Heel pain and body weight

Investigation of The Effectiveness of Extracorporeal Shock Wave Therapy in Patients Diagnosed with Plantar Fasciitis: Comparison of Radial and Focus Applications

The aim of the study was to investigate the effectiveness of radial and focus ESWT treatment on pain, function and size of the calcaneal spur in patients with clinical and radiological diagnosis of plantar fasciitis. A total of 112 patients aged between 18 and 95 years, were divided into two groups; group 1, rESWT (2.4 bar 12 hz 2000 beats), group 2 received fESWT (0.14 bar 14 hz 1000 beats) three times a week for three weeks. All patients were evaluated using the Visual Analog Scale (VAS)-pain and Foot Function Index (FFI) before and after the treatment, at 4 week and 12 weeks. Calcaneal spur size was measured radiographically in the patients before and after the treatment at the 12 th week follow-up. According to our records, VAS scores were found to be similar between the groups before treatment and at follow-ups (all p>0.05). In both groups, a significant decrease in VAS scores was found in the follow-ups compared to before treatment (p<0.001). FFI total, pain, activity and disability scores were found to be similar between the groups before treatment and at follow-up (all p>0.05). In both groups, a significant decrease in FFI scores was found in the follow-ups compared to before treatment (p<0.001). Both of rESWT and fESWT were effective in plantar fasciitis treatment there were no significiant difference between two modalities in long term. LEVEL OF CLINICAL EVIDENCE: III.

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.

A Step in the Right Direction: A Prospective Randomized, Controlled Crossover Trial of Autologous Fat Grafting for Rejuvenation of the Heel

BACKGROUND

The shock-absorbing soft tissues of the heel are composed of dermis and specialized fat pads. Heel fat pad atrophy is common and can be painful and debilitating. In our previous work, autologous fat grafting was effective for treating pain from forefoot fat pad atrophy.

OBJECTIVES

The authors hypothesized that autologous fat grafting to the heel would relieve pain and improve function in patients with heel fat pad atrophy.

METHODS

Patients with heel fat pad atrophy and associated pain were recruited and randomized into 2 groups. Group 1 received autologous fat grafting on enrollment and was followed for 2 years. Group 2 received offloading and activity modification for 1 year, then crossed over, underwent autologous fat grafting, and was followed for 1 year afterward. Outcome measures included ultrasound-measured fat pad and dermal thickness; pedobarograph-measured foot pressures and forces; and patient-reported outcomes as measured by the Manchester Foot Pain and Disability Index.

RESULTS

Thirteen patients met the inclusion criteria and completed the study. Seven (12 affected feet) were randomized into Group 1; and 6 (9 affected feet) were randomized into Group 2. The average age was 55 years and BMI was 30.5 kg/m2. Demographics did not significantly differ between groups. Heel fat pad thickness increased after autologous fat grafting but returned to baseline at 6 months. However, autologous fat grafting increased dermal thickness significantly and also increased fat pad thickness under a compressive load compared with controls at 6 and 12 months. Foot pain, function, and appearance were also significantly improved compared with controls at 6 and 12 months.

CONCLUSIONS

Autologous fat grafting improved patient-reported foot pain, function, and appearance and may rejuvenate local soft tissues in patients with heel fat pad atrophy.

LEVEL OF EVIDENCE: 3

Evolutionary anatomy of the plantar aponeurosis in primates, including humans

The plantar aponeurosis in the human foot has been extensively studied and thoroughly described, in part, because of the incidence of plantar fasciitis in humans. It is commonly assumed that the human plantar aponeurosis is a unique adaptation to bipedalism that evolved in concert with the longitudinal arch. However, the comparative anatomy of the plantar aponeurosis is poorly known in most mammals, even among non-human primates, hindering efforts to understand its function. Here, we review previous anatomical descriptions of 40 primate species and use phylogenetic comparative methods to reconstruct the evolution of the plantar aponeurosis and its relationship to the plantaris muscle in primates. Ancestral state reconstructions suggest that the overall organization of the human plantar aponeurosis is shared with chimpanzees and that a similar anatomical configuration evolved independently in different primate clades as an adaptation to terrestrial locomotion. The presence of a plantar aponeurosis with clearly developed lateral and central bands in the African apes suggests that this structure is not prohibitive to suspensory locomotion and that these species possess versatile feet adapted for both terrestrial and arboreal locomotion. This plantar aponeurosis configuration would have been advantageous in enhancing foot stiffness for bipedal locomotion in the earliest hominins, prior to the evolution of a longitudinal arch. Hominins may have subsequently evolved thicker and stiffer plantar aponeuroses alongside the arch to enable a windlass mechanism and elastic energy storage for bipedal walking and running, although this idea requires further testing.

Plantar fasciitis in physicians and nurses: a nationwide population-based study

Physicians and nurses in Taiwan have heavy workload and long working hours, which may contribute to plantar fasciitis. However, this issue is unclear, and therefore, we conducted this study to delineate it. We conducted a nationwide population-based study by identifying 26,024 physicians and 127,455 nurses and an identical number of subjects for comparison (general population) via the National Health Insurance Research Database. The risk of plantar fasciitis between 2006 and 2012 was compared between physicians and general population, between nurses and general population, and between physicians and nurses. We also compared the risk of plantar fasciitis among physician subgroups. Physicians and nurses had a period prevalence of plantar fasciitis of 8.14% and 13.11% during the 7-yr period, respectively. The risk of plantar fasciitis was lower among physicians (odds ratio [OR]: 0.660; 95% confidence interval [CI]: 0.622-0.699) but higher among nurses (OR: 1.035; 95% CI: 1.011-1.059) compared with that in the general population. Nurses also had a higher risk than the physicians after adjusting for age and sex (adjusted odds ratio [AOR]: 1.541; 95% CI: 1.399-1.701). Physician subspecialties of orthopedics and physical medicine and rehabilitation showed a higher risk. Female physicians had a higher risk of plantar fasciitis than male physicians. This study showed that nurses, physician specialties of orthopedics and physical medicine and rehabilitation, and female physicians had a higher risk of plantar fasciitis. Improvement of the occupational environment and health promotion are suggested for these populations.

The thickness of heel fat-pad in patients with plantar fasciitis

Objective

The aim of this study was to investigate the thickness of heel fat pad (THP) and to detect the relationship between the plantar fasciitis (PF) and age, occupation, BMI, longitudinal arch, the thickness of heel fat-pad in the patients with PF.

Methods

A total of 50 patients (29 women and 21 men; mean age: 46.5 years (range: 22–70)) that were diagnosed with PF were included to this study. Patients' affected side were compared with the healthy opposite side with the angle of medial arch (AMA) and first metatarsophalangeal angle (FMTPA) on the foot radiograms, and THP and thickness of first metatarsal fat pad (TFMFP) using ultrasonography (USG) of both feet.

Results

The mean AMAs of feet with pain and without pain were 122.56° and 120.60°, respectively. The mean FMTPAs of feet with pain and without pain were 14.72° and 14.40°, respectively. The mean THPs of feet with pain at the point of the medial calcaneal tubercle and the mean TFMFPs of the feet with pain at the point of the first metatarsal head were 19.45 mm and 6.75 mm, respectively. The mean THPs of feet without pain at the point of the medial calcaneal tubercle and the mean TFMFPs of the feet without pain at the point of the first metatarsal head were 19.94 mm and 6.75 mm, respectively. It was observed that the mean AMA in the heels with pain was significantly higher than that of the heel without pain (p < 0.05) and the mean THP in the heels with pain was significantly thinner than that of the heel without pain (p < 0.05).

Conclusion

The results indicate that USG is an accurate and reliable imaging technique for the measurement of THP in the diagnosis of plantar fasciitis and the heel pad was thinner in the painful heels of patients with plantar fasciitis.

Level of evidence

Level III, Diagnostic Study.

Plantar fasciitis in patients with type 1 and type 2 diabetes: A contemporary cohort study

OBJECTIVE

Hyperglycemia leads to increase advanced glycation end products (AGEs) in patients with type 1 and type 2 diabetes. Subsequently, formation of AGEs can cause increased plantar fascial thickness (PFT), an imaging feature of plantar fasciitis (PF). This study evaluates the prevalence of PF in a contemporary cohort of type 1 diabetes and type 2 diabetes patients managed according to current standards, compared to patients without diabetes.

RESEARCH DESIGN AND METHODS

This is a five-year prevalence study in a large tertiary health system (approximately 535,000 patients/visits/year) with a single electronic medical record (EMR), applying a cohort discovery tool and database screen (Data Direct) with use of ICD-9 and ICD-10 codes. All patients with a PF diagnosis between 01/01/2011 and 01/01/2016 were included and divided into 3 groups: type 1 diabetes (7148 patients), type 2 diabetes (61,632 patients), and no diabetes (653,659 patients). Prevalence rates were calculated, accounting for other risk factors including BMI and gender using Fisher's exact test.

RESULTS

The overall prevalence of PF in the entire study population was 0.85%. Prevalence rates were higher in patients with diabetes, particularly with type 2 diabetes (42% and 64% higher compared with patients with type 1 diabetes and no diabetes respectively). Individually, PF rates were 0.92% in type 1 diabetes and 1.31% in type 2 diabetes compared with 0.80% in patients with no diabetes (Type 1 vs. no diabetes p = 0.26; Type 2 vs. no diabetes p ≪ 0.0001; Type 1 vs. Type 2 diabetes p = 0.0054). Females in all groups had higher prevalence of PF than males (p ≪ 0.0001 for all), with those patients with diabetes having higher prevalence rates than those without diabetes. Patients with higher BMI levels (BMI ≥ 30 kg/m²) were also more likely to have PF in all categories except males with type 1 diabetes (p = 0.40).

CONCLUSIONS

In this large contemporary population managed in a tertiary health system, prevalence rates of PF were substantially higher in patients with diabetes compared with no diabetes, particularly in type 2 diabetes. Female gender and higher BMI were also associated with higher prevalence of PF in this cohort.

Calcaneal osteochondroma masquerading as plantar fasciitis: An approach to plantar heel pain - A case report and literature review

BACKGROUND

Heel pain is a common orthopaedic complaint, and if left untreated can be a source of chronic morbidity. Accurate diagnosis can be challenging, owing to the complex anatomy and multiple pain generators present in the foot. We aim to share our clinical experience managing an unusual case of chronic heel pain secondary to osteochondroma.

CASE SUMMARY

A 41-year-old obese male who works as a porter presented with a long-standing history of left plantar heel pain. He was assessed to have point tenderness over the plantar insertion of the calcaneus as well as a positive Silfverskiöld test. He was treated for plantar fasciitis and tight gastrocnemius but failed conservative therapies as well as surgical intervention. Magnetic resonance imaging revealed the presence of a pedunculated bony protrusion over the plantar aspect of the calcaneus. The decision was made for excision of the osteochondroma, and the patient has been pain-free since.

CONCLUSION

Osteochondromas are rarely symptomatic in skeletally mature patients. While most are benign with a very low risk of malignant transformation, surgical excision can yield excellent results and significant pain relief in symptomatic patients.

Should I Stay or Should I Go? A Prospective, Blinded Study Comparing the Diagnostic Capability of Dynamic and Stationary Pedobarography in Plantar Fasciitis

The aim of this study was to determine the diagnostic capability of a dynamic gait analysis insole and compare its ability to detect clinical correlations to a common stationary analysis tool. Twenty-five patients with chronic plantar fasciitis were included in this prospective, blinded, diagnostic study. Conventional, stationary gait analysis on a force plate on an even surface and continuous dynamic pedobarography on a standardized course consisting of different gait tasks were performed and correlated to the disease severity. Mean patient age was 53.6 (range 41 to 68) years, with a mean pain level of 6.1 (range 4 to 10) on the Visual Analogue Scale and a calcaneodynia score of 48.7 (range 33 to 66). Significant correlations were seen between several dynamic gait values and clinical scoring: cadence (r_s = 0.56, p = .004), stance time (r_s = -0.6, p = .002), center-of-pressure velocity (r_s = 0.44, p = .046), and double support time (r_s = 0.42, p = .042). No significant correlations were seen between any force plate gait analysis values and clinical scoring. In this study setting, dynamic gait analysis was able to identify clinically relevant correlations to plantar fasciitis disease severity that standard force plate measurements could not.

Gastrocnemius recession for recalcitrant plantar fasciitis in overweight and obese patients

BACKGROUND

Plantar fasciitis is a common foot pathology that is typically treated non-operatively. However, a minority of patients fail non-operative management, develop chronic symptoms, and request a surgical option. Gastrocnemius recession has recently been shown to be effective for the treatment of chronic plantar fasciitis. The purpose of this paper is to present evidence that gastrocnemius recession is safe and effective in the subset of chronic plantar fasciitis patients who are overweight and obese.

METHODS

We retrospectively reviewed 18 cases (17 patients) of chronic plantar fasciitis in overweight or obese patients who underwent gastrocnemius recession (mean age=46years, mean body mass index=34.7kg/m², mean follow-up=20months). Data was gathered regarding pre-operative and post-operative pain (visual analog scale, 0-10), Foot Function Index score, and complications.

RESULTS

Mean Foot Function Index score improved from 66.4 (range, 32.3-97.7) preoperatively to 26.5 (range, 0-89.4) postoperatively (p<0.01). Mean pain score improved from 8.3 (range, 5-10) preoperatively to 2.4 (range, 0-7) at final follow-up (p<0.01).

CONCLUSIONS

Gastrocnemius recession improved foot function and pain symptoms in overweight and obese patients with chronic plantar fasciitis.

American College of Foot and Ankle Surgeons Clinical Consensus Statement: Diagnosis and Treatment of Adult Acquired Infracalcaneal Heel Pain

Adult acquired inferior calcaneal heel pain is a common pathology seen in a foot and ankle practice. A literature review and expert panel discussion of the most common findings and treatment options are presented. Various diagnostic and treatment modalities are available to the practitioner. It is prudent to combine appropriate history and physical examination findings with patient-specific treatment modalities for optimum success. We present the most common diagnostic tools and treatment options, followed by a discussion of the appropriateness of each based on the published data and experience of the expert panel.

Comparison of Plantar Fasciitis Injected With Platelet-Rich Plasma vs Corticosteroids

BACKGROUND

Plantar fasciitis is one of the most common causes of heel pain. This prospective study compared the efficacy of local injection of corticosteroids vs platelet-rich plasma (PRP) in the treatment of plantar fasciitis.

METHODS

Patients were randomly allocated into 2 groups of 40 each (group A and group B). Patients were treated with local corticosteroid injection in group A and autologous PRP injection in group B. Clinical assessment was done prior to the injection and at 1 month, 3 months, and 6 months following the injection, which included visual analog pain scale, subjective rating using the modified Roles and Maudsley score, functional outcome score by the Foot and Ankle Outcome Instrument (FAI) core scale, and the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale. Radiological assessment was done by measuring the thickness of the plantar fascia using ultrasonography. The mean age, sex, and body mass index of both groups were comparable.

RESULTS

Postinjection, there was significant improvement of visual analog score, modified Roles and Maudsley score, FAI core scale, AOFAS ankle-hindfoot score, and plantar fascia thickness in both the groups. However, with the numbers available, no significant difference in improvement could be detected between the above-mentioned variables in the 2 groups.

CONCLUSION

We found that the treatment of plantar fasciitis with steroid or PRP injection was equally effective.

LEVEL OF EVIDENCE

Level II, prospective randomized comparative series.

Development of a clinical prediction rule to identify patients with plantar heel pain likely to benefit from biomechanical anti-pronation taping: A prospective cohort study

OBJECTIVES

To develop a clinical prediction rule (CPR) to identify patients with plantar heel pain (PHP) likely to benefit from biomechanical anti-pronation taping (BAPT).

DESIGN

A prospective cohort study.

SETTING

An outpatient rehabilitation department in a general hospital.

PARTICIPANTS

Seventy-five patients with PHP.

MAIN OUTCOME MEASURES

After completing a series of physical examinations, all patients received BAPT and were evaluated with a numeric rating scale for pain intensity, the patient-specific functional scale and foot function index (FFI) for function, and the global rating of change for perceived improvement.

RESULTS

Twenty-eight patients achieved a successful outcome. A CPR with 6 significant variables was identified by a multivariate logistic regression: FFI score less than 33.3, hip adduction angle of the most affected side was greater than the contralateral side, ankle plantarflexors and hip abductors on the most affected side were not weaker than those on the contralateral side, ankle invertors on the most affected side were weaker than the contralateral side, and having more than 2 painful sites in the low back and lower extremity regions. If 5 or more of the 6 predictors were presented, the probability of success increased from 37% to 80%.

CONCLUSIONS

A CPR has been developed to identify patients with PHP likely to benefit from BAPT.

The effectiveness of raising the heel height of shoes to reduce heel pain in patients with calcaneal spurs

[Purpose] To investigate the effect of heel height on the distribution of plantar foot force and heel pain in patients with a heel spur. [Subjects and Methods] Plantar force was measured using 8 force sensors in 16 patients (3 men, 13 women), with symptomatic heel spur for 4 heel heights (0-4 cm). Sensors were located at the hallux (T1); medial to lateral metatarsals (M1 through M3), mid-foot (MF); and at the central, lateral, and medial heel (CH, LH, and MH). Pain was evaluated using the minimum compression force that caused pain and was measured using an algometer. [Results] Load bearing shifted from the heel (CH) to the mid-foot (MF) and hallux (T1) with increasing heel height. Raising the heel from 2 to 3 cm reduced the magnitude of load bearing, relative to the minimum compression force for pain, by 3.70% at the LH and 2.35% at the MH. Excellent clinical outcomes, defined by a 70-100% decrease in pain, were achieved in 10/16 participants with the use of a 2-cm and 3-cm heel height in men and women, respectively. [Conclusion] Increasing heel height effectively decreases the plantar force on the heel during weight-bearing activities.

Efficacy of PU foam materials for scientific investigation in footwear research

People across the world are primarily concerned with the importance of inserts in footwear in terms of their effectiveness to accomplish therapeutic benefits. Body weight has been implicated as a factor in plantar heel pain, and foot orthoses are commonly used in its conservative treatment and are helpful in reducing symptoms of strain in the fascia during standing and ambulation. It is necessary to investigate the effectiveness of footwear inserts and their impact especially for people with high body mass index (BMI). Hence, research on polyurethane (PU) foams is warranted to identify an ideal material that provides comfort for high-BMI individuals. This article presents details on the physical characteristics of PU foam and its efficacy on functional performances as footwear inserts. PU foam materials have been assessed on various physical characteristics such as density, hardness, compression set followed by resilience, and cushioning behaviors. Of the four densities evaluated, D120 has the highest resilience on static and dynamic conditions. The cushion energy behaviors with respect to walking/running on static and dynamic condition were superior, as they possess better cushioning performance on footwear applications. Hence, the D120 PU foam material is concluded to be the best material for footwear insert for alleviating foot and ankle pain-related problems and for providing therapeutic benefits to high-BMI individuals.

High Prevalence of Obesity and Female Gender Among Patients With Concomitant Tibialis Posterior Tendonitis and Plantar Fasciitis

The link between increased body weight and hindfoot complaints is largely based on correlation to single foot pathology. We retrospectively reviewed 6879 patients with tibialis posterior tendonitis (TPT), plantar fasciitis (PF), or both. Among patients with either TPT or PF, 1 in 11 (9%) had both. We then compared age, gender, and body mass index among these groups. Patients with both diagnoses were neither statistically older nor more obese than patients with single diagnoses. However, they were statistically more female. Given the overall high prevalence of obesity in the study population, we feel these data support the link between obesity and multiple foot pathology.

LEVELS OF EVIDENCE

Prognostic, Level IV: Case series.

Sonoelastography of Plantar Fascia: Reproducibility and Pattern Description in Healthy Subjects and Symptomatic Subjects

The purpose of the work reported here was to describe the sonoelastographic appearance of the plantar fascia of healthy volunteers and patients with fasciitis. Twenty-three healthy subjects and 21 patients with plantar fasciitis were examined using B-mode and real-time sonoelastography (RTSR) scanning. B-Mode examination included fascia thickness and echotexture. Echogenicity and echovariation of the color histogram were analyzed. Fasciae were classified into type 1, blue (more elastic); type 2, blue/green (intermediate); or type 3, green (less elastic). RTSE revealed 72.7% of fasciae as type 2, with no significant association with fasciitis (χ(2) = 3.6, df = 2, p = 0.17). Quantitative analysis of the color histogram revealed a significantly greater intensity of green (mean = 77.8, 95% confidence interval [CI] = 71.9-83.6) and blue (mean = 74.2, 95% CI = 69.7-78.8) in healthy subjects. Echovariation of the color red was 33.4% higher in the fasciitis group than in the healthy group (95% CI = 16.7-50.1). Sonoelastography with quantitative analysis of echovariation can be a useful tool for evaluation of plantar fascia pathology.

Plantar fasciopathy: revisiting the risk factors

BACKGROUND

Plantar fasciopathy is the most common cause of acquired sub-calcaneal heel pain in adults. To-date, research of this condition has mainly focused on management rather than causal mechanisms. The aetiology of plantar fasciopathy is likely to be multifactorial, as both intrinsic and extrinsic risk factors have been reported. The purpose of this review is to critically reevaluate risk factors for plantar fasciopathy.

METHODS

A detailed literature review was undertaken using English language medical databases.

RESULTS

No clear consensus exists as to the relative strength of the risk factors reported.

CONCLUSIONS

To-date numerous studies have examined various intrinsic and extrinsic risk factors implicated in the aetiology of plantar fasciopathy. How these factors interact may provide useful data to establish an individuals' risk profile for plantar fasciopathy and their potential for response to treatment. Further research is indicated to rank the relative significance of these risk factors.

Surgical stabilization of calcaneal fat pad for treatment of structural insufficiency and instability

Level of Evidence: V, Expert Opinion

Reproducibility of sonographic measurement of thickness and echogenicity of the plantar fascia

BACKGROUND

To evaluate the intra- and interrater reliability of ultrasonographic measurements of the thickness and echogenicity of the plantar fascia.

METHODS

Eleven patients (20 feet), who complained of inferior heel pain, and 26 volunteers (52 feet) were enrolled. Two sonographers independently imaged the plantar fascia in both longitudinal and transverse planes. Volunteers were assessed twice to evaluate intrarater reliability. Quantitative evaluation of the echogenicity of the plantar fascia was performed by measuring the mean gray level of the region of interest using Digital Imaging and Communications in Medicine viewer software.

RESULTS

Sonographic evaluation of the thickness of the plantar fascia showed high reliability. Sonographic evaluations of the presence or absence of hypoechoic change in the plantar fascia showed surprisingly low agreement. The reliability of gray-scale evaluations appears to be much better than subjective judgments in the evaluation of echogenicity. Transverse scanning did not show any advantage in sonographic evaluation of the plantar fascia.

CONCLUSIONS

The reliability of sonographic examination of the thickness of the plantar fascia is high. Mean gray-level analysis of quantitative sonography can be used for the evaluation of echogenicity, which could reduce discrepancies in the interpretation of echogenicity by different sonographers. Longitudinal instead of transverse scanning is recommended for imaging the plantar fascia.

The short-term effects of treating plantar fasciitis with a temporary custom foot orthosis and stretching

STUDY DESIGN

Prospective single-group cohort study.

OBJECTIVES

To identify the effectiveness of a temporary custom foot orthosis (TCFO), followed by a stretching program, for the treatment of plantar fasciitis (PF).

BACKGROUND

PF, a common cause of heel pain, often leads to disability. Optimal treatment for this often challenging clinical condition is still unknown.

METHODS

Fifteen individuals with PF were recruited from the general public. All participants received a TCFO and were instructed to wear it for 2 weeks while weight bearing. Following the initial 2 weeks, participants were weaned off of the TCFO and instructed to begin a daily stretching program. Follow-up appointments occurred at 2, 4, and 12 weeks. The primary outcome measures included first-step heel pain via numeric pain rating scale (NPRS), the Foot and Ankle Ability Measure activities of daily living subscale (FAAM-A), and the Foot and Ankle Ability Measure sports subscale (FAAM-S). Secondary outcome included the global rating of change (GRC) score.

RESULTS

Individuals with a primary complaint of plantar foot pain entered and completed this study. Repeated-measures ANOVAs for the NPRS, FAAM-A, and FAAM-S showed statistically significant changes (P<.001). Post hoc analysis using paired t tests demonstrated statistically and clinically significant change at all follow-up times, compared to the initial intervention (P<.001). Mean GRC scores at 2, 4, and 12 weeks were 4.4, 4.5, and 4.2, respectively.

CONCLUSION

In treating PF, a TCFO used for 2 weeks, followed by a stretching program, provided preliminary evidence that first-step heel pain and foot and ankle function improve in the short term and up to 12 weeks.

LEVEL OF EVIDENCE

Therapy, level 2b.

Exercise effects in plantar pressure of postmenopausal women

OBJECTIVE

The aim of this study was to investigate the effect of a 12-month moderate-to-vigorous exercise program on plantar pressure among postmenopausal women.

METHODS

A total of 121 white postmenopausal women participated in a randomized controlled trial (60 women in the exercise group and 61 women in the control group). Women in the exercise group attended training sessions of 60 minutes, 3 days per week, on nonconsecutive days. Weight and basal metabolic rate were evaluated by bioimpedance, and height was evaluated with a stadiometer. Plantar pressure data were collected using the Footscan platform and Software 7.1.

RESULTS

After the 1-year intervention, women from the exercise group had (1) lower body mass index, (2) equal basal metabolic rate, (3) lower peak pressures, and (4) lower absolute impulses compared with the women from the control group. Interaction between the exercise group and practice time was found for most of the maximal peak pressure areas (except for metatarsal 4), for all absolute impulse values, and for relative impulses in the hallux, metatarsal 4, midfoot, and medial heel.

CONCLUSIONS

This study seems to prove that women who exercise have decreased loading of maximal peak pressures and absolute impulses and, consequently, self-reported pain, soreness, and discomfort in the lower extremity. An interaction effect between group and practice time was found for most of the variables considered, meaning that this 12-month exercise program is effective in the improvement of the biomechanic parameters of plantar pressure.

Influence of obesity and sarcopenic obesity on plantar pressure of postmenopausal women

BACKGROUND

Menopause is associated with a decrease in fat-free mass and an increase in fat mass. Sarcopenic obesity is more strongly associated with physical limitations than either obesity or sarcopenia and their effect in plantar pressure is not known. Consequently, the scope of the present study was to examine the effect of obesity and sarcopenic obesity on plantar pressure of postmenopausal women, during walking.

METHODS

Body composition and biomechanics parameters of plantar pressure were assessed in 239 postmenopausal women.

FINDINGS

Compared to non-obese and non-sarcopenic women, obese postmenopausal women have higher peak pressure in the metatarsal areas 1, 4, 5, midfoot and lateral heel and higher absolute impulses in all metatarsal and heel areas. On the other hand, sarcopenic obese postmenopausal women presented higher peak pressure and absolute impulses under all metatarsal areas, midfoot and heels. When the absolute values of maximal peak pressures and absolute impulses were normalised to body mass, pressure increases were only perceived for midfoot.

INTERPRETATION

The pressure increase found in different foot areas of obese and particularly in sarcopenic obese could cause discomfort and pain in the foot. Sarcopenic obese postmenopausal women also present a higher loading during the stance phase comparing with non-sarcopenic non-obese, fact that might limit their basic daily activity tasks, such as walking.

The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010

Heel pain, whether plantar or posterior, is predominantly a mechanical pathology although an array of diverse pathologies including neurologic, arthritic, traumatic, neoplastic, infectious, or vascular etiologies must be considered. This clinical practice guideline (CPG) is a revision of the original 2001 document developed by the American College of Foot and Ankle Surgeons (ACFAS) heel pain committee.

Intracorporeal pneumatic shock application for the treatment of chronic plantar fasciitis: a randomized, double blind prospective clinical trial

OBJECTIVE

Plantar fasciitis (PF) is a common clinical condition that usually resolves with non-operative treatments. Extracorporeal shock wave therapy (ESWT) has been used in the treatment of chronic PF not responding to other conservative measures; however, ESWT devices are expensive and available for daily practice in only few centers (In developing countries). A pneumatic lithotripter is a cheap and readily available device which uses pneumatic shock application for the intracorporeal lithotripsy. The aim of this study was to investigate the clinical efficacy of intracorporeal pneumatic shock therapy (IPST) application for the treatment of chronic PF using a cheap and readily available pneumatic lithotripter.

METHODS

A randomized, double-blind, placebo-controlled study was conducted. A total of 50 patients with clinically and radiologically confirmed PF were randomly allocated to either an active- (treatment) (n = 25) or inactive (placebo) (n = 25) group. Under local anesthesia and posterior tibial nerve block, a rigid probe was directly introduced into the calcaneal spur under fluoroscopic control; a standard protocol of 1,000 shock was applied during a single session into the calcaneal spur. The main outcome measure was the patients' subjective assessment of pain by means of a Visual Analog Scale (VAS) and the Roles and Maudsley Score before the treatment and 6 months later.

RESULTS

At the 6 months, the rate of successful outcomes (excellent + good results) in the treatment group (92%) were significantly higher comparing to the control group (24%) (P < 0.001). Heel pain measured 6 months after using the VAS were 2.04 +/- 1.67 in treatment group and 7.16 +/- 1.57 in control group as compared to 8.92 +/- 1.22 and 9.12 +/- 1.23 before the commencement of the treatment. No complications attributable to the procedure such as rupture of the planter fascia, hematoma, or infection were observed during the study.

CONCLUSIONS

This pilot study showed that IPST is an effective and safe method of treatment of patients with chronic PF not responding to conservative measures. IPST application should be considered before surgical intervention when the extracorporeal shock devices are not available for daily practice. However, further evaluation of this novel treatment is necessary to understand the exact mechanism of action.

The incidence of plantar fasciitis in the United States military

BACKGROUND

Although plantar fasciitis is the most common cause of heel pain, little has been reported on the incidence rates of this disorder. We sought to determine the incidence rate and demographic risk factors of plantar fasciitis in an ethnically diverse and physically active population of United States military service members.

METHODS

A query was performed with use of the Defense Medical Epidemiology Database for the International Classification of Diseases, Ninth Revision, Clinical Modification, code for plantar fasciitis (728.71). Multivariate Poisson regression analysis was used to estimate the rate of plantar fasciitis per 1000 person-years, while controlling for sex, race, rank, service, and age.

RESULTS

The overall unadjusted incidence rate of plantar fasciitis was 10.5 per 1000 person-years. Compared with men, women had a significantly increased adjusted incidence rate ratio for plantar fasciitis of 1.96 (95% confidence interval, 1.94 to 1.99). The adjusted incidence rate ratio for black service members compared with white service members was 1.12 (95% confidence interval, 1.09 to 1.12). With junior officers as the referent category, junior enlisted, senior enlisted, and senior officer rank groups had a significantly increased adjusted incidence rate ratio for plantar fasciitis: 1.20 (95% confidence interval, 1.18 to 1.23), 1.19 (95% confidence interval, 1.17 to 1.22), and 1.56 (95% confidence interval, 1.52 to 1.61), respectively. Compared with service members in the Air Force, those in the Army and Marines had a significantly increased adjusted incidence rate ratio for plantar fasciitis of 1.85 (95% confidence interval, 1.82 to 1.87) and 1.28 (95% confidence interval, 1.25 to 1.30), respectively. The adjusted incidence rate ratio for the age group of forty years old or more compared with the twenty to twenty-four-year-old group was 3.42 (95% confidence interval, 3.34 to 3.51).

CONCLUSIONS

Female sex; black race; junior enlisted, senior enlisted, and senior officer rank groups; service in the Army or Marines; and increasing age are all risk factors for plantar fasciitis.

Extracorporeal shock wave for chronic proximal plantar fasciitis: 225 patients with results and outcome predictors

Plantar fasciitis can be a chronic and disabling cause of foot pain in the adult population. For refractory cases, extracorporeal shock wave therapy (ESWT) has been proposed as therapeutic option to avoid the morbidity of surgery. We hypothesized that the success of extracorporeal shock wave therapy in patients with chronic plantar fasciitis is affected by patient-related factors. A retrospective review of 225 patients (246 feet) who underwent consecutive ESWT treatment by a single physician at our institution between July 2002 and July 2004 was performed. Subjects were included only if they had plantar fasciitis for more than 6 months and failure to response to at least 5 conservative modalities. Patients were evaluated prospectively with health questionnaires, Roles and Maudsley scores, and American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores at regular intervals. Follow-up was 30.2 +/- 8.7 months post procedure. Multivariable analysis was performed to assess factors leading to successful outcomes. Success rates of 70.7% at 3 months and 77.2% at 12 months were noted in this population. Previous cortisone injections, body mass index, duration of symptoms, presence of bilateral symptoms, and plantar fascia thickness did not influence the outcome of ESWT. The presence of diabetes mellitus, psychological issues, and older age were found to negatively influence ESWT outcome. Whereas many factors have been implicated in the development of plantar fasciitis, only diabetes mellitus, psychological issues, and age were found to negatively influence ESWT outcome.

LEVEL OF CLINICAL EVIDENCE

2.

The practical application of multimedia technology to facilitate the education and treatment of patients with plantar fasciitis: a pilot study

This study was designed to evaluate the efficacy of a multimedia patient education module when incorporated into the standard treatment protocol for patients diagnosed with plantar fasciitis. A thorough, standardized surgeon-patient education discourse took place following diagnosis. At the conclusion of the consultation, patients viewed the multimedia module. Questionnaires designed to assess understanding and satisfaction with information delivery were completed by patients following the consultation and again after viewing the module. Forty-one patients participated in the study. After viewing the module, patients achieved an average of 87% correct responses on the knowledge questionnaire, a significant improvement (P < .0001) over the 64% achieved following the surgeon-patient discourse. Ease of understanding of the information delivered by the module was rated significantly better (P < .0001) than the surgeon-patient discourse. Ninety-eight percent of patients indicated they felt well informed about plantar fasciitis following viewing the module compared with 68% following the surgeon-patient discourse. Sixty-three percent of patients indicated that the module best answered their questions, 7% preferred the surgeon, and 30% rated both equally. Multimedia plantar fasciitis educational material improved patient understanding of the standard treatment protocol and satisfaction with the information delivery in an orthopedic private practice.

Ultrasonographic evaluation in plantar fasciitis

The heels of 23 patients who were diagnosed with unilateral/bilateral plantar fasciitis were evaluated via ultrasonography and compared with their asymptomatic feet and a control group of 23 people. Plantar fascial thickness, echogenity, and heel pad thickness were evaluated, and the results were statistically analyzed. For symptomatic feet, increased thickness of the fascia and reduced echogenity were constant ultrasonographic findings (mean, 4.79 mm for symptomatic feet; 2.17 mm for control group, P < .05). No significant difference was found between heel pads of the diseased and healthy feet (mean, 12.96 mm for symptomatic feet; 13.10 mm for control group; P > .05). Ultrasonography seems to be a valuable, noninvasive diagnostic tool for the evaluation of plantar fasciitis.

Musculoskeletal disorders associated with obesity: a biomechanical perspective

Despite the multifactorial nature of musculoskeletal disease, obesity consistently emerges as a key and potentially modifiable risk factor in the onset and progression of musculoskeletal conditions of the hip, knee, ankle, foot and shoulder. To date, the majority of research has focused on the impact of obesity on bone and joint disorders, such as the risk of fracture and osteoarthritis. However, emerging evidence indicates that obesity may also have a profound effect on soft-tissue structures, such as tendon, fascia and cartilage. Although the mechanism remains unclear, the functional and structural limitations imposed by the additional loading of the locomotor system in obesity have been almost universally accepted to produce aberrant mechanics during locomotor tasks, thereby unduly raising stress within connective-tissue structures and the potential for musculoskeletal injury. While such mechanical theories abound, there is surprisingly little scientific evidence directly linking musculoskeletal injury to altered biomechanics in the obese. For the most part, even the biomechanical effects of obesity on the locomotor system remain unknown. Given the global increase in obesity and the rapid rise in musculoskeletal disorders, there is a need to determine the physical consequences of continued repetitive loading of major structures of the locomotor system in the obese and to establish how obesity may interact with other factors to potentially increase the risk of musculoskeletal disease.

Factors associated with chronic plantar heel pain: a systematic review

Chronic plantar heel pain (CPHP) is one of the most common soft tissue disorders of the foot, yet its aetiology is poorly understood. The purpose of this systematic review was to examine the association between CPHP and the various aetiological factors reported in the literature. Seven electronic databases and the reference lists of key articles were searched in August 2005. The resulting list of articles was assessed by two independent reviewers according to pre-determined selection criteria and a final list of articles for review was created. The methodological quality of the included articles was assessed and the evidence presented in each of the articles was descriptively analysed. From the 16 included articles, body mass index in a non-athletic population and the presence of calcaneal spur were the two factors found to have an association with CPHP. Increased weight in a non athletic population, increased age, decreased ankle dorsiflexion, decreased first metatarsophalangeal joint extension and prolonged standing all demonstrated some evidence of an association with CPHP. Evidence for static foot posture and dynamic foot motion was inconclusive and height, weight and BMI in an athletic population were not associated with CPHP. The findings of this review should be used to guide the focus of prospective cohort studies, the results of which would ultimately provide a list of risk factors for CPHP. Such a list is essential in the development of new and improved preventative and treatment strategies for CPHP.

The Pathomechanics of Plantar Fasciitis

Plantar fasciitis is a musculoskeletal disorder primarily affecting the fascial enthesis. Although poorly understood, the development of plantar fasciitis is thought to have a mechanical origin. In particular, pes planus foot types and lower-limb biomechanics that result in a lowered medial longitudinal arch are thought to create excessive tensile strain within the fascia, producing microscopic tears and chronic inflammation. However, contrary to clinical doctrine, histological evidence does not support this concept, with inflammation rarely observed in chronic plantar fasciitis. Similarly, scientific support for the role of arch mechanics in the development of plantar fasciitis is equivocal, despite an abundance of anecdotal evidence indicating a causal link between arch function and heel pain. This may, in part, reflect the difficulty in measuring arch mechanics in vivo. However, it may also indicate that tensile failure is not a predominant feature in the pathomechanics of plantar fasciitis. Alternative mechanisms including 'stress-shielding', vascular and metabolic disturbances, the formation of free radicals, hyperthermia and genetic factors have also been linked to degenerative change in connective tissues. Further research is needed to ascertain the importance of such factors in the development of plantar fasciitis.

Sonographic evaluation of plantar fasciitis and relation to body mass index

PURPOSE

We have investigated the role of sonography in the diagnosis of plantar fasciitis.

MATERIALS AND METHODS

This study evaluates 39 patients with plantar fasciitis and control group of 22 healthy volunteers. The plantar fascia thickness was measured 5 mm distal to the insertion of the calcaneus of plantar aponeurosis. Qualitative parameters such as decreased echogenity, biconvexity, perifascial fluid and calcification of plantar fascia were also noted.

RESULTS

Mean plantar fascia thickness was measured 2.9 mm in patients with unilateral heel pain, 2.2 mm for contralateral normal heel and 2.5mm for control group. There was a statistically significant difference between heel with plantar fasciitis, contralateral normal heel and control groups (p=0.009 and 0.0001, respectively). Mean body mass index was 28 kg/m(2) in patients with heel pain and 25 kg/m2 in control group. Body mass index measurements were significantly different between plantar fasciitis and control groups. We found reduced plantar fascia echogenity in 16 cases (41%), calcaneal spur in 20 cases (51%), biconvex appearance in two cases (5.1%) and perifascial fluid in one case (2.5%).

CONCLUSION

We conclude that in patients with plantar fasciitis, ultrasound may detect relatively small differences in plantar fascia thickness even in clinically unequivocal plantar fasciitis.

Clinical utility of sonography in diagnosing plantar fasciitis

OBJECTIVE

The purpose of this study was to investigate the efficacy of sonography in the detection of plantar fasciitis (PF) compared with magnetic resonance imaging (MRI) findings in subjects with inferior heel pain.

METHODS

Seventy-seven patients with unilateral (n = 9) and bilateral (n = 68) heel pain were studied. Seventy-seven age- and sex-matched asymptomatic subjects served as a control group. Magnetic resonance imaging was used to establish a diagnosis of PF with sagittal T1-weighted, T2-weighted, and short tau inversion recovery sequences. The sonographic appearances of PF were compared with MRI findings. Plantar fascia and heel pad thickness were also measured on both imaging modalities.

RESULTS

Compared with MRI, sonography showed 80% sensitivity and 88.5% specificity in assessing PF. A strong correlation was found between plantar fascia and fat pad thickness measurements done by sonography (P < .001; r = 0.854) and MRI (P < .001; r = 0.798). Compared with the asymptomatic volunteers, patients with PF had significant increases in plantar fascia and heel pad thicknesses, weight, and body mass index (P = .0001). Heel pad thickness was also significantly increased with pain duration (P = .021).

CONCLUSIONS

Although MRI is the modality of choice in the morphologic assessment of different plantar fascia lesions, sonography can also serve as an effective tool and may substitute MRI in the diagnosis of PF.

Evidence-Based Soft Tissue Rheumatology. V

Present evidence indicates that the main cause of plantar talalgia (PT) is a noninflammatory derangement at the proximal insertion of the plantar fascia. In athletes, predisposing ankle and rear-foot biomechanical abnormalities have been identified; in nonathletes, risk factors for the condition remain controversial. PT diagnosis is largely clinical, the key findings being pain and tenderness on the plantar aspect of the rear foot. Ultrasonography is a reliable confirmatory study in doubtful cases. Therapies in PT include nonsteroidal anti-inflammatory drugs, orthotic devices, night ankle dorsiflexion splints, physiotherapy, local glucocorticoid, and extracorporeal shockwave therapy. In recalcitrant cases, surgery may be offered. Of these therapies, only local glucocorticoid, as delivered by injection or iontophoresis, has shown short-term efficacy in controlled trials. The efficacy of ankle dorsiflexion splints and extracorporeal shockwave therapy is still controversial. Thus, important knowledge gaps remain on etiology, diagnosis, and treatment of PT.

Extracorporeal shock wave therapy for the treatment of plantar fasciitis

One hundred fifty patients were enrolled in a multicenter, randomized, placebo-controlled, prospective, double-blind study to assess the clinical safety and effectiveness of extracorporeal shock wave therapy (ESWT) using the Dornier Epos Ultra for the treatment of plantar fasciitis. The Active Group was treated with electromagnetically generated shocks using ultrasound guidance during a single therapy session. The Control Group received a sham treatment under similar clinical conditions. The groups were demographically similar with respect to age, height, and weight. The average duration of symptoms was nearly 2 years in both groups. All patients were evaluated by the visual analog scale for pain, American Orthopaedic Foot and Ankle Society scores, Roles and Maudsley Score, SF-12 health status questionnaire, and physical examination. The Active Group reported 56% success at 3 months and 94% success at 12 months posttreatment. The Control Group reported 47% success at 3 months posttreatment. Twelve-month data were not collected for the Control Group as they were unblinded at 3 months and offered treatment. ESWT represents a safe treatment option for chronic proximal plantar fasciitis.

Bilateral chronic proximal plantar fasciopathy: treatment with electrohydraulic orthotripsy

BACKGROUND

Patients presenting for treatment of chronic plantar fasciopathy often have bilateral involvement. When various nonoperative treatments fail, subsequent intervention may be problematic, especially since bilateral surgery (bilateral fascial release) may not be realistic because of variable, frequently restrictive postoperative weightbearing limitations.

METHODS

Twenty-three patients (46 heels) were treated with electrohydraulic high-energy orthotripsy to the plantar entheses of both feet while under the same anesthesia (conscious sedation). Following orthotripsy, all patients immediately were fully weightbearing and resumed normal activities of daily living and work, usually within 24 hours. Progressive return to athletic activities was allowed. Patients were assessed by three outcome parameters: (1) pain measured objectively by a dolorimeter combined with the patient's subjective evaluation of the level of pain; (2) pain after 5 minutes of walking upon arising; and (3) pain with daily activities. All pain measurements were done by the visual analog scale.

RESULTS

Patients initially experienced varied pain relief responses. This included earlier pain relief in one heel compared to the other, as well as better pain relief in one heel than the other at the 6- and 12-week evaluations, but with much less variance at the 1-year evaluation. By 3 months following orthotripsy, 28 heels (61%) had good or excellent results. These results were maintained or improved at 1 year. In 18 heels (39%), the outcome was fair or poor. Nineteen heels received a second orthotripsy application; one patient requested a second orthotripsy treatment of only one heel, while nine patients requested a second treatment of both heels. The outcome showed further improvement following the second application of orthotripsy. At 1 year after one or two orthotripsy applications, 19 patients (38 heels) were satisfied with the results in both heels (83%), while four patients (eight heels) still had an unsatisfactory outcome (17%).

CONCLUSION

Electrohydraulic high-energy orthotripsy is a reasonable nonincisional method for treating patients with bilateral chronic proximal plantar fasciopathy under a single anesthetic without the prolonged nonweightbearing status often recommended for patients following unilateral open or endoscopic fascial release.

Radiotherapy in painful heel spurs (plantar fasciitis)—results of a national patterns of care study

PURPOSE

After a general patterns of care study, the German Cooperative Group on Radiotherapy for Benign Diseases conducted a multicenter cohort study to analyze radiotherapy (RT) in painful heel spur syndrome (HSS).

METHODS AND MATERIALS

In 2001, a patterns of care study was conducted in all German RT institutions using a standardized structured questionnaire. Patient accrual, patient number, pretreatment, pain record, treatment indications, RT technique, and target volume concepts for painful HSS were assessed. In addition, the functional and subjective outcomes were evaluated.

RESULTS

Of the institutions, 146 (79.3%) returned the questionnaire: 10 (6.8%) reported no clinical experience with RT for HSS, and 136 (93.2%) treated 3621 patients annually, a median of 23 cases/institution. The indications for treatment were chronic or therapy refractory pain. The total dose ranged between 2.5 and 18.75 Gy (median 6), and single fractions ranged between 0.3 and 1. 5 Gy (median 1). Of the responding institutions, 44.9% applied two fractions and 37.5% three fractions weekly. RT was delivered with orthovoltage units (38.2%), linear accelerators (53.7%), (60)Co units (5.1%), or other treatment units (3%). Seventy-six institutions presented their retrospective clinical evaluation in a total of 7947 patients. Pain reduction for at least 3 months was reported in 70%, and persistent pain reduction was reported in 65% of the treated patients. In 19 institutions, a second RT series was applied for inadequate pain response or early pain recurrence. No radiogenic acute or chronic side effects were observed.

CONCLUSION

The study comprised the largest number of cases reported of RT for painful HSS. Despite variations in the daily RT practice, this national patterns of care study represents a very large number of painful and refractory HSS cases that were treated effectively with RT.

Ultrasonographic appearance of the plantar fasciitis

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Toe flexors strength and passive extension range of motion of the first metatarsophalangeal joint in individuals with plantar fasciitis

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To determine if a difference exists in toe flexors strength and passive extension range of motion of the first metatarsophalangeal joint between individuals with unilateral plantar fasciitis and control subjects.

BACKGROUND

Weakness of the dynamic longitudinal arch supporters and shortening of the plantar fascia have been suggested as etiologic factors for plantar fasciitis. METHOD AND MEASURES: Twenty subjects with unilateral plantar fasciitis participated in the study. Subjects had had symptoms for an average (+/-SD) of 19.9 +/- 33.2 months prior to participating in the study. Twenty control subjects matched for sex and age were also tested. Each subject was measured bilaterally for passive extension range of motion of the first metatarsophalangeal joint and peak resistance force observed during an isometric test of toe flexors strength.

RESULTS

Subjects with unilateral plantar fasciitis demonstrated weaker toe flexors (P<.05) than the control subjects. A significant main effect for feet also indicated that the toe flexors for the involved feet were significantly weaker than the uninvolved feet (P<.05) of subjects with unilateral plantar fasciitis. Passive extension range of motion of the first metatarsophalangeal joint was not significantly different between the involved and the uninvolved feet for subjects with plantar fasciitis.

CONCLUSION

Results for our subjects indicate that the extensibility of soft tissues influencing extension of the first metatarsophalangeal joint was not related to the presence of plantar fasciitis. Additional research is needed to determine if toe flexors weakness is a cause or a result of plantar fasciitis and if strengthening regimes for the toe flexors are effective interventions for plantar fasciitis.

The influence of local steroid injections, body weight and the length of symptoms in the treatment of painful subcalcaneal spurs with extracorporeal shock wave therapy

OBJECTIVE

To evaluate the effectiveness of extracorporeal shock wave therapy (ESWT) for the treatment of painful subcalcaneal spurs and evaluate whether local steroid injections, body weight and the length of symptoms can affect the clinical results.

DESIGN

Subjects were selected through clinical examination and heel radiograms according to diagnosis of painful subcalcaneal spurs.

SUBJECTS

Sixty-four subjects were divided into two groups of treatment depending on their past history of previous local steroid injections.

INTERVENTIONS

Each subject received a three-session ESWT (performed weekly). A rehabilitative programme was instituted, consisting of self-assisted plantar fascia and plantar flexors stretching exercises.

MAIN OUTCOME MEASURES

The Mayo Clinical Scoring System (MCSS) was utilized to evaluate each subject before the treatment and at two- and ten-month follow-ups. In addition, standard radiograms were done both before the treatment and at the ten-month follow-up.

RESULTS

Patients with no past treatment using steroids did not show any statistically significant improvement of the MCSS at the two-month follow-up. The statistical significance was obtained at the ten-month follow-up. Patients with past treatment using steroids did not show any statistically significant improvement of the MCSS at either follow-up. At the radiogram check, none of the subjects showed any modification of the heel spurs.

CONCLUSIONS

According to the results of the present study ESWT should be considered as an effective treatment for painful subcalcaneal spurs. Previous local steroid injections may negatively affect the result of ESWT.

A retrospective study of standing gastrocnemius-soleus stretching versus night splinting in the treatment of plantar fasciitis

Plantar fasciitis is the most common cause of heel pain, yet the conservative treatment of plantar fasciitis is not standardized. This open retrospective study compared the effects of standing gastrocnemius-soleus stretching to a prefabricated night splint. One hundred and sixty patients with unilateral or bilateral plantar fasciitis were evaluated and treated according to the standard regimen in addition to either night splints or stretching. Seventy-one patients performed standing stretching of the gastrocnemius-soleus complex. Eighty-nine patients utilized the prefabricated night splint without standing stretching. The night splint treatment group had a significantly shorter recovery time (p < .001), fewer follow-up visits to recovery (p < .001), and fewer total additional interventions (p = .034) compared to the stretching group. Absolute body weight, body mass index, and age did not have a statistically significant effect on the time to recovery or additional interventions needed. The duration of pain prior to this treatment was a predictive factor and was associated with increased time to recovery and increased number of treatment interventions. Its was concluded that early treatment in a standardized four-tiered treatment approach, including the night splint without standing stretching of the gastrocnemius-soleus complex, speeds time to recovery.

The effects of duration and frequency of Achilles tendon stretching on dorsiflexion and outcome in painful heel syndrome: a randomized, blinded, control study

The American Orthopedic Foot and Ankle Society recommends at least six months of nonsurgical treatment before considering surgical intervention for painful heel syndrome. Achilles tendon stretching exercises are consistently reported to be one of the more effective nonsurgical modalities for treatment of painful heel syndrome. However, the optimal duration and frequency of the exercises has not been reported. The purpose of this study was to evaluate and compare the effectiveness of sustained and intermittent Achilles tendon stretching for the relief of pain associated with painful heel syndrome. This prospective, randomized, blinded study was performed from May 1997 to July 2000. A total of 94 people (122 affected feet) fit the inclusion criterion and agreed initially to participate in a treatment study group. To achieve our purpose, study participants were randomized into two stretching groups. One group performed sustained Achilles tendon stretches (three minutes, three times daily), the other performed intermittent stretches (five sets, 20 seconds each, two times daily). Participants were evaluated once a month for a period of four months subsequent to diagnosis. At each monthly visit, participants completed subjective questionnaires about their pain. Also, a physical therapist measured each participant's Achilles tendon flexibility. The study determined that both sustained and intermittent Achilles tendon stretching exercises increase Achilles tendon flexibility. This increase in flexibility correlated with a decrease in pain. There was no significant difference in outcome between the sustained and intermittent stretching groups. The data suggest that both sustained and intermittent Achilles tendon stretching exercises were effective nonsurgical treatments for painful heel syndrome.

Distal tarsal tunnel release with partial plantar fasciotomy for chronic heel pain: an outcome analysis

This study evaluated the effectiveness of distal tarsal tunnel release with a partial plantar fasciotomy for chronic subcalcaneal pain syndrome in patients who failed nonoperative management through a retrospective review of all patients undergoing this procedure between 1994 and 1999. Distal tarsal tunnel release and a partial plantar fasciotomy were offered only to those patients with disabling heel pain and were performed under general anesthesia or ankle block. Seventy-five patients (80 heels), averaging 20 months of nonoperative treatment, were identified (group I). Postoperative outcome questionnaires (SF-36 and Foot Function Index [FFI]) were sent to these patients and 44 (46 heels) responded (group II). In group I, 88% of patients had a good to excellent result. Many continued with mild to moderate residual symptoms, which typically did not limit their activity. In group II, 91% of patients were somewhat to very satisfied with their outcome. Visual analogue scale scores for pain were reduced by a mean of 55. SF-36 scores, matched against a control group of patients receiving just nonoperative treatment, showed a statistically significant improvement in all pain and functioning subcategories. We conclude that a distal tarsal tunnel release with a partial plantar fasciotomy may successfully increase function and decrease pain in patients who fail nonoperative treatment.

Heel pad thickness--a contributing factor associated with plantar heel pain in young adults

Thirty-three runners were clinically diagnosed with plantar heel pain (PHP) and 107 runners were designated into a non-PHP group (NPHP). Cases were matched with a further control group of 64 subjects with regard to body mass index and age. A weight-bearing platform measured heel pad thickness by real-time ultrasound scanning. The results demonstrated a significant difference between the PHP and both the NPHP and control groups (P <0.05). The results also demonstrated that body mass index had a significant effect (P <0.05) on the heel pad thickness of all subjects, regardless of the heel pad group. The results from the current study, with some precaution, conclude that body mass index as such is not related to PHP in the athletic population. In the current study the observed differences of body mass index on heel pad thickness between the PHP and NPHP groups, and the similarity between the control group and NPHP subjects suggests other risk factors may play an important role in heel pad thickening and associated development of PHP.

Correlation of heel pain with body mass index and other characteristics of heel pain

A prospective, descriptive study was performed at Oakwood Healthcare medical clinics to determine the body mass index (BMI) of patients with heel pain and of a control group of patients presenting for other reasons. A questionnaire was used to obtain information in each of the patient groups and to determine characteristics of patients with plantar fascial heel pain. Standard weightbearing lateral radiographs were taken to determine overall foot structure. The typical patient was female, had heel pain for just over 1 year, with a sedentary to moderate activity level. Although height was comparable, patients with heel pain had a higher BMI (30.4 +/- 0.7) than those without heel pain (28.2 +/- 0.7, p = .04). The BMI appears to play a greater role in heel pain than does foot structure, as the authors found no structural commonalities that would explain these patients' pain. Control patients also reported a higher level of activity. Fifty-one percent exercised three or more times per week for more than 20 minutes each time, while less than half that (25.4%) of heel pain patients did so. While half of the heel pain patients had been treated by other providers prior to visiting our clinic, fewer than 25% of these patients had been instructed to lose weight by a physician. The authors feel that a BMI of 25 (the target for decreased cardiovascular risk) represents a reasonable goal for weight loss that may reduce heel pain.

Plantar pressure differences between obese and non-obese adults: a biomechanical analysis

OBJECTIVE

To investigate plantar pressure differences between obese and non-obese adults during standing and walking protocols using a pressure distribution platform.

SUBJECTS

Thirty-five males (age 42.4+/-10.8 y; 67-179 kg) and 35 females (age 40.0+/-12.6 y; 46-150 kg) divided into obese (body mass index (BMI) 38.75+/-5.97 kg/m2) and non-obese (BMI 24.28+/-3.00 kg/m2) sub-groups, respectively.

MEASUREMENTS

Data collection was performed with a capacitive pressure distribution platform with a resolution of 2 sensors/cm2 (Emed F01, Novel GmbH, München). The measurement protocol included half and full body weight standing on the left, right and both feet, respectively, and walking across the platform, striking with the right foot. Pressures were evaluated for eight anatomical sites under the feet.

RESULTS

For both men and women, the mean pressure values of the obese were higher under all anatomical landmarks during half body weight standing. Significant increases in pressure were found under the heel, mid-foot and metatarsal heads II and IV for men and III and IV for women. Foot width during standing was also significantly increased in obese subjects. For walking, significantly higher peak pressures were also found in both obese males and females.

CONCLUSION

Compared to a non-obese group, obese subjects showed increased forefoot width and higher plantar pressures during standing and walking. The greatest effect of body weight on higher peak pressures in the obese was found under the longitudinal arch of the foot and under the metatarsal heads. The higher pressures for obese women compared to obese men during static weight bearing (standing) may be the result of reduced strength of the ligaments of the foot.

The role of ultrasonography in the diagnosis and management of idiopathic plantar fasciitis

OBJECTIVE

To compare ultrasonography with bone scintigraphy in the diagnosis of plantar fasciitis and to compare ultrasound-guided injection with palpation-guided injection in the management of idiopathic plantar fasciitis.

METHODS

Twenty-three patients with a clinical diagnosis of idiopathic plantar fasciitis in 28 heels underwent ultrasonography and bone scintigraphy of both heels at baseline. The patients were randomized to ultrasound- or palpation-guided injection of triamcinolone hexacetonide and xylocaine into the plantar fascia. The 100 mm visual analogue scale (VAS) of pain, the heel tenderness index (HTI), and ultrasonography were performed at baseline and follow-up (mean=13.4 weeks).

RESULTS

The mean thickness (+/-standard error of the mean) of the plantar fascia, measured by ultrasonography, was 5.7+/-0.3 mm in symptomatic heels as compared with 3.8+/-0.2 mm in asymptomatic heels (P<0.001). Ultrasonography findings correlated with bone scintigraphic findings in the diagnosis of plantar fasciitis (P<0.001). Fourteen heels were randomized to ultrasound-guided injection, 10 heels were randomized to palpation-guided injection and four heels were not injected. Ultrasound- and palpation-guided injection resulted in significant mean improvements in VAS [39.6+/-9.2 (ultrasound) vs 41.5+/-8 (palpation)] and HTI [1.35+/-0.2 (ultrasound) vs 1.3+/-0.4 (palpation)]. There was no significant difference in the response rate following corticosteroid injection by either modality (ultrasound=13/14, palpation=8/10). Following injection, the mean thickness of the plantar fascia decreased from 5.7+/-0.3 mm to 4.65+/-0.4 mm (P<0.01).

CONCLUSION

Ultrasonography and bone scintigraphy are equally effective in the diagnosis of plantar fasciitis. Ultrasound-guided injection is effective in the management of plantar fasciitis but is not more effective than palpation-guided injection. Ultrasonography may be used as an objective measure of response to treatment in plantar fasciitis.