We compared diagnostic ultrasound images of the plantar fascia with available patient histories for symptomatic patients previously diagnosed as having plantar fasciitis. Plantar fascia thickness and depth, the prevalence of perifascial hypoechoic lesions, and injury timelines in patients were reviewed.
Images and histories for 126 symptomatic patients were collected from a patient database. We documented plantar fascia depth and thickness and the visualization of hypoechoic perifascial lesions. After image analysis, the obtained plantar fascia thickness measurements were compared with various patient attributes for possible relationships, including age, weight, and body mass index. In addition, plantar fascia thickness measurements were separated based on injury timeline as well as symptomatic/asymptomatic foot for patients with unilateral conditions to check for significant differences between subgroups. These were, in turn, compared with a control group of 71 individuals with no heel pain or diagnosis of plantar fasciitis.
Overall, mean ± SD symptomatic thickness (n = 148) was 6.53 ± 1.56 mm. Mean ± SD symptomatic depth (n = 136) was 13.36 ± 2.14 mm. For the control group, mean ± SD thickness was 3.20 ± 0.66 mm and depth was 10.30 ± 2.00 mm. Comparison of thickness based on injury timeline showed two significant differences: acute injuries (≤3 months) are significantly thicker than chronic injuries (>3 months), and only acute symptomatic thicknesses are significantly different from their asymptomatic thickness counterparts. Age, weight, and body mass index did not show significant correlations to thickness. Analysis of ultrasound images showed that 93% of symptomatic feet had hypoechoic lesions.
Injury timeline and the presence of hypoechoic lesions may play important roles in patient discomfort, diagnosis, and treatment of plantar fasciitis.
This article describes a patient with plantar fascial pain who presented to the office of one of the authors. Physical examination and the patient’s description of the history of symptoms revealed classic signs and symptoms of plantar fasciitis. The patient was treated with numerous conservative modalities, including ultrasound, nonsteroidal anti-inflammatory medications, trigger-point injections, over-the-counter orthoses, and stretching exercises. When the pain was not relieved by these conservative measures, magnetic resonance imaging of the area was performed. Visualization of the insertional area of the plantar fascia revealed a mass inferior to, as well as infiltrated into, the plantar fascia. Surgical excision of the lesion resulted in complete elimination of the patient’s pain. (J Am Podiatr Med Assoc 91(2): 89-92, 2001)
A 16-question post-treatment survey was sent to 874 patients after extracorporeal shockwave treatment for chronic plantar fasciitis. Of the 377 surveys returned, 353 were used for analysis. These patients were treated by 169 physicians in 19 states using either electrohydraulic or electromagnetic extracorporeal shockwave equipment. Seventy-six percent of the patients underwent treatment after having had continued pain for a year or longer. Seventy percent of patients who rated their pretreatment pain level as severe (score ≥ 8 on a scale from 1 to 10) experienced sharp declines in pain, with a sharp decline considered to be a difference in pain level before and after treatment of 3 or more. In addition, 66% of patients who rated their pretreatment immobility as severe (score ≥ 8 on a scale from 1 to 10) experienced sharp declines in immobility. Of the patients who underwent extracorporeal shockwave treatment, 69% indicated that they would recommend this procedure to someone in a similar situation. If extracorporeal shockwave treatment were not available, 62% of patients indicated that they would have undergone open or invasive surgery, and 41% indicated that they would have continued with additional physician office visits. (J Am Podiatr Med Assoc 95(6): 517–524, 2005)
We compared the long-term clinical and ultrasonographic effects of radial extracorporeal shockwave therapy (rESWT) versus ultrasound-guided corticosteroid injection treatment in patients with plantar fasciitis unresponsive to conservative therapy.
Seventy-two patients with unilateral plantar fasciitis were randomized to receive either rESWT (three times once per week) (n = 36) or corticosteroid treatment (a single 1-mL dose of betamethasone sodium plus 0.5 mL of prilocaine under ultrasound guidance by injection into the plantar fascia) (n = 36). The primary outcome measures were visual analog scale (VAS) and Foot Function Index (FFI) scores. Secondary outcome measures included the heel tenderness index (HTI) score and plantar fascia thickness (PFT) as obtained by ultrasound examination. All of the assessments were performed at baseline and 1, 3, and 6 months after treatment.
Significant improvements were observed in the rESWT group in VAS, HTI, and FFI scores and PFT at the end of treatment and were maintained during follow-up. Posttreatment improvements in VAS, HTI, and FFI scores and PFT were also seen in the corticosteroid group but were not maintained for VAS and FFI scores after the completion of therapy and were lost at 1 and 6 months, respectively. No serious treatment-related complications occurred.
Both rESWT and corticosteroid injection therapy are effective modalities for treatment of chronic plantar fasciitis. However, rESWT seems to be superior to corticosteroid injection therapy due to its longer duration of action.
Background: The aim of this study was to evaluate the results of high-dose extracorporeal shockwave therapy applied with an ankle block and corticosteroid injection in patients with plantar fasciitis whose symptoms persisted for more than 6 months.
Methods: Sixty patients were assessed clinically at presentation and at 3-month follow-up with a patient-assessed 100-mm visual analog scale of pain and a physician-assessed heel tenderness index. A therapeutic response rate was evaluated. A decrease of at least 50% from baseline to 3 months in visual analog scale or heel tenderness index scores was accepted as a successful result.
Results: Extracorporeal shockwave therapy and corticosteroid injection provided significant improvements in visual analog scale and heel tenderness index scores, but between the two groups there was no significant difference in the visual analog scale score change 3 months after treatment (P > .05). Twenty-seven of 33 patients (82%) in the extracorporeal shockwave therapy group and 23 of 27 (85%) in the corticosteroid injection group had a successful therapeutic response after 3 months.
Conclusions: Corticosteroid injection and extracorporeal shockwave therapy are successful treatment modalities for plantar fasciitis. Corticosteroid injection treatment is cost effective compared with extracorporeal shockwave therapy, and corticosteroid injection may be the first treatment choice according to these results. (J Am Podiatr Med Assoc 100(2): 105–110, 2010)
Plantar fasciitis (PF) is one of the most common causes of heel pain. Obesity is recognized as a major factor in PF development, possibly due to increased mechanical loading of the foot due to excess weight. The benefit of bariatric surgery is documented for other comorbidities but not for PF.
A retrospective medical record review was performed for patients with PF identified from a prospectively maintained database of the Cleveland Clinic Bariatric and Metabolic Institute. Age, sex, surgery, excess weight loss, body mass index (BMI), and health-care use related to PF treatment were abstracted. Comparative analyses were stratified by surgery type.
Two hundred twenty-eight of 10,305 patients (2.2%) had a documented diagnosis of PF, of whom 163 underwent bariatric surgery and were included in the analysis. Eighty-five percent of patients were women, mean ± SD age was 52.2 ± 9.9 years, and mean ± SD preintervention BMI was 45 ± 7.7. Postoperatively, mean ± SD BMI and excess weight loss were 34.8 ± 7.8 and 51.0% ± 20.4%, respectively. One hundred forty-six patients (90%) achieved resolution of PF and related symptoms. The mean ± SD number of treatment modalities used for PF per patient preoperatively was 1.9 ± 1.0 (P = .25). After surgery, the mean ± SD number of treatment modalities used per patient was reduced to 0.3 ± 0.1 (P = .01).
We present new evidence suggesting that reductions in BMI after bariatric surgery may be associated with decreasing the number of visits for PF and may contribute to symptomatic improvement.
Recently, transcranial direct current stimulation (tDCS), a noninvasive brain stimulation technique, was proposed as a suitable method for the treatment of several chronic pain syndromes. We describe a case of severe heel pain in a diabetic patient with plantar fasciitis successfully treated with tDCS.
The present study investigated whether tDCS treatment could reduce pain and pain-related anxiety in a 65-year-old diabetic man affected by treatment-resistant right heel pain due to plantar fasciitis. The patient underwent five tDCS treatment sessions on 5 consecutive days. Each session consisted of 20-min anodal tDCS over the left primary motor cortex leg area.
The neurostimulation protocol induced a decrease in pain intensity and pain-related anxiety that outlasted the stimulation (1 week). Furthermore, the patient stopped the intake of opioid medication.
Therapeutic neuromodulation with tDCS may represent an alternative option for treating severe lower-extremity pain.
In a prospective randomized study, we compared two different surgical techniques used in plantar fasciitis surgery.
Forty-eight patients diagnosed as having plantar fasciitis and treated for at least 6 months with no response to conservative modalities were included in this study. The patients were randomly assigned to receive endoscopic plantar fascia release (EPFR) or cryosurgery (CS). Patients were evaluated using the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS-AHS) as a primary outcome measurement at baseline and 3 weeks and 3, 6, and 12 months after surgery. At the final follow-up visit, the Roles-Maudsley score was used to determine patient satisfaction.
Five patients did not complete the 1-year follow-up examination (one in the EPFR group and four in the CS group). Thus, the study group included 43 patients. Although both groups showed significant improvement at the final evaluation, the patients in the EPFR group had significantly better AOFAS-AHS scores at 3 months. The success rate (Roles-Maudsley scores of excellent and good) in the EPFR group at 12 months was 87% and in the CS group was 65%.
Both EPFR and CS were associated with statistically significant improvements at 1-year follow-up. At 3-month follow-up, EPFR was associated with better results and a higher patient satisfaction rate compared with CS.
Background: Plantar fasciitis is a common cause of musculoskeletal discomfort. Minimally invasive interventions are preferred as second-line treatments following failure of conservative management. We report on a novel technique of ultrasound-guided percutaneous release of the medial third of the plantar fascia with the use of a fine cutting device for the treatment of persistent plantar fasciitis.
Methods: This is a retrospective case series of all patients treated with the technique between 2013 and 2015. Patients had failed conservative management for a minimum of 6 months. The procedure was performed in an outpatient setting under local anesthesia. Under continuous ultrasound guidance, release of the medial third of the plantar fascia from the calcaneus was performed using an ophthalmic V-Lance knife through a medial stab wound entry point.
Results: Fifteen patients (six men and nine women) with an average age of 54.7 years were included. The mean (standard deviation [SD]) visual analogue scale score for pain improved significantly, from 66.0 (SD, 18.8) preoperatively to each consecutive follow-up point: 29.3 (SD, 25.2) at 2 weeks, 30.0 (SD, 27.8) at 4 weeks, and 34.0 (SD, 26.1) at 12 weeks (P < .001). The mild increase in visual analogue scale score between 4 and 12 weeks was statistically significant (P = .018). Average duration of required analgesia was 5.5 days and average time required to return to usual activities was 5.7 days. Two patients suffered with refractory neuropathic pain over the lateral border of the foot without any obvious abnormality.
Conclusions: Ultrasound-guided percutaneous release with the use of a fine cutting device could be an alternative option for the treatment of persistent plantar fasciitis. The technique is not without complications, and a mild but statistically significant decline in pain levels from early to short term has been detected. Therefore, the long-term outcomes of this technique need to be investigated before we can advocate its routine use.
This case report demonstrates the use of the tissue stress model to develop an examination, evaluation, and management plan for a patient with an 8-week history of plantar fasciitis. The patient history focused on determining which tissues were being excessively stressed, and the physical examination was used to apply controlled stresses to these tissues and to determine factors contributing to the patient’s condition. After it was confirmed that the patient’s plantar fascia was under excessive mechanical stress, treatment first focused on reducing pain, inflammation, and stress on the plantar fascia and then on returning the patient to her running program while maintaining symptoms at a diminished level. The patient reported being free of pain 7 weeks after the initial physical therapy examination and at the 11-week telephone follow-up. Although no experimental evidence is given, this report suggests that this patient responded positively to treatment based on the tissue stress model. (J Am Podiatr Med Assoc 92(9): 499-506, 2002)