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

Outpatient Point-of-Care Ultrasound

The most commonly used outpatient primary care point-of-care ultrasound (POCUS) applications are similar to those used in the inpatient setting (eg, cardiac, pulmonary, and abdominal ultrasound). However, there are several additional POCUS applications that are highly applicable to the outpatient setting and should be considered for use by primary care practitioners. This article reviews 3 outpatient POCUS applications and their potential role in the primary care setting.

Effect of extracorporeal shockwave therapy on plantar fascia thickness in plantar fasciitis: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Extracorporeal shockwave therapy (ESWT) has been used as a therapeutic option for plantar fasciitis. The objective was to investigate the effect of ESWT over the plantar fascia thickness.

METHODS

MEDLINE, Embase, Web of Science, and SCOPUS databases were searched for randomized controlled trials evaluating the effect of ESWT in patients with plantar fasciitis, comparing ESWT with another treatment. Meta-analysis was conducted using a random-effects model and the generic inverse variance method. Meta-regression and subgroup analyses were also carried out.

RESULTS

A total of 14 studies (867 participants) were included. ESWT significantly decreased plantar fascia thickness (weighted mean difference [WMD], -0.21 mm [95% CI -0.39, -0.02]; p = 0.03). No significant improvement in pain was observed (WMD, -0.51 cm [95% CI -1.04, 0.01]; p = 0.06) compared with non-surgical interventions.

CONCLUSIONS

Our results suggest that plantar fascia thickness is significantly decreased after ESWT intervention in patients with plantar fasciitis. However, pain relief was not significantly improved compared to other non-surgical interventions.

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.

Prevalence of Sonographic Achilles Tendon, Patellar Tendon, and Plantar Fascia Abnormalities in Division I Collegiate Athletes From a Variety of Sports

OBJECTIVE

This study aimed to determine the prevalence of ultrasound abnormalities in the Achilles tendon, patellar tendon, and plantar fascia among a large cohort of collegiate student-athletes.

DESIGN

Observational cross-sectional study.

SETTING

Three Division I institutions.

PARTICIPANTS

243 student-athletes participated in this study. Exclusion criteria included those younger than 18 years or who underwent prior surgery/amputation of structures, including anterior cruciate ligament (ACL) surgeries with patellar tendon grafts.

INTERVENTIONS

Ultrasound examination of the Achilles tendon, patellar tendon, and plantar fascia of each leg was performed. An experienced sonographer reviewed each tendon video in a blinded manner, with a separate experienced sonographer separately reviewing to establish inter-rater reliability.

MAIN OUTCOME MEASURES

The primary outcome measured was the presence of any sonographic abnormality including hypoechogenicity, thickening, or neovascularity.

RESULTS

Ultrasound abnormalities were identified in 10.1%, 37.2%, and 3.9% of all Achilles tendons, patellar tendons, and plantar fasciae, respectively. Abnormalities were significantly associated with the presence of concurrent pain for all structures ( P < 0.01). Specifically, athletes with sonographic abnormalities were approximately 4 times [relative risk (RR) = 4.25; 95% confidence interval (CI), 2.05-8.84], 6 times (RR = 5.69; 95% CI, 2.31-14.00), and 5 times (RR = 5.17; 95% CI, 1.76-15.25) more likely to self-report pain in the Achilles tendon, patellar tendon, and plantar fascia, respectively.

CONCLUSIONS

This multi-institutional study completed at 3 Division I institutions is the largest study of its kind to identify the prevalence of sonographic abnormalities in the Achilles tendon, patellar tendon, and plantar fascia among collegiate student-athletes of various sports.

Ultrasound Strain Elastography Reliability in the Assessment of the Plantar Fascia and Its Relationship with the Plantar Thickness in Healthy Adults: An Intra and Interobserver Reliability Study in Novice Evaluators

PURPOSE

This study was aimed at verifying both the intraobserver and interobserver reliability of measuring plantar fascia stiffness for a given image in healthy active adults.

METHODOLOGY

This study is reported following the Guidelines of Reporting Reliability and Agreement Studies. A total of 20 plantar fascia from healthy volunteers were analyzed. The thickness of the plantar fascia was measured vertically from the anterior edge of the inferior calcaneal border to the inferior border of the plantar fascia and the ultrasound elastography measurement was taken at the calcaneal insertion of the plantar fascia with the region of interest one centimeter away from the insertion.

RESULTS

The ultrasound strain elastography measurements: the right intraobserver 1 showed an ICC value of 0.9 and the left intraobserver 1 showed an ICC value of 0.78, while the right intraobserver 2 showed an ICC value of 0.91 and the left intraobserver 2 showed an ICC value of 0.83. Interobserver measurements showed excellent reliability with a right ICC value of 0.8 and a left ICC value of 0.9 for the plantar fascia thickness measurements.

DISCUSSION

The results of this study showed a strong correlation between left and right plantar fascia thickness. The intraobserver reliability was excellent for both plantar fascia ultrasound strain elastography and thickness measurements, with interobserver measurements showing excellent reliability.

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.

Variations in the Thickness of the Plantar Fascia After Training Based in Training Race. A Pilot Study

Plantar fascia (PF) is a connective tissue made up of mostly type 1 collagen that is subjected to constant loads. This study evaluated the effect of continuous running on tissue stress in the PF by measuring changes in the thickness of the PF using ultrasound scans. It was a cross-sectional study involving 24 runners from the University of Valencia, recruited as volunteers between December 2018 and February 2019. A variety of data was recorded: (age, body mass index, type of footwear, number of workouts per week, KM run per week, sports injuries in the last year, pre and postrace ultrasound PF measurements). There were significant differences in the 3 postrace measurements of the left foot (<0.001). PF thicknesses were measured before and after running, with a minimal average difference of 0.4 mm in the medial and central fascicles, and 0.3 mm in the lateral fascicle. We observed PF thicknesses above 4mm in asymptomatic patients with no signs of vascularisation, proving that increased PF thickness is not the only criterion for diagnosis of plantar fasciitis.