Treatment of proximal plantar fasciitis with ultrasound-guided steroid injection

Intralesional Steroid Injection Versus Extracorporeal Shockwave Therapy in the Treatment of Plantar Fasciitis: A Comparative, Prospective, Case Series Study

Background This study aimed to compare and evaluate the outcomes of intralesional steroid injections (ultrasound-guided) versus extracorporeal shockwave therapy in the treatment of plantar fasciitis. Methodology Between January 2021 and March 2022, 120 (84 male, 36 female) patients with a confirmed diagnosis of plantar fasciitis were identified. Subjective assessment was done using Mayo Clinical Score, and objective evaluation was done by measuring plantar fascia thickness using ultrasonography. For this study, two groups were made, wherein group A was administered a high dose of extracorporeal shockwave therapy, and group B was administered ultrasound-guided intralesional or local steroid injections. Results Plantar fascia thickness was considerably reduced after therapy in both groups; however, the difference in thickness reduction was not statistically significant between both groups. Mayo Clinic Scores showed statistically significant improvement in pain; however, the difference in pain reduction was not statistically significant between both groups. Conclusions A considerable clinical and radiological improvement was noted in both groups; however, we did not record statistically significant and superior results in either group. Intralesional steroid injections provided faster clinical improvement and better patient compliance.

Perforating Fat Injections for Chronic Plantar Fasciitis: A Randomized, Crossover Clinical Trial

SUMMARY

Plantar fasciitis affects 2 million patients per year. Ten percent of cases are chronic, with thickened plantar fascia. Treatment may lead to prolonged recovery, foot instability, and scar. The authors hypothesized that perforating fat injections would decrease plantar fascia thickness, reduce pain, and improve quality of life. Adults with plantar fascia greater than 4 mm for whom standard treatment had failed were included in a prospective, randomized, crossover pilot study. Group 1 (intervention) was followed for 12 months. Group 2 was observed for 6 months, injected, and then followed for 6 months. Validated patient reported outcome measures, ultrasound, and complications were assessed. Group 1 had nine female patients and group 2 had five patients. A total of 2.6 ± 1.6 ml of fat was injected per foot at one to two sites. In group 1, plantar fascia thickness decreased from screening at 6 and 12 months (p < 0.05). Group 2 had decreased plantar fascia thickness from screening to 6 months after injection (p < 0.05). Group 1 had pain improvements at 6 and 12 months compared with screening (p < 0.01). Group 2 reported no pain difference after injections (p > 0.05). Group 1 had improved activities of daily living and sports activity at 6 and 12 months compared with screening (p < 0.003). Group 2 noted increased sports activity 6 months after injection compared with screening (p < 0.03). In conclusion, perforating fat injections for chronic plantar fasciitis demonstrate significant improvement in pain, function, and plantar fascia thickness.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VI, foot and ankle

Objectives

Clarity regarding accuracy and effectiveness for interventional procedures around the foot and ankle is lacking. Consequently, a board of 53 members of the Ultrasound and Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) reviewed the published literature to evaluate the evidence on image-guided musculoskeletal interventional procedures around this anatomical region.

Methods

We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around foot and ankle in order to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper that was shared with all panel members for final approval.

Results

A list of 16 evidence-based statements on clinical indications for image-guided musculoskeletal interventional procedures in the foot and ankle were drafted after a literature review. The highest level of evidence was reported for four statements, all receiving 100% agreement.

Conclusion

According to this consensus, image-guided interventions should not be considered a first-level approach for treating Achilles tendinopathy, while ultrasonography guidance is strongly recommended to improve the efficacy of interventional procedures for plantar fasciitis and Morton’s neuroma, particularly using platelet-rich plasma and corticosteroids, respectively.

Key Points

• The expert panel of the ESSR listed 16 evidence-based statements on clinical indications of image-guided musculoskeletal interventional procedures in the foot and ankle.

• Strong consensus was obtained for all statements.

• The highest level of evidence was reached by four statements concerning the effectiveness of US-guided injections of corticosteroid for Morton’s neuroma and PRP for plantar fasciitis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-08125-z.

Reliability in ultrasound measurements of plantar aponeurosis thickness

PURPOSE

Given the increasing research interest in ultrasound plantar aponeurosis (PA) thickness measurements, this study aimed to analyze the inter and intra-rater reliability of independent sonograms and to identify the error related to the image analysis procedure.

METHODS

Twenty-one healthy men participated in this study. Imaging of PA consisted of two independent sonograms per subject. Two raters (R1 and R2) evaluated each sonogram twice using standardized steps. Precision of the image analysis procedure was analyzed using the Bland and Altman plot and Intraclass Correlation Coefficient (ICC). Agreement estimates and ICC were used to assess absolute and relative inter and intra-rater reliability.

RESULTS

Reliability of PA thickness was found to depend strongly on the number of images acquired per subject. Intra-rater agreement for single measurements were 0.696 (R1) and 0.495 (R2), whereas average measurements yielded values of 0.821 (R1) and 0.662 (R2), respectively. Precision within a sonogram varied from ICC values of 0.873 to 0.960 (intra-rater) and 0.670 to 0.822 (inter-rater).

CONCLUSION

Most part of the error in PA thickness measurements seems to be related to the sonogram acquisition process and not to the visual inspection of the image. To minimize error, average values of a minimum of two images per subject should be used. The moderate agreement between raters found in this study ratifies the need of all measurements being made by the same rater or group of raters. If a single rater evaluates all subjects, performing multiple measurements over one image does not seem to affect ICC as much as acquiring multiple images.

Outcome of Corticosteroid Injections, Extracorporeal Shock Wave Therapy, and Radiofrequency Thermal Lesioning for Chronic Plantar Fasciitis

BACKGROUND

Chronic heel pain with plantar fasciitis is relatively common and can affect adults of all ages regardless of an active or sedentary lifestyle. The purpose of the present study was to evaluate the effectiveness of corticosteroid injection (CSI), extracorporeal shock wave therapy (ESWT), and radiofrequency thermal lesioning (RTL) treatments in chronic plantar heel pain that has been unresponsive to other conservative treatments.

METHODS

We retrospectively analyzed the results of 217 patients treated with CSI (n = 73), ESWT (n = 75), and RTL (n = 69). The treatment efficacy and pain intensity, as measured using the visual analog scale, were recorded and compared at the 6-month follow-up.

RESULTS

Pain intensity decreased significantly in all patients. However, it decreased significantly more in the CSI and RTL groups than in the ESWT group (P < .001). Age, sex, body mass index, calcaneal spur presence, and symptom duration were similar among 3 groups (P > .05). No complications were noted after the CSI, ESWT, or RTL sessions.

CONCLUSION

CSI, ESWT, and RTL successfully treated chronic plantar heel pain that did not respond to other conservative treatments; however, CSI and RTL yielded better therapeutic outcomes.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Comparison of midterm results of Platelet Rich Plasma (PRP) versus Steroid for plantar fasciitis: A randomized control trial of 118 patients

BACKGROUND

Plantar fasciitis, which is a common cause of heel pain, often results in significant morbidity. In cases who are not responsive to initial conservative treatment, invasive procedures, often in the form of local infiltration of steroid are required. These procedures are associated with significant complications. Local Platelet Rich Plasma (PRP) infiltration is an emerging addition to these treatments. However, whether it is more effective in reducing pain and improving function than other treatments (such as steroid injections or whole blood) remains controversial.

METHODS

Skeletally mature patients with plantar fasciitis who had failed conservative therapy were randomized using envelope method into 2 groups: PRP and Steroid group. The participants were assessed for pain using Visual Analog Scale on the day of presentation, and then after therapy at 2 weeks, 4 weeks, 3 months, and 6 months. They were additionally assessed on final follow-up using AOFAS hind-foot Score.

RESULTS

118 patients were randomized into 2 groups: 58 patients to the PRP group and 60 to the Steroid group. PRP was associated with greater improvement in VAS score and resulted in superior AOFAS score at 6 months as compared to steroid injection. The authors did not find any local or systemic complications in any of the groups. The result and difference were more pronounced as the time from injection increased and maximal benefit was observed at 6 months follow-up. None of the patients needed a repeat injection at 6 months.

CONCLUSION

Our study expands on the previous studies to provide a better evidence for superiority of PRP over local injection of steroid in plantar fasciitis, and the authors conclude that PRP provides better pain relief and function as compared to steroid injection.

LEVEL OF EVIDENCE

Level 1 Prospective Randomized Control Trial (RCT).

The Effect of Corticosteroid Local Injection Versus Platelet-Rich Plasma for the Treatment of Plantar Fasciitis in Obese Patients: A Single-Blind, Randomized Clinical Trial

Chronic plantar heel pain (CPHP) is one of the most common painful and disabling foot conditions, for which various treatments have been proposed. We aimed to investigate the efficacy of local injection of platelet-rich plasma (PRP) compared with the conventional method of local corticosteroid injection in obese patients who were resistant to other nonsurgical treatments. In this single-blind, randomized clinical trial, 32 obese patients with chronic plantar heel pain were randomly allocated to 2 groups of 16 participants each. In 1 group, 40 mg of dimethylprednisolone was injected once into the painful heel, whereas the other group received 3 separate injections of PRP, with each injection administered 1 week apart. The groups were compared at baseline and at 24 weeks after the injection, or course of injections, was administered. Exposures, total morning pain, and foot function index were not statistically significantly different between the groups at baseline; however, at 24 weeks after the treatment, final pain and morning pain scores were statistically significantly (p < .001) better in the corticosteroid group, and the mean foot function index scores were 65.4 ± 3.2 and 58.3 ± 2.9 (p < .001) in patients treated with corticosteroid and PRP, respectively. In obese patients with plantar fasciitis, injection with corticosteroid was more effective than PRP at reducing pain and improving function.

The Effect of Monophasic Pulsed Current with Stretching Exercise on the Heel Pain and Plantar Fascia Thickness in Plantar Fasciitis: A Randomized Controlled Trial

Plantar fasciitis (PF) is one of the most common causes of heel and foot pain. Monophasic pulsed current (MPC) is an electrical stimulation used to accelerate the healing processes. The purpose of this study was to determine the effect of MPC and MPC combined with plantar fascia stretching exercises (SE) on heel pain and plantar fascia thickness in treatment of PF and see if there is any relationship between heel pain and plantar fascia thickness after intervention. Forty-four participants diagnosed with PF were randomly assigned to two group; MPC group or MPC combined with plantar fascia SE. Plantar fascia thickness was measured with musculoskeletal ultrasound. Although no statistical differences between the two groups were found, heel pain and the plantar fascia thickness significantly decreased in both groups after the intervention (p < 0.001). No significant correlation was found between changes in heel pain and plantar fascia thickness after 4 weeks of treatment. Our results indicated that MPC can reduce heel pain and plantar fascia thickness caused by PF. However, MPC combined with plantar fascia SE is not superior to MCP only in terms of reduction in heel pain and plantar fascia thickening.

Is Platelet-rich Plasma Injection more Effective than Steroid Injection in the Treatment of Chronic Plantar Fasciitis in Achieving Long-term Relief?

Introduction: Plantar fasciitis is characterised by pain in the heel, which is aggravated on weight bearing after prolonged rest. Many modalities of treatment are commonly used in the management of plantar fasciitis including steroid injection. Many studies show that steroid injection provides pain relief in the short term but not long lasting. Recent reports show autologous platelet-rich plasma (PRP) injection promotes healing, resulting in better pain relief in the short as well as long term. The present study was undertaken to compare the effects of local injection of platelet-rich plasma and Corticosteroid in the treatment of chronic plantar fasciitis. Materials and methods: Patients with the clinical diagnosis of chronic plantar fasciitis (heel pain of more than six weeks) after failed conservative treatment and plantar fascia thickness more than 4mm were included in the study. Patients with previous surgery for plantar fasciitis, active bilateral plantar fasciitis, vascular insufficiency or neuropathy related to heel pain, hypothyroidism and diabetes mellitus were excluded from the study. In this prospective double-blind study, 60 patients who fulfilled the criteria were divided randomly into two groups. Patients in Group A received PRP injection and those in Group B received steroid injection. Patients were assessed with visual analog scale (VAS) and American Orthopedic Foot and Ankle Society (AOFAS) score. Assessment was done before injection, at six weeks, three months and six months follow-up after injection. Plantar fascia thickness was assessed before the intervention and six months after treatment using sonography. Results: Mean VAS in Group A decreased from 7.14 before injection to 1.41 after injection and in Group B decreased from 7.21 before injection to 1.93 after injection, at final follow-up. Mean AOFAS score in Group A improved from 54 to 90.03 and in Group B from 55.63 to 74.67 at six months' follow-up. The improvements observed in VAS and AOFAS were statistically significant. At the end of six months' follow-up, plantar fascia thickness had reduced in both groups (5.78mm to 3.35mm in Group A and 5.6 to 3.75 in Group B) and the difference was statistically significant. Conclusion: Local injection of platelet-rich plasma is an effective treatment option for chronic plantar fasciitis when compared with steroid injection with long lasting beneficial effect.

Prevalence and sensitivity of trigger points in lumbo-pelvic-hip muscles in patients with patellofemoral pain syndrome

OBJECTIVES

Changes in the activity of the lumbo-pelvic-hip muscles have been established as a major cause of patellofemoral pain syndrome (PFPS), a common orthopedic problem. The present study aimed to compare the prevalence and sensitivity of myofascial trigger points (MTrPs) in lumbo-pelvic-hip muscles in persons with and without PFPS.

METHODS

Thirty women with PFPS and 30 healthy women 18-40 years old were recruited for this study. The prevalence of MTrPs was assessed by palpation, and pressure algometry was used to measure the pressure pain threshold. This study evaluated the areas where MTrPs are most commonly found in the lumbar muscles (internal oblique, erector spinae and quadratus lumborum), pelvic muscles (gluteus maximus, gluteus medius, gluteus minimus and piriformis), and hip muscles (hip adductor, quadriceps, hamstring, tensor fascia lata and sartorius). Independent t-tests were used to compare mean pressure pain thresholds between the two groups. Chi-squared tests were used to compare the prevalence of MTrPs.

RESULTS

The prevalence of MTrPs was significantly higher in most of the lumbo-pelvic-hip muscles in patients with PFPS compared to healthy persons. However, there were no significant differences between groups in the prevalence of MTrPs in the gluteus minimus or adductor muscles. The pressure pain threshold in lumbo-pelvic-hip muscles was lower in patients with PFPS compared to healthy participants.

CONCLUSION

In patients with PFPS the prevalence of MTrPs in the lumbo-pelvic-hip region was higher, and the pressure pain threshold was lower, than in healthy people. Thus therapy to treat PFPS should target the lumbo-pelvic-hip muscles.

Percutaneous Plantar Fascia Release With Needle: Anatomic Evaluation with Cadaveric Specimens

Percutaneous plantar fascia release with needle is a novel procedure for the treatment of plantar fasciitis. The objective of this cadaveric study is to perform an anatomic evaluation of the percutaneous plantar fascia release method using a conventional hypodermic needle. In this study, we used 14 fresh-frozen cadaveric trans-tibial amputation specimens. Percutaneous plantar fasciotomy with a conventional hypodermic needle was performed. After a proper dissection, the width of the plantar fascia, the thickness of the medial border, and the width of the cut segment were measured and recorded. Any muscle damage on the flexor digitorum brevis and damaged area depth were recorded. Any damage on the lateral plantar nerve and the first branch of the lateral plantar nerve, also known as Baxter's nerve, and their distance to fasciotomy were also recorded. Mean width (± standard deviation) of the plantar fascia was measured as 20.34 ± 4.25 mm. The mean thickness of the medial border of the plantar fascia was 3.04 ± 0.54 mm. Partial fasciotomy was performed in all cadavers with 49.47% ± 7.25% relative width of the plantar fascia. No lateral plantar nerve, or its first branch Baxter's nerve, was damaged, and the mean distance from the deepest point of the fasciotomy up to the Baxter's nerve was 8.62 ± 2.62 mm. This cadaveric study demonstrated that partial plantar fasciotomy can be achieved via percutaneous plantar fascia release with a conventional hypodermic needle without any nerve damage.

Effectiveness of Four Different Treatment Modalities in the Treatment of Chronic Plantar Fasciitis During a 36-Month Follow-Up Period: A Randomized Controlled Trial

No consensus has been reached about the best treatment method of plantar fasciitis and the results of the treatment methods have been inconsistent. The objective of the present study was to compare the therapeutic effects of extracorporeal shock wave therapy, platelet-rich plasma injection, local corticosteroid injection, and prolotherapy for the treatment of chronic plantar fasciitis using a randomized, controlled, prospective study. We performed a randomized controlled prospective clinical study of 4 groups. The first group received extracorporeal shock wave therapy, the second group received prolotherapy, the third group received platelet-rich plasma injection, and the fourth group received a local corticosteroid injection. The study included 158 consecutive patients with a diagnosis of chronic plantar fasciitis with a symptomatic heel spur. The clinical outcomes were assessed using the visual analog scale and Revised Foot Function Index. At the end of the follow-up period, the mean visual analog scale scores for all 4 groups were similar to the mean visual analog scale scores before treatment. At the end of the follow-up period, no significant improvement was noted in the Revised Foot Function Index score in any of the groups. The corticosteroid injection was more effective in the first 3 months and extracorporeal shock wave therapy was an effective treatment method in the first 6 months in regard to pain. The corticosteroid injection lost its effectiveness during the follow-up period. The effect of prolotherapy and platelet-rich plasma was seen within 3 to 12 months; however, at the 36-month follow-up point, no differences were found among the 4 treatments.

Effects of platelet-rich plasma in the treatment of plantar fasciitis: A meta-analysis of randomized controlled trials

BACKGROUND

Plantar fasciitis is a common cause of heel pain, which often results in significant morbidity. There have been several treatment options that are used for plantar fasciitis, including nonsteroidal anti-inflammatory drugs, orthoses, physical therapy, and steroid injections.

OBJECTIVES

The aim of this meta-analysis was to compare the effects of platelet-rich plasma (PRP) and other treatments in patients with plantar fasciitis.

SEARCH METHODS

Medline, Web of Science, and Embase were systematically searched to identify relevant trials.

SELECTION CRITERIA

Randomized controlled trials (RCTs) that compared the effects of PRP and other treatments on plantar fasciitis were included.

DATA COLLECTION AND ANALYSIS

The main outcomes included changes from baseline in visual analog scale (VAS) score, American Orthopaedic Foot and Ankle Society Score (AOFAS), and Roles-Maudsley score (RMS). Results were expressed as weight mean difference (WMD) with 95% confidence interval (95% CI). The meta-analysis was performed using a fixed-effects or random-effects model according to heterogeneity.

MAIN RESULTS

Ten RCTs involving a total of 445 patients with plantar fasciitis were included. Among these studies, 9 compared PRP with steroid, and 1 compared PRP with whole blood.Four studies were categorized as being at low risk of bias, and the remaining 6 as being at unclear risk of bias.Pooled estimates suggested that PRP had greater changes in VAS and AOFAS scores than other treatments. However, it had no benefit effect in the RMS.Subgroup analysis for VAS and AOFAS showed that PRP had superior effect than other treatments at 12 months, but not at the 1, 3, 6 months.Subgroup analysis based on treatment regimens demonstrated that PRP was more effective than steroid in the change from baseline in AOFAS, but not in VAS and RMS scores.

AUTHORS' CONCLUSION

PRP was as effective as other treatments in reducing pain and improving function in patients with plantar fasciitis. Subgroup analysis indicated that PRP had better effect than steroid in AOFAS Score and its effect was durable in a long term. However, considering the potential limitations in this study, more large-scale RCTs are needed to confirm the current findings.

Endoscopic Plantar Fasciotomy; Deep Fascial Versus Superficial Fascial Approach: A Prospective Randomized Study

In the present randomized prospective study, 2 different surgical techniques of endoscopic plantar fascia release were compared. Of 547 patients with a diagnosis of plantar fasciitis, 46 with no response to conservative treatment for ≥6 months were included. Of the 46 patients, 5 were lost to follow-up. In group 1 (n = 21), plantar fascia release was performed using a deep fascial approach (DFA), and in group 2 (n = 20), the superficial fascial approach (SFA) with a slotted cannula technique was used. Patients were evaluated using the American Orthopaedic Foot and Ankle Society Ankle Hindfoot scale and visual analog scale at baseline and 3 weeks and 3, 6, and 12 months after the initial surgery. At the final follow-up appointment, the Roles-Maudsley score was used to determine patient satisfaction. At the final follow-up examination, the mean American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale scores had increased from 53.12 to 83.68, with a decrease in the mean visual analog scale score from 7.95 to 1.65 noted. According to the Roles-Maudsley score, the success rate after 1 year was 90.47% for DFA group, 95% for the SFA group, and 92.68% for all patients. Although no significant difference was found between the final functional scores, better early postoperative scores were found in the SFA group. The mean duration of the procedure was measured as 27.22 ± 9.41 minutes overall, 35 ± 5.62 minutes in the DFA group, and 19.05 ± 4.01 minutes in the SFA group. Two early and two late complications occurred in the DFA group with none reported in the SFA group. In conclusion, the SFA is a faster and safer method of endoscopic plantar fascia release with better early postoperative scores.

Shall We Inject Superficial or Deep to the Plantar Fascia? An Ultrasound Study of the Treatment of Chronic Plantar Fasciitis

We compared the effectiveness of ultrasound (US)-guided corticosteroid, injected superficial or deep to the fascia, in patients with plantar fasciitis. Thirty patients (24 females [75%] and 6 males [25%]) with unilateral chronic plantar fasciitis were divided into 2 groups according to the corticosteroid injection site: superficial (n = 15) or deep (n = 15) to the plantar fascia. Patient heel pain was measured using a Likert pain scale and the Foot Ankle Outcome Scale (FAOS) for foot disability, evaluated at baseline and repeated in the first and sixth weeks. The plantar fascia and heel pad thicknesses were assessed on US scans at baseline and the sixth week. The groups were similar in age, gender, and body mass index (p > .05 for all). Compared with the baseline values, the Likert pain scale (p < .001 for all) and FAOS subscale (p < .01 for all) scores had improved at the first and sixth week follow-up visits in both groups. Although the plantar fascia thickness had decreased significantly in both groups at the sixth week (p < .001 for both), the heel pad thickness remained unchanged (p > .05 for both). The difference in the FAOS subscales (pain, p = .002; activities of daily living, p = .003; sports/recreational activities, p = .008; quality of life, p = .009) and plantar fascia thickness (p = .049) showed better improvement in the deep than in the superficial injection group. US-guided corticosteroid injections are safe and effective in the short-term therapeutic outcome of chronic plantar fasciitis. Additionally, injection of corticosteroid deep to the fascia might result in greater reduction in plantar fascia thickness, pain, and disability and improved foot-related quality of life.

Evaluation of the Analgesic Effect of Combination Therapy on Chronic Plantar Pain Through the Myofascial Trigger Points Approach

BACKGROUND

Closely related pathologic disorders sometimes manifest with the same symptoms, making for a complex differential diagnosis. This is the situation in plantar fasciitis (PF) and myofascial pain syndrome (MPS) with myofascial trigger points (MTPs) in the sole of the foot. This research assessed the analgesic effect on plantar pain of combination therapy with interferential current stimulation therapy (ICST), treating MTPs in the great toe adductor muscle and the short flexor muscles of the toes in patients whose diagnosis was compatible with PF or MPS.

METHODS

This study included 22 feet of 17 patients with a diagnosis compatible with PF or MPS with MTP. Participants received combination therapy with ICST for 15 sessions, and the decrease in pain was measured with an algometer and the visual analog scale. Both measurements were taken before and after every fifth session. The pressure pain threshold (PPT) results obtained with the Student t test and the pain intensity perception (PIP) results obtained with the Wilcoxon signed rank test were analyzed by comparing the measurements taken before the treatment and after the fifth, tenth, and 15th sessions.

RESULTS

The decrease in PIP was significant after the fifth, tenth, and 15th sessions ( P < .001). The increase in PPT was also significant after the fifth ( P = .010), tenth ( P = .023), and 15th ( P = .001) sessions ( P < .05).

CONCLUSIONS

The suggested combination therapy of ultrasound with ICST is clinically significant for reducing plantar pain after 15 treatment sessions, with a 6.5-point reduction in mean PIP and a 4.6-point increase in PPT.

Injected corticosteroids for treating plantar heel pain in adults

BACKGROUND

Plantar heel pain, commonly resulting from plantar fasciitis, often results in significant morbidity. Treatment options include nonsteroidal anti-inflammatory drugs (NSAIDs), orthoses, physical therapy, physical agents (e.g. extracorporeal shock wave therapy (ESWT), laser) and invasive procedures including steroid injections.

OBJECTIVES

To assess the effects (benefits and harms) of injected corticosteroids for treating plantar heel pain in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (the Cochrane Library), MEDLINE, Embase, CINAHL, clinical trials registries and conference proceedings. Latest search: 27 March 2017.

SELECTION CRITERIA

Randomised and quasi-randomised trials of corticosteroid injections in the treatment of plantar heel pain in adults were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected studies, assessed risk of bias and extracted data. We calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcome measures. We used a fixed-effect model unless heterogeneity was significant, when a random-effects model was considered. We assessed the overall quality of evidence for individual outcomes using the GRADE approach.

MAIN RESULTS

We included a total of 39 studies (36 randomised controlled trials (RCTs) and 3 quasi-RCTs) that involved a total of 2492 adults. Most studies were small (median = 59 participants). Participants' mean ages ranged from 34 years to 59 years. When reported, most participants had heel pain for several months. The trials were usually conducted in outpatient specialty clinics of tertiary care hospitals in 17 countries. Steroid injection was given with a local anaesthetic agent in 34 trials. Follow-up was from one month to over two years. With one exception, trials were assessed at high risk of bias in one or more domains, mostly relating to lack of blinding, including lack of confirmation of allocation concealment. With two exceptions, we rated the available evidence as very low quality, implying in each case that we are 'very uncertain about the estimate'.The 39 trials covered 18 comparisons, with six of the seven trials with three or four groups providing evidence towards two comparisons.Eight trials (724 participants) compared steroid injection versus placebo or no treatment. Steroid injection may lead to lower heel pain visual analogue scores (VAS) (0 to 100; higher scores = worse pain) in the short-term (< 1 month) (MD -6.38, 95% CI -11.13 to -1.64; 350 participants; 5 studies; I² = 65%; low quality evidence). Based on a minimal clinically significant difference (MCID) of 8 for average heel pain, the 95% CI includes a marginal clinical benefit. This potential benefit was diminished when data were restricted to three placebo-controlled trials. Steroid injection made no difference to average heel pain in the medium-term (1 to 6 months follow-up) (MD -3.47, 95% CI -8.43 to 1.48; 382 participants; 6 studies; I² = 40%; low quality evidence). There was very low quality evidence for no effect on function in the medium-term and for an absence of serious adverse events (219 participants, 4 studies). No studies reported on other adverse events, such as post-injection pain, and on return to previous activity. There was very low quality evidence for fewer treatment failures (defined variously as persistent heel pain at 8 weeks, steroid injection at 12 weeks, and unrelieved pain at 6 months) after steroid injection.The available evidence for other comparisons was rated as very low quality. We are therefore very uncertain of the estimates for the relative effects on people with heel pain of steroids compared with other interventions in:1. Tibial nerve block with anaesthetic (2 trials); orthoses (4 trials); oral NSAIDs (2 trials); and intensive physiotherapy (1 trial).2. Physical modalities: ESWT (5 trials); laser (2 trials); and radiation therapy (1 trial).3. Other invasive procedures: locally injectable NSAID (1 trial); platelet-rich plasma injections (5 trials); autologous blood injections (2 trials); botulinum toxin injections (2 trials); cryopreserved human amniotic membrane injection (1 trial); localised peppering with a needle (1 trial); dry needling (1 trial); and mini scalpel needle release (1 trial).We are also uncertain about the estimates from trials testing different techniques of local steroid injection: ultrasonography-guided versus palpation-guided (5 trials); and scintigraphy-guided versus palpation-guided (1 trial).An exploratory analysis involving pooling data from 21 trials reporting on adverse events revealed two ruptures of plantar fascia (reported in 1 trial) and three injection site infections (reported in 2 trials) in 699 participants allocated to steroid injection study arms. Five trials reported a total of 27 participants with less serious short-term adverse events in the 699 participants allocated steroid injection study arms. Reported treatments were analgesia, ice or both. Given the high risk of selective reporting for these outcomes and imprecision, this evidence was rated at very low quality.

AUTHORS' CONCLUSIONS

We found low quality evidence that local steroid injections compared with placebo or no treatment may slightly reduce heel pain up to one month but not subsequently. The available evidence for other outcomes of this comparison was very low quality. Where available, the evidence from comparisons of steroid injections with other interventions used to treat heel pain and of different methods of guiding the injection was also very low quality. Although serious adverse events relating to steroid injection were rare, these were under-reported and a higher risk cannot be ruled out.Further research should focus on establishing the effects (benefits and harms) of injected steroids compared with placebo in typical clinical settings, subsequent to a course of unsuccessful conservative therapy. Ideally, this should be preceded by research, including patient involvement, aimed to obtain consensus on the priority questions for treating plantar heel pain.

Sonoelastography in the Evaluation of Plantar Fasciitis Treatment: 3-Month Follow-Up After Collagen Injection

OBJECTIVE

The aim of this study was to investigate whether ultrasound elastography can demonstrate the outcome of the treatment in comparison with gray-scale imaging.

METHODS

Sixteen patients (mean age, 46.9 years) with plantar fasciitis were prospectively enrolled after unsuccessful conservative treatment. Individuals graded their heel pain on a 100-mm visual analogue scale (VAS) and underwent gray-scale ultrasonography and sonoelastography. Collagen was injected in the heels. Fascial thickness and hypoechogenicity, perifascial edema, and plantar fascial elasticity were evaluated. Follow-up sonoelastography and VAS grading were done 3 months after the injection. Statistical analyses were performed by the paired t test and the Fisher exact test. A P < 0.05 was considered statistically significant.

RESULTS

Mean plantar fascial thickness showed insignificant decrease on follow-up (from 4.30 [1.37] to 4.23 [1.15] mm, P = 0.662). Fascial hypoechogenicity and perifascial edema did not change significantly after treatment. The mean strain ratio of the plantar fascia was significantly increased (from 0.71 [0.24] to 1.66 [0.72], P = 0.001). Softening of the plantar fascia decreased significantly after injection (from 12 to 3 ft, P = 0.004). Twelve (75%) of 16 patients showed significant VAS improvement at the follow-up.

CONCLUSIONS

Sonoelastography revealed a hardening of the plantar fascia after collagen injection treatment and could aid in monitoring the improvement of the symptoms of plantar fasciitis, in cases where gray-scale imaging is inconclusive.

Chronic Plantar Fasciitis: Effect of Platelet-Rich Plasma, Corticosteroid, and Placebo

Plantar fasciitis is a common cause of heel pain. It is a disabling disease in its chronic form. It is a degenerative tissue condition of the plantar fascia rather than an inflammation. Various treatment options are available, including nonsteroidal anti-inflammatory drugs, corticosteroid injections, orthosis, and physiotherapy. This study compared the effects of local platelet-rich plasma, corticosteroid, and placebo injections in the treatment of chronic plantar fasciitis. In this double-blind study, patients were divided randomly into 3 groups. Local injections of platelet-rich plasma, corticosteroid, or normal saline were given. Patients were assessed with the visual analog scale for pain and with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle and Hindfoot score before injection, at 3 weeks, and at 3-month follow-up. Mean visual analog scale score in the platelet-rich plasma and corticosteroid groups decreased from 7.44 and 7.72 preinjection to 2.52 and 3.64 at final follow-up, respectively. Mean AOFAS score in the platelet-rich plasma and corticosteroid groups improved from 51.56 and 55.72 preinjection to 88.24 and 81.32 at final follow-up, respectively. There was a significant improvement in visual analog scale score and AOFAS score in the platelet-rich plasma and corticosteroid groups at 3 weeks and at 3-month follow-up. There was no significant improvement in visual analog scale score or AOFAS score in the placebo group at any stage of the study. The authors concluded that local injection of platelet-rich plasma or corticosteroid is an effective treatment option for chronic plantar fasciitis. Platelet-rich plasma injection is as effective as or more effective than corticosteroid injection in treating chronic plantar fasciitis.

Analysis of Pressure Pain Hypersensitivity, Ultrasound Image, and Quality of Life in Patients with Chronic Plantar Pain: A Preliminary Study

OBJECTIVES

To evaluate widespread pressure pain in patients with chronic plantar heel pain compared with that in healthy controls and to investigate the differences in ultrasound imaging and quality of life between these two groups.

METHODS

A total of 22 patients (11 female) with chronic plantar heel pain and the same number of healthy patients, matched according to age and gender, were included in this pilot study. Pressure pain thresholds (PPTs) were bilaterally assessed over the calcaneus bone, the plantar fascia, the first and fifth metatarsals, the soleus muscle, the second metacarpal, and the zygapophyseal joint of C5-C6. Plantar fascia thickness was measured via ultrasound imaging. In addition, quality of life and physical function were assessed using the Short-Form 36 (SF-36) questionnaire and the Foot and Ankle Ability Measure (FAAM) questionnaire, respectively.

RESULTS

Analysis of covariance (ANCOVA) results showed significant differences in the PPTs at all points between the groups (P < 0.001), but not between sides. The PPTs were significantly lower in the patients than in the controls at all sites (P < 0.05). The results showed significant increases in fascia thickness at the calcaneus insertion (group: F = 74.172, P ≤ 0.001; side: F = 8.920, P ≤ 0.001) and the middle fascia point (group: F = 133.685, P = <0.001; side: F = 11.414, P = <0.001) on ultrasound in the patient group compared with the matched control group. The analysis also revealed that the patient group had a significantly lower score on every subscale of the SF-36 and FAAM questionnaires (all P < 0.001), except for the mental component, compared with the matched control group.

DISCUSSION

Patients suffering from chronic plantar heel pain showed widespread and bilateral hypersensitivity, increased thickness of the plantar fascia in the affected foot, and deterioration in quality of life and physical functioning compared with matched controls.

American Medical Society for Sports Medicine (AMSSM) position statement: interventional musculoskeletal ultrasound in sports medicine

The use of diagnostic and interventional ultrasound has significantly increased over the past decade. A majority of the increased utilization is by nonradiologists. In sports medicine, ultrasound is often used to guide interventions such as aspirations, diagnostic or therapeutic injections, tenotomies, releases, and hydrodissections. This American Medical Society for Sports Medicine (AMSSM) position statement critically reviews the literature and evaluates the accuracy, efficacy, and cost-effectiveness of ultrasound-guided injections in major, intermediate, and small joints, and soft tissues, all of which are commonly performed in sports medicine. New ultrasound-guided procedures and future trends are also briefly discussed. Based upon the evidence, the official AMSSM position relevant to each subject is made.

American Medical Society for Sports Medicine position statement: interventional musculoskeletal ultrasound in sports medicine

The use of diagnostic and interventional ultrasound has significantly increased over the past decade. A majority of the increased utilization is by nonradiologists. In sports medicine, ultrasound is often used to guide interventions such as aspirations, diagnostic or therapeutic injections, tenotomies, releases, and hydrodissections. This American Medical Society for Sports Medicine (AMSSM) position statement critically reviews the literature and evaluates the accuracy, efficacy, and cost-effectiveness of ultrasound-guided injections in major, intermediate, and small joints, and soft tissues, all of which are commonly performed in sports medicine. New ultrasound-guided procedures and future trends are also briefly discussed. Based on the evidence, the official AMSSM position relevant to each subject is made.

Platelet-rich plasma injections for chronic plantar fasciopathy: a systematic review

INTRODUCTION

There is an increasing interest in platelet-rich plasma (PRP) injection as a treatment for chronic plantar fasciopathy (PF). We wished to evaluate the evidence for the use of PRP in PF/fasciitis.

SOURCES OF DATA

We performed a systematic review on the effects of PRP in PF. In June 2014, we searched Medline, Cochrane, CINAHL and Embase databases using various combinations of the commercial names of each PRP preparation and 'plantar' (with its associated terms). We only included prospectively designed studies in humans.

AREAS OF AGREEMENT

Eight articles met the inclusion criteria, three of them were randomized. All studies yielded a significantly greater improvement in symptoms between baseline and last follow-up assessment. None of the papers recorded major complications.

AREAS OF CONTROVERSY

Only three randomized studies were identified; none of them had a true controlled group treated with placebo and one of the three studies had a very short (6 week) follow-up. A non-randomized study evaluating PRP versus corticosteroids (CCS) injections, and a randomized controlled trial comparing PRP and dextrose prolotherapy reported no statistical significant differences at 6 months. Most studies did not have a control group and imaging evaluation.

GROWING POINTS AND AREAS FOR RESEARCH

Evidence for the use of PRP in PF shows promising results, and this therapy appears safe. However, the number of studies available is limited and randomized placebo-controlled studies are required. Characterizing the details of the intervention and standardizing the outcome scores would help to better document the responses and optimize the treatment.

American Medical Society for Sports Medicine (AMSSM) position statement: interventional musculoskeletal ultrasound in sports medicine

BACKGROUND

The use of diagnostic and interventional ultrasound has significantly increased over the past decade. A majority of the increased utilisation is by non-radiologists. In sports medicine, ultrasound is often used to guide interventions such as aspirations, diagnostic or therapeutic injections, tenotomies, releases and hydrodissections.

OBJECTIVE

Critically review the literature related to the accuracy, efficacy and cost-effectiveness of ultrasound-guided injections (USGIs) in major, intermediate and small joints; and soft tissues.

DESIGN

Systematic review of the literature.

RESULTS

USGIs are more accurate than landmark-guided injections (LMGIs; strength of recommendation taxonomy (SORT) Evidence Rating=A). USGIs are more efficacious than LMGIs (SORT Evidence Rating=B). USGIs are more cost-effective than LMGIs (SORT Evidence Rating=B). Ultrasound guidance is required to perform many new procedures (SORT Evidence Rating=C).

CONCLUSIONS

The findings of this position statement indicate there is strong evidence that USGIs are more accurate than LMGI, moderate evidence that they are more efficacious and preliminary evidence that they are more cost-effective. Furthermore, ultrasound-guided (USG) is required to perform many new, advanced procedures and will likely enable the development of innovative USG surgical techniques in the future.

Long-term outcome of low-energy extracorporeal shock wave therapy for plantar fasciitis: comparative analysis according to ultrasonographic findings

Objective

To investigate the long-term effect of low-energy extracorporeal shock wave therapy (ESWT) for plantar fasciitis (PF) according to ultrasonography (US) findings.

Methods

Thirty feet of 25 patients with clinical diagnosis of PF were enrolled and divided into two groups (Apparent-US and Uncertain-US) according to US findings, such as plantar fascia thickening or hypoechogenicity. Inclusion criteria were symptom duration >6 months and a fair or poor grade in Roles-Maudsley score (RMS). ESWT (0.10 mJ/mm², 600 shocks) was given once a week for 6 weeks. Numeric rating scale (NRS) and RMS were evaluated prior to each ESWT session, at short-term follow-up (one week after all ESWT sessions) and long-term follow-up telephone interview (mean 24 months after ESWT). Good and excellent grade in RMS were considered as treatment success.

Results

Repeated measure ANOVA demonstrated that NRS significantly decreased with time after ESWT up to the long-term follow-up (time effect, p<0.001) without group-time interaction (p=0.641), indicating that ESWT equally decreased pain in both groups. Overall success rate was 63.3% (short-term follow-up) and 80.0% (long-term follow-up). In comparative analysis between groups, success rate of Apparent-US and Uncertain-US at short-term follow-up was 61.9% and 66.7%, respectively, and 85.7% and 66.7%, respectively, at long-term follow-up.

Conclusion

If other causes of heel pain are ruled out through meticulous physical examination and ultrasonography, low-energy ESWT in PF seems to be beneficial regardless of US findings. In terms of success rate, however, long-term outcome of Apparent-US appears to be superior to Uncertain-US.

Application of ultrasound in the assessment of plantar fascia in patients with plantar fasciitis: a systematic review

Plantar fasciitis (PFS) is one of the most common causes of heel pain, estimated to affect 10% of the general population during their lifetime. Ultrasound (US) imaging technique is increasingly being used to assess plantar fascia (PF) thickness, monitor the effect of different interventions and guide therapeutic interventions in patients with PFS. The purpose of the present study was to systematically review previously published studies concerning the application of US in the assessment of PF in patients with PFS. A literature search was performed for the period 2000-2012 using the Science Direct, Scopus, PubMed, CINAHL, Medline, Embase and Springer databases. The key words used were: ultrasound, sonography, imaging techniques, ultrasonography, interventional ultrasonography, plantar fascia and plantar fasciitis. The literature search yielded 34 relevant studies. Sixteen studies evaluated the effect of different interventions on PF thickness in patients with PFS using US; 12 studies compared PF thickness between patients with and without PFS using US; 6 studies investigated the application of US as a guide for therapeutic intervention in patients with PFS. There were variations among studies in terms of methodology used. The results indicated that US can be considered a reliable imaging technique for assessing PF thickness, monitoring the effect of different interventions and guiding therapeutic interventions in patients with PFS.

Miniscalpel-Needle versus Steroid Injection for Plantar Fasciitis: A Randomized Controlled Trial with a 12-Month Follow-Up

Plantar fasciitis is the most common cause of heel pain in adults. A novel alternative medical instrument, the miniscalpel-needle (MSN), which is based on an acupuncture needle, has been recently developed in China. The objective of this study was to evaluate the effectiveness of the MSN release treatment versus that of traditional steroid injection for plantar fasciitis. Patients with plantar fasciitis were randomly assigned to 2 groups and followed up for 12 months, with 29 receiving MSN treatment and 25 receiving steroid injection treatment. The results showed that visual analog scale scores for morning pain, active pain, and overall heel pain all were decreased significantly in the MSN group from 1 to 12 months after treatment. In contrast, treatment with steroid injection showed a significant effect only at the 1-month follow-up but not at 6 or 12 months after treatment. Moreover, the MSN group achieved more rapid and sustained improvements than the steroid group throughout the duration of this study. No severe side effects were observed with MSN treatment. Our data suggest that the MSN release treatment is safe and has a significant benefit for plantar fasciitis compared to steroid injection.

Comparison of a physiotherapy program versus dexamethasone injections for plantar fasciopathy in prolonged standing workers: a randomized clinical trial

OBJECTIVE

To investigate the effectiveness of a physiotherapy-based exercise program versus dexamethasone injection for chronic plantar fasciopathy in workers standing for prolonged periods of time.

DESIGN

A parallel group nonblinded randomized controlled trial with 12-week follow-up.

SETTING

An outpatient sports medicine clinic in Vancouver, British Columbia, Canada.

PARTICIPANTS

Fifty-six workers required to stand for greater than 5 h/d with chronic plantar fasciopathy took part. Diagnosis from a physiotherapist must include signs of structural changes to the plantar fascia seen on ultrasound.

INTERVENTIONS

The PHYSIO group included 7 physiotherapy-led exercises performed daily over a 12-week period. The INJECTION group received 1 palpation-guided dexamethasone injection followed by a daily routine of calf stretching.

MAIN OUTCOME MEASURES

The Foot and Ankle Disability Index (FADI) scores 12-weeks postintervention and ultrasound-based measures of ligament appearance.

RESULTS

At follow-up, both groups reported significant improvements in FADI and visual analog scales for pain at work and with activities of daily living at 6 and 12 weeks compared with baseline scores (P < 0.001). There were no significant between-group differences. There were no significant changes to plantar fascia thickness reported at the 6- and 12-week follow-up point. Both the number of cases with focal anechoic areas and the size of these anechoic areas improved significantly in the PHYSIO (P = 0.003) and INJECTION (P < 0.001) groups at 12-week follow-up.

CONCLUSIONS

Workers standing for prolonged periods experienced the same short-term therapeutic effectiveness with a physiotherapy-led exercise program compared with an injection of corticosteroid with stretching.

Sonographic evaluation of hindfoot disorders

Foot pain is a common orthopedic condition that can have an impact on health-related quality of life. The evaluation of plantar hindfoot pain begins with history and physical examination. Imaging modalities, standard radiographs, sonography, MR, CT are often utilized to clarify the diagnosis. The article is a detailed description of the sonographic evaluation of the plantar fascia and its disorders as well as the common etiologies in the differential diagnosis of plantar fasciopathy.

Ultrasound- versus palpation-guided injection of corticosteroid for plantar fasciitis: a meta-analysis

BACKGROUND

It is controversial whether ultrasound-guided injection of corticosteroid is superior to palpation-guided injection for plantar fasciitis. This meta-analysis was performed to compare the effectiveness of ultrasound-guided and palpation-guided injection of corticosteroid for the treatment of plantar fasciitis.

METHODS

Databases (MEDLINE, Cochrane library and EMBASE) and reference lists were searched from their establishment to August 30, 2013 for randomized controlled trials (RCTs) comparing ultrasound-guided with palpation-guided injection for plantar fasciitis. The Cochrane risk of bias (ROB) tool was used to assess the methodological quality. Outcome measurements were visual analogue scale (VAS), tenderness threshold (TT), heel tenderness index (HTI), response rate, plantar fascia thickness (PFT), hypoechogenicity and heel pad thickness (HPT). The statistical analysis was performed with software RevMan 5.2 and Stata 12.0. When I2<50%, the fixed-effects model was adopted. Otherwise the randomized-effects model was adopted. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to assess the quality of evidence.

RESULTS

Five RCTs with 149 patients were identified and analyzed. Compared with palpation-guided injection, ultrasound-guided injection was superior with regard to VAS, TT, response rate, PFT and hypoechogenicity. However, there was no statistical significance between the two groups for HPT and HTI.

CONCLUSION

Ultrasound-guided injection of corticosteroid tends to be more effective than palpation-guided injection. However, it needs to be confirmed by further research.

Use of ultrasonography as a diagnostic and therapeutic tool in sports medicine

Ultrasonography has many important advantages over other imaging modalities and many important applications in sports medicine. This article presents an evidence-based discussion of the use of ultrasound technology to diagnose and treat common musculoskeletal disorders, with emphasis on the shoulder, elbow, hip, knee, and foot and ankle. Topics include basic principles, scan artifacts, the appearance of musculoskeletal structure characteristics and pathologies, and various diagnostic and therapeutic applications in sports medicine.

Platelet-rich plasma for the treatment of chronic plantar fasciopathy in adults: a case series

Plantar fasciopathy (PF) is a common source of pain and disability that is often refractory to conservative management. There are no uniformly effective standard-of-care treatments for chronic recalcitrant PF. Corticosteroid injection is considered a viable treatment option when traditional therapies fail, but is limited by suboptimal long-term efficacy and potential adverse effects. Platelet-rich plasma (PRP) is an emerging injection-based treatment for various chronic degenerative soft-tissue diseases. It is postulated to promote native tissue regeneration; however, consistent scientific evidence remains lacking. A prospective case series, including 24 consecutive PF cases, was conducted to report patient-rated pain and disability following PRP injection. Foot and Ankle Ability Measure (FAAM) scores were the primary clinical outcome measure. Foot-Single Assessment Numeric Evaluation (Foot-SANE) scores, Short Form-12 Health Survey version 2 (SF-12v2) questionnaires, and PRP treatment satisfaction surveys were secondary outcome measures. Statistical analysis compared baseline and 32 weeks post-injection time points. Patients receiving PRP injection reported clinically and statistically significant improvement in all outcome measures during this interval. There were no serious adverse events associated with treatment. PRP is considered a safe therapeutic option with the ability to decrease heel pain in patients with chronic PF refractory to appropriate conservative management.

Update on evidence-based treatments for plantar fasciopathy

Plantar fasciopathy, a common, painful condition of the foot, is often diagnosed by a musculoskeletal physiatrist in an outpatient practice setting. This focused review examines the most recent recommendations for the management of plantar fasciopathy in acute, subacute, and chronic phases. The evidence for treatment with various interventions is discussed, and suggestions for clinical care (along with the respective rationales for those therapies) are provided. The purpose of this review is to enable clinicians to make informed evidence-based decisions about the best available treatments for patients with any phase of plantar fasciopathy. Emerging technologies for the treatment of the condition are also addressed.

Plantar fascia calcification a sequelae of corticosteroid injection in the treatment of recalcitrant plantar fasciitis

We report the case of a 72-year-old woman suffering with severe plantar fasciitis who received a therapeutic corticosteroid injection. Two-and-a-half years after the injection she developed a small calcified lump under the skin which subsequently caused ulceration and infection. She went on to develop a diabetic foot infection requiring an extended course of intravenous antibiotics.

Sonographically guided deep plantar fascia injections: where does the injectate go?

OBJECTIVES

To determine the distribution of sonographically guided deep plantar fascia injections in an unembalmed cadaveric model.

METHODS

A single experienced operator completed 10 sonographically guided deep plantar fascia injections in 10 unembalmed cadaveric specimens (5 right and 5 left) obtained from 6 donors (2 male and 4 female) aged 49 to 95 years (mean, 77.5 years) with a mean body mass index of 23.2 kg/m(2) (range, 18.4-26.3 kg/m(2)). A 12-3-MHz linear array transducer was used to direct a 22-gauge, 38-mm stainless steel needle deep to the plantar fascia at the anterior aspect of the calcaneus using an in-plane, medial-to-lateral approach. In each case, 1.5 mL of 50% diluted colored latex was injected deep to the plantar fascia. After a minimum of 72 hours, study coinvestigators dissected each specimen to assess injectate placement.

RESULTS

All 10 injections accurately placed latex adjacent to the deep side of the plantar fascia at the anterior calcaneus. However, the flexor digitorum brevis (FDB) origin from the plantar fascia variably limited direct latex contact with the plantar fascia, and small amounts of latex interdigitated with the FDB origin in 90% (9 of 10). In all 10 specimens, latex also covered the traversing first branch of the lateral plantar nerve (FBLPN, ie, Baxter nerve) between the FDB and quadratus plantae muscles. No latex was found in the plantar fat pad or plantar fascia in any specimen.

CONCLUSIONS

Sonographically guided deep plantar fascia injections reliably deliver latex deep to the plantar fascia while avoiding intrafascial injection. However, the extent of direct plantar fascia contact is variable due to the intervening FDB. On the contrary, the traversing FBLPN is reliably covered by the injection. Deep plantar fascia injections may have a role in the management of refractory plantar fasciitis, particularly following failed superficial perifascial or intrafascial injections, in cases of preferential deep plantar fascia involvement, or when entrapment/irritation of the distal FBLPN is suspected.

The comparison of the effect of corticosteroids and platelet-rich plasma (PRP) for the treatment of plantar fasciitis

INTRODUCTION

In this study, the results of local injection of platelet-rich plasma (PRP) and corticosteroids in the treatment of plantar fasciitis were compared.

PATIENTS AND METHODS

Sixty patients who were diagnosed as plantar fasciitis and treated conservatively for at least 3 months and had no response to conservative treatment modalities were involved in this study. The first 30 consecutive patients were treated by local injection of 2 mL of 40 mg Methylprednisolone with 2 mL of 2% prilocaine (metilprednizalone) and the second 30 patients were treated by injecting 3 mL PRP after 2 mL of 2% prilocaine injection. Patients were evaluated according to the modified criteria of the Roles and Maudsley scores and visual analog scale before injection and 3 weeks and 6 months following injection.

RESULTS

The mean VAS heel pain scores measured 6 months after treatment were 3.4 in steroid group and 3.93 in PRP group, and the scores in both groups were significantly lower when compared with pretreatment levels (6.2 in steroid group and 7.33 in PRP group). There was no significant difference between steroid and PRP groups in visual analog scale scores and modified criteria of the Roles and Maudsley scores measured at 3 weeks and 6 months (P > 0.05).

CONCLUSION

Our results revealed that both methods were effective and successful in treating plantar fasciitis. When the potential complication of corticosteroid treatment was taken into consideration, PRP injection seems to be safer and at least having same effectivity in the treatment of plantar fasciitis.

The correlation between plantar fascia thickness and symptoms of plantar fasciitis

BACKGROUND

The purpose of this study was to determine whether changes in plantar fascia thickness are a reliable gauge of efficacy of treatment protocols for plantar fasciitis.

METHODS

Thirty-nine feet (30 patients) with plantar fasciitis received an ultrasound examination to measure the thickness of the medial band of the plantar fascia. Each patient assessed his or her pain using the visual analogue scale. Following various treatments, a second ultrasound examination was performed and the thickness of the plantar fascia was again measured and subjective pain level assessed.

RESULTS

Twenty-nine feet (74.4%) showed a decrease in plantar fascia thickness and a decrease in pain. One foot (2.6%) experienced an increase in fascia thickness and reported an increase in pain. Four feet (10.3%) had an increase in thickness of the plantar fascia and reported no change in pain level. Three feet had minor increases in fascia thickness but reported a decrease in pain (7.7%). One foot (2.6%) had no change in fascia thickness but a decrease in pain and one foot (2.6%) had a decrease in the plantar fascia but no change in pain level. The average reduction in fascia thickness was 0.82 mm ± 1.04 mm, correlating with an average improvement in pain of 3.64 ± 2.7 (P < 0.005).

CONCLUSIONS

This study provides evidence that changing thickness of the plantar fascia is a valid objective measurement to assess effectiveness of new or existing treatment protocols.

A comparative study of efficacy of oral nonsteroidal antiinflammatory agents and locally injectable steroid for the treatment of plantar fasciitis

OBJECTIVES

To compare the effectiveness of oral nonsteroidal antiinflammatory drugs (NSAIDs) and locally injectable steroid (methylprednisolone) in the treatment of plantar fasciitis.

MATERIALS AND METHODS

One hundred and twenty subjects with unilateral plantar fasciitis were recruited and randomly allocated to two study groups. Group I (NSAIDs group) (n=60) received oral tablet diclofenac (50 mg) and paracetamol (500 mg) twice a day (BD) along with tab. ranitidine 150 mg BD. Group II (injectable steroid group) (n=60) received injection of 1 ml of methylprednisolone (Depomedrol) (40 mg) and 2 ml of 0.5% bupivacaine into the inflammed plantar fascia. Pain intensity was measured using 10 cm visual analog scale (VAS). Subjects were evaluated clinically before, and 1 week, 2 weeks, 4 weeks, and 8 weeks (2 months) after the initiation of treatment in both the groups. The outcome was assessed in terms of VAS score and recurrence of the heel pain.

STATISTICAL ANALYSIS USED

"Z" test and Chi-square test were used wherever applicable.

RESULTS

Pain relief was significant after steroid injection (P<0.001) and the improvement was sustained. The recurrence of heel pain was significantly higher in the oral NSAIDS group (P<0.001).

CONCLUSION

Local injection of steroid is more effective in the treatment of plantar fasciitis than oral NSAIDs.

Sonographically guided corticosteroid injection for treatment of plantar fasciosis

OBJECTIVES

The purpose of this study was to prospectively investigate the effect of sonographically guided corticosteroid injection on the clinical and radiologic responses in patients with proximal plantar fasciosis.

METHODS

Thirty-one consecutive patients with unilateral plantar fasciosis were enrolled. A 4-cm 21-gauge needle was positioned in a caudocranial oblique manner, and the needle was withdrawn to the near edge of the fascia so that the solution dispersed around the edge. Two milliliters (20 mg/mL) of lignocaine/prilocaine, 1%, and 0.5 mL (20 mg) of methylprednisolone acetate solutions were injected separately. The plantar fascia and fat pad thickness, fascial echogenicity, and perifascial edema were assessed with a 10-5 MHz linear array transducer. The American Orthopedic Foot and Ankle Society midfoot scale was used to assess function, alignment, and pain. The initial radiologic and clinical measurements were compared with data obtained not less than 6 weeks after the injections.

RESULTS

A statistically significant decrease in the mean plantar fascia thickness was detected after treatment (P < .0001). There was no statistically significant difference in the plantar fascia echogenicity before and after treatment (P = .11). A statistically significant decrease was found for perifascial edema (P < .0001), and a statistically significant increase in American Orthopedic Foot and Ankle Society scores was detected (P = .0007). There was no decrease in fat pad thickness (P > .1). Plantar fascia rupture was detected in 1 patient.

CONCLUSIONS

Sonographically guided corticosteroid injection enables real-time imaging of the plantar fascia during needle insertion. A caudocranial oblique injection beneath the fascia may have an incremental value in the treatment response in patients with plantar fasciosis.

Patient information and results of training program in the treatment of plantar fasciitis

A sarokfájdalmak egyik leggyakoribb okozója a plantaris fasciitis. Kezelésére számos nem invazív eljárás ismert, amelyek gyakran nem hozzák meg a várt eredményt. Ilyen esetekben elhamarkodottan kerülhet sor helyi szteroidinfiltrációra vagy a műtéti beavatkozásra. Célkitűzés: Kidolgoztunk egy könnyen elsajátítható, otthon alkalmazható betegtájékoztató-tréning programot, melynek hatásosságát kívántuk vizsgálni a hagyományos kezelésünkkel összevetve. Módszer: A program Achilles-ín- és plantarisfascia-nyújtó, masszázs- és krioterápiás gyakorlatokat tartalmaz, cipőviselési tanácsokat nyújt, amelyet saját képanyagunkkal illusztráltunk. A betegeinket 3 különböző csoportra osztva kezeltük. Eredmények: Hathetes kezelést követően a csak iontoforézist kapott betegekhez képest lényegesen javultak a boka- és lábízületi funkciók, ezzel párhuzamosan a betegek panaszai jobban csökkentek a gyógytorna hatására. Következtetés: Az általunk kidolgozott betegtájékoztató-tréning program hasznos segítség a mindennapi ortopédiai és a háziorvosi gyakorlat számára is. Műtéti kezelés csak korrektül véghezvitt és eredménytelen konzervatív kezelés után jöhet szóba.