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

Sonographic and clinical effects of manual physical therapy for plantar fasciitis: randomized prospective controlled trial

OBJECTIVE

This study aimed to evaluate the efficacy of manual physiotherapy on clinical outcomes, morphology of plantar fascia (PF), thicknesses of calcaneal fat pad (CFP) and Kager's fat pad (KFP) with ultrasound imaging in plantar fasciitis (PFS) patients. Also, to evaluate the PF thickness, pain and foot functional outcomes among PFS phases.

METHODS

A randomized controlled trial was conducted on 122 subjects divided into three groups: group A (40 patients with PFS) underwent manual physiotherapy, group B (42 patients with PFS) without any intervention and group C (40 healthy subjects) were matched by age, gender and BMI with each patient in group A and B. The following outcomes were evaluated at baseline and one-month of follow-ups: morphology of PF and thicknesses of CFP and KFP, pain, foot functional limitation.

RESULTS

PF thickness was significantly thickened in group A and B compared to group C (P < 0.001). A significant decrease in incidence of PF echogenicity and CFP thickness were found in group A and B compared to group C. Moreover, significant improvement was observed in PF thickness (P < 0.001), PF echogenicity (P < 0.001) and CFP thickness (P = 0.002) in group A at one-month after the treatment. Furthermore, pain intensity and foot functional limitation was significantly improved within group A after receiving the treatment. Significant improvement was noted in PF thickness, pain intensity and foot functional limitation among patients with acute phase.

CONCLUSION

The manual physiotherapy is effective in treatment of PF thickening, hypoechogenicity, pain intensity and activity limitations, particularly in patients associated with acute PFS.

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.

Coxa pedis: can calcaneal pronation angle be considered a predictive sign of medial plantar arch overload?

PURPOSE

To assess whether a correlation between the calcaneal pronation angle and the presence of internal plantar arch overload signs (such as upper-medial spring ligament lesion, posterior tibial tendon tenosynovitis, etc.) could lead to a better understanding of coxa pedis pathology.

MATERIAL AND METHODS

One hundred ankle MRIs of consecutive patients were retrospectively reviewed measuring the calcaneal pronation angle and either the presence or absence of internal plantar arch overload signs. Next, the association of overload signs with increasing pronation angle was evaluated to establish a cut-off point beyond which coxa pedis pathology could be defined.

RESULTS

The tibial-calcaneal angle values in patients with and without effusion proved to be significantly different (p < 0.0001). The tibial-calcaneal angle values in patients with and without oedema also demonstrated a significant difference (p < 0.0056). Regarding posterior tibial tendon, a significant difference was found between the two groups (p < 0.0001). For plantar fascia enthesopathy, the result was borderline significant (p < 0.054). A linear correlation was found between the value of pronation angle and the extent of spring ligament injury (p < 0.0001). In contrast, no correlation with age was found.

CONCLUSION

In conclusion, the literature associates medial longitudinal plantar arch overload with posterior tibial tendinopathy and spring ligament complex injuries. Our data show that both injuries are highly correlated with increased calcaneal pronation angle, which could be considered a predictive sign of internal plantar arch overload, prior to the development of the associated signs.

Effect of corticosteroids over plantar fascia thickness in plantar fasciitis: a systematic review and meta-analysis

OBJECTIVES

Corticosteroid injections have been typically used for the management of plantar fasciitis with apparently good clinical outcomes; however, there is no information of the effect of corticosteroids on the thickness of the plantar fascia which is typically altered in this pathology. We aimed determine whether treatment with corticosteroid injections induces plantar fascia thickness changes in plantar fasciitis.

METHODS

MEDLINE, Embase, Web of Science, and Scopus databases were searched for randomized controlled trials (RCT) reporting the use of corticosteroid injection to treat plantar fasciitis to July 2022. Studies must have reported plantar fascia thickness measurement. The risk of bias in all studies was assessed with the Cochrane Risk of Bias 2.0 tool. Meta-analysis was conducted using a random-effects model and the generic inverse variance method.

RESULTS

Data from 17 RCT (including 1109 subjects) were collected. The follow-up period ranged from one to six months. Most studies measured the thickness of the plantar fascia at the insertion into the calcaneus using ultrasound. Pooled analysis revealed that corticosteroid injections had no significant effect on plantar fascia thickness (weighted mean differences [WMD], 0.06 mm [95% CI: -0.17, 0.29]; p = 0.61) or pain relief (WMD, 0.12 cm [95% CI: -0.36, 0.61]; p = 0.62) above active controls.

CONCLUSION

Corticosteroid injections do not perform better than other common interventions in terms of a decrease of plantar fascia thickness and pain relief for plantar fasciitis.

Utility of Shear Wave Elastography for the Diagnosis of Plantar Fasciitis: Comparison Between Symptomatic and Asymptomatic Sides in Unilaterally Affected Patients

INTRODUCTION

Plantar fasciitis (PF) can cause pain in the heel, which can affect everyday activities. While it often resolves on its own, diagnosing PF to rule out other hind foot conditions by imaging modality in cases of recurrence can be difficult. Methods such as MRI and ultrasonography are helpful, but the use of elastography, specifically shear wave elastography (SWE), as a tool for diagnosing PF is being studied.

METHODOLOGY

This comparative observational study included patients over 18 years presenting with unilateral hind foot pain who were investigated using SWE. Exclusions comprised those who were bilaterally affected and with foot deformities, trauma history, or prior injection therapy. Patients' AOFAS Ankle-Hindfoot Scores were assessed along with visual analog scale (VAS) scores, followed by SWE examination of both heels.

RESULTS

The study found no significant difference in the plantar fascia thickness between affected and unaffected sides, with a mean thickness of 4.3±0.8mm and 5.1±0.6mm, respectively. Shear wave velocity (SWV) was lower on the affected side, indicating reduced stiffness compared to the unaffected side. The Spearman rank test revealed strong direct correlations between SWV and both the VAS and HF-AOFAS scores on the affected side.

CONCLUSION

The study observed that SWE enhances B-mode ultrasonography in detecting early PF even with normal plantar fascia thickness, offering a user-independent and reliable tool for treatment monitoring and correlation with functional and pain scores. Further research with larger populations can aid in developing a clinico-radiological classification system for PF, improving prognostication and treatment guidance.

3D isotropic MRI of ankle: review of literature with comparison to 2D MRI

The ankle joint has complex anatomy with different tissue structures and is commonly involved in traumatic injuries. Magnetic resonance imaging (MRI) is the primary imaging modality used to assess the soft tissue structures around the ankle joint including the ligaments, tendons, and articular cartilage. Two-dimensional (2D) fast spin echo/turbo spin echo (FSE/TSE) sequences are routinely used for ankle joint imaging. While the 2D sequences provide a good signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) with high spatial resolution, there are some limitations to their use owing to the thick slices, interslice gaps leading to partial volume effects, limited fluid contrast, and the need to acquire separate images in different orthogonal planes. The 3D MR imaging can overcome these limitations and recent advances have led to technical improvements that enable its widespread clinical use in acceptable time periods. The volume imaging renders the advantage of reconstructing into thin continuous slices with isotropic voxels enabling multiplanar reconstructions that helps in visualizing complex anatomy of the structure of interest throughout their course with improved sharpness, definition of anatomic variants, and fluid conspicuity of lesions and injuries. Recent advances have also reduced the acquisition time of the 3D datasets making it more efficient than 2D sequences. This article reviews the recent technical developments in the domain 3D MRI, compares imaging with 3D versus 2D sequences, and demonstrates the use-case scenarios with interesting cases, and benefits of 3D MRI in evaluating various ankle joint components and their lesions.

The Heel Complex: Anatomy, Imaging, Pathologic Conditions, and Treatment

The differential diagnosis for heel pain is broad but primarily involves abnormalities of the Achilles tendon, calcaneus, and plantar fascia. Achilles tendon disorders include tendinosis, tendinitis, and partial or complete tears. Tendinosis refers to tendon degeneration, while tendinitis is inflammation after acute overload. Untreated tendinosis can progress to partial or complete tears. Tendon disorders can be accompanied by paratenonitis or inflammation of the loose sheath enclosing the tendon. Initial management involves rehabilitation and image-guided procedures. Operative management is reserved for tendon tears and includes direct repair, tendon transfer, and graft reconstruction. The calcaneus is the most commonly fractured tarsal bone. The majority of fractures are intra-articular; extra-articular fractures, stress or insufficiency fractures, medial process avulsion, and neuropathic avulsion can also occur. Posterosuperior calcaneal exostosis or Haglund deformity, retrocalcaneal bursitis, and insertional Achilles tendinosis form the characteristic triad of Haglund syndrome. It is initially managed with orthotics and physiotherapy. Operative management aims to correct osseous or soft-tissue derangements. The plantar fascia is a strong fibrous tissue that invests the sole of the foot and contributes to midfoot stability. Inflammation or plantar fasciitis is the most common cause of heel pain and can be related to overuse or mechanical causes. Acute rupture is less common but can occur in preexisting plantar fasciitis. Conservative treatment includes footwear modification, calf stretches, and percutaneous procedures. The main operative treatment is plantar fasciotomy. Plantar fibromatosis is a benign fibroblastic proliferation within the fascia that can be locally aggressive and is prone to recurrence. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Recurrence Rate After Wide Resection of Plantar Fibromatosis: A Case Series and Systematic Literature Review

BACKGROUND

The aim was to assess the recurrence rate and clinical outcome after wide resection for plantar fibromatosis.

METHODS

A total of 12 patients, 2 to 13 years after wide resection, were assessed for local and magnetic resonance imaging tomographic signs of recurrence at the clinical follow-up. In addition, a systematic review of the literature was conducted.

RESULTS

After 7.8 years (2-13), 2 patients (17%) suffered a recurrence. At the last follow-up, median Foot Functional Index was 1 (0-66) and American Orthopaedic Foot and Ankle Society score was 95 (44-100). Six studies with 109 feet (92 patients) were included in the systematic review. The recurrence rate depends on the width of the resection: 67% after local resection, 42% after wide resection, and 27% after fasciectomy.

CONCLUSION

In patients with symptomatic plantar fibromatosis, we recommend a wide resection or fasciectomy over a local resection because of the inferior recurrence rate.

LEVELS OF EVIDENCE

Level IV: Retrospective case series.

Muscle strength and foot pressure vary depending on the type of foot pain

This study compared muscle strength and foot pressure among patients with metatarsalgia, patients with plantar fasciitis, and healthy controls. A total of 31 patients with foot pain (14 metatarsalgia and 17 plantar fasciitis) and 29 healthy controls participated in the study. The strengths of the plantar flexor and hip muscles were measured using isokinetic and handheld dynamometers, respectively. Foot pressure parameters, including the pressure-time integral (PTI) and foot arch index (AI), were assessed using pedobarography. Compared with the healthy control group, plantar flexor strength was significantly reduced in the affected feet of the metatarsalgia and plantar fasciitis groups (F = 0.083, all p < 0.001); however, hip strength was significantly decreased only in the affected feet of the metatarsalgia group (F = 20.900, p < 0.001). Plantar flexor (p < 0.001) and hip (p = 0.004) strength were significantly lower in the metatarsalgia group than in the plantar fasciitis group. The PTI was lower in the forefeet of the affected feet in the metatarsalgia (p < 0.001) and plantar fasciitis (p = 0.004) groups. Foot AI (p < 0.001) was significantly reduced only in the metatarsalgia group. These results suggest the need to consider the evaluation of muscle strength and foot pressure in both feet for the diagnosis and treatment of foot pain.

Effects of Kinesiotape versus Low-Dye Tape on Pain and Comfort Measures in Patients with Plantar Fasciitis: A Randomized Clinical Trial

BACKGROUND

Bandages are commonly used to relieve pain in patients with plantar fasciitis. The goal was to compare the effects of using kinesiotape versus low-dye tape in the acute phase of plantar fasciitis on pain and comfort measures.

METHODS

Forty individuals with plantar fasciitis were allocated to the kinesiotape or low-dye tape interventions. The patients were assessed at baseline and every 24 h until the fifth day. The primary measure was a visual analog scale of pain. The other measures were comfort, mobility, durability, personal hygiene, sweating, and allergies. The effects were compared with an ANOVA test, 95% CI.

RESULTS

Kinesiotape was more effective in reducing pain; the greater effect occurred during the first day, with a between-group difference of 2.0 (95% CI: 1.8 to 2.2). The pain differences between the treatments progressively reduced each day from the second day. Kinesiotape offered significantly higher performance than low-dye tape in mobility, comfort, and comfort in hygiene, sweating, and durability, with a large effect size d > 0.8.

CONCLUSIONS

Kinesiotape could be more effective than low-dye tape in relieving pain in patients with plantar fasciitis, with a significant clinical impact on the first day of treatment. Kinesiotape can also provide higher performance in terms of comfort.

Effects on pain of kinesiology tape in patients with plantar fasciitis: a randomized controlled study

PURPOSE.

Plantar fasciitis is the most frequent cause of heel pain. Custom-made plantar supports are a common treatment solution, while the application of kinesiology tape (KT) can be an effective measure to alleviate pain. The objective was to evaluate the effects of KT on the pain of patients with plantar fasciitis.

METHODS.

Randomized controlled trial including participants with plantar fasciitis. There was an experimental group (n = 17), whose participants underwent a KT treatment, and a control (sham tape) group (n = 17). The pain, measured with a visual analog scale (VAS), was the primary outcome and was assessed daily until the fifth day of wearing the tape and 24 h after removing it. Inferential statistics looked for time, group, and time per group differences with CI at 95%.

RESULTS.

The greatest between-group VAS difference was 3.5 points, and occurred at the 2-day follow-up assessment. Then, pain differences decreased over time until the last assessment point. Statistically significant time, group, and time*group differences were found with p < 0.001.

CONCLUSION.

This study supports that KT is effective in reducing pain in the short term in patients with plantar fasciitis, and more effective than a sham intervention with tape.

Imaging Features of Plantar Vein Thrombosis: An Easily Overlooked Condition in the Differential Diagnosis of Foot Pain

Plantar vein thrombosis is a venous disorder affecting deep plantar veins that can manifest with non-specific localized pain, plantar foot pain, swelling, and sensation of fullness. Plantar veins are not routinely assessed during sonographic scans for deep venous thrombosis, which makes plantar venous thrombosis a commonly missed diagnosis. This paper provides a comprehensive review of the venous anatomy of the foot and imaging findings of plantar venous thrombosis as well as discusses the current literature on the topic and its differential diagnoses.

Ultrasound imaging in professional soccer: when is it adequate?

Ultrasound imaging plays an important role in the diagnosis, monitoring and treatment of injuries in professional soccer players. With the rapid increase in the availability of hand-held portable ultrasound devices and the pressure to make timely and accurate diagnosis in professional soccer where return to play time is crucial, ultrasound imaging is an essential diagnostic tool. In this article, we discuss examples of injuries that can be adequately assessed by ultrasound imaging alone and injuries where ultrasound imaging provides a useful first step to guide further investigation and management.

Ledderhose's Disease: An Up-to-Date Review of a Rare Non-Malignant Disorder

Plantar fibromatosis (or Ledderhose's disease) is a rare benign condition, difficult to treat, defined by gradual-growing nodules in the central medial part of the plantar fascia, with the possibility of sclerosis and shrinkage of the entire fascia or, rarely, contractures of the toes. From a histopathological point of view, it is linked to Dupuytren's contracture of the hand and Peyronie's disease of the penis, being part of a large group of fibromatoses, based on a proliferation of collagen and fibroblasts. Its etiology is still not fully understood, even though it has been associated with trauma, diabetes mellitus, use of anticonvulsants, frozen shoulder, alcohol consumption, and liver disease. Typically, ultrasound confirms the diagnosis, and magnetic resonance imaging is used for more aggressive and advanced types. Several conservative treatment techniques, such as steroid injections, verapamil, imatinib, radiation therapy, extracorporeal shock wave therapy, tamoxifen, sorafenib, mitomycin C, and collagenase, have been documented. When non-operative care fails, surgical measures may be considered, even though recurrence is expected. We attempted to provide a better understanding of this disease by covering all of the important aspects: its history, clinical and radiologic findings, diagnosis, pathophysiology features, conservative and surgical treatment, recurrence rate, and prognosis.

Global Status and Future Trends of Fascia and Pain Research in 2013-2022: Bibliometric Analysis Based on CiteSpace and VOSviewer

Background

Fascial pathological pain is the main type of chronic pain in older adults today, and studying the relationship between fascia and pain can help in the clinical search for effective treatments. However, in the face of the vast amount of research findings, there is no systematic assessment of the relationship between fascia and pain in a bibliometric analysis. Therefore, the purpose of this study is to analyze studies on fascia and pain using CiteSpace and VOSviewer to identify research hotspots and future directions.

Materials and Methods

A total of 744 papers related to fascia and pain from 2013 to 2022 were collected from the core collection database of Web of Science, and the authors, countries, institutions, keyword co-occurrence, keyword clustering, and keyword emergence were analyzed by CiteSpace and VOSviewer to construct a knowledge map.

Results

Literature publication has shown an overall upward trend over the past decade, but there have been some fluctuations. Carmelo Pirri, Caterina Fede, and Raffaele De Caro are the top three authors with the most articles. The United States, China, and Spain are major contributors to fascial and pain research. The University of Padua, Universidad Complutense and Harvard Medical School are leading institutions in this field. However, it is noteworthy that the collaboration between authors, countries and institutions is not active. Keyword analysis showed that hot spots and trends in research on fascia and pain focused on hot diseases, major interventions, and mechanism exploration.

Conclusion

This analysis identifies the most influential authors, institutions, and countries in the field of fascial and pain research and provides a reference for assessing their academic impact. The analysis of keywords and co-cited literature is useful for analyzing research hotspots and their evolution, as well as for predicting future trends.

Emerging role of bone scintigraphy single-photon emission computed tomography/computed tomography in foot pain management

Foot and ankle joints being weight-bearing joints are commonly subjected to wear and tear and are prone to traumatic and other pathologies. Most of these foot and ankle pathologies present with pain. The diagnosis of pathology and localization of pain generators is difficult owing to the complex anatomy of the foot and similar clinical presentation. This makes the management of foot pain clinically challenging. Conventional anatomical imaging modalities are commonly employed for evaluation of any anatomical defect; however, these modalities often fail to describe the functional significance of the anatomical lesions, especially in presence of multiple lesions which is common in ankle and foot; however, hybrid single-photon emission computed tomography/computed tomography (SPECT/CT) by virtue of its dual modalities, that is, highly sensitive functional imaging and highly specific anatomical imaging can serve as a problem-solving tool in patient management. This review attempts to describe the role of hybrid SPECT/CT in overcoming the limitation of conventional imaging and describes its potential application in the management of foot and ankle pain.

Role of shear wave elastography in the diagnostic evaluation of plantar fasciitis: a prospective case-control study

OBJECTIVES

To assess the advantage of the addition of shear wave elastography (SWE) to gray-scale sonography in the diagnosis of plantar fasciitis.

METHODS

30 subjects between 18-60 years of age with unilateral heel pain who were clinically suspected of having plantar fasciitis were included in this study. Their affected feet were taken as cases; while their contralateral feet served as controls. On gray-scale ultrasound, the thickness of plantar fascia, its echopattern, presence of hypoechoic areas, and perifasicular collections were recorded. SWE was done by placing seven ROIs within the plantar fascia; and the mean of their Young's modulus was taken in kPa.

RESULTS

Plantar fascial thickening more than 4 mm had 70% sensitivity and 66.7% specificity, echopattern had 90% sensitivity and 96.7% specificity, hypoechoic areas had 80% sensitivity and 96.7% specificity, and perifascial edema had 26.7% sensitivity and 100% specificity for diagnosing plantar fasciitis. Using the ROC curve, the cut-off value of Young's modulus for the diagnosis of plantar fasciitis was found to be ≤ 99.286 kPa. This predicted plantar fasciitis with 97% sensitivity and 100% specificity. The primary diagnostic feature of ultrasound of plantar fascia thickness more than 4 mm detected 21 out of 30 cases of plantar fasciitis; whereas elastography detected an additional 8 cases which would have been missed on B-mode ultrasound alone.

CONCLUSIONS

SWE is a useful supplement and improves the diagnostic accuracy of gray-scale ultrasound in plantar fasciitis.

Acute Rupture of the Plantar Fascia in a Soccer Player

Acute rupture of the plantar fascia is a rare but potentially debilitating injury in athletes, particularly those involved in running and jumping sports. Early recognition and prompt treatment are crucial for a successful recovery and return to play. Conservative treatment, including rest, immobilization, and physical therapy, may be effective in most cases, while surgical intervention may be required in those that are nonresponsive to conservative treatment. We report a case of plantar fascia rupture in a 22-year-old male semi-professional football player who presented with sudden severe pain in the sole of his right foot during a match, followed by a popping sensation and inability to weight bear. The athlete was healthy and had no history of previous injury in the right foot. MRI confirmed a complete rupture of the plantar fascia. The player was treated conservatively and underwent a rehabilitation program. The player returned to full competition after nine weeks, with no limitations.

Response to Mechanical Properties and Physiological Challenges of Fascia: Diagnosis and Rehabilitative Therapeutic Intervention for Myofascial System Disorders

Damage to the fascia can cause significant performance deficits in high-performance sports and recreational exercise and may contribute to the development of musculoskeletal disorders and persistent potential pain. The fascia is widely distributed from head to toe, encompassing muscles, bones, blood vessels, nerves, and internal organs and comprising various layers of different depths, indicating the complexity of its pathogenesis. It is a connective tissue composed of irregularly arranged collagen fibers, distinctly different from the regularly arranged collagen fibers found in tendons, ligaments, or periosteum, and mechanical changes in the fascia (stiffness or tension) can produce changes in its connective tissue that can cause pain. While these mechanical changes induce inflammation associated with mechanical loading, they are also affected by biochemical influences such as aging, sex hormones, and obesity. Therefore, this paper will review the current state of knowledge on the molecular level response to the mechanical properties of the fascia and its response to other physiological challenges, including mechanical changes, innervation, injury, and aging; imaging techniques available to study the fascial system; and therapeutic interventions targeting fascial tissue in sports medicine. This article aims to summarize contemporary views.

Ultrasonographic Assessment of Indian Patients With Plantar Fasciitis and Its Clinical Correlation: A Prospective Observational Study

INTRODUCTION

Plantar fasciitis is a debilitating clinical condition and is one of the most common causes of heel pain. The risk factors include frequent and prolonged running, obesity, a sedentary lifestyle, work-related weight bearing, and inappropriate footwear. Ultrasonography being a non-invasive, cost-effective, and easily available modality is a useful adjunct in the diagnosis.

METHODS

A prospective observational study was conducted among 30 patients with unilateral plantar fasciitis. The diagnosis was based on history and examination. Heel pad thickness and plantar fascia thickness were recorded using ultrasonography.

RESULTS

The ultrasonography results showed increased plantar fascia and heel pad thickness in the affected limb with plantar fasciitis than the normal one (p<0.001). The BMI was positively correlated with the heel pad thickness (p<0.05). The receiver operating characteristic (ROC) curve showed 90% sensitivity and 60% specificity for heel pad thickness (p<0.001).

CONCLUSIONS

Ultrasonography is a sensitive and specific tool to identify patients with plantar fasciitis.

Effects of dry needling and stretching exercise versus stretching exercise only on pain intensity, function, and sonographic characteristics of plantar fascia in the subjects with plantar fasciitis: a parallel single-blinded randomized controlled trial

OBJECTIVES

Plantar fasciitis is a common problem in the foot region which has negative considerable impact on foot function.

METHODS

In this parallel blinded randomized controlled trial, a total of thirty-seven subjects with plantar fasciitis (forty feet) were enrolled randomly to either the control group (stretching exercise) or the experimental group (stretching exercise plus dry needling). All interventions lasted six weeks and both groups were followed for two weeks. Primary outcomes were first step pain, pain, and activity daily function subscales of the FAOS questionnaire and secondary outcomes were plantar fascia thickness, and echogenicity.

RESULTS

The mixed model ANOVAs showed significant group × time interactions for all primary outcomes. In both groups, first step pain and both subscales of the FAOS questionnaire were improved compared to baseline measurements. There were considerable differences between the two groups and the experimental group experienced more improvements in primary outcomes compared to the control group. For secondary outcomes, plantar fascia thickness at insertion significantly decreased, and the echogenicity in the two regions significantly increased in the experimental group compared to the control group.

CONCLUSION

These results suggest that the combination of dry needling and stretching exercises can be an effective conservative treatment for plantar fasciitis subjects.

Particularities on Anatomy and Normal Postsurgical Appearances of the Ankle and Foot

The anatomy of the ankle and foot is complex, allowing for a wide range of functionality. The movements of the joints represent a complex dynamic interaction. A solid understanding of the characteristics and actions of the anatomic elements helps explain the mechanisms and patterns of injury. This article reviews the anatomy, with special focus on concepts that are the object of recent study and the features that favor the development of symptoms. Good understanding of the surgical procedures helps in providing information to guarantee a favorable outcome. We review the commonly expected postsurgical appearances and the most common postsurgical complications.

The effect of transcutaneous electrical nerve stimulation on pain and electrical stimulation muscle thickness in patients with non-specific chronic low back pain-based ultrasonographic evaluation

Aim: The existing mechanisms of transcutaneous electrical nerve stimulation (TENS) focuses more on the effect of neural tissue. This study investigated the effect of TENS on the thickness of the erector spinae muscles and reducing pain. Patients & methods: 56 individuals with low back pain participated in this single-blind, pre/post-test study. For 2 weeks, participants underwent ten sessions of TENS. The ultrasound evaluations examined the thickness of the erector spinae muscle, and the visual analog scale measured the severity of low back pain. Results: There was a decrease in pain score and muscle thickness after the interventions (p ≤ 0.004). There was also a strong correlation between reducing pain and decreasing muscle thickness (R = 0.709; p = 0.000). Conclusion: Following TENS in the lumbar, in addition to reducing pain, the thickness of the erector spinae muscles also decreased. Clinical Trial Registration: IRCT20200423047173N1 (ClinicalTrials.gov).

Anatomical features of plantar fasciitis in various age cohorts: Based on magnetic resonance imaging

BACKGROUND

Due to the lack of further studies on the influence of age factors on plantar fasciitis, this study evaluates the characteristic observation points of magnetic resonance imaging in various age cohorts of patients with plantar fasciitis to help diagnosis.

METHODS

A retrospective analysis of 160 cases of plantar fasciitis patients and normal subjects (who have the disease unrelated to plantar fasciitis) who have undergone an MRI examination in our institution. The two groups were separately divided into young adult subjects (36 to 44 years old), middle age adult subjects (45 to 59 years old), and older adult subjects (60 to 79 years old). Data was gathered regarding plantar fascia thickness, the coronal length of the plantar fascia at the calcaneal origin, the signal intensity of plantar fascia and surrounding structures, and the presence or absence of plantar calcaneal spurs, all of which were assessed objectively by the investigators.

RESULTS

There were statistical differences in the thickness of plantar fascia between two groups of three age cohorts (Older adult patients: 0.59 ± 0.09 cm; Middle age adult patients: 0.49 ± 0.09 cm; Young adult patients: 0.47 ± 0.05 cm) (all p < 0.001). In addition, there were also statistical differences in the high signal intensity changes of the plantar fascia and surrounding soft tissues between two groups of three age cohorts (all p < 0.001). In older adult plantar fasciitis patients, with regard to plantar calcaneal spur discovery, there was a statistical difference between the two groups (Chi-square = 12.799. df = 1. p < 0.001).

CONCLUSION

In plantar fasciitis cases where a diagnosis is difficult, abnormalities in the soft tissue surrounding the plantar fascia in patients of low age are noteworthy. In older adult patients, the discovery of plantar calcaneal spurs with abnormal thickening of plantar fascia deserves attention, and abnormal MRI findings are more manifest. But the final diagnosis should be based on the medical history.

LEVEL OF EVIDENCE

Level 3.

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.

Effect of Age and BMI on Sonographic Findings of Plantar Fascia

Biomechanical dysfunction of the foot is most common cause of plantar fascia disorder and obesity and increasing age are well-known risk factors. Due to being inexpensive and quick, ultrasound imaging techniques are considered the modality of choice to assess plantar fascia. The aim of this study was to investigate the effect of age and body mass index (BMI) on sonographic findings of plantar fascia in normal population. Ultrasonography was used to measure the plantar fascia thickness of 148 healthy adults (54 males, 36.5% and 94 females, 63.5%) during a period of one year. The age, BMI, and walking distance of each participant were recorded and statistically analyzed. The mean plantar fascia thicknesses at 0.5, 1.0, and 2.0 cm distal to the insertion of the plantar fascia were 1.76 ± 0.32 mm, 2.50 ± 0.50 mm and 2.11 ± 0.41 mm respectively. The mean plantar fascia thickness for individuals ≥45 years and BMI ≥25 were significantly higher (p < .001) compared to individuals <45 years and BMI <25. In a normal population, the thickness of the plantar fascia determined by ultrasound measurement was less than 3 mm. We recommend using the position 1.0 cm distal to the calcaneal insertion of the plantar fascia as the reference point for diagnosing plantar fasciitis. The thickness of plantar fascia was significantly increased with age and BMI whereas gender, walking activity, exercise and running did not seem to affect the plantar fascia thickness.

Radial Extracorporeal Shockwave Therapy (rESWT) is not superior to "minimal-dose" rESWT for patients with chronic plantar fasciopathy; a double-blinded randomised controlled trial

BACKGROUND

Investigating outcomes following radial-extra-corporeal-shockwave-therapy (rESWT) in patients with chronic plantar fasciopathy METHODS: This double-blinded RCT in a single NHS Sports medicine clinic recruited 117 patients with chronic plantar fasciopathy randomised equally to either 3 sessions of rESWT or "minimal-dose" respectively. Mean age 51.7 ± 9.6 years, 66 % female, symptom duration: 32.6 ± 30.8 months.

RESULTS

"Average pain" improved by 50 % at 6-months, (>1/3 at interim time-points). Statistically significant within-group improvements were identified in pain, local function, and "ability" PROMs in both groups. Fewer benefits in activity levels or mood. No between-group differences were seen at the interim or final time-points.

CONCLUSION

3 sessions of "recommended-dose" rESWT is non-superior to "minimal-dose" rESWT in patients with chronic plantar fasciopathy. rESWT may be ineffective in the treatment of patients with chronic plantar fasciopathy, "minimal-dose" rESWT may be sufficient for a therapeutic effect, or a greater number of treatment sessions may be required for benefit.

LEVEL OF EVIDENCE

Level I - Randomised controlled trial.

Presurgical Perspective and Postsurgical Evaluation of the Plantar Fascia

The plantar fascia is an important structure in the foot that acts as a major stabilizer of the longitudinal arch, along with the midfoot ligaments and intrinsic and extrinsic muscles. It is composed predominantly of longitudinally oriented collagen fibers that vary in thickness and are organized into bundles closely associated with the interstitial tissues of the foot. This composition enables the plantar fascia to withstand the weight-bearing forces concentrated on the foot while standing, jumping, walking, or running. This article discusses the normal anatomy and the various pathologies that affect the plantar fascia with an emphasis on presurgical and postoperative appearances on magnetic resonance and ultrasonography imaging.

Are models of plantar heel pain suitable for competitive runners? A narrative review

Background

Plantar heel pain (PHP), or plantar fasciopathy, is a common condition in active and sedentary populations, contributing to short- and long-term reductions in quality of life. The condition's aetiology and pathophysiology are the subjects of a significant body of research. However, much of this research has been conducted with sedentary participants, and comparatively little research exists in a population of highly-trained athletes focused on performance outcomes. Models for PHP and proposed mechanisms, such as high body mass index or systemic disease, are mostly absent from an athletic population. Even less is known about the origins of pain in PHP. Pain is believed to be a complex multifactorial process and may be experienced differently by sedentary and highly active populations, particularly endurance athletes. Consequently, conservative through to surgical treatment for athletes is informed by literature for a different population, potentially hindering treatment outcomes.

Aims

The aim of this review, therefore, is to summarise what is known about PHP in athletic populations and propose potential directions for future research.

Methods

Embase, PubMed, and Scopus using MeSH search terms for PHP and competitive sport and common synonyms.

Discussion

Two explanatory models for PHP were found. These primarily propose mechanical factors for PHP. It remains unclear how gait, body composition, and psychological factors may differ in an athletic population with and without PHP. Therefore, research in these three areas is needed to inform clinical and training interventions for this population.

Magnetic Resonance Neuroimaging Contrast Agents of Nanomaterials

Since the early 1980s when MRI imaging technology was put into clinical use, the number of MRI clinical tests has steadily increased by more than 10% every year. At the same time, exogenous MRI contrast agents have also been developed with the development of MRI technology. However, there are still challenges in the preparation of contrast agents for magnetic resonance imaging, such as how to prepare high-efficiency contrast agents with high stability and low biological toxicity. In order to study the contrast agent with simple preparation method, low cost, and good imaging effect, a magnetic resonance contrast agent was prepared by magnetic nanoparticles. By acting on magnetic resonance imaging detection method, and using polymer ligands to synthesize magnetic nanoparticles, experiments and tests of P(MA-alt-VAc) polymer ligand-modified magnetic nanoparticles were carried out. The experimental results showed that when nanoparticles containing different iron ion concentrations were incubated with DC 2.4 normal cells for 48 hours, the cell viability was still higher than 80% at concentrations up to 200 μm. It shows that the nanoparticle has high cell activity and good biological adaptability. The transverse relaxation (r²) value of the nanoparticles in aqueous solution at 37°C and 1.5 T magnetic field is 231.1 m⁻¹ s⁻¹, which is much higher than that of PTMP-PMAA (r² = 35.1 mM⁻¹ s⁻¹), which is also more than five times the relaxation of SHU-555C (r² = 44 mM⁻¹ s⁻¹). It shows that the nanoparticles prepared in this paper have good effect and can be used as a contrast agent in human brain for magnetic resonance imaging.

Clinical and Imaging Outcomes of Plantar Fasciotomy Using Microdebrider Coblation Wand

Background:

A plantar fasciotomy using a microdebrider coblation wand may be an effective treatment for treating chronic plantar fasciitis. The objective of this prospective study was to determine the success rate of performing a plantar fasciotomy using a microdebrider coblation wand to treat plantar fasciitis and determine utility of ultrasonographic imaging to evaluate for recovery after treatment.

Methods:

Patients with plantar fasciitis treated with a plantar fasciotomy using a microdebrider coblation wand were prospectively followed for 1 year. Outcome measures included numeric rating scale (NRS) for pain, Foot and Ankle Disability Index (FADI), the Foot and Ankle Ability Measure for activities of daily living (FAAMA) and for sports (FAAMS), and plantar fascia thickness evaluated with ultrasonographic imaging.

Results:

Forty patients were included. Average patient age was 53.4 ± 9.9 years. Average symptom duration prior to the procedure was 20 ± 26 months. Five patients dropped out of the study at various points, most due to the COVID quarantine. The mean preoperative NRS score was 4.7 and at 3 and 6 months postprocedure was ≤2. At 1 year, the outcomes were all improved compared to the preoperative status: NRS 0.7±1.3 (P < .001), FADI 107±16 (P < .001), FAAMA 95%±10% (P < .001), FAAMS 84%±19% (P < .001), and plantar fascia thickness 6.8 ± 1.2 mm (P = .014). Furthermore, 86% of patients had clinically successful outcome in pain, defined as NRS score ≤ 2 (95% CI 0, 2), and 91% of patients had a clinically successful outcome in their function, defined as having an FAAMA score ≥75%. There were no complications at the operative site either during or after the procedure.

Conclusion:

In this study of 40 patients followed prospectively, we found percutaneous plantar fasciotomy using a microdebrider coblation wand to be an effective treatment for plantar fasciitis, with a low incidence of complications. Ultrasonographic imaging may help evaluate for interval healing.

Level of Evidence: Level IV, prospective case series.

Myofascial points treatment with focused extracorporeal shock wave therapy (f-ESWT) for plantar fasciitis: an open label randomized clinical trial

BACKGROUND

Plantar fasciitis (PF) is a common cause of heel pain. Among the several conservative treatment options, extracorporeal shock wave therapy (ESWT) is considered the standard treatment. However, recent studies suggest that PF may be sustained by a myofascial impairment proximal to the pain area with a biomechanical disequilibrium of the entire limb and pelvis.

AIM

By combining the concepts of fascial manipulation and ESWT, the purpose of this study was to evaluate the effectiveness of the ESWT on myofascial points in a sample of subjects with PF.

DESIGN

Open label randomized controlled clinical trial.

SETTING

Outpatient clinic.

POPULATION

Patients with PF were randomly assigned to an experimental treatment group (EG), treated with focused ESWT on myofascial points, and a control group (CG), treated with the focused ESWT traditional approach on the medial calcaneal tubercle.

METHODS

Every patient underwent a 3-session program and follow-up after 1 and 4 months. Outcome measures included the Foot and Ankle Outcome Score (FAOS) and the Italian Foot Functional Index (17-iFFI).

RESULTS

Thirty patients were enrolled in the study. Four patients of the CG dropped out the study, therefore twenty-six patients were included in the final analysis. Improvement in 17-iFFI and FAOS scores was observed in both groups starting from the third treatment and confirmed at the 1-month and 4-month follow-ups, with earlier improvement in the score values observed in the EG.

CONCLUSIONS

Treatment of the myofascial points with ESWT in subjects suffering from plantar fasciitis could be an effective treatment option. It fosters the hypothesis that a global biomechanical re-equilibrium of the body would be necessary to completely solve the pathology.

CLINICAL REHABILITATION IMPACT

ESWT on myofascial points could provide an interesting alternative with better outcomes in terms of time needed for recovery compared to traditional ESWT for the conservative management of PF.

Current understanding of the diagnosis and management of the tendinopathy: An update from the lab to the clinical practice

Tendinopathy is labeled by many authors as a troublesome, common pathology, present in up to 30% medical care consultations involving musculoskeletal conditions. Despite the lasting interest for addressing tendon pathology, current researchers agree that even the exact definition of the term tendinopathy is unclear. Tendinopathy is currently diagnosed as a clinical hypothesis based on the patient symptoms and physical context. One of the main goals of current clinical management is to personalize treatment approaches to adapt them to the many different needs of the population. Tendons are complex structures that unite muscles and bones with two main objectives: to transmit forces and storage and release energy. Regarding the tensile properties of the tendons, several authors argued that tendons have higher tensile strength compared with muscles, however, are considered less flexible. Tendinopathy is an accepted term which is used to indicated a variety of tissue conditions that appear in injured tendons and describes a non-rupture damage in the tendon or paratendon, which is intensified with mechanical loading Even when the pathoetiology of tendinopathy is unclear, there is a wide array of treatments available to treat and manage tendinopathy. Although tendinitis usually debuts with an inflammatory response, the majority of chronic tendinopathies do not present inflammation and so the choosing of treatment should vary depending on severity, compliance, pain and duration of symptoms. The purpose of this article is to review and provide an overview about the currently research of the tendon diagnosis, management and etiology.

Magnetic resonance imaging of ankle disorders in adult Nigerians in Lagos

Objectives:

The aim of this study was to establish the frequency, distribution, and spectrum of abnormalities on ankle magnetic resonance imaging (MRI) in adult Nigerians.

Materials and Methods:

A retrospective analysis of ankle MRI of 50 adult patients was conducted at a single health facility. All adult Nigerians with complete clinical data, MRI images, and radiologists’ reports were included. The clinical history and ankle MRI findings were recorded and analysed. The threshold for statistical significance was established at P≤0.05.

Results:

There were 50 subjects comprising 27 males (54%) and 23 females (46%) aged 25–66 years (mean age = 42.84 ± 9.63 years). The right ankle was evaluated in 27 subjects (54%), while the left ankle was studied in 23 (46%). There was a history of trauma in 40 subjects (80%; 27 right ankles and 13 left ankles). Ankle joint effusion was the most common abnormality—seen in 50% of all subjects and in 62.5% of those with antecedent trauma. Achilles tendinosis and Kager (pre-Achilles) fat pad oedema (8–12%), deltoid ligament tear (8%), and medial malleolar fracture (4%) were the other frequently detected pathologies. The other pathologies detected were posterior tibial tendinosis (2%), plantar fasciopathy (2%), and talar contusion (2%). Joint effusion was significantly more prevalent in post-traumatic ankles than in the non-traumatic ankles and in the right ankles than the left ankles. There was no significant difference in the frequency of ankle abnormalities between the male and female subjects and between subjects younger than and older than the mean age.

Conclusion:

Joint effusion, deltoid ligament tear, and Achilles tendinopathy were the prevalent derangements in evaluated ankle joints. Trauma was the main indication for ankle MRI in this study.

Percutaneous plantar fasciotomy: An anatomical study about its safety and efficacy

BACKGROUND

Percutaneous plantar fasciotomy is one of the available options for recalcitrant cases of plantar fasciopathy, but there is a mismatch in the clinical results between different author's experience, possibly due to variability when choosing the exact cutaneous entry point. The purpose of this study is to validate the plantar approach in the surgical treatment of plantar fasciopathy, describing a safe path and cutaneous entry point to perform a percutaneous plantar fasciotomy with a 2 mm incision testing the procedure on cadavers.

METHODS

a unicentric cross-sectional analytical study was conducted in 12 cadaveric feet to verify the accuracy of the percutaneous fasciotomy entry point. Independent variables analysed were: extent of fasciotomy, entry point location, spur resection, and soft tissues injuries. A double evaluation was performed: an indirect evaluation under fluoroscopic vision, and a direct evaluation after anatomical dissection.

RESULTS

No cases of plantar cortical lesion on the calcaneus was observed. Satisfactory fasciotomy was performed in 91.7% of the cases. An optimal entry point was noticed in all cases with a mean distance to the tip of tibial malleolus of 22.5 mm (±6.9; 35.1-12.1) and a mean distance to foot midline of 7.8 mm (±1.7; 11.8-5.1). No neurological nor vascular lesions were found. In all the feet, a laceration of the plantar part of flexor digitorum brevis muscle was noted.

CONCLUSION

the plantar approach for percutaneous total plantar fasciotomy is a safe procedure. The current study provides an intraoperative guideline for minimising the possible risks.

Extracorporeal Shockwave Therapy Versus Ultrasound Therapy for Plantar Fasciitis: A Systematic Review and Meta-Analysis

The objective of this study was to compare the outcomes of extracorporeal shockwave therapy (ESWT) versus ultrasound therapy (UST) in plantar fasciitis. A systematic review and meta-analysis were performed. An electronic search identifying studies comparing ESWT and UST for plantar fasciitis was conducted. Primary outcomes were morning and activity pain, functional impairment, and the American Orthopaedic Foot and Ankle Society (AOFAS) scale score. Secondary outcomes included the fascial thickness, primary efficacy success rate, activity limitations, pain intensity, and satisfaction. Seven studies enrolling 369 patients were identified. No significant difference was found between ESWT and UST for functional impairment (mean difference [MD] = -2.90, P = 0.22), AOFAS scale score (MD = 35, P = 0.20), and pain in the first steps in the morning (MD = -4.72, P = 0.39). However, there was a significant improvement in pain during activity for the ESWT group (MD = -1.36, P = 0.005). For secondary outcomes, ESWT had improved results in terms of primary efficacy success rate, activity limitations, and patient satisfaction. The reduction of plantar fascia thickness showed no significant difference. Pain intensity after treatment had varied results amongst included studies. In conclusion, ESWT is superior to UST for plantar fasciitis as it improves pain activity and intensity, primary efficacy success rate, and activity limitations.

Ultrasonographic measurements of plantar fascia thickness and echogenicity in individuals with and without plantar fasciitis: Reliability and group differences

OBJECTIVE

Imaging techniques such as ultrasonography are beneficial for diagnosis of plantar fasciitis. The purpose of this study was to investigate intra-rater reliability of plantar fascia thickness and echogenicity in subjects with and without plantar fasciitis and to compare the measurements between the two groups.

DESIGN

Sonographic evaluation of the plantar fascia was performed in prone position in 20 subjects without plantar fasciitis and 20 subjects with plantar fasciitis. The outcome measures extracted from the ultrasound images included plantar fascia thickness at the insertion, 1 cm and 3 cm distal from the insertion and plantar fascia echogenicity. The reliability of outcome measures was estimated for both groups using absolute and relative reliability variables. The two groups were compared using analysis of variance (ANOVA).

RESULTS

ICCs _{(3, 3)} for intra-rater reliability of plantar fascia thickness and echogenicity were, respectively, ≥0.89 and ≥0.89 in the healthy controls and 0.87≥ and 0.90≥ in the plantar fasciitis group. The subjects with plantar fasciitis showed a thicker plantar fascia with lower echogenicity in all of measurement stations of plantar fascia compared to the healthy controls.

CONCLUSION

The results of the present study indicated that ultrasonography is a reliable method to measure plantar fascia thickness and echogenicity. Furthermore, the findings showed that plantar fascia is affected not only at its insertion but also in other points remote from the insertion in patients with plantar fasciitis. These findings support the diagnostic value of ultrasonography in therapy and research of the patients with plantar fasciitis.

Prediction of clinical response to corticosteroid or platelet-rich plasma injection in plantar fasciitis with MRI: A prospective, randomized, double-blinded study

PURPOSE

The purpose of this study was to identify association between magnetic resonance imaging (MRI) features and clinical data at baseline and six months following platelet-rich plasma (PRP) or corticosteroid (CS; cortivazol) injection in patients with plantar fasciitis, and to identify initial MRI criteria associated with a favorable clinical response to treatment.

MATERIAL AND METHODS

The study was registered on ClinicalTrials.gov (NCT03857334). MRI examinations of 36 patients with plantar fasciitis lasting more than 3 months who were randomly assigned to receive ultrasound-guided PRP (PRP group, 20 patients) or CS (CS group, 18 patients) injection were quantitatively and qualitatively analyzed with respect to plantar fascia thickness, plantar fascia hyperintensity on T2-weighted STIR (HSTIR) images, calcaneal bone marrow and surrounding soft tissues. Clinical evaluation including visual analytic scale (VAS) assessment and MRI examinations were obtained before and 6 months after treatment. Good clinical response was defined as pain VAS decrease > 50% at 6 months. ROC curves with AUC measurements were used to determine cut-off points.

RESULTS

In the whole study population, an association was found between MRI features (deep soft tissue and calcaneal bone marrow HSTIR) and pain VAS scores for the first steps of the day (P = 0.028 and P = 0.007, respectively). No significant radioclinical associations on post-treatment MRI examinations were found in either group. Initial coronal thickness of plantar fascia was associated with a good clinical response in the CS group (P < 0.01). ROC curve analysis found that 7-mm or thicker plantar aponeurosis at initial MRI was predictive of good clinical response in patients with CS treatment (Youden index = 0.6). PRP infiltrations were effective regardless of fascia thickness (73% of patients with ≤ 7 mm aponeurosis and 67% for thicker ones).

CONCLUSION

Initial facia thickness (> 7 mm) is predictive of good clinical response six months after CS injection, whereas PRP injection shows effectiveness regardless of fascia thickness.

Irregularity in Plantar Fascia, Muscle Edema and Tendon Thickness in Patients with High-Risk for Diabetic Foot

AIM

To investigate the alterations in the plantar fascia (PF), intrinsic muscles, and tendons in the feet of patients at high risk for developing diabetic foot.

METHODS

The healthy feet of 22 patients with type 2 diabetes, who had developed diabetic foot ulcers on a single foot without any pathology on the contralateral extremity, and those of 22 healthy volunteers were evaluated by magnetic resonance imaging. The volume of the Achilles tendon (AT), the surface area of the PF, the thickness of AT, flexor hallucis longus, flexor digitorum longus, tibialis posterior, and peroneus longus tendons, irregularity in the PF, and edema of intrinsic foot muscles were examined.

RESULTS

Nineteen patients (86%) had irregularity in the PF, whereas none of the healthy controls had any (p<0.001). Intrinsic muscle edema was more common in the group with diabetes (p=0.006). The volume of AT and the surface area of PF were decreased in patients with peripheral arterial disease (PAD) (p<0.05). Patients with diabetes mellitus but without PAD had a larger surface area of PF than that of controls (p<0.05). There were no differences in the volume of AT, the surface area of the PF, and other tendon thickness between the groups.

CONCLUSION

Irregularity in the PF and muscle edema may indicate a high risk for the diabetic foot. The presence of PAD may lead to regression in the structure of AT and PF.

Heel fat pad syndrome beyond acute plantar fascitis

Heel pain is a frequent cause of pain and disability in adult active population. In patients with this clinical presentation, several causes must be ruled out, among them plantar fasciitis the most common. Other etiologies of plantar heel pain are the entrapment of muscular branch of the lateral plantar nerve (Baxter nerve) or fat pad atrophy, being the last one the second cause of heel pain after plantar fasciitis. A case series of patients with pathological findings of the heel fat pad area using MRI and US to provide a differential diagnosis of heel pain. Observational case series study. Nine patients visited presented with pain in the plantar aspect of the heel. The plantar aspect of the heel was evaluated in detail with US and MRI. Main inclusion criteria were to present acute or chronic pain on the plantar aspect. In five cases the right heel was affected, in three cases the left heel. One case presented bilateral complaints. All patients presented mechanical pain. Specifically, four of them also described a constant clunk during footstep. Heel fat pad lesion was confirmed with MRI and US in the medial aspect, observed in five patients. In four patients, the heel fat pad was globally affected respectively. This case series tries to put some light on other heel conflicts beside plantar fasciitis that should be ruled out, being one of those, heel fat pad atrophy. Our presentation highlight the role that bed side ultrasound can play in the definition of a specific pattern confirmed with MRI after the US.

Therapeutic considerations for patients with chronic plantar fasciitis (Review)

Heel pain is a common complaint in the population, leading to a limitation in daily activities and a poor quality of life. Chronic plantar fasciitis is the most common cause of heal pain. Despite its name, which suggests inflammation, the underlying process is rather a degenerative one. The clinical course is often chronic or relapsing, as a challenge to physicians to find the most effective therapeutically approach. First-line treatment consists of rest, shoe modification, orthosis and physiotherapy. Physical exercise is an important tool which can be combined with other therapeutic options. Medication is usually administered in acute cases, in the form of simple analgesics, non-steroidal anti-inflammatory drugs (NSAIDs) or opioids, in different regimens. For chronic evolution, the use of NSAIDs is controversial. Second-line treatment includes extracorporeal shock wave therapy and corticosteroid local injection. New therapies have emerged, as autologous blood derivatives and prolotherapy, with growing evidence, to be included in clinical practice. The present review article discusses the therapeutic options for patients with chronic plantar fasciitis, to with an aim to shed light on the treatment strategies for this condition.

Dextrose prolotherapy versus radial extracorporeal shock wave therapy in the treatment of chronic plantar fasciitis: A randomized, controlled clinical trial

In the recent years, prolotherapy is increasingly being used in the field of musculoskeletal medicine. However, few studies have investigated its effectiveness in plantar fasciitis (PF). The purpose of this study was to compare the effectiveness of ultrasound-guided dextrose prolotherapy with radial extracorporeal shock wave therapy (ESWT) in the treatment of chronic PF. This randomized controlled trial was conducted on 59 patients with chronic PF. Patients were randomly assigned into two groups receiving three sessions of radial ESWT (29 patients) vs. two sessions of ultrasound-guided intrafascial 2 cc dextrose 20% injection (30 patients). The following outcome measures were assessed before and then six weeks and 12 weeks after the treatments: pain intensity by visual analog scale (VAS), daily life and exercise activities by Foot and Ankle Ability Measure (FAAM), and the plantar fascia thickness by ultrasonographic imaging. The VAS and FAAM scales showed significant improvements of pain and function in both study groups 6 weeks and 12 weeks after the treatments. A significant reduction was noted for plantar fascia thickness at these intervals (all p < .05). The inter-group comparison revealed that except for the FAAM-sport subscale which favored ESWT, the interaction effects of group and time were not significant for other outcome measures. Dextrose prolotherapy has comparable efficacy to radial ESWT in reducing pain, daily-life functional limitation, and plantar fascia thickness in patients with PF. No serious adverse effects were observed in either group. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

Plantar forefoot pain: ultrasound findings before and after treatment with custom-made foot orthoses

PURPOSE

No prior studies investigated the role of ultrasound in the assessment of response of patients undergoing treatment of metatarsalgia with custom-made orthoses. Our aim was to describe ultrasound findings of patients with plantar forefoot pain treated with custom-made foot orthoses.

METHODS

Twenty patients (15 females; mean age: 62.6 ± 11 years) affected by metatarsalgia in 27/40 feet underwent clinical evaluation before, three months and six months after treatment with custom-made full foot insole with a support proximal and an excavation below the painful metatarsals. Ultrasound was performed before and three months after the use of orthoses to examine the presence of intermetatarsal/submetatarsal bursitis, metatarsophalangeal joints effusion, anterior plantar fat pad oedema, flexor tendinitis/tenosynovitis, and Morton's neuroma. Outcome measures were clinical response with Foot Function Index (FFI)/Visual Analogue Scale (VAS) and ultrasound features changes.

RESULTS

Median VAS and FFI before treatment were 8[5-8.5] and 45.85[32.4-59.4], respectively. After 3 and 6 months of insoles use, both median VAS (2.5 [0-5] and 0 [0-2.75], respectively) and median FFI (7.9 [3.95-20] and 0 [0-3.95], respectively) showed a significant reduction in pain and disability (p < .001). Before treatment, ultrasound revealed 22 intermetatarsal bursitis, 16 submetatarsal bursitis, 10 joint effusions, 20 fat pad oedema, 3 flexor tendinitis/tenosynovitis and 3 Morton's neuromas. After 3 months of treatment, a significant decrease of intermetatarsal bursitis (7, p < .001) was observed. No significant changes were observed in any other ultrasound parameters.

CONCLUSION

Ultrasound might be able to detect some imaging features associated with the response of forefoot pain to custom-made foot orthoses, especially intermetatarsal bursitis.

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.

Development and Validation of a Novel Scoring System for Severity of Plantar Fasciitis

OBJECTIVES

Plantar fasciitis (PF) is the most common cause of heel pain. Though PF is self-limited, it can develop into chronic pain and thus treatment is needed. Early and accurate prognostic assessment of patients with PF is critically important for selecting the optimal treatment pathway. Nevertheless, there is no scoring system to determine the severity of PF and no prognostic model in choosing between conservative or surgical treatment. The study aimed to develop a novel scoring system to evaluate the severity of plantar fasciitis and predict the prognosis of conservative treatment.

METHODS

Data of consecutive patients treated from 2014 to 2018 were retrospectively collected. One hundred and eighty patients were eligible for the study. The demographics and clinical characteristics served as independent variables. The least follow-up time was 6 months. A minimal reduction of 60% in the visual analog scale (VAS) score from baseline was considered as minimal clinically important difference (MCID). Those factors significantly associated with achieving MCID in univariate analyses were further analyzed by multivariate logistic regression. A novel scoring system was developed using the best available literature and expert-opinion consensus. Inter-observer reliability and intra-observer reproducibility were evaluated. The appropriate cut-off points for the novel score system were obtained using receiver operating characteristic (ROC) curves.

RESULTS

The system score = VAS (0-3 point = 1; 3.1-7 point = 3; 7.1-10 point = 5) + duration of symptoms (<6 months = 1; ≥1 6 months = 2) + ability to walk without pain (>1 h = 1; ≤1 h = 4) + heel spur in X-ray (No = 0; Yes = 2) + high intensity zone (HIZ) in MRI (No = 0; Yes = 2). The total score was divided in four categories of severity: mild (2-4 points), moderate (5-8 points), severe (9-12 points), and critical (13-15 points). Inter-observer agreement with a value of 0.84 was considered as perfect reliability. Intra-observer reproducibility with a value of 0.92 was considered as perfect reproducibility. The optimum cut-off value was 10 points. The sensitivity of predictive factors was 86.37%, 84.21%, 91.22%, 84.12%, and 89.32%, respectively; the specificity was 64.21%, 53.27%, 67.76%, 62.37%, and 79.58%, respectively; the area under curve was 0.75, 0.71, 0.72, 0.87, and 0.77, respectively. The Hosmer-Lemeshow test showed a good fitting of the score system with an overall accuracy of 90.6%.

CONCLUSIONS

Based on prognostic factors, the present study establishes a novel scoring system which is highly comprehensible, reliable, and reproducible. This score system can be used to identify the severity of plantar fasciitis and predict the prognosis of conservative treatment accurately. The application of this scoring system in clinical settings can significantly improve the decision-making process.

ACR Appropriateness Criteria® Chronic Foot Pain

Chronic foot pain is a frequent clinical complaint, which can significantly impact the quality of live in some individuals. These guidelines define best practices with regards to requisition of imaging studies based on specific clinical scenarios, which have been grouped into different variants. Each variant is accompanied by a brief description of the usefulness, advantages, and limitations of different imaging modalities. The present narrative is the result of an exhaustive assessment of the available literature and a thorough review process by a panel of experts on Musculoskeletal Imaging. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.