Plantar fasciitis: US evaluation

Plantar vein thrombosis masquerading as plantar fasciitis: A case report

Plantar vein thrombosis is an uncommon and under-diagnosed cause of plantar foot pain characterised by the formation of a blood clot (thrombus) within one of the plantar veins. There is no current diagnostic guideline for this condition however compression ultrasound and magnetic resonance imaging appear suitable. Treatments range from rest and non-steroidal anti-inflammatory drugs to six months of anticoagulant therapy. A 51-year old female was referred reporting a two-week history of left heel pain suspicious of plantar fasciitis. Ultrasonography and Magnetic Resonance Imaging showed thickening and expansion of the lateral plantar vein. The patient's symptoms disappeared following two weeks of non-steroidal anti-inflammatory medication and compression therapy, and follow-up ultrasound six weeks later showed recanalisation of the lateral plantar vein.

Plantar vein thrombosis

Plantar vein thrombosis is an uncommon and under-diagnosed cause of plantar foot pain. It is characterized by the formation of a blood clot (thrombus) within one of the plantar veins. Factors leading to this condition are unclear and multiple potential causes have been proposed. Plantar vein thrombosis presents as non-specific unilateral plantar foot pain, swelling, and a heavy feeling in the affected foot. There is no current diagnostic guideline for this condition however compression ultrasound and magnetic resonance imaging appear suitable. Treatments range from rest and non-steroidal anti-inflammatory drugs to six months of anticoagulant therapy. Herein, we aim to consolidate the current literature on plantar vein thrombosis to guide clinicians and future researchers.

Potential for foot dysfunction and plantar fasciitis according to the shape of the foot arch in young adults

This study investigated potential for foot dysfunction and plantar fasciitis according to the shape of the foot arch in young adults. Fifty-two participants were required for the present study design to achieve 80% power, 0.8 effect size (η2), and an alpha level of 0.05. This study recruited 52 young adults (30 men and 22 women). All participants voluntarily agreed to participate in the study after hearing explanations about the purpose and process of the study. They were divided into two groups of 26 according to the shape of foot with and without flat foot using the navicular drop test. The participants were measured the foot function index (FFI), range of motion (ROM) of ankle, and four-way ankle strength. Additionally, the thickness of the plantar fascia was measured using ultrasonography. Intraclass correlation coefficient (ICC) was used to verify the inter- and intrarater reliability of ultrasonography. The inter- and intrarater reliability was excellent (ICC2,1=0.88, ICC3,1=0.93). There were significant differences in dorsi-flexion of ankle ROM, FFI, dorsi-flexion and eversion of ankle strength, and the thickness of the plantar fascia between the two groups (P<0.05). Based on the results, the group with flat foot may gradually generate potential of the foot dysfunction and plantar fasciitis. Therefore, the interventions are necessary to improve the foot dysfunction and plantar fasciitis in people with flat foot.

Plantar fascia softening in plantar fasciitis with normal B-mode sonography

OBJECTIVE

To investigate plantar fascia elasticity in patients with typical clinical manifestations of plantar fasciitis but normal plantar fascia morphology on B-mode sonography.

MATERIALS AND METHODS

Twenty patients with plantar fasciitis (10 unilateral and 10 bilateral) and 30 healthy volunteers, all with normal plantar fascia morphology on B-mode sonography, were included in the study. Plantar fascia elasticity was evaluated by sonoelastographic examination. All sonoelastograms were quantitatively analyzed, and less red pixel intensity was representative of softer tissue. Pixel intensity was compared among unilateral plantar fasciitis patients, bilateral plantar fasciitis patients, and healthy volunteers by one-way ANOVA. A post hoc Scheffé's test was used to identify where the differences occurred.

RESULTS

Compared to healthy participants (red pixel intensity: 146.9 ± 9.1), there was significantly less red pixel intensity in the asymptomatic sides of unilateral plantar fasciitis (140.4 ± 7.3, p = 0.01), symptomatic sides of unilateral plantar fasciitis (127.1 ± 7.4, p < 0.001), and both sides of bilateral plantar fasciitis (129.4 ± 7.5, p < 0.001). There were no significant differences in plantar fascia thickness or green or blue pixel intensity among these groups.

CONCLUSION

Sonoelastography revealed that the plantar fascia is softer in patients with typical clinical manifestations of plantar fasciitis, even if they exhibit no abnormalities on B-mode sonography.

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.

Sonoelastography: musculoskeletal applications

All participants for image samplings provided written informed consent. Conventional B-mode ultrasonography (US) has been widely utilized for musculoskeletal problems as a first-line approach because of the advantages of real-time access and the relatively low cost. The biomechanical properties of soft tissues reflect to some degree the pathophysiology of the musculoskeletal disorder. Sonoelastography is an in situ method that can be used to assess the mechanical properties of soft tissue qualitatively and quantitatively through US imaging techniques. Sonoelastography has demonstrated feasibility in the diagnosis of cancers of the breast and liver, and in some preliminary work, in several musculoskeletal disorders. The main types of sonoelastography are compression elastography, shear-wave elastography, and transient elastography. In this article, the current knowledge of sonoelastographic techniques and their use in musculoskeletal imaging will be reviewed.

Spontaneous plantar vein thrombosis: state of the art

We aim here to highlight the importance of diagnosing and treating promptly the rarely thought of diagnosis of plantar vein thrombosis. We hereby report two cases with no known thrombotic risk factors. Less than 20 cases are reported in the literature. Detection of this unusual site of involvement of the deep venous system can be easily made by ultrasound examination if searched for. Plantar vein thrombosis is a rarely evoked pathology. Knowledge of its occurrence could further improve its diagnosis especially that it could reveal an unknown neoplasia or coagulation abnormality.

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.

Ultrasonography of the lower extremity

Ultrasonography is a useful imaging tool for various soft tissue and joint pathologies affecting the lower extremity. This article reviews the normal sonographic appearance of muscles, tendons, ligaments, nerves, bone, and cartilage. The ultrasound imaging appearance of various pathologic conditions affecting the hip, thigh, knee, lower leg, ankle,and foot are illustrated. The advantages of ultrasonography are highlighted.

Power Doppler findings in plantar fasciitis

The study was performed to characterize the power Doppler ultrasonographic (PDU) findings in plantar fasciitis using a 7.5 MHz linear transducer. Both feet of 20 patients who had a clinical and ultrasound (US) diagnosis of unilateral plantar fasciitis were evaluated with PDU. The pain level was assessed with a visual analogue scale (VAS). A total of 20 healthy volunteers were evaluated as a control group. Moderate or marked hyperemia was found in PDU in the plantar fascia and the surrounding soft tissue along the first cm distally from the insertion in 8 (40%) of the 20 symptomatic heels and in 1 patient (5%) on the asymptomatic side. Moderate or marked hyperemia was associated with a history of less than 6 months and high pain levels. The difference between both groups was significant (p < 0.05). PDU improves the value of US as a noninvasive technique for the diagnosis of plantar fasciitis, providing additional information on local hyperemia.

Ultrasonographic appearance of the plantar fasciitis

PURPOSE

To study high frequency sonographic in the examination of plantar fasciitis (PF), which is a common cause of heel pain.

MATERIALS AND METHODS

Our study was done with 25 PF (21 unilateral, 4 bilateral) and 15 control cases of similar age, weight and gender. In this study, the plantar fascial thickness (mainly), fascial echogenity and biconvexity were examined using 7.5 MHz linear phase array transducer. Perifascial fluid collection, fascial rupture and fascial calcification that are rarely seen were also examined.

RESULTS

The fascial thickness ranges for the PF cases: for the symptomatic heels: 3.9-9.1 mm (mean: 4.75 +/- 1.52 mm), for the asymptomatic heels: 2.0-5.9 mm (mean: 3.37 +/- 1.0 mm) and for the control group: 2.1-4.7 mm (3.62 +/- 0.68 mm). The results were significantly different in Group I for symptomatic heels and the control group statistically for PF (P < .05). The echogenity of plantar fascia and biconvexity of plantar fascia were the major criteria for symptomatic heels. In three heels (10%), perifascial fluid was diagnosed, in three heels (10%) fascial calcification, in one heel (3%) partial fascial rupture. Subcalcaneal spur was encountered sonographically in both cases of Groups I and II.

CONCLUSION

Ultrasonography (US) is the first step for PF, because of its easy and quick performance, availability and high sensitivity of diagnosis, low-cost and free radiation.

The value of ultrasound in sports medicine

Musculoskeletal ultrasound is increasingly being used in the evaluation and treatment of sports-related injuries. This technique is widely available, rapid, and has a high patient acceptance. Its multiplanar capability and dynamic real-time imaging can be correlated with clinical symptoms and compared to contralateral asymptomatic structures.

Ultrasound evaluation of plantar fasciitis

OBJECTIVE

To investigate the sonographic features of plantar fasciitis (PF).

METHODS

High-resolution ultrasound was used to measure the thickness and echogenicity of the proximal plantar fascia and associated heel pad thickness for 102 consecutive patients with PF (unilateral: 81, bilateral: 21) and 33 control subjects.

RESULTS

The mean thickness of the plantar fascia was greater on the symptomatic side for patients with bilateral and unilateral PF than on the asymptomatic side for patients with unilateral PF, and also control subjects (5.47+/-1.09, 5.61+/-1.19, 3.83+/-0.72, 3.19+/-0.43 mm, respectively, p<0.001). A substantial difference in thickness between the asymptomatic side of patients with unilateral PF and control subjects was also noted (p=0.001). The heel pad thickness was not show different between control subjects and patients with PF. The incidence of hypoechoic fascia was 68.3% (84/123). Other findings among the patients from our test group included intratendinous calcification (two cases), the presence of perifascial fluid (one case), atrophic heel pads (one case), and the partial rupture of plantar fascia (one case).

CONCLUSION

Increased thickness and hypoechoic plantar fascia are consistent sonographic findings in patients exhibiting PF. These objective measurements can provide sufficient information for the physician to confirm an initial diagnosis of PF and assess individual treatment regimens.

Treatment of proximal plantar fasciitis with ultrasound-guided steroid injection

OBJECTIVE

To investigate the efficacy of ultrasound-guided steroid injection for the treatment of proximal plantar fasciitis and to evaluate mechanical properties of the heel pad after steroid injection.

DESIGN

Proximal plantar fascia and heel pad were assessed with a 10-MHz linear array ultrasound transducer. Pain intensity was quantified with a tenderness threshold (TT) and visual analog scale (VAS). The transducer was incorporated into a specially designed device to measure mechanical properties of the heel pad. Evaluations were performed before injection and at 2 weeks and 3 months after injection.

SETTING

An outpatient clinic of a tertiary care center.

PATIENTS

Fourteen consecutive patients with unilateral proximal plantar fasciitis.

INTERVENTION

Ultrasound-guided injection of 7 mg betamethasone and 0.5 mL of 1% lidocaine into the inflamed proximal plantar fascia.

MAIN OUTCOME MEASURES

VAS, TT, heel pad and plantar fascia thickness, and echogenicity of the proximal plantar fascia on sonogram were assessed. Mechanical properties included unloaded heel pad thickness, compressibility index, and energy dissipation ratio.

RESULTS

Both VAS score +/- standard deviation (SD; 5.43 +/- 2.03, 1.39 +/- 2.19, 0.57 +/- 1.40 at the 3 measurements, respectively) and TT +/- SD (5.05 +/- 1.42, 9.34 +/- 1.84, 9.93 +/- 1.98 kg/cm2 at the 3 measurements, respectively) improved significantly (p < .001) after steroid injection. The mean thickness of the plantar fascia was greater in the symptomatic side than in the asymptomatic side before treatment (0.58 +/- 0.13 cm vs 0.40 +/- 0.11 cm, p < .001). The thickness had decreased significantly 3 months after injection (0.46 +/- 0.12 cm at 2 weeks, 0.42 +/- 0.10 cm at 3 months, p < .001). The hypoechogenicity at the proximal plantar fascia disappeared after steroid injection (p < .001). Mechanical properties of the heel pad did not change 3 months after steroid injection (p > .05).

CONCLUSION

Ultrasound offers an objective measurement of the therapeutic effect on proximal plantar fasciitis. Accurate steroid injection under ultrasound guidance can effectively treat proximal plantar fasciitis without significant deterioration of the mechanical properties of the heel pads.

Ultrasound in inflammatory disease

US may be used effectively to diagnose and treat a wide range of musculoskeletal inflammatory conditions. It is likely that its usage will increase with regards to such conditions especially in the management of rheumatology clinic patients.

Foot and ankle sonography

Sonography of the foot and ankle offers many advantages. Currently, sonographic evaluation rivals or exceeds MR imaging for evaluation of tendons, joint and bursal pathology, and specific soft tissue pathology. The advantages of sonographic evaluation provide a strong impetus for applying this modality to imaging of foot and ankle pathology. Those who accept the challenge will have an expanded repertoire to offer in the pursuit of efficient and effective patient care.