Sonoelastography in the Evaluation of Plantar Fasciitis Treatment: 3-Month Follow-Up After Collagen Injection

Evaluation of the effectiveness of ultrasound-guided corticosteroid injection treatment in plantar fasciitis using shear wave elastography

PURPOSE

To evaluate the effectiveness of ultrasound-guided corticosteroid injection in patients with plantar fasciitis (PF) and assess changes in shear wave elastography (SWE) measurements and clinical outcomes.

METHODS

Between March and August 2024, 66 patients (aged 27 to 67 years) diagnosed with PF were enrolled in the study. Plantar fascia thickness, shear wave velocity (SWV) in meters per second (m/s), and Young's modulus in kilopascals (kPa) were measured before the injection and at a 1-month follow-up. The correlation of these measurements with the Visual Analog Scale (VAS, 0-10) and the American Orthopedic Foot and Ankle Society (AOFAS) scores was analyzed.

RESULTS

Before treatment, the plantar fascia thickness, SWV, and Young's modulus were recorded as 5.02 ± 0.66 mm, 2.37 ± 0.22 m/s, and 18.64 ± 3.28 kPa, respectively. At the 1-month follow-up, these values significantly changed to 3.53 ± 0.39 mm, 3.39 ± 0.32 m/s, and 35.49 ± 7.25 kPa, respectively (p < 0.001 for all). A significant reduction in plantar fascia thickness and a significant increase in SWV and Young's modulus were observed. Additionally, improvements in VAS and AOFAS scores were strongly correlated with increases in SWV and Young's modulus (VAS-m/s: r = -0.632, p = 0.011; AOFAS-m/s: r = 0.695, p = 0.001; VAS-kPa: r = -0.673, p < 0.001; AOFAS-kPa: r = 0.798, p < 0.001).

CONCLUSION

Ultrasound-guided corticosteroid injection significantly increased plantar fascia stiffness, and SWE measurements strongly correlated with clinical improvements. SWE proves to be a valuable adjunctive tool for evaluating treatment response in PF.

Efficacy of Ultrasound-Guided Injections of Type I Collagen-Based Medical Device for Greater Trochanteric Pain Syndrome: A Pilot Study

Background: Greater Trochanteric Pain Syndrome (GTPS) is a frequent clinical condition characterized by acute or chronic pain in the lateral region of the hip. This condition is primarily due to gluteus minimus and medius tendinopathy. Swine-derived type I collagen has shown a positive effect on tenocytes through in vitro studies and on tendinopathies in clinical studies. This pilot study aims to evaluate the clinical effects of swine-derived type I collagen injections on pain, hip function, and strength in GTPS patients. Methods: The study group was treated with three ultrasound-guided swine-derived type I collagen injections once a week for three consecutive weeks. The primary endpoint was pain reduction of at least 3 points on the Numeric Rating Scale (NRS) at ten weeks. Secondary endpoints were NRS average reduction at rest and palpation, modified Harris Hip Score (mHHS), abductor strength, and magnetic resonance imaging (MRI) improvement at six months. Results: 52 patients were screened, 47 enrolled, and 43 completed the study. The primary endpoint was reached by 60.5% of the patients. All secondary endpoints were also reached with statistical significance. Neither early nor late adverse effects were found. Conclusions: In this pilot study, ultrasound-guided peritrochanteric swine-derived type I collagen injections are safe and effective for most patients with GTPS included in the study. Further and more extensive confirmatory investigation studies with a longer follow-up are needed to confirm this pilot study's results and the clinical benefit's persistence.

Collagen Injections for Rotator Cuff Diseases: A Systematic Review

BACKGROUND

Because of its anatomy and function, the rotator cuff (RC) is vulnerable to considerable morbidity. The prevalence of RC diseases (RCDs) among the general population is 5-39%, reaching over 30% in patients older than 60. The aim of the present systematic review is to investigate the effects of the use of collagen injections in the treatment of RCDs.

METHODS

A systematic search of scientific electronic databases (such as PubMed, Scopus and Web of Science) was performed up to November 2024, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two independent authors conducted the search and assessed the articles. The inter-rater reliability for the quality assessment was measured using Cohen's kappa coefficient, while the Modified Coleman Methodology Score (CMS) was applied to evaluate the methodological quality of the articles included in this systematic review.

RESULTS

A total of eight articles were included, with the overall quality of the included articles being evaluated as fair. Despite the use of different types of collagen and injection protocols, as well as the different scores applied, each included study showed clinically relevant improvements. However, given the high degree of heterogeneity of the included studies, we cannot draw conclusions regarding which type of collagen and injection protocol are best for RCD treatment.

DISCUSSION

Collagen administration for RCDs seems to be effective at reducing pain and improving function, as well as the tendon structure, especially in partial tears and RC tendinopathy. High-quality, prospective studies with long-term follow-up are necessary to validate the findings of the articles included in this systematic review.

Short-term effects of 448 kilohertz radiofrequency stimulation on plantar fascia measured by quantitative ultrasound elastography and thermography on active healthy subjects: an open controlled clinical trial

Objective: This study is an open clinical trial. The aim of this study was to show the changes that occur in the viscoelastic properties of the plantar fascia (twenty healthy volunteers) measured by SEL and the changes in the plantar fascia temperature measured by thermography after the application of a 448 kHz capacitive resistive monopolar radiofrequency (CRMR) in active healthy subjects immediately after treatment and at the 1-week follow-up.

Methods: Furthermore, to analyze if an intervention with 448 kHz CRMR in the plantar fascia of the dominant lower limb produces a thermal response in the plantar fascia of the non-dominant lower limb. The final objective was to analyze the level of association between the viscoelastic properties of the PF and the temperature before and after the intervention with 448 kHz CRMR.

Results: Our results showed that a temperature change, which was measured by thermography, occurred in the plantar fascia after a single intervention (T0-T1) and at the 1-week follow up (T1-T2).

Conclusion: However, no changes were found in the viscoelastic properties of the plantar fascia after the intervention or at the 1-week follow up. This is the first study to investigate changes in both plantar fascia viscoelastic properties and in plantar fascia temperature after a radiofrequency intervention.

Effects of Paraspinal Intramuscular Injection of Atelocollagen in Patients with Chronic Low Back Pain: A Retrospective Observational Study

Background/Objectives: Atelocollagen is used for soft tissue repair and reconstruction by replacing defective or damaged muscles, membranes, ligaments, and tendons. This study aimed to evaluate the clinical efficacy and safety of additional paraspinal intramuscular injection of atelocollagen on lumbar epidural steroid injection for reducing pain and improving functional capacity of patients with chronic low back pain (CLBP). Methods: We retrospectively enrolled 608 consecutive patients with CLBP who received lumbar epidural steroid injection with or without additional paraspinal intramuscular injection of atelocollagen. The Numerical Rating Scale and the Oswestry Disability Index were used to assess pain and functional capacity, respectively, before the procedure, and three months after the injection. Also, we analyzed the relationship between the additional paraspinal intramuscular injection of atelocollagen and the success rate. Results: Both Numerical Rating Scale and the Oswestry Disability Index scores were significantly reduced in both groups at three months after injection. However, there was a significant difference between the two groups. Furthermore, the success rate was significantly higher in the additional paraspinal intramuscular injection of atelocollagen group. Conclusions: This study's results showed that additional paraspinal intramuscular injection of atelocollagen on lumbar epidural steroid injection reduced pain and improved functional capacity for patients with CLBP. Therefore, the paraspinal intramuscular injection of atelocollagen may be a promising option for the treatment of patients with CLBP.

The Intra-rater reliability and validity of ultrasonography in the evaluation of hypertrophic scars caused by burns

PURPOSE

Hypertrophic scars that occur after burns are less flexible and less elastic than normal skin. Objective measurement tools are required to assess hypertrophic scars after thermal injury. Cutometer® MPA 580 has been widely used for evaluating the properties of hypertrophic scars. Ultrasonography can evaluate elasticity, stiffness, and structure of tissues simultaneously using elastography and B-mode. This study aimed to investigate the intra-rater reliability and validity of elastography to visualize hypertrophic scars.

METHODS

Sixteen participants with a total of 96 scars were evaluated. The measurement sequence was elastography, Cutometer®, and elastography every 10 min. We then analyzed the intra-rater reliability using intraclass correlation coefficients (ICC). The results measured using elastography on the hypertrophic scars and surrounding normal skin were compared. The relationships between the elastographic and Cutometer® measurements using the 2-and 8-mm probes were compared.

RESULTS

The intra-rater reliability of elastographic measurements was acceptable for clinical use in terms of strain ratio (SR), shear-wave elastography (SWE), shear-wave speed (SWS), and SWE ratio ( ICC = 0.913, ICC=0.933, ICC = 0.842, and ICC = 0.921). The average SWS and SWE in hypertrophic scars were significantly greater than that for normal skin ( p < 0.001 and p < 0.001). SWE showed correlations with the R0 (r = -0.32, p = 0.002) and R8 (r = -0.30, p = 0.003) measured with the 8-mm probe. The SWE ratio was correlated with the R7 (r = -0.34, p = 0.001) measured with the 2-mm probe. The thickness of hypertrophic scars showed correlations with the R5 (r = 0.33, p < 0.001), R6 (r = 0.44, p < 0.001) and R8 (r = -0.35, p < 0.001) measured with the 8-mm probe. R0-R9 measured with 2-mm Cutometer® probes were not correlated with scar thickness ( r < 0.30, P > 0.05). The total scores of mVSS showed correlations with the R0 (r = 0.35, p < 0.001), R1(r = 0.32., p = 0.001), R3 (r = 0.38, p < 0.001), R4 (r = 0.38, p < 0.001), R8 (r = 0.34, p = 0.001), and R9 (r = 0.34, p = 0.001) measured with the 2-mm probe. R0-R9 measured with 8-mm Cutometer® probes were not correlated with mVSS ( r < 0.30, P > 0.05). The thickness of hypertrophic scars showed correlations with the SWE (r = 0.38, p < 0.001) and SWE ratio (r = 0.35, p < 0.001). Elastographic findings were not correlated with mVSS ( r < 0.30, P > 0.05).

CONCLUSION

In this study, together with the Cutometer®, ultrasound was confirmed as an evaluation tool that can objectively compare and analyze the difference between normal skin and hypertrophic scars.

An Update on the Clinical Efficacy and Safety of Collagen Injectables for Aesthetic and Regenerative Medicine Applications

Soft tissues diseases significantly affect patients quality of life and usually require targeted, costly and sometimes constant interventions. With the average lifetime increase, a proportional increase of age-related soft tissues diseases has been witnessed. Due to this, the last two decades have seen a tremendous demand for minimally invasive one-step resolutive procedures. Intensive scientific and industrial research has led to the recognition of injectable formulations as a new advantageous approach in the management of complex diseases that are challenging to treat with conventional strategies. Among them, collagen-based products are revealed to be one of the most promising among bioactive biomaterials-based formulations. Collagen is the most abundant structural protein of vertebrate connective tissues and, because of its structural and non-structural role, is one of the most widely used multifunctional biomaterials in the health-related sectors, including medical care and cosmetics. Indeed, collagen-based formulations are historically considered as the "gold standard" and from 1981 have been paving the way for the development of a new generation of fillers. A huge number of collagen-based injectable products have been approved worldwide for clinical use and have routinely been introduced in many clinical settings for both aesthetic and regenerative surgery. In this context, this review article aims to be an update on the clinical outcomes of approved collagen-based injectables for both aesthetic and regenerative medicine of the last 20 years with an in-depth focus on their safety and effectiveness for the treatment of diseases of the integumental, gastrointestinal, musculoskeletal, and urogenital apparatus.

The Prevalence and Risk Factors of Plantar Fasciitis Amongst the Population of Jazan

Background

Plantar fasciitis develops as a consequence of irritation of the plantar fascia, which is responsible for supporting the arches and absorbing shock. Multiple factors can contribute to plantar fasciitis, but the most common factor is overuse stress. The classical presentation is a sharp pain that is felt at the plantar aponeurosis (near the area of its insertion on the medial process of the calcaneal tuberosity), and it is possible to find a heel spur (osteophyte) in some cases. Most treatments for plantar fasciitis are ineffective and unsatisfactory for patients.

Objective

To estimate the prevalence and assess risk factors for plantar fasciitis among the population of the Jazan region.

Methods

A cross-sectional online survey was conducted on the population of the Jazan region. An online Google form questionnaire was prepared and distributed to the study population. Data was then entered and analyzed using IBM SPSS (Statistical Package for the Social Sciences) Statistics, version 21.0.

Results

A total of 695 participants were enrolled in the study. Out of that, 350 (50.4%) of the participants were males, while 345 (49.6%) were females. About the age of the participants, 507 (72.9%) were younger than 40 years of age. Participants with hypertension were 43 (6.2%), and 37 (5.3%) participants had diabetes. In terms of occupation, 120 (17.3%) worked in healthcare, 187 (26.9%) taught, and 43 (6.2%) served in the military. A great quantity of standing or walking was necessary for the jobs for 127 people (18.3%), while moderate amounts were recorded for 273 people (39.3%). The most commonly reported lower limb conditions were: pes planus (low arches) in 26 (3.7%) participants; and weakness of the gastrocnemius, soleus, and intrinsic foot muscles. The most commonly reported exercises were walking for 499 (71.8%) participants and jogging for 97 (14%) participants. The prevalence of plantar fasciitis was found to be 37% of the participants. Regarding the Foot and Ankle Outcome Score (FAOS) survey, the mean symptoms subscale score was 57.81 + 11.28, the mean pain subscale score was 72.87±20.84, the mean daily living subscale score was 72.73 ± 22.25, the mean sports and recreation subscale score was 76.83 ± 23.06, and the mean quality of life subscale score was 70.23 ± 25.17. Multivariate logistic regression was done and the following factors predicted a higher rate of plantar fasciitis: being 40 to 55 years old (p < 0.001, odds ratio = 2.15), being 56 to 65 years old (p = 0.037, odds ratio = 3.58), being obese (p = 0.031, odds ratio = 2.16), having weakness of the gastrocnemius, soleus, and the intrinsic foot muscles (p = 0.003, odds ratio = 7.39), jobs requiring a great amount of time standing or walking (p < 0.001, odds ratio = 3.17), and jobs requiring a moderate amount of time standing or walking (p = 0.012, odds ratio = 1.83). Being male predicted a lower rate of plantar fasciitis (p < 0.001, odds ratio = 0.52).

Conclusion

Plantar fasciitis is a prevalent and disabling condition with considerable effects on quality of life. Jobs that require long hours of walking or standing were associated with an increased risk of developing plantar fasciitis. Middle age, prolonged exercise, and gastrocnemius muscle tightness were also associated with plantar fasciitis. Efforts should be directed towards health education of the population regarding the risk factors and management of plantar fasciitis.

Ultrasound elastography for the evaluation of plantar fasciitis: A systematic review and meta-analysis

PURPOSE

This meta-analysis aimed to investigate the utility of ultrasound (US) elastography in the assessment of plantar fasciitis (PF).

METHODS

We searched PubMed, Embase, and Scopus and systemically reviewed clinical studies that used US elastography for imaging PF. The primary outcome was the comparison of plantar fascia stiffness between healthy controls and patients with PF, quantified using the weighted mean difference (WMD) and standardized mean difference (SMD).

RESULTS

Eleven studies were included in the final systematic review and meta-analysis. In six studies that employed shear wave elastography, patients with PF had a lower shear wave velocity, with a WMD of -1.772 m/s (95 % confidence interval [CI], -2.663 to -0.880) and an SMD of -1.239 m/s (95 % CI, -1.876 to -0.603), compared to those with asymptomatic heels. One study using the strain ratio showed that the WMD and SMD of patients with diseased heels vs healthy controls were -0.400 (95 % CI, -0.850 to 0.050) and -0.442 (95 % CI, -0.946 to 0.062), respectively. In six articles that use the color histogram of strain elastography, less stiffness was consistently reported in the diseased plantar fascia compared with healthy controls.

CONCLUSION

This meta-analysis showed that the plantar fasciae were less stiff in the PF group than in asymptomatic subjects. The diagnostic performance of US elastography (over B-mode) warrants further investigation.

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.

Intra-articular Injection of Type I Atelocollagen to Alleviate Knee Pain: A Double-Blind, Randomized Controlled Trial

OBJECTIVE

Collagen disruption is one of the underlying causes of knee pain in patients with osteoarthritis and/or diverse cartilage defects. Atelocollagen is a type of collagen that lacks telopeptides and thus has reduced antigenicity. The intra-articular injection of type I atelocollagen supplements collagen levels in the disrupted articular cartilage. This randomized controlled trial evaluated the effects of the intra-articular injection of atelocollagen for the management of knee pain.

DESIGN

Two hundred patients with osteoarthritis, chondromalacia, or other cartilage defects were randomly assigned to receive a 3-mL intra-articular injection of atelocollagen (BioCollagen group) or saline (Placebo group). Clinical improvement was evaluated over a 24-week period using the 100-mm visual analogue scale (VAS), the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), and the 36-item Short-Form Health Survey (SF-36).

RESULTS

VAS scores were significantly better in the BioCollagen group as compared with the Placebo group at 24 weeks. More patients in the BioCollagen group reported exceeding 20% and 40% VAS improvements. The WOMAC and SF-36 scores were also significantly improved from baseline after the intra-articular injection of atelocollagen; although, the differences between the BioCollagen and Placebo groups were not significant. There were no unexpected or severe adverse events reported for either group.

CONCLUSIONS

The results show that an intra-articular injection of atelocollagen effectively alleviates knee pain, as intended. Therefore, the intra-articular injection of atelocollagen can be considered an alternative solution to controlling knee pain due to osteoarthritis and diverse cartilage defects.

Shear wave elastography for treatment monitoring of plantar fasciitis

BACKGROUND

Plantar fasciitis is a common cause of heel pain. Monitoring therapy effects is challenging with conventional B-mode ultrasound. Shear wave elastography (SWE) provides important diagnostic information beyond B-mode, with typically lower tissue stiffness in symptomatic plantar fascia. Up to now little is known about SWE features for therapy monitoring in plantar fasciitis. We evaluated the clinical effects of a 3-month physical therapy based treatment and its influence on B-mode and SWE ultrasound findings in patients suffering from plantar fasciitis, correlating ultrasound findings to score-based symptom development.

METHODS

Prospective, IRB-approved clinical study in plantar fasciitis patients undergoing a 3-month physical therapy based treatment. Measurement time points were before (T0), after 1 (T1) and 3 (T2) months of treatment, consisting of clinical orthopedic (FFI, AOFAS-Score) and multimodal radiologic sonographic examinations (B-mode/SWE) using a high-resolution linear 18-MHz probe.

RESULTS

A total of 33 patients with 43 symptomatic plantar fascia were included. We found a significant (P<0.001) clinical score improvement (AOFAS +14, FFI-Pain -21, FFI-Function -18) between T0 and T2. Mean initial thickness (T0) of symptomatic plantar fascia was 4.2 (±1.2) mm, compared to 3.2 (±0.7) mm at the asymptomatic contralateral side (P<0.001). No significant thickness changes were seen at T1 (4.2±1.1 mm) and T2 (4.5±1.3 mm), even though clinical scores improved significantly. Mean initial stiffness (T0) of symptomatic plantar fascia was 59.57 (±43.3) kPa, compared to 83.23 (±47.3) kPa at the asymptomatic contralateral side (P<0.001). In contrast to B-mode ultrasound, SWE values increased significantly between T0 (59.6±43.3 kPa), T1 (82.6±47.3 kPa) and T2 (102.5±47.2 kPa) (P<0.001-0.009), with positive correlations for AOFAS/FFI-Pain/Function scores (r=0.285-0.473, P<0.001-0.002).

CONCLUSIONS

A physical therapy based treatment relieves plantar fasciitis symptoms during a 3-month period. In line with symptom reduction, stiffness (Young's-moduli) of plantar fascia increased significantly, while B-mode ultrasound revealed no measurable changes during the healing process. Shear wave elastography was able to quantify plantar fascia pathologies and their recovery under therapy.

Application of purified porcine collagen in patients with chronic refractory musculoskeletal pain

Background

This study aimed to assess the potential efficacy of purified porcine atelocollagen (PAC) for the management of refractory chronic pain due to suspected connective tissue damage.

Methods

Patients treated with PAC were retrospectively evaluated. Patients with chronic refractory pain, suspected to have originated from musculoskeletal damage or defects with the evidence of imaging studies were included. Pain intensity, using the 11-point numerical rating scale (NRS), was assessed before the procedure, and 1 month after the last procedure.

Results

Eighty-eight patients were finally included for investigation. The mean NRS score was decreased from 5.8 to 4.1 after 1 month of PAC injection (P < 0.001). No independent factor was reported to be directly related to the decrease in NRS score by more than half.

Conclusions

Application of PAC may have potential as a treatment option for refractory chronic musculoskeletal pain. PAC might promote tissue recovery, act as a scaffold for repair, or directly reduce inflammation.

Evaluation of plantar fascia using high-resolution ultrasonography in clinically diagnosed cases of plantar fasciitis

Purpose

The aim of this study was to assess the efficacy of high-resolution ultrasonography in the assessment of plantar fascia in individuals with heel pain, before and after treatment.

Material and methods

This study was conducted from 2016 to 2019, during which time 44 clinically diagnosed patients of plantar fasciitis were compared to 50 normal volunteers. There were 25 males and 25 females in the control group and 42 females and two males in the study group. Thirty-eight patients had unilateral disease, and six patients had bilateral disease. The thickness of the plantar fascia was measured just anterior to its calcaneal attachment using ultrasonography. Body mass index (BMI) was also calculated in both groups.

Results

The plantar fascia was 2-4 mm thick in the control group whereas it was > 4 mm thick in 48 heels in the study group. With cut-off of > 4 mm as diagnostic of plantar fasciitis, this study had a sensitivity of 96%, specificity of 100%, and accuracy of 98%. BMI was increased in 60% of female patients. All patients were treated with local infiltration of corticosteroid. In 37/42 patients (43 heels) who had improved clinically, the thickness of plantar fascia was reduced to < 4 mm when assessed after six weeks of corticosteroid injection.

Conclusions

Diagnosis of plantar fasciitis can be easily verified by ultrasonography with plantar fascia thickness > 4 mm being suggestive of plantar fasciitis. Ultrasound can also be used to evaluate treatment response. Ultrasono-graphy helps the clinician in confirming the diagnosis of plantar fasciitis and also in assessing the response to treatment.

Atelocollagen Injection Improves Tendon Integrity in Partial-Thickness Rotator Cuff Tears: A Prospective Comparative Study

Background:

Ongoing controversy surrounds the best treatment modality for partial-thickness rotator cuff tears.

Purpose:

To investigate the effects of atelocollagen injection in patients with small, symptomatic, intratendinous rotator cuff tears.

Study Design:

Randomized controlled trial; Level of evidence, 1.

Methods:

From January 2014 to December 2017, 94 patients who had small, symptomatic, intratendinous rotator cuff tears were enrolled and randomly allocated to 1 of 3 groups: intratendinous injection with 0.5 mL of type I atelocollagen (group 1, n = 32), intratendinous injection with 1 mL of type I atelocollagen (group 2, n = 30), and no injection of type I atelocollagen (group 3, n = 32). American Shoulder and Elbow Surgeons score, Constant Shoulder Score, visual analog scale pain score, and range of motion were evaluated before injection; at 3, 6, and 12 months after injection; and at final follow-up. Magnetic resonance imaging (MRI) was performed at least 6 months after injection to evaluate rotator cuff integrity.

Results:

Demographic data did not differ significantly among the 3 groups before injection (P > .05). The mean follow-up period was 24.7 months. The functional and pain scores in groups 1 and 2 were significantly improved at final follow-up (P < .05). No significant improvement was seen in functional or pain scores at final follow-up in group 3 (P > .05). Groups 1 and 2 had significantly better functional scores compared with group 3 at final follow-up (P < .05). The proportion of patients with a decrease in size of the torn tendon on follow-up MRI at least 6 months after atelocollagen injection was significantly higher in group 1 (28.1%; P = .02) and group 2 (36.7%; P = .003) compared with group 3 (6.3%).

Conclusion:

Atelocollagen injection can improve the functional outcome and integrity of the tendon in intratendinous rotator cuff tears.

Shear Wave Elastography (SWE) for the Evaluation of Patients with Plantar Fasciitis

RATIONALE AND OBJECTIVES

The current imaging standard for diagnosing plantar fasciitis is B-Mode ultrasound (B-US). The aim of this study was to determine the diagnostic potential of Shear Wave Elastography (SWE) and the correlation of clinical scores to elastographic parameters.

MATERIALS AND METHODS

Diagnostic case-control study with n = 82 plantar fascia (PF). PF were divided into three subgroups: (1) symptomatic PF (n = 39); (2) control group of unilateral asymptomatic PF (n = 23); (3) bilateral asymptomatic PF (n = 20). Reference standard for positive findings in B-US was a PF thickness greater than 4 mm. For SWE tissue elasticity (Young's modulus kPa; shear wave speed m/s) was measured at Location 1: directly at the calcaneus; Location 2: +1 cm distal of the calcaneus and Location 3: central part of the calcaneus. Sensitivity, specificity, and diagnostic accuracy as well as correlation to American Orthopaedic Foot and Ankle Score (AOFAS) and Food Functional Index (FFI) were determined.

RESULTS

Symptomatic PF are thicker (4.2 mm, n = 39) than asymptomatic (3.0 mm, n = 43) (p < 0.001). Thickness of the PF (n = 82) correlated poorly to clinical scores (p = 0.001): FFI-pain (r = 0.349); FFI-function (r = 0.381); AOFAS (r = -0.387). Cut-off point for positive SWE finding was 51.5 kPa (4.14 m/s). Symptomatic PF (31.9 kPa, 3.26 m/s, n = 39) differ significantly from asymptomatic PF (93.3 kPa, 5.58 m/s, n = 43) with significant differences at L1 between all groups (p < 0.001). Correlation between Young's modulus (n = 82) and clinical scores was strong (p < 0.001): FFI-pain (r = -0.595); FFI-function (r = -0.567); AOFAS (r = 0.623,). B-US: sensitivity (61%), specificity (95%); SWE sensitivity (85%), specificity (83%). The combination of SWE and B-US increases the sensitivity (100%) with a diagnostic accuracy of 90%.

CONCLUSION

Based on our results, we could show that SWE can improve the diagnostic accuracy in patients with plantar fasciitis compared to B-US.

LEVEL OF EVIDENCE

II.

Sonoelastographic evaluation of plantar fascia after shock wave therapy for recalcitrant plantar fasciitis: A 12-month longitudinal follow-up study

Extracorporeal shockwave therapy (ESWT) is proposed to be effective in reducing pain and improving functional outcome in chronic plantar fasciitis. However, no long-term reports exist on the changes in plantar fascia (PF) elasticity after ESWT. We aimed to evaluate the changes in PF stiffness in patients with plantar fasciitis undergoing ESWT. The visual analogue scale (VAS, 0–100) was used for evaluating heel pain severity. B-mode sonography and strain sonoelastography were used for evaluating the PF thickness and stiffness. The sonoelastogram was analyzed using hue histogram analysis (value: 0–255, from stiffer to softer). All evaluations were recorded before ESWT, and 1 week, 1 month, 3 months, 6 months, and 12 months after ESWT. Repeated measures ANOVA was used to compare pain VAS, PF thickness, and PF hue value at different follow-up time-points. Twenty-two participants (8 men, 14 women) completed all measurements for 12 months. The VAS of heel pain, PF thickness, and PF hue values at pre-ESWT, and 1-week, 1-month, 3-month, 6-month, and 12-month evaluations after ESWT were 62.4 ± 4.2, 49.3 ± 5.8, 38.3 ± 5.7, 27.9 ± 5.3, 18.9 ± 4.7, and 13.2 ± 3.0 (p < 0.01 in all measurements post ESWT versus pre-ESWT); 5.57 ± 0.22 mm, 5.64 ± 0.18 mm, 5.45 ± 0.24 mm, 5.37 ± 0.20 mm, 5.08 ± 0.20 mm, and 4.62 ± 0.15 mm (p < 0.01 at 6-month; otherwise p > 0.05); and 24.5 ± 2.4, 35.2 ± 3.1, 31.0 ± 4.1, 30.5 ± 3.9, 21.4 ± 2.1, and 15.9 ± 1.6 (p < 0.01 at 1-week and 6-month; otherwise p > 0.05), respectively. In conclusion, the heel pain intensity and PF thickness reduced gradually over 12 months after ESWT. The PF stiffness decreased during the first week and increased thereafter; at the 12-month follow-up, stiffness was more than at pre-ESWT.

Morphological and mechanical properties of plantar fascia and intrinsic foot muscles in individuals with and without flat foot

PURPOSE

Many musculoskeletal disorders are associated with over-pronated foot and decreased medial longitudinal arch (MLA) height. Foot intrinsic muscles and plantar fascia (PF) are the primary structures that support MLA. An important reason for the over-pronated foot and the reduction in the MLA height may be the morphological characteristics of the foot intrinsic muscles and PF as well as changes in their mechanical properties. The aim of the present study is to investigate the morphologic structure and mechanical properties of PF, flexor hallucis brevis (FHB), flexor digitorum brevis (FDB), and abductor hallucis (AbH) muscles in individuals with flat foot and to compare the results with those of healthy individuals.

METHODS

The study included 80 participants, 40 with flat foot and 40 with normal foot posture. The foot posture of the participants was assessed using the Foot Posture Index. PF, FHB, FDB, and AbH thickness and stiffness were measured with an ultrasonography device using a linear ultrasonography probe.

RESULTS

Individuals with flat foot had higher AbH thickness compared to individuals with normal foot posture ( p < 0.001), whereas both groups were similar in terms of PF ( p = 0.188), FHB ( p = 0.627), and FDB ( p = 0.212) thickness. Stiffness values of the assessed tissues were similar in both groups ( p > 0.05).

CONCLUSION

AbH thickness was higher in individuals with flat foot; however, PF, FHB, and FDB thickness were similar in both groups. In addition, our results suggest that foot posture is not related to the stiffness of the assessed tissues.

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.

Real-time sonoelastography: principles and clinical applications in tendon disorders. A systematic review

Background

Sonoelastography (SE) is a new ultrasound-based method adopted in an increased number of scientific reports to analyse normal and pathological tendons. The aim of this study is to provide a systematic overview of clinical applications of SE in normal and pathological tendons.

Methods

A systematic research of PubMed, Ovid, and Cochrane Library electronic databases was performed according to PRISMA guideline. Two Authors searched and evaluated the articles independently; a third Author was involved to solve any disagreement. The Oxford Level of Evidence (LoE) was used to assess each article.

Results

There is an increasing interest in the application of SE in the evaluation of healthy and diseased tendons. Many different tendons are amenable for SE evaluation, such as the Achilles and patellar tendons, rotator cuff, common extensor tendons, quadriceps tendon, and the plantar fascia.

Conclusion

SE appears to be a very useful diagnostic tool, in particular in tendon pathology. This is a dynamic examination, provides an immediate evaluation of the tissue elasticity, and may be useful in recognizing tendon abnormalities and in implementing the information available with conventional US.

Level of evidence

IV.