To assess the accuracy of dual-energy CT (DECT) for diagnosing gout, and to explore whether it can have any impact on clinical decision making beyond the established diagnostic approach using polarising microscopy of synovial fluid (diagnostic yield). METHODS: Diagnostic single-centre study of 40 patients with active gout, and 41 individuals with other types of joint disease. Sensitivity and specificity of DECT for diagnosing gout was calculated against a combined reference standard (polarising and electron microscopy of synovial fluid). To explore the diagnostic yield of DECT scanning, a third cohort was assembled consisting of patients with inflammatory arthritis and risk factors for gout who had negative synovial fluid polarising microscopy results. Among these patients, the proportion of subjects with DECT findings indicating a diagnosis of gout was assessed. RESULTS: The sensitivity and specificity of DECT for diagnosing gout was 0.90 (95% CI 0.76 to 0.97) and 0.83 (95% CI 0.68 to 0.93), respectively. All false negative patients were observed among patients with acute, recent-onset gout. All false positive patients had advanced knee osteoarthritis. DECT in the diagnostic yield cohort revealed evidence of uric acid deposition in 14 out of 30 patients (46.7%). CONCLUSIONS: DECT provides good diagnostic accuracy for detection of monosodium urate (MSU) deposits in patients with gout. However, sensitivity is lower in patients with recent-onset disease. DECT has a significant impact on clinical decision making when gout is suspected, but polarising microscopy of synovial fluid fails to demonstrate the presence of MSU crystals.

The use of PriMatrix, a fetal bovine acellular dermal matrix, in healing chronic diabetic foot ulcers: a prospective multicenter study.

OBJECTIVE: The objective of this multicenter study was to prospectively evaluate the healing outcomes of chronic diabetic foot ulcers (DFUs) treated with PriMatrix (TEI Biosciences, Boston, Massachusetts), a fetal bovine acellular dermal matrix. METHODS: Inclusion criteria required the subjects to have a chronic DFU that ranged in area from 1 to 20 cm² and failed to heal more than 30% during a 2-week screening period when treated with moist wound therapy. For qualifying subjects, PriMatrix was secured into a clean, sharply debrided wound; dressings were applied to maintain a moist wound environment, and the DFU was pressure off-loaded. Wound area measurements were taken weekly for up to 12 weeks, and PriMatrix was reapplied at the discretion of the treating physician. RESULTS: A total of 55 subjects were enrolled at 9 US centers with 46 subjects progressing to study completion. Ulcers had been in existence for an average of 286 days, and initial mean ulcer area was 4.34 cm². Of the subjects completing the study, 76% healed by 12 weeks with a mean time to healing of 53.1 ± 21.9 days. The mean number of applications for these healed wounds was 2.0 ± 1.4, with 59.1% healing with a single application of PriMatrix and 22.9% healing with 2 applications. For subjects not healed by 12 weeks, the average wound area reduction was 71.4%. CONCLUSION: The results of this multicenter prospective study demonstrate that the use of PriMatrix integrated with standard-of-care therapy is a successful treatment regimen to heal DFUs.

Acellular fetal bovine dermal matrix for treatment of chronic ulcerations of the midfoot associated with Charcot neuroarthropathy.

BACKGROUND: Gross deformity of the foot in Charcot neuroarthropathy can lead to collapse and subsequent ulceration, infection, amputation, or premature death. This study evaluated healing of midfoot ulcerations of Charcot neuroarthropathy using PriMatrix, a novel acellular fetal bovine dermal matrix. METHODS: In this retrospective analysis, 20 patients with ulcerations of the midfoot associated with Charcot neuroarthropathy were treated with either PriMatrix in addition to standard wound care (PriMatrix group,n = 12) or standard wound care alone (control group, n = 8). All patients had chronic, nonhealing foot ulcerations of at least 2250 mm(3) for a minimum of 30 days duration. All foot ulcerations were full thickness with subcutaneous involvement. Ankle brachial index ≥0.90 and/or transcutaneous oximetry (TcPo(2)) ≥40 mm Hg at the periulcer site was necessary for inclusion. Patients were excluded if they had acute or chronic osteomyelitis of the foot. RESULTS: Demography, risk factors, baseline severity of Charcot neuroarthropathy, and wound volume (control 4078 mm(3), PriMatrix 3737.5 mm(3), P = nonsignificant) were similar between treatment groups. Mean time to healing in the PriMatrix group (116 days, 95% CI = 109-123) was significantly shorter than in the control group (180 days, 95% confidence interval [CI] = 171-188); P < .0001. A significantly faster rate of healing was observed with PriMatrix (87.9 mm(3)/wk, 95% CI = 115.2% to 60.6%) compared with control (59.0 mm(3)/wk, 95% CI = 72.8% to 45.3%); P < .0001). CONCLUSIONS: The significantly faster rate of healing and steeper slope of volume reduction in the PriMatrix group warrants further investigation into its effects on healing of neuropathic ulcerations and potential limb salvage.

Forefoot plantar pressure reduction of off-the-shelf rocker bottom provisional footwear.

BACKGROUND: Increased plantar pressures have been shown to be a risk factor in ulceration of the neuropathic foot. Prescriptive footwear is a common medical treatment, yet evidence regarding the efficacy of these prescriptions is underdeveloped. The purpose of this study is to determine the off-loading properties of four provisional shoes; a rocker sole compared to a flat sole shoe with and without the addition of a 1.25 cm plastizote insert. METHODS: Fifteen subjects with peripheral neuropathy and a normal longitudinal arch were recruited to compare four types of provisional (post-operative) footwear. Plantar surface foot pressures were measured while wearing a rocker sole shoe or a flat stiff sole shoe. Both shoes were worn with and without a 1.25 cm plastizote insert. Peak plantar pressures were recorded for the hallux, metatarsal heads (1-5), midfoot, and heel. FINDINGS: The rocker sole shoe with plastizote had the best off-loading properties. While wearing this footwear, mean peak plantar pressure was 2.8 kg/cm(2) (range: 1.7 to 4.5 kg/cm(2), 50% mean reduction from flat sole shoe without plastizote) and 1.9 kg/cm(2) (range: 0.7 to 3.6 kg/cm(2), 35% mean reduction) at the five metatarsal heads and hallux, respectively. INTERPRETATION: For patients with a normal longitudinal arch and forefeet, either at risk of developing an ulcer or are healing a forefoot ulcer, a provisional shoe with a rocker sole and plastizote insole provides plantar pressure reduction of the forefoot. However, when results were analyzed for the subjects individually the amount of off-loading varied.

Comparative biomechanical effectiveness of over-the-counter devices for individuals with a flexible flatfoot secondary to forefoot varus.

OBJECTIVES: Evaluate effects of a new off-the-shelf insert on frontal plane foot biomechanics and compare effectiveness of the new and an existing off-the-shelf insert and a motion-control shoe in neutralizing frontal plane foot biomechanics. DESIGN: Descriptive. SETTING: Biomechanics laboratory. PARTICIPANTS: Fifteen uninjured subjects with a flexible flatfoot secondary to forefoot varus. ASSESSMENT OF RISK FACTORS: Three-dimensional kinematic and kinetic data were collected as subjects walked and jogged at their self-selected speed while wearing a motion-control running shoe, the shoe with a new off-the-shelf insert, and the shoe with an existing off-the-shelf insert. MAIN OUTCOME MEASURES: Frontal plane kinematics and rearfoot kinetics were evaluated during stance. Statistical analysis was performed using a repeated measures analysis of variance and Student-Newman-Keuls post hoc tests (α ≤ 0.05). RESULTS: The new insert and motion-control shoe placed the forefoot in a less-everted position than the existing off-the-shelf insert during walking. There were no differences in forefoot kinematics during jogging, nor were there differences in rearfoot motion during walking or jogging. The rearfoot eversion moment was significantly lower with the new off-the-shelf insert compared with the motion-control shoe and the existing insert during walking and jogging. CONCLUSIONS: A new off-the-shelf device is available that promotes more neutral frontal plane biomechanics, thus providing a theoretical rationale for using this device for injury prevention and treatment. The comparative biomechanical effectiveness of a motion-control shoe and the orthotic inserts may assist health care professionals in selecting a device to correct the flatfoot structure.

In vitro activity of the Qoustic Wound Therapy System against planktonic and biofilm bacteria.

OBJECTIVE: The purpose of this study was to determine whether the Qoustic Wound Therapy System (Arobella Medical, LLC, Minnetonka, Minnesota) kills planktonic bacterial cells and/or removes bacterial biofilms. DESIGN: The Qoustic Wound Therapy System was evaluated against Pseudomonas aeruginosa, Staphylococcus epidermidis, and Staphylococcus aureus planktonic cells and biofilms in vitro. MAIN RESULTS: P aeruginosa, S epidermidis, and S aureus planktonic cells decreased by a mean of 5.10, 4.99, and 5.22 log10 colony-forming units/mL, respectively, with 4 Qoustic Wound Therapy System treatment minutes. After 10 minutes of treatment, P aeruginosa, S epidermidis, and S aureus biofilms decreased by a mean of 1.34, 1.46, and 1.02 log10 colony-forming units/cm, respectively. CONCLUSION: The Qoustic Wound Therapy System, using the Qoustic Qurette, kills planktonic bacteria and reduces bacterial biofilms in vitro.

Expedited wound healing with noncontact, low-frequency ultrasound therapy in chronic wounds: a retrospective analysis.

OBJECTIVE: To evaluate the clinical role of noncontact, low-frequency ultrasound therapy (MIST Therapy System; Celleration, Eden Prairie, Minnesota) in the treatment of chronic lower-extremity wounds. DESIGN: A retrospective observational study. SETTING: A multidisciplinary, vascular wound-healing clinic. PATIENTS: One hundred sixty-three patients who received MIST Therapy plus standard of care (treatment group) and 47 patients who received the standard of care alone (control group). INTERVENTIONS: All wounds in the control and treatment groups received the standard of wound care and were followed for 6 months. In the treatment group, MIST Therapy was administered to wounds 3 times per week for 90 days or until healed. MAIN OUTCOME MEASURES: Proportion of wounds healed and wound volume reduction. Rate of healing was also quantified using 1-way analysis of variance to determine the slope of the regression line from starting volume to ending volume, where a steeper slope indicates a faster healing rate. Outcomes were evaluated in all wounds and etiology-specific subgroups. MAIN RESULTS: A significantly greater percentage of wounds treated with MIST Therapy and standard of care healed as compared with those treated with the standard of care alone (53% vs 32%; P = 0.009). The slope of the regression line in the MIST arm (1.4) was steeper than the slope in the control arm (0.22; P = .002), indicating a faster rate of healing in the MIST-treated wounds. CONCLUSION: The rate of healing and complete closure of chronic wounds in patients improved significantly when MIST Therapy was combined with standard wound care.

Improving limb salvage in critical ischemia with intermittent pneumatic compression: a controlled study with 18-month follow-up.

BACKGROUND: Intermittent pneumatic compression (IPC) is an effective method of leg inflow enhancement and amelioration of claudication in patients with peripheral arterial disease. This study evaluated the clinical efficacy of IPC in patients with chronic critical limb ischemia, tissue loss, and nonhealing wounds of the foot after limited foot surgery (toe or transmetatarsal amputation) on whom additional arterial revascularization had been exhausted. METHODS: Performed in a community and multidisciplinary health care clinic (1998 through 2004), this retrospective study comprises 2 groups. Group 1 (IPC group) consisted of 24 consecutive patients, median age 70 years (interquartile range [IQR], 68.7-71.3) years, who received IPC for tissue loss and nonhealing amputation wounds of the foot attributable to critical limb ischemia in addition to wound care. Group 2 (control group) consisted of 24 consecutive patients, median age 69 years (IQR, 65.7-70.3 years), who received wound care for tissue loss and nonhealing amputation wounds of the foot due to critical limb ischemia, without use of IPC. Stringent exclusion criteria applied. Group allocation of patients depended solely on their willingness to undergo IPC therapy. Vascular assessment included determination of the resting ankle-brachial pressure index, transcutaneous oximetry (TcPO(2)), duplex graft surveillance, and foot radiography. Outcome was considered favorable if complete healing and limb salvage occurred, and adverse if the patient had to undergo a below knee amputation subsequent to failure of wound healing. Follow-up was 18 months. Wound care consisted of weekly débridement and biologic dressings. IPC was delivered at an inflation pressure of 85 to 95 mm Hg, applied for 2 seconds with rapid rise (0.2 seconds), 3 cycles per minute; three 2-hourly sessions per day were requested. Compliance was closely monitored. RESULTS: Baseline differences in demography, cardiovascular risk factors (diabetes mellitus, smoking, hypertension, dyslipidemia, renal impairment), and severity of peripheral arterial disease (ankle-brachial indices, TcPO(2), prior arterial reconstruction) were not significant. The types of local foot amputation that occurred in the two groups were not significantly different. In the control group, foot wounds failed to heal in 20 patients (83%) and they underwent a below knee amputation; the remaining four (17%, 95% confidence interval [CI], 0.59%-32.7%) had complete healing and limb salvage. In the IPC group, 14 patients (58%, 95% CI, 37.1%-79.6%) had complete foot wound healing and limb salvage, and 10 (42%) underwent below knee amputation for nonhealing foot wounds. Wound healing and limb salvage were significantly better in the IPC group (P < .01, chi(2)). Compared with the IPC group, the odds ratio of limb loss in the control group was 7.0. On study completion, TcPO(2) on sitting was higher in the IPC group than in the control group (P = .0038). CONCLUSION: IPC used as an adjunct to wound care in patients with chronic critical limb ischemia and nonhealing amputation wounds/tissue loss improves the likelihood of wound healing and limb salvage when established treatment alternatives in current practice are lacking. This controlled study adds to the momentum of IPC clinical efficacy in critical limb ischemia set by previously published case series, compelling the pursuit of large scale multicentric level 1 studies to substantiate its actual clinical role, relative indications, and to enhance our insight into the pertinent physiologic mechanisms.

Treatment of ischemic wounds with noncontact, low-frequency ultrasound: the Mayo clinic experience, 2004-2006.

OBJECTIVE: To evaluate the clinical role of a novel, noncontact, low-intensity, low-frequency ultrasound therapy (MIST Therapy) in the treatment of nonhealing leg and foot ulcers associated with chronic critical limb ischemia. DESIGN: Prospective, parallel-group, randomized, controlled trial. SETTING: A multidisciplinary, vascular wound-healing clinic. PATIENTS: Thirty-five patients who received MIST Therapy plus the standard of wound care (treatment group) and 35 patients who received the standard of wound care alone (control group). INTERVENTIONS: Standard of wound care alone or standard of wound care plus MIST Therapy for 12 weeks or until fully healed. MIST Therapy was administered 3 times per week for 5 minutes per treatment. MAIN OUTCOME MEASURE: Percentage of patients with greater than 50% reduction in wound size from the index measurement after 12 weeks of treatment. The relationship of transcutaneous oximetry pressure in the supine and dependent position was evaluated as a factor in assessing the potential to heal ischemic ulcerations of the foot and leg. MAIN RESULTS: A significantly higher percentage of patients treated with the standard of care plus MIST Therapy achieved greater than 50% wound healing at 12 weeks than those treated with the standard of care alone (63% vs 29%; P < .001). Thus, failure to achieve the minimum wound healing requirement occurred in 37% of patients in the treatment group and 71% of patients in the control group. The predictive value of baseline transcutaneous oxygen pressure may benefit the clinician when assessing the potential to heal ischemic wounds. CONCLUSION: The rate of healing of cutaneous foot and leg ulcerations in patients with chronic critical limb ischemia improved significantly when MIST Therapy was combined with the standard of wound care.

Use of noncontact low-frequency ultrasound in the treatment of chronic foot and leg ulcerations: a 51-patient analysis.

BACKGROUND: A feasibility study was conducted to characterize the effects of noncontact low-frequency ultrasound therapy for chronic, recalcitrant lower-leg and foot ulcerations. METHODS: The study was an open-label, nonrandomized, baseline-controlled clinical case series. Patients were initially treated with the Mayo Clinic standard of care before the addition of or the switch to noncontact low-frequency ultrasound therapy. We analyzed the medical records of 51 patients (median +/- SD age, 72 +/- 15 years) with one or more of the following conditions: diabetes mellitus, neuropathy, limb ischemia, chronic renal insufficiency, venous disease, and inflammatory connective tissue disease. All of the patients had lower-extremity ulcers, 20% had a history of amputation, and 65% had diabetes. Of all the wounds, 63% had a multifactorial etiology, and 65% had associated transcutaneous oximetry levels below 30 mm Hg. RESULTS: The mean +/- SD treatment time of wounds during the baseline standard of care control period versus the noncontact low-frequency ultrasound therapy period was 9.8 +/- 5.5 weeks versus 5.5 +/- 2.8 weeks (P < .0001). Initial and end measurements were recorded, and percent volume reduction of the wound was calculated. The mean +/- SD percent volume reduction in the baseline standard of care control period versus the noncontact low-frequency ultrasound therapy period was 37.3% +/- 18.6% versus 94.9% +/- 9.8% (P < .0001). CONCLUSIONS: Using noncontact low-frequency ultrasound improved the rate of healing and closure in recalcitrant lower-extremity ulcerations.

Use of intermittent pneumatic compression for treatment of upper extremity vascular ulcers.

Ischemic vascular ulcerations of the upper extremities are an uncommon and frequently painful condition most often associated with scleroderma and small vessel inflammatory diseases. Digital amputation has been advocated as primary therapy because of the poor outcome with medical care. Intermittent pneumatic compression (IPC) pump therapy can improve ulcer healing in lower extremity ischemic ulcerations; however, the value of this treatment in upper extremity ischemic ulcerations is not known. This observational pilot study consisted of a consecutive series of 26 patients with 27 upper extremity ischemic vascular ulcers seen at the Mayo Gonda Vascular Center from 1996 to 2003. Inclusion criteria were documented index of ulcer size and follow-up ulcer size and use of the IPC pump as adjunctive wound treatment. Twenty-six of 27 ulcers (96%) healed with the use of the IPC pump. Mean baseline ulcer size was 1.0 cm2 (SD=0.3 cm2) and scleroderma was the underlying disease in 65% (17/26) of cases. Laser Doppler blood flow in the affected digit was 7 flux units (normal greater than 100). The mean ulcer duration before IPC treatment was 31 weeks. The average pump use was 5 hours per day. The mean time to wound healing was 25 weeks. Twenty-five of 26 patients reported an improvement in wound pain with pump use. Intensive IPC pump use is feasible and associated with a high rate of healing in upper extremity ischemic ulcers. A prospective, randomized, sham-controlled study of IPC is needed to determine whether IPC treatment improves wound healing compared to standard medical care.

The efficacy of a pneumatic compression device in the treatment of plantar fasciitis.

Plantar fasciitis is a common foot disorder that affects more than two million Americans each year. Conservative management of plantar fasciitis is the first line of treatment by the medical specialist who frequently encounters this common foot complaint. In this study, 50 patients with plantar fasciitis of 4 weeks duration but less than 12 weeks were randomized into two groups. One group of 25 patients used the AirHeel (Aircast, Inc.) and the second group of 25 used the 1st Step prefabricated foot insert (Wrymark, Inc). Standardized weight-bearing radiographs were obtained in order to categorize the foot type: normal arch, pes planus, or pes cavus. Patients were initially evaluated and at 12 weeks they returned for a subsequent visit. The contact area of the foot with the AirHeel and 1st Step insert were similar, an increase of 27% and 26%, respectively, over the contact area barefoot. There was a noted difference in force reduction with the two devices. The AirHeel reduced the midstance force by 20.19%, as compared to the 1st Step insert which showed a 1.03% increase in midstance force. Patients with a higher initial pain score seemed to respond better initially to the AirHeel (p = 0.015) than the 1st Step insert (p = 0.035). This study demonstrates the benefits of offloading the foot at midstance with two devices to relieve the discomfort associated with plantar fasciitis. The Aircast AirHeel is a new modality for dynamic, functional treatment of proximal plantar fasciitis.