Concept: Plantar fasciitis
BACKGROUND: Plantar fibromatosis is a benign disease creating nodules on the medial plantar side of affected patients. While surgical removal is regarded as the therapeutic mainstay, recurrence rates and impairment of daily activities remains substantial. High-energy focussed extracorporeal shockwave therapy has been suggested to be potentially effective in plantar fibromatosis in terms of pain reduction.HypothesisHigh-energy focussed extracorporeal shockwave therapy reduces pain in plantar fibromatosis. FINDINGS: A total number of six patients (5 males, 58+/-4 years) were included with plantar fibromatosis (Ledderhose’s disease) associated with pain. Three patients were operated on previously, one had concomitant Dupuytren’s contracture. High-energy focussed ESWT was applied using a Storz Duolith SD1 (2000 impulses, 3 Hz, 1.24mJ/mm2) in two sessions with 7 days between. Pain was 6+/-2 at baseline, 2+/-1 after 14 days and 1+/-1 after 3 months. Softening of the nodules was noted by all patients. No adverse effects were noted. CONCLUSIONS: High-energy focussed extracorporeal shockwave energy reduces pain in painful plantar fibromatosis (Morbus Ledderhose). Further large-scale prospective trials are warranted to elucidate the value of high-energy focussed extracorporeal shockwave therapy (ESWT) in plantar fibromatosis in terms of recurrence and efficacy.
Randomised controlled trials (RCTs) have reported conflicting results on whether extracorporeal shock wave therapy alleviates the pain of recalcitrant plantar fasciitis patients. We focused on high-energy extracorporeal shock wave therapy (HESWT) and aimed to assess the effectiveness and feasibility of HESWT versus placebo in the treatment of recalcitrant plantar fasciitis.
Soft tissue injuries and tendinopathies account for large numbers of chronic musculoskeletal disorders. Extracorporeal shockwave therapy (ESWT) is popular, and effective in the management of chronic tendon conditions in the elbow, shoulder, and pain at and around the heel.
High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up
- Scandinavian journal of medicine & science in sports
- Published over 3 years ago
The aim of this study was to investigate the effectiveness of shoe inserts and plantar fascia-specific stretching vs shoe inserts and high-load strength training in patients with plantar fasciitis. Forty-eight patients with ultrasonography-verified plantar fasciitis were randomized to shoe inserts and daily plantar-specific stretching (the stretch group) or shoe inserts and high-load progressive strength training (the strength group) performed every second day. High-load strength training consisted of unilateral heel raises with a towel inserted under the toes. Primary outcome was the foot function index (FFI) at 3 months. Additional follow-ups were performed at 1, 6, and 12 months. At the primary endpoint, at 3 months, the strength group had a FFI that was 29 points lower [95% confidence interval (CI): 6-52, P = 0.016] compared with the stretch group. At 1, 6, and 12 months, there were no differences between groups (P > 0.34). At 12 months, the FFI was 22 points (95% CI: 9-36) in the strength group and 16 points (95% CI: 0-32) in the stretch group. There were no differences in any of the secondary outcomes. A simple progressive exercise protocol, performed every second day, resulted in superior self-reported outcome after 3 months compared with plantar-specific stretching. High-load strength training may aid in a quicker reduction in pain and improvements in function.
PURPOSE: The purpose of this study was to assess the safety and preliminary clinical results of platelet-rich plasma (PRP) injections for treating chronic plantar fasciitis. METHODS: Fourteen consecutive patients with chronic plantar fasciitis receiving three injections of PRP into the plantar fascia were assessed 12 months after the procedure. The modified Roles and Maudsley score and a visual analogue scale (VAS) for pain were used to evaluate the clinical results. RESULTS: According to criteria of the Roles and Maudsley score, at 12 months of follow-up, results were rated as excellent in nine (64.3 %), good in two (14.3 %), acceptable in two (14.3 %) and poor in one (7.1 %) patient. VAS for pain was significantly decreased from 7.1 ± 1.1 before treatment to 1.9 ± 1.5 at the last follow-up (p < 0.01). CONCLUSIONS: In this single-centre, uncontrolled, prospective, preliminary study, results indicate that treating chronic plantar fasciitis with PRP injections is safe and has the potential to reduce pain.
- American journal of physical medicine & rehabilitation / Association of Academic Physiatrists
- Published about 5 years ago
OBJECTIVE: The aim of this study was to investigate the effectiveness of device-assisted ultrasound-guided steroid injection for treating plantar fasciitis. DESIGN: An ultrasound-guided injection device designed with space for securing a transducer and syringe was used to guide steroid injection. Patients with unilateral plantar fasciitis were enrolled and randomly divided into device-assisted ultrasound-guided and palpation-guided groups. Pain intensity was measured using a visual analog scale and tenderness threshold. Ultrasound and pain intensity evaluations were performed before injection and at 3 wks and at 3 mos postinjection. Betamethasone (7 mg) and 1% lidocaine (0.5 ml) were injected into the inflamed plantar fascia. RESULTS: Thirty-three patients who received either device-assisted ultrasound-guided or palpation-guided injection had significantly lower visual analog scale scores (P < 0.001) and higher tenderness threshold (P < 0.01) postinjection. However, the device-assisted group had higher tenderness threshold (9.02 ± 1.38 vs. 7.18 ± 2.11 kg/cm; P = 0.007), lower visual analog scale score (1.88 ± 2.13 vs. 3.63 ± 2.60; P = 0.046), and lower hypoechogenicity incidence in the plantar fascia (3/16 vs. 9/16; P = 0.033) than the palpation-guided group did at 3 mos postinjection. The heel pad was significantly thin (P = 0.004) in the palpation-guided group postinjection. CONCLUSIONS: Device-assisted ultrasound-guided injection for treating plantar fasciitis results in better therapeutic outcomes than palpation-guided injection does.
OBJECTIVE: To investigate effects of dry needling in chronic heel pain due to plantar fasciitis. METHOD: During the present single-blinded clinical trial, 20 eligible patients were randomized into two groups; a case group treated by dry needling and a control group. Patients' plantar pain severity [using modified visual analog scale (VAS) scoring], range of motion of ankle joint in dorsiflexion (ROMDF) and plantar extension (ROMPE) and foot function index (by standard questionnaires SEM5 and MDC7) were assessed at baseline, four weeks after intervention and four weeks after withdrawing treatment. RESULTS: The mean VAS scores in the case group was significantly lower than the control group after four weeks of intervention (P<0.001). Comparison of the ROMDF and ROMPE did not reveal any significant change after four weeks of intervention in both the case and control groups (P=0.7 and P=0.65, respectively). The mean of MDC7 and SEM5 scores in the case group was significantly lower than the control group following four weeks of intervention (P<0.001). CONCLUSIONS: Despite the insignificant effect on ROMDF and ROMPE, trigger point dry needling by improving the severity of heel pain can be used as a good alternative option before proceeding to more invasive therapies of plantar fasciitis.
Plantar fasciitis is a common cause of heel pain in the U.S. Army soldier, resulting in a significant loss of man hours. Given the heavy operations tempo of the U.S. military, successful treatment options need to be considered and used as quickly as possible. Plantar fasciitis can be successfully treated in up to 90% of patients using conservative measures. Operative intervention might need to be considered for those in whom conservative measures have failed. The present report is a review of 105 consecutive uniport endoscopic plantar fascial release procedures performed by the principal investigator during a 9-year period. The following data were collected and analyzed: gender, age, weight, height, body mass index, medical treatment facility, procedure laterality, preoperative pain levels, postoperative pain levels at 3 months, first ambulatory day in the controlled ankle motion boot, return to activity as tolerated, and complications. Three major points were of interest: evidence of improvement in chronic plantar fasciitis when treated with uniport endoscopic procedures; the patient attributes associated with self-reported pain levels 90 days postoperatively; and the patient attributes associated with the average time until patients were able to return to activities as tolerated in a controlled ankle motion boot. It was noted that 44.5% of those with a body mass index of 29.80 kg/m(2) or greater reported a postoperative pain level of 0; and 96.3% of those with a body mass index of 25.53 kg/m(2) or less reported postoperative pain levels of 0. The analyzed data were used to characterize the clinical outcomes of the procedure, identify changes in outcome with surgeon experience, and identify whether certain patient subgroups have better outcomes, allowing surgeons to identify which patient might be the best candidates for an endoscopic release procedure.
Sonographic visualization of the first branch of the lateral plantar nerve (baxter nerve): technique and validation using perineural injections in a cadaveric model
- Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine
- Published over 4 years ago
Objectives- The primary purpose of this investigation was to document the ability of high-resolution sonography to accurately identify the first branch of the lateral plantar nerve (FBLPN) using sonographically guided perineural injections in an unembalmed cadaveric model. Methods- single experienced operator completed sonographically guided perineural FBLPN injections in 12 unembalmed cadaveric specimens (6 right and 6 left) obtained from 10 donors (5 male and 5 female) aged 47 to 95 years (mean, 71 years) with an average body mass index of 24.2 kg/m(2) (range, 17.2-31.6 kg/m(2)). All injections were completed using 22-gauge, 38-mm stainless steel needles to deliver 1 mL of 50% diluted colored latex adjacent to the FBLPN in the abductor hallucis-quadratus plantae (AH-QP) interval. Six injections were completed using a cart-based ultrasound (US) machine and a 17-5-MHz transducer, and 6 were completed using a portable US machine and a 12-3-MHz transducer. Nerve conspicuity was graded on a 4-point scale (1, poor; 4, excellent). After a minimum of 24 hours, study coinvestigators dissected each specimen to assess injectate placement. Results- All 12 injections accurately placed latex onto the FBLPN within the AH-QP interval, with 11 of 12 (91%) resulting in complete nerve coverage. Proximal latex overflow to the lateral plantar nerve occurred in 82% of cases (10 of 12). The average distance between the plantar fascia and injected latex was 1.2 cm (range, 1.0-1.75 cm). No vascular injury was seen in any specimen. The average nerve conspicuities were 3.7 (range, 3-4) using the cart-based US machine and 1.8 (range, 1-4) using the portable US machine. Conclusions- Sonographic visualization of the FBLPN in the AH-QP interval is feasible and should be considered for diagnostic and therapeutic purposes in patients presenting with chronic or atypical heel pain syndromes. Further clinical experience should refine the role of FBLPN sonography and explore the utility of sonographically guided diagnostic and therapeutic FBLPN perineural injections.
Although the plantar fascia (PF) has been studied quite well from a biomechanical viewpoint, its microscopic properties have been overlooked: nothing is known about its content of elastic fibers, the features of the extracellular matrix or the extent of innervation. From a functional and clinical standpoint, the PF is often correlated with the triceps surae muscle, but the anatomical grounds for this link are not clear. The aim of this work was to focus on the PF macroscopic and microscopic properties and study how Achilles tendon diseases might affect it. Twelve feet from unembalmed human cadavers were dissected to isolate the PF. Specimens from each PF were tested with various histological and immunohistochemical stains. In a second stage, 52 magnetic resonance images (MRI) obtained from patients complaining of aspecific ankle or foot pain were analyzed, dividing the cases into two groups based on the presence or absence of signs of degeneration and/or inflammation of the Achilles tendon. The thickness of PF and paratenon was assessed in the two groups and statistical analyses were conducted. The PF is a tissue firmly joined to plantar muscles and skin. Analyzing its possible connections to the sural structures showed that this fascia is more closely connected to the paratenon of Achilles tendon than to the Achilles tendon, through the periosteum of the heel. The PF extended medially and laterally, continuing into the deep fasciae enveloping the abductor hallucis and abductor digiti minimi muscles, respectively. The PF was rich in hyaluronan, probably produced by fibroblastic-like cells described as ‘fasciacytes’. Nerve endings and Pacini and Ruffini corpuscles were present, particularly in the medial and lateral portions, and on the surface of the muscles, suggesting a role for the PF in the proprioception of foot. In the radiological study, 27 of the 52 MRI showed signs of Achilles tendon inflammation and/or degeneration, and the PF was 3.43 ± 0.48 mm thick (99%CI and SD = 0.95), as opposed to 2.09 ± 0.24 mm (99%CI, SD = 0.47) in the patients in which the MRI revealed no Achilles tendon diseases; this difference in thickness of 1.29 ± 0.57 mm (99%CI) was statistically significant (P < 0.001). In the group of 27/52 patients with tendinopathies, the PF was more than 4.5 mm thick in 5, i.e. they exceeded the threshold for a diagnosis of plantar fasciitis. None of the other 25/52 paitents had a PF more than 4 mm thick. There was a statistically significant correlation between the thicknesses of the PF and the paratenon. These findings suggest that the plantar fascia has a role not only in supporting the longitudinal arch of the foot, but also in its proprioception and peripheral motor coordination. Its relationship with the paratenon of the Achilles tendon is consistent with the idea of triceps surae structures being involved in the PF pathology, so their rehabilitation can be considered appropriate. Finally, the high concentration of hyaluronan in the PF points to the feasibility of using hyaluronan injections in the fascia to treat plantar fasciitis.