Association between plantar fascia vascularity and morphology and foot dysfunction in individuals with chronic plantar fasciitis

The Importance of Preconditioning for the Sonographic Assessment of Plantar Fascia Thickness and Shear Wave Velocity

Plantar fasciopathy is a very common musculoskeletal complaint that leads to reduced physical activity and undermines the quality of life of patients. It is associated with changes in plantar fascia structure and biomechanics which are most often observed between the tissue's middle portion and the calcaneal insertion. Sonographic measurements of thickness and shear wave (SW) elastography are useful tools for detecting such changes and guide clinical decision making. However, their accuracy can be compromised by variability in the tissue's loading history. This study investigates the effect of loading history on plantar fascia measurements to conclude whether mitigation measures are needed for more accurate diagnosis. The plantar fasciae of 29 healthy participants were imaged at baseline and after different clinically relevant loading scenarios. The average (±standard deviation) SW velocity was 6.5 m/s (±1.5 m/s) and it significantly increased with loading. Indicatively, five minutes walking increased SW velocity by 14% (95% CI: -1.192, -0.298, t(27), p = 0.005). Thickness between the calcaneal insertion and the middle of the plantar fascia did not change with the tissues' loading history. These findings suggest that preconditioning protocols are crucial for accurate SW elastography assessments of plantar fasciae and have wider implications for the diagnosis and management of plantar fasciopathy.

Clinical Efficacy of Application-Linked Stretching Ball as Digital Therapeutics in Plantar Fasciitis

Background/Objectives: This study aimed to evaluate the efficacy of application-linked stretching ball instruments that record the rolling time and force of patients compared with a traditional simple stretching ball. Methods: Fourteen participants with plantar fasciitis were divided into a simple massage ball group (group A, n = 8) and an application-linked massage ball group (group B, n = 6). The application-linked massage ball sends information regarding the massages, such as the frequency and force of the massage on the foot, to the application on the patient's smartphone. All clinical outcomes were evaluated at the beginning of the study and 1-, 2-, and 3-month follow-up. The primary outcome measure was the Manchester-Oxford Foot Questionnaire (MOXFQ) score. Results: At the beginning of the study, the initial MOXFQ score was not significantly different between the two groups (p = 0.948). At each time point, the MOXFQ score of the whole population did not improve significantly compared to that of the initial state (p = 0.131). Generalized estimating equation modeling demonstrated that there was no significant difference in the improvement of the MOXFQ score between groups A and B during follow-up (p = 0.826). In addition, no group-by-time interactions were observed (p = 0.457). Conclusions: The efficacy of an application-linked massage ball for the treatment of plantar fasciitis was not as definite as that of a traditional simple stretching ball in patients whose symptoms persisted for at least six months. Future studies that include patients with acute plantar fasciitis are required.

Functional Morphologic Changes of the Heel Fat Pad and Plantar Fascia in Patients With Heel Pain During Weightbearing and Nonweightbearing

Background

This study aimed to investigate the thickness changes of the heel fat pad and the plantar fascia associated with loading and unloading in healthy individuals and patients with heel pain and reveal the differences between them.

Methods

The study included adult male participants with (n = 9) and without (n = 26) heel pain. The participants placed their right foot on an evaluation apparatus with a polymethylpentene resin board (PMP), while their left foot was positioned on a weighing scale used to adjust the loading weight. The heel fat pad was differentiated into superficial Microchamber and deep Macrochamber layers. These layers and plantar fascia thickness were measured using an ultrasonographic imaging device at loading phase ranging from 0% to 100% of their body weight and unloading phase from 100% to 0%. Additionally, the study examined the thickness change ratios of the superficial and deep heel fat pad layers when the load increased from 0% (unload) to 100% (full load).

Results

In healthy individuals and patients with heel pain, no significant thickness changes were observed in the Microchamber layer of the heel fat pad or the plantar fascia during loading and unloading evaluations. However, significant thickness changes were observed in the Macrochamber layer of the heel fat pad, and the pattern of change differed between the loading and unloading phases. Additionally, patients with heel pain showed differences in the thickness change and thickness change ratios of the microchamber and macrochamber layers of the heel fat pad during both loading and unloading phases. The thickness of the plantar fascia did not show significant differences between both groups.

Conclusion

Compared with healthy individuals, in our relatively small study, patients with heel pain had greater deep fat pad compression in loading and less recovery after load removal. This finding suggests that these patients have different intrinsic fat pad function and related morphology than those without heel pain.

Level of Evidence

Level III, retrospective cohort study.

Evaluation of the efficacy of trigger points combined with extracorporeal shock waves in the treatment of plantar fasciitis: heel temperature and plantar pressure

BACKGROUND

Plantar fasciitis (PF) is the most common cause of heel pain. Among conservative treatments, extracorporeal shock wave therapy (ESWT) is considered effective for refractory PF. Studies have shown that applying ESWT to the trigger points (TrPs) in the triceps surae may play an important role in pain treatment in patients with PF. Therefore, the purpose of this study was to combine the concept of trigger points and ESWT to explore the effect of this combination on plantar temperature and pressure in patients with PF.

METHODS

After applying inclusion and exclusion criteria, 86 patients with PF were recruited from the pain clinic of Huadong Hospital, Fudan University and randomly divided into experimental (n = 43) and control groups (n = 43). The experimental group was treated with extracorporeal shock waves to treat the medial heel pain point and the gastrocnemius and soleus TrPs. The control group was only treated with extracorporeal shock waves at the medial heel pain point. The two groups were treated twice with an interval of 1 week. Primary measurements included a numerical rating scale (NRS) score (overall, first step, heel pain during daily activities), and secondary measurements included heel temperature, Roles-Maudsley score (RMS), and plantar pressure. All assessments were performed before treatment (i.e., baseline) and 6 and 12 weeks after treatment.

RESULTS

During the trial, 3 patients in the experimental group withdrew from the study, 2 due to interruption of the course of treatment by the COVID-19 epidemic and 1 due to personal reasons. In the control group, 3 patients fell and were removed due to swelling of the heel. Therefore, only 80 patients with PF were finally included. After treatment, the two groups showed good results in NRS score (overall, first step, heel pain during daily activities), RMS, and plantar temperature, especially in the experimental group, who showed a significantly better effect than the control group.

CONCLUSION

ESWT of the heel combined with the triceps trigger point of the calf can more effectively improve the pain, function and quality of life of refractory PF than ESWT of the heel alone. In addition, ESWT of the heel combined with the triceps trigger point of the calf can effectively reduce the skin temperature of the heel on the symptomatic side, indicating that the heel temperature as measured by infrared thermal imaging may be used as an independent tool to evaluate the therapeutic effect for patients with chronic PF. Although extracorporeal shock waves combined with TrPs treatment can cause changes in the patients' gait structure, plantar pressure is still difficult to use as an independent tool to evaluate the therapeutic effect for PF.

TRIAL REGISTRATION

Registered in the Chinese Clinical Trial Registry ( www.chictr.org.cn ) on 12/17/2021 with the following code: ChiCTR-INR-2,100,054,439.

Early outcomes of transcatheter arterial embolization using imipenem/cilastatin for plantar fasciitis refractory to conservative therapy

OBJECTIVE

The conservative therapy for chronic plantar fasciitis works for a few patients, while surgical options have drawbacks. Before considering surgical options, transcatheter arterial embolization may help patients with plantar fasciitis who are experiencing discomfort resistant to conservative treatment.

METHODS

We report evaluation data of 10 patients treated with transcatheter arterial embolization using imipenem/cilastatin as embolic agents to relieve chronic pain due to plantar fasciitis. All the patients were refractory to conservative therapy.

RESULTS

The technical success of the procedure was found to be 100%. Further, effective pain relief was observed as there was no pain relapse in 6 months, and patients did not require any other form of therapy.

CONCLUSION

This report warrants further adequately designed randomized clinical studies for evaluating the efficacy of transcatheter arterial embolization in plantar fasciitis.

ADVANCES IN KNOWLEDGE

Resorting to surgical option for chronic pain relief in plantar fasciitis might be reconsidered and replaced with arterial embolization. However, adequately designed long-term clinical studies are required to prove its long-term efficacy.

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.

Rat Plantar Fascia Stem/Progenitor Cells Showed Lower Expression of Ligament Markers and Higher Pro-Inflammatory Cytokines after Intensive Mechanical Loading or Interleukin-1β Treatment In Vitro

The pathogenesis of plantar fasciitis is unclear, which hampers the development of an effective treatment. The altered fate of plantar fascia stem/progenitor cells (PFSCs) under overuse-induced inflammation might contribute to the pathogenesis. This study aimed to isolate rat PFSCs and compared their stem cell-related properties with bone marrow stromal cells (BMSCs). The effects of inflammation and intensive mechanical loading on PFSCs' functions were also examined. We showed that plantar fascia-derived cells (PFCs) expressed common MSC surface markers and embryonic stemness markers. They expressed lower Nanog but higher Oct4 and Sox2, proliferated faster and formed more colonies compared to BMSCs. Although PFCs showed higher chondrogenic differentiation potential, they showed low osteogenic and adipogenic differentiation potential upon induction compared to BMSCs. The expression of ligament markers was higher in PFCs than in BMSCs. The isolated PFCs were hence PFSCs. Both IL-1β and intensive mechanical loading suppressed the mRNA expression of ligament markers but increased the expression of inflammatory cytokines and matrix-degrading enzymes in PFSCs. In summary, rat PFSCs were successfully isolated. They had poor multi-lineage differentiation potential compared to BMSCs. Inflammation after overuse altered the fate and inflammatory status of PFSCs, which might lead to poor ligament differentiation of PFSCs and extracellular matrix degeneration. Rat PFSCs can be used as an in vitro model for studying the effects of intensive mechanical loading-induced inflammation on matrix degeneration and erroneous stem/progenitor cell differentiation in plantar fasciitis.

Effects of radial extracorporeal shockwave therapy versus high intensity laser therapy in individuals with plantar fasciitis: A randomised clinical trial

This study aimed to compare the effects of radial extracorporeal shockwave therapy (rESWT) to the effects of high-intensity laser therapy (HILT) in the treatment of individuals with plantar fasciitis. Thirty-two individuals with unilateral plantar fasciitis were randomized into two groups: rESWT and HILT. In each group, the individuals underwent the intervention two sessions per week, for three weeks. Outcome measures included morning pain, resting pain, pain at 80 newtons (N) pressure, skin blood flow and temperature, plantar fascia (PF) and flexor digitorum brevis (FDB) thickness, and Foot Function Index (FFI). There was no significant difference in baseline characteristics of the individuals in both groups. All outcome measures, except skin blood flow and temperature, and FDB thickness, were significantly different (p < 0.05) over time. Skin blood flow was significantly different between groups at the end of the program. Either HILT or rESWT could alleviate pain in individuals with plantar fasciitis significantly. However, HILT was better at reducing FFI (functional limitation domain) rather than rESWT. This study was a randomized clinical trial and was approved by Mahidol University-Central Institutional Review Board (MU-CIRB) following the Declaration of Helsinki, COA no. MU_CIRB 2020/207.0412, the Thai Clinical Trials Registry (TDTR) numbered TCTR2021012500.

Medical imaging for plantar heel pain: a systematic review and meta-analysis

Background

Medical imaging can be used to assist with the diagnosis of plantar heel pain. The aim of this study was to synthesise medical imaging features associated with plantar heel pain.

Methods

This systematic review and meta-analysis conducted searches in MEDLINE, CINAHL, SPORTDiscus, Embase and the Cochrane Library from inception to 12th February 2021. Peer-reviewed articles of cross-sectional observational studies written in English that compared medical imaging findings in adult participants with plantar heel pain to control participants without plantar heel pain were included. Study quality and risk of bias was assessed using the National Institutes of Health quality assessment tool for observational cohort and cross-sectional studies. Sensitivity analyses were conducted where appropriate to account for studies that used unblinded assessors.

Results

Forty-two studies (2928 participants) were identified and included in analyses. Only 21% of studies were rated ‘good’ on quality assessment. Imaging features associated with plantar heel pain included a thickened plantar fascia (on ultrasound and MRI), abnormalities of the plantar fascia (on ultrasound and MRI), abnormalities of adjacent tissue such as a thickened loaded plantar heel fat pad (on ultrasound), and a plantar calcaneal spur (on x-ray). In addition, there is some evidence from more than one study that there is increased hyperaemia within the fascia (on power Doppler ultrasound) and abnormalities of bone in the calcaneus (increased uptake on technetium-99 m bone scan and bone marrow oedema on MRI).

Conclusions

People with plantar heel pain are more likely to have a thickened plantar fascia, abnormal plantar fascia tissue, a thicker loaded plantar heel fat pad, and a plantar calcaneal spur. In addition, there is some evidence of hyperaemia within the plantar fascia and abnormalities of the calcaneus. Whilst these medical imaging features may aid with diagnosis, additional high-quality studies investigating medical imaging findings for some of these imaging features would be worthwhile to improve the precision of these findings and determine their clinical relevance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-021-00507-2.

Intra-arterial Infusion of Temporary Embolic Material in a Patient with Plantar Fasciitis: A Case Report

This case report concerns a 51-year-old woman with a 6-month history of severe right heel pain diagnosed as plantar fasciitis (PF) treated with intra-arterial infusion of imipenem/cilastatin (IPM/CS) through a 24G indwelling needle directly inserted into the posterior tibial artery (PTA). Angiography of the indwelling needle immediately before the infusion of IPM/CS demonstrated an increased number of abnormal vessels at the calcaneal attachment of the plantar fascia. Two procedures were planned: The first procedure was performed, and the second was performed 1 month after the first. A week after the first treatment, her pain gradually decreased. Three months after the first treatment, she no longer had difficulties with activities of daily living. Intra-arterial infusion of IPM/CS directly through an indwelling needle into the PTA represents a minimally invasive embolic treatment option for PF.

Elasticity of the Achilles Tendon in Individuals With and Without Plantar Fasciitis: A Shear Wave Elastography Study

The elastic properties of the Achilles tendon (AT) are altered in local injury or other diseases and in response to changes in mechanical load. Recently, elastography has been used to evaluate variations in tendon elastic properties, mainly among healthy individuals or athletes. Therefore, this study evaluated the biomechanical changes in ATs in individuals with and without plantar fasciitis (PF). The purposes were as follows: (1) to evaluate the passive stiffness of three regions of the AT which defined as 0 (AT0 cm), 3 (AT3 cm), and 6 cm (AT6 cm) above the calcaneal tuberosity in participants with and without PF, (2) to investigate the interplay between the passive stiffness in patients with PF and pain, (3) to detect optimal cut-off points of stiffness of the AT in assessing individuals with chronic PF, and (4) to determine the correlation between the plantar fascia thickness (PFT) and pain. This cross-sectional study included 40 participants (mean age = 51 ± 13 years). When the ankle was in a relaxed position, patients with PF experienced increased passive stiffness in AT0 cm (p = 0.006) and AT3 cm (P = 0.003), but not in the neutral position. Significant correlations were observed between pain and stiffness of AT (AT0 cm r = 0.489, P = 0.029; AT3 cm r = 487, P = 0.030; AT6 cm r = 0.471, P = 0.036), but not in the PFT (P = 0.557). Optimal cut-off stiffness was AT (452 kPa) in the relaxed ankle position. The plantar fascia of patients with PF was significantly thicker than that of the controls (P < 0.001). Findings from the present study demonstrate that tendon stiffness is a good indicator of the clinical situation of patients with PF. Monitoring passive tendon stiffness may provide additional information to assess severity of the condition and guide therapeutic. The treatment programs for PF should also be tailored to the distal AT, as conventional therapy might not be targeted to tight tendons.

Greater Postural Sway and Tremor during Balance Tasks in Patients with Plantar Fasciitis Compared to Age-Matched Controls

Plantar fasciitis (PF) is a common condition found in men and women and can reoccur throughout life. PF is commonly diagnosed by prolonged foot pain lasting more than 3 months and a plantar fascia over 0.4 mm thick, as measured using ultrasound imaging. This study examined the ability to balance and the occurrence of muscle tremor during different balance tasks in patients with PF compared to their control counterparts. Fifty subjects (25 patients with PF and 25 control subjects) participated in this study. Subjective pain (measured with a visual analog scale (VAS)), pressure pain threshold (PPT), and postural sway and tremor during eight different balance tasks were measured. Postural sway was measured by a balance platform, while tremor was measured as the mechanical movement of the platform in the 8 Hz frequency range. Thickness of plantar fascia, subjective pain, and PPT were significantly greater in the PF group compared to the controls (p < 0.001). Postural sway and 8 Hz tremor were significantly greater in the PF group compared to the control group for all eight balance tasks (p < 0.01). These results indicate that the lack of plantar fascia elasticity is probably the cause of the reduced balance and increased muscle tremor.

Modulation in the elastic properties of gastrocnemius muscle heads in individuals with plantar fasciitis and its relationship with pain

The objectives of this study were (1) to investigate the passive stiffness of the medial gastrocnemius (MG) and lateral gastrocnemius (LG) in patients with and without plantar fasciitis (PF), (2) to explore the correlation between gastrocnemius stiffness and plantar fascia thickness (PFT) as well as the intensity of pain in patients with PF, (3) to detect optimal cut-off points for stiffness of the MG and LG for identifying patients with PF. Forty patients (mean age = 51.1 years ± 12.9) participated in this study. The elastic properties of the MG and LG were quantified using shear wave elastography ultrasound. The thickness of the plantar fascia was measured by B-mode imaging. The intensity of pain was assessed using a visual analogue scale. The results showed that when the ankle was in the relaxed position, patients with PF had increased passive stiffness in the MG (P < 0.05) but not in the LG. Significant correlations were found between pain and the stiffness of the MG (middle, distal; all P-values < 0.05) and no correlation was observed between pain and PFT (P = 0.416). The initial cut-off point for the stiffness of the MG was 29.08 kPa when the ankle was in the relaxed position. The findings from the present study show that an increase in muscle stiffness is not the same in the individual muscles of the gastrocnemius muscle. Traditional treatment of the whole gastrocnemius muscle might not be targeted at the tight muscle.

Imaging the patient with heel pain

Heel pain is a common presentation in primary care and affects a wide range of the population but predominantly elderly, obese and athletic patients. History and clinical assessment are paramount in the management of this condition but the presentation can confound clinicians, necessitating the use of imaging to confirm or clarify the diagnosis when there is clinical uncertainty. This article illustrates the various conditions producing heel pain to help clinicians determine the appropriate imaging modality to image the common causes of heel pain. A linked article detailing the management of heel pain is included in this issue ( https://doi.org/10.12968/hmed.2019.80.4.196 ).

Assessment the reliability of ultrasonography in the imaging of the plantar fascia: a comparative study

BACKGROUND

Imaging methods for the plantar fascia have included radiography, ultrasound and magnetic resonance imaging (MRI), all of which have provided valuable information. This study assessed the reliability of ultrasonography examinations of the plantar fascia using a comparative study.

METHODS

Fifty healthy adult volunteers (25 males and 25 females, mean age 31.6 ± 3.5 years) were included in this study. Images of the plantar fascia from 100 ft were acquired with ultrasonography, CT and MRI. Ultrasound was used to measure the thickness of the plantar fascia. Imaging data from CT and MRI in a DICOM format were transformed into the Materialise Mimics Innovation Suite 16.0 software for digital analysis. SPSS software (SPSS, USA) was used for statistical analysis. The reliability was established by a t-test. Moreover, 42 patients with unilateral plantar fasciitis were examined by ultrasonography.

RESULTS

There were no significant differences between the three imaging modalities for patients of the same sex (P > 0.05). There were no statistically significant differences between the left and right sides for patients of the same sex (P > 0.05), but the difference between males and females was statistically significant (P < 0.01). There were no significant differences between US, CT and MRI in the normal group, but there were significant differences in the plantar fasciitis group evaluated with ultrasound. The plantar fascii of normal male subjects are significantly thicker than those of the normal female.

CONCLUSION

Ultrasonography can be a relatively simple and reliable method for the measurement of plantar fascia thickness.

Electrical dry needling as an adjunct to exercise, manual therapy and ultrasound for plantar fasciitis: A multi-center randomized clinical trial

Study Design

Randomized, single-blinded, multi-center, parallel-group trial.

Objectives

To compare the effects of adding electrical dry needling into a program of manual therapy, exercise and ultrasound on pain, function and related-disability in individuals with plantar fasciitis (PF).

Background

The isolated application of electrical dry needling, manual therapy, exercise, and ultrasound has been found to be effective for PF. However, no previous study has investigated the combined effect of these interventions in this population.

Methods

One hundred and eleven participants (n = 111) with plantar fasciitis were randomized to receive electrical dry needling, manual therapy, exercise and ultrasound (n = 58) or manual therapy, exercise and ultrasound (n = 53). The primary outcome was first-step pain in the morning as measured by the Numeric Pain Rating Scale (NPRS). Secondary outcomes included resting foot pain (NPRS), pain during activity (NPRS), the Lower Extremity Functional Scale (LEFS), the Foot Functional Index (FFI), medication intake, and the Global Rating of Change (GROC). The treatment period was 4 weeks with follow-up assessments at 1 week, 4 weeks, and 3 months after the first treatment session. Both groups received 6 sessions of impairment-based manual therapy directed to the lower limb, self-stretching of the plantar fascia and the Achilles tendon, strengthening exercises for the intrinsic muscles of the foot, and therapeutic ultrasound. In addition, the dry needling group also received 6 sessions of electrical dry needling using a standardized 8-point protocol for 20 minutes. The primary aim was examined with a 2-way mixed-model analysis of covariance (ANCOVA) with treatment group as the between-subjects variable and time as the within-subjects variable after adjusting for baseline outcomes.

Results

The 2X4 ANCOVA revealed that individuals with PF who received electrical dry needling, manual therapy, exercise and ultrasound experienced significantly greater improvements in first-step morning pain (F = 22.021; P<0.001), resting foot pain (F = 23.931; P<0.001), pain during activity (F = 7.629; P = 0.007), LEFS (F = 13.081; P<0.001), FFI Pain Subscale (F = 13.547; P<0.001), FFI Disability Subscale (F = 8.746; P = 0.004), and FFI Total Score (F = 10.65; P<0.001) than those who received manual therapy, exercise and ultrasound at 3 months. No differences in FFI Activity Limitation Subscale (F = 2.687; P = 0.104) were observed. Significantly (X² = 9.512; P = 0.023) more patients in the electrical dry needling group completely stopped taking medication for their pain compared to the manual therapy, exercise and ultrasound group at 3 months. Based on the cutoff score of ≥+5 on the GROC, significantly (X² = 45.582; P<0.001) more patients within the electrical dry needling group (n = 45, 78%) achieved a successful outcome compared to the manual therapy, exercise and ultrasound group (n = 11, 21%). Effect sizes ranged from medium to large (0.53<SMD<0.85) at 3 months in favor of the electrical dry needling group.

Conclusion

The inclusion of electrical dry needling into a program of manual therapy, exercise and ultrasound was more effective for improving pain, function and related-disability than the application of manual therapy, exercise and ultrasound alone in individuals with PF at mid-term (3 months).

Level of evidence

Therapy, Level 1b.

Relationship of Plantar Fascia Thickness and Preoperative Pain, Function, and Quality of Life in Recalcitrant Plantar Fasciitis

BACKGROUND

The measurement of plantar fascia thickness has been advocated as a diagnostic and prognostic instrument in patients with plantar fasciitis, but there are no data relative to it in recalcitrant plantar fasciitis. The aim of the study is to evaluate the correlation between plantar fascia thickness and pain, functional score, and health perception in patients with this condition.

METHODS

Thirty-eight feet were studied with ultrasound and magnetic resonance imaging to measure plantar fascia thickness. The visual analogue scale (VAS), American Orthopaedic Foot & Ankle Society Hindfoot Score (AOFAS), and SF-36 were then recorded for each patient. The relationship between the fascia and these scores was analyzed to evaluate the correlation of thickness with pain, functional level, and health perception of patients.

RESULTS

In patients with recalcitrant plantar fasciitis, plantar fascia thickness did not correlate with pain (VAS), AOFAS, or any item of the SF-36.

CONCLUSION

The thickness of the plantar fascia in patients with recalcitrant plantar fasciitis did not correlate with its clinical impact, and thus, we believe it should not be used in treatment planning.

LEVEL OF EVIDENCE

Level IV, case series.

Tendon vascularity in overhead athletes with subacromial pain syndrome and its correlation with the resting subacromial space

BACKGROUND

Supraspinatus tendinopathy is one of the common causes of subacromial pain syndrome (SAPS) in overhead athletes. Changes in tendon vascularity have been reported in painful tendons; however, the prevalence and distribution have not been investigated in young overhead athletes.

METHODS

We conducted a cross-sectional study of 47 overhead athletes (male, 31; female, 16) aged 18 to 36 years with SAPS for >3 months. A sonographer graded the severity of the tendinopathy and area of vascularization. Ultrasound imaging was used to measure supraspinatus tendon thickness, vascularity, and resting subacromial space. A self-written program was used to semiquantify the intensity of vascularity, expressed as the vascular index.

RESULTS

The majority (87.2%) of the participants had signs of tendinopathy in the supraspinatus tendon, and 40 (85.1%) of the tendinopathic tendons had vascularity. The majority (66.0%) of the vascularized subjects presented with minimal increase in vascularity, and 19.1% had moderate to severe vascularization. Most (79.2%) of the vascularization was observed in the pericortical region. The vascular index was negatively correlated with the resting subacromial space in male athletes with a reduced subacromial space (ρ = -0.63; P = .038).

CONCLUSION

Of overhead athletes with SAPS, 87.2% had supraspinatus tendinopathy with minimal to moderate vascularization, with the majority of vascularization occurring in the pericortical region. In male athletes with a reduced subacromial space, greater vascularity in the supraspinatus tendon was associated with a smaller resting subacromial space.

Applicability of contrast-enhanced ultrasound in the diagnosis of plantar fasciitis

Contrast-enhanced ultrasound (CEUS) is used to visualize the microvascularization in various tissues. The purpose of this study was to investigate whether CEUS could be used to visualize the microvascular volume (MV) in the plantar fascia, and to compare the method to clinical symptoms and B-mode ultrasound (US) in patients with plantar fasciitis (PF). Twenty patients with unilateral PF were included and were divided by US in insertional thickening (10), midsubstance thickening (5), and no US changes (5). The MV was measured simultaneously in both heels. Four areas in the plantar fascia and plantar fat pad were measured independently by two observers. Inter- and intra-observer correlation analyses were performed. The asymptomatic heels showed a constantly low MV, and for the whole group of patients, a significantly higher MV was found in the symptomatic plantar fascia and plantar fat pad. Inter-observer correlation as well as intra-observer agreement was excellent. The MV in the plantar fascia and plantar fat pad can be measured reliably using CEUS, suggesting that it is a reproducible method to examine patients with plantar fasciitis.

Static, dynamic balance and functional performance in subjects with and without plantar fasciitis

Abstract Introduction: Plantar fasciitis (PF) is characterized by non-inflammatory degeneration and pain under the heel, and is one of the most common foot complaints. The compensations and adjustments made to decrease the discomfort caused by the disease are clinical findings and can be a factor that contributes to impaired balance and decreased functional performance. Objective: To compare functional performance as well as static and dynamic balance among subjects with and without PF. Methods: The sample consisted of 124 subjects of both sexes aged 20-60 years. Participants were divided into two groups: a bilateral PF group (PFG; n = 62) and a control group (CG, n = 62). The following outcomes were analyzed: static and dynamic balance (using functional tests) and functional performance (using a questionnaire). We used Student’s t test for independent samples to compare variables between the groups. The alpha error was set at 0.05. Results: Subjects with PF showed greater impairment in their overall dynamic balance performance (p < 0.001) than the control group, except for left posteromedial movement (p = 0.19). The CG showed showed better functional performance (p < 0.001) than the PF group. There was no difference between groups for the variable static balance on stable (p = 0.160) and unstable surfaces (p = 0.085). Conclusion: Subjects with PF displayed smaller reach distances in the overall Star Excursion Balance Test (SEBT), demonstrating a deficit in dynamic balance and functional performance when compared with healthy subjects.

Imaging of plantar fascia disorders: findings on plain radiography, ultrasound and magnetic resonance imaging

Plantar fascia (PF) disorders commonly cause heel pain and disability in the general population. Imaging is often required to confirm diagnosis. This review article aims to provide simple and systematic guidelines for imaging assessment of PF disease, focussing on key findings detectable on plain radiography, ultrasound and magnetic resonance imaging (MRI). Sonographic characteristics of plantar fasciitis include PF thickening, loss of fibrillar structure, perifascial collections, calcifications and hyperaemia on Doppler imaging. Thickening and signal changes in the PF as well as oedema of adjacent soft tissues and bone marrow can be assessed on MRI. Radiographic findings of plantar fasciitis include PF thickening, cortical irregularities and abnormalities in the fat pad located deep below the PF. Plantar fibromatosis appears as well-demarcated, nodular thickenings that are iso-hypoechoic on ultrasound and show low-signal intensity on MRI. PF tears present with partial or complete fibre interruption on both ultrasound and MRI. Imaging description of further PF disorders, including xanthoma, diabetic fascial disease, foreign-body reactions and plantar infections, is detailed in the main text. Ultrasound and MRI should be considered as first- and second-line modalities for assessment of PF disorders, respectively. Indirect findings of PF disease can be ruled out on plain radiography.

Teaching Points

• PF disorders commonly cause heel pain and disability in the general population.

• Imaging is often required to confirm diagnosis or reveal concomitant injuries.

• Ultrasound and MRI respectively represent the first- and second-line modalities for diagnosis.

• Indirect findings of PF disease can be ruled out on plain radiography.

Three single leg standing tests for clinical assessment of chronic plantar heel pain syndrome: static stance, half-squat and heel rise

OBJECTIVE

To assess reliability and validity of three single leg standing clinical tests in patients with plantar heel pain syndrome (PHPS).

DESIGN

Cross-sectional reliability study.

PARTICIPANTS

Forty patients diagnosed with PHPS.

MAIN OUTCOME MEASURES

Patients stood on their affected foot in a static stance for up to 30seconds, a half squat for up to 10 repetitions, and a heel rise for up to 10 repetitions. The first sensation of pain (p1) determined the termination of each test, and established a positive test result. The level of p1 was measured using a visual analogue scale (VAS); time or repetitions for each test were recorded. Prior to performing the tests, all patients completed the Foot & Ankle Computerized Adaptive Test to measure functional status (FS).

RESULTS

Detection of p1 in each test showed good reliability for inter- and intrarater assessment (Kappa=0.60 to 0.78 and 0.56 to 0.77, respectively). The intraclass correlation coefficient for the VAS measures was 0.85 to 0.95 for inter-rater assessment and 0.78 to 0.92 for intrarater assessment. However, the Bland and Altman limits of agreement were wide, indicating that these measures were less reliable than the correlation coefficients suggested. Thirty-five patients (88%) experienced a positive pain response to at least one test. Significant correlations were found between the VAS measures in each test and FS (r=0.63 to 0.72).

CONCLUSIONS

The static stance, half squat and heel rise tests were easily implemented, and found to be reliable and valid according to one analysis, yet less reliable with another, for pain provocation and VAS levels in patients with PHPS. All three VAS levels correlated well with FS.

Plantar fasciitis: A randomized comparative study of platelet rich plasma and low dose radiation in sportspersons

BACKGROUND

Plantar Fasciitis makes up about 15% of patients requiring professional care due to foot symptoms. The treatment methods are numerous with none proving to be clearly superior to others. We aimed to compare two common treatment methods in search of the best treatment.

METHOD

All consecutive sportspersons presenting to our OPD with clinical diagnosis of plantar fasciitis underwent treatment consisting of stretching exercises, activity modification, and NSAID's for 6 months. First 40 patients who did not respond to the treatment were divided randomly into two groups of 20 patients each, Group A (Platelet rich plasma - PRP) and Group B (low dose radiation - LDR). At the time of final follow-up (6 months) the mean improvement in the pain score (Visual-Analogue-Scale), American Orthopaedic Foot and Ankle Score (AOFAS) and Plantar fascia thickness on ultrasound were compared.

RESULT

Significant improvement in all 3 parameters was noted at the time of final follow up within both groups. When compared to each other, the difference in outcome of both these Groups on the given 3 parameters came out to be insignificant (p>0.05).

CONCLUSION

PRP is as good as LDR in patients with chronic recalcitrant plantar fasciitis not responding to physical therapy.

Classification of Calcaneal Spurs and Their Relationship With Plantar Fasciitis

Calcaneal spurs, as a cause of plantar fasciitis, are currently debatable. A prospective study was performed to classify calcaneal spurs according to the findings from an investigation of the relationship between calcaneal spurs and plantar fasciitis. Thirty patients with calcaneal spurs and plantar heel pain underwent calcaneal spur removal and endoscopic plantar fasciotomy. The relationship between the classification of calcaneal spurs and plantar fasciitis was evaluated by endoscopic findings, clinical symptoms, radiographic images, and biopsy findings. The visual analog scale for pain and the American Orthopedic Foot and Ankle Society ankle-hindfoot scores for functional evaluation were used preoperatively and postoperatively, respectively. The mean follow-up period was 24 months. Two separate types of calcaneal spurs were recognized. Type A calcaneal spurs were located superior to the plantar fascia insertion, and type B calcaneal spurs were located within the plantar fascia. Magnetic resonance imaging results showed a more severe plantar fasciitis grade in type B calcaneal spurs preoperatively. Histologic examination showed that the numbers of granulocytes per image in type B spurs were significantly increased compared with those in type A spurs. Statistically significant improvements were found in the mean visual analog scale and American Orthopedic Foot and Ankle Society scores and magnetic resonance imaging results in both groups. The amount of change in the visual analog scale score and American Orthopedic Foot and Ankle Society score, the number of granulocytes per image, and calcaneal spur length showed a high association with the classification of the calcaneal spurs. Calcaneal spurs were completely removed and did not recur in any of the patients on radiographic assessment during the follow-up period. Calcaneal spurs can be classified into 2 distinct types that are indicative of the severity of plantar fasciitis.