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

Common foot and ankle disorders in pregnancy: the role of diagnostic ultrasound

Foot and ankle disorders are common during pregnancy, driven by significant physiological changes including weight distribution, hormonal fluctuations, and fluid balance. These changes often result in conditions such as varicose veins, thrombophlebitis, deep vein thrombosis (DVT), edema, overpronation, ankle sprains, metatarsalgia, stress fractures, ligament tears, synovitis, tendon tears, tenosynovitis, paratenonitis, plantar fasciitis, and Morton's neuroma. This paper emphasizes the diagnostic utility of ultrasound for these conditions, given its safety, non-invasiveness, and real-time imaging capabilities without ionizing radiation. Ultrasound is particularly effective for diagnosing venous disorders like varicose veins and thrombophlebitis, leveraging Doppler ultrasound to assess vein structure and function. It is also instrumental in identifying DVT, detecting vein dilation, reflux, and thrombosis. For conditions such as edema, ultrasound helps differentiate physiological from pathological causes, ensuring accurate diagnosis and management. In cases of musculoskeletal issues like overpronation, ankle sprains, ligament tears, and tendon pathologies, ultrasound provides detailed images of soft tissues, allowing for precise diagnosis and effective treatment planning. It is equally useful for detecting metatarsalgia, plantar fasciitis, and Morton's neuroma, offering insights into soft tissue abnormalities and guiding therapeutic interventions. Ultrasound's role extends to diagnosing foreign bodies in the foot and ankle, where it demonstrates high sensitivity and specificity. The accessibility and cost-effectiveness of ultrasound make it an invaluable tool in various healthcare settings, ensuring timely and accurate diagnosis and management of foot and ankle disorders during pregnancy, ultimately enhancing patient outcomes and quality of life.

Ultrasound-guided procedures for plantar fasciitis: a randomized clinical study

BACKGROUND

Corticosteroid injections are commonly used for the treatment of plantar fasciitis. In recent years, ultrasound-guided multipuncture treatment of the fascia has been described in the literature. Our study aimed to compare the effectiveness of these two techniques in the treatment of plantar fasciitis.

METHODS

The outcomes achieved over 120 days following the use of these techniques to treat plantar fasciitis were examined. A total of 81 patients were randomly selected for the study; 41 were treated with ultrasound-guided multipuncture and 40 with ultrasound-guided corticosteroid injection. Clinical examinations and ultrasound assessments were performed before treatment and at 30, 60 and 120 days post-treatment. Clinical assessments included the use of a visual analog scale (VAS) to record pain and the Foot Function Index (FFI) to evaluate function. Ultrasound was used to measure the thickness of the plantar fascia.

RESULTS

Both the ultrasound-guided multipuncture and corticosteroid injection techniques were associated with significant functional and echographic improvements at 4 months post-treatment (P < 0.001). Pain did not improve significantly after 120 days with ultrasound-guided corticosteroid injection, whereas significant pain reduction was observed with ultrasound-guided multipuncture.

CONCLUSION

Corticosteroid injection provides better short-term results in terms of VAS pain and FFI scores. However, ultrasound-guided multipuncture shows superior outcomes in VAS pain and FFI scores at 120 days.

Plantar Fasciitis: An Updated Review

Plantar fasciitis (PF) is a common musculoskeletal disease. Histologic findings of patients with PF showed mainly chronic degenerative processes rather than inflammation. In addition to mechanical factors, such as repetitive stress and reduced ankle dorsiflexion, PF is also linked to rheumatologic diseases and genetic factors. Ultrasound is becoming a standard imaging technique for assessing PF. Major sonographic findings included increased plantar fascia thickness and hypoechoic plantar fascia. In addition to traditional B-mode ultrasound, sonoelastography can also be utilized to diagnose PF. Ultrasound can also be used to guide therapeutic interventions. Over 80% of patients with PF improved under nonsurgical treatment. Treatment options for PF include physical therapy, modalities (laser, therapeutic ultrasound), extracorporeal shock wave therapy (ESWT), injections, transcatheter arterial embolization, and surgery. For injections, corticosteroid was mostly used in the past but has been replaced gradually by other techniques such as platelet-rich plasma or dextrose prolotherapy. There is also more and more evidence about ESWT in treating PF. Surgery serves as an option for recalcitrant PF cases, and endoscopic fasciotomy seemed to have good outcomes. Ultrasound plays an important role in diagnosing of PF and evaluating the treatment effect, and the use of sonoelastography in addition to traditional B-mode ultrasound may help in the early detection of PF and assessment of the treatment effect.

Comparison of the Effect of Ultrasound-Guided Injection of Botulinum Toxin Type A and Corticosteroid in the Treatment of Chronic Plantar Fasciitis: A Randomized Controlled Trial

OBJECTIVE

The aim of the study was to compare the efficacy of ultrasound-guided injection of botulinum toxin type A with corticosteroid in patients with chronic plantar fasciitis (PF).

DESIGN

This randomized controlled trial was conducted on 35 patients with chronic plantar fasciitis. Participants were randomly allocated into two groups: one group received methylprednisolone in to the plantar fascia ( n = 18) and the other group received botulinum toxin type A injection into the flexor digitorum brevis and quadratus plantae ( n = 17). All injections were performed under ultrasound guidance. Patients were evaluated using the Visual Analog Scale, Foot and Ankle Ability Measures, and plantar fascia thickness before the intervention, 3 wks, 12 wks, and 6 mos after the treatment.

RESULTS

In both groups, patients' pain and function improved significantly up to 3 wks after injection. In the botulinum toxin type A group, morning Visual Analog Scale improved significantly at 12 wks after intervention and the improvement was sustained for another 3 mos. In the botulinum toxin type A group, Foot and Ankle Ability Measures-sports subscale improved in all evaluated points, whereas in the corticosteroid group, the improvement was significant only when comparing follow-ups values to baseline.

CONCLUSIONS

Both ultrasound-guided botulinum toxin type A and corticosteroid injection were effective in the treatment of plantar fasciitis. Our study showed that the effects of botulinum toxin type A injection last longer than those of steroid injection.

Ultrasonographic Evaluation of the Femoral Cartilage, Achilles Tendon, and Plantar Fascia in Young Women Wearing High-Heeled Shoes

BACKGROUND

Specific attention on the musculoskeletal impact of wearing high-heeled shoes (HHS) has mainly focused on knee osteoarthritis and the literature is limited to biomechanical changes. The distal femoral cartilage has not been morphologically studied. Additionally, although heel elevation is coupled with a shear stress at the heel and overloaded calf muscles, Achilles tendon (AT) and plantar fascia (PF) thicknesses have not been assessed either.

OBJECTIVE

To investigate whether the distal femoral cartilage, AT, and PF were different in women wearing HHS and flat-heeled shoes (FHS) and specifically, different in terms of AT/PF and distal femoral cartilage thicknesses.

DESIGN

Cross-sectional observational study.

SETTING

Tertiary care center.

PARTICIPANTS

There were 34 women (mean age; 31.1 ± 6.4, body mass index [BMI]; 21.6 ± 2.4 kg/m² ) in the HHS group and 54 women (mean age; 29.5 ± 7.2 years, BMI 22.5 ± 2.9 kg/m² ) in the FHS group (P = .271, P = .102, respectively). Women wearing shoes with a heel height of >5 cm were enrolled in the HHS group, and those wearing shoes with a heel height of <1.4 cm were included in the FHS group.

MAIN OUTCOME MEASUREMENTS

Distal femoral cartilage from the lateral condyle, intercondylar area and medial condyle (MFC), AT and PF thicknesses, and any abnormalities were evaluated bilaterally by ultrasound.

RESULTS

Within-group comparisons yielded thicker right MFC (P = .022) and left AT (P = .028) only in the HHS group. Between-group comparisons yielded thicker left AT in the HHS group (P = .040). PF thicknesses were similar both within and between group comparisons (all P > .05). Right AT thickness was positively correlated with right (r = .469, P = .005) and left (r = .402, P = .018) PF thicknesses only within the HHS group. Only calcaneal irregularity/spur was found to be common in the HHS group (P = .038).

CONCLUSIONS

We found thickening of the right MFC and left AT in those wearing HHS, whereas PF thickness was not significantly different between those wearing HHS and those wearing FHS.

LEVEL OF EVIDENCE

III.

Preliminary Report on the Role of Dry Needling Versus Corticosteroid Injection, an Effective Treatment Method for Plantar Fasciitis: A Randomized Controlled Trial

Plantar fasciopathy (PF) is a common disorder for which there is no consensus regarding an optimal treatment strategy. We hypothesized that dry needling would be as effective as the use of corticosteroid injections for treating PF while avoiding the potential adverse effects of corticosteroids. After approval was received from the institutional review board, patients diagnosed with PF were prescribed a 3-week nonoperative treatment regimen. In addition to using oral and topical antiinflammatory drugs, patients engaged in plantar fascia and gastrocnemius stretching exercises. A study population of 98 patients was planned. An appointment was made in the third week of first-line treatment. Patients whose pain did not abate and who required further treatment were included in the study. One week later, we randomly divided patients into 2 groups using an online random number generator. Group 1 underwent dry needling, and group 2 underwent corticosteroid injection. All dry needling was performed by a single physiotherapist, and all corticosteroid injections were performed by the second author. Patients were assessed in the third week and sixth month by a single investigator using the foot function index. In terms of foot function index scores, dry needling caused significant decrease in the third week and also in the sixth month. However, although corticosteroid use led to a significant decrease at the third week, it lost efficacy in the sixth month (p < .001). In conclusion, dry needling seems to be a reliable procedure for treating PF, with better outcomes than corticosteroid injection.

Corticosteroid injection is the best treatment in plantar fasciitis if combined with controlled training

PURPOSE

Plantar fasciitis is a very common (lifetime incidence ~ 10%) and long-lasting injury with major impact on daily function. Combining corticosteroid injection and physical training (strength training and stretching) was hypothesized to result in a superior effect compared to each treatment separately.

METHODS

A single blinded randomized controlled superiority trial conducted in 2013-2014 with a 2-year follow-up (end Sept 2016). 123 consecutive patients (20-65 years) referred to two study centers in Denmark: Institute of Sports Medicine, Bispebjerg Hospital, University of Copenhagen and a private rheumatology clinic with symptoms of plantar fasciitis, and ultrasound measured thickness above 4.0 mm were invited. 25 did not fulfill the inclusion criteria (mainly ultrasound criteria) and 8 refused participation. 90 patients were randomized (pulling sealed envelopes) to 3 groups: (1) 3 months strength training and stretching (n = 30), (2) corticosteroid injections with monthly intervals until thickness < 4.0 mm (maximum 3 injections) (n = 31), (3) combination of the two treatments (n = 29). During the 3 months intervention period load reduction was recommended (cushioning shoes and insoles and abstaining from running and jumping). The main outcome was improvement in Pain at function on a 100-mm VAS score and in Foot Function Index (FFI, range 0-230) at 6 months (Clinicaltrials.gov Identifier: NCT01994759).

RESULTS

All groups improved significantly over time, but the combination of corticosteroid injection and training (strength training and stretching) had a superior effect at all time points. The mean difference between the combined treatment and training was 40 points in FFI (95% confidence interval (CI) 63-17 points, p < 0.001) and 20 mm for VAS function pain (CI 35-5 mm, p < 0.01). The mean difference between the combined treatment and corticosteroid injections only was 29 points in FFI (CI 52-7 points, p < 0.01) and 17 mm for VAS function pain (CI 32-2 mm, p < 0.05). All differences were clinically relevant.

CONCLUSION

The best treatment for plantar fasciitis is the combination of corticosteroid injections and training (strength training and stretching). This combined treatment is superior both in the short- and in the longterm. Corticosteroid injections combined with controlled training are recommended as first line treatment in patients with plantar fasciitis.

LEVEL OF EVIDENCE

1.