Plantar fasciitis (fasciosis) treatment outcome study: Plantar fascia thickness measured by ultrasound and correlated with patient self-reported improvement
Introduction
Plantar fasciitis (PF), the most common cause of heel pain, accounts for 15% of all foot disorders [17], with approximately two million Americans seeking treatment for it every year [20]. The disorder typically results from repetitive trauma or excessive load on the fascia [2], disproportionately afflicting middle-aged women and younger, predominantly male runners [16]. Although the term “fasciitis” denotes inflammation, histological studies by Lemont et al. have shown non-inflammatory changes within the fascia and evidence of “fiber fragmentation in association with myxoid degeneration” [13]. For this reason, they suggested that PF be more appropriately termed “plantar fasciosis.”
The role of imaging in the management of PF is essential in making the correct diagnosis and differentiating from other causes of heel pain [3]. Imaging may also be of value in patient follow-up, especially for athletes in determining when they may return to physical activity [7]. Ultrasound has been well recognized as an effective diagnostic imaging tool for PF [1], [5], [7], [9], [15], [16], [17], [18], because it is non-invasive, well tolerated by patients, cost effective, free of radiation and provides perfect spatial resolution for superficial structures [7], [15], [16]. Furthermore, several authors have reported the thickening of the plantar fascia together with hypo-echoic changes as characteristic features of PF when imaged by ultrasound [7], [10], [11], [18], [19].
Because the thickening of the plantar fascia in patients with PF is commonly observed with ultrasound, the authors postulated a decrease in the plantar fascia thickness when patients undergo treatment. Previous studies had tested this hypothesis and reported a decrease in the mean thickness of the plantar fascia after being treated with corticosteroid injection [9], [10]; however, the study was done with a limited number of patients.
The purposes of the prospective study were threefold:
- 1.
Compare the plantar fascia thickness using ultrasound between a control group and a group of PF patients of statistically significant number.
- 2.
Analyze the difference in the plantar fascia thickness using ultrasound in the study group before and after treatment.
- 3.
Observe patients as they grade their pain levels from three specific time periods (morning, noon and evening) and correlate their symptomatic improvement with plantar fascia thickness reduction as measured by ultrasound.
Section snippets
Study methods and materials
This prospective study involved 30 patients with plantar fascia pain at the heel and instep that were recruited with their consent from the private practice of senior author. Diagnosis was based on clinical history and physical examination in accordance with the diagnostic guidelines of Leach et al. [12]. Excluded from the study group were patients with direct trauma, systemic inflammatory disease, connective tissue disease, lumbar spine disc herniation, suspected history of secondary pain gain
Results
Differences in the thickness of the plantar fascia between the control group and the pre-treatment study group were analyzed. All 30 patients in the study group reported unilaterally symptomatic feet. The 12 symptomatic right feet in the study group were compared to 29 right feet in the control group, and the 18 symptomatic left feet in the study group were compared to 32 left feet in the control group. The study group showed a significantly thicker plantar fascia when compared to the control
Discussion
In the literature, normal thickness of the plantar fascia when measured in ultrasound varies in range. The mean plantar fascia thickness was reported to be 2.6 mm (1.6–3.8 mm) by Cardinal et al. [5], 3.3 mm (2.4–4.3 mm) by Gibbon and Long [7], 2.2 mm for the contra-lateral normal heel and 2.5 mm for the control group by Ozdemir et al. [15], and 3.4 mm for women and 3.6 mm for men by Wall et al. [19]. It is generally accepted that plantar fascia thickness of more than 4 mm would be abnormal, and
Study limitations
The patients entered into the study all graded their pain according to the faces of pain rating scale. During the examination, some patients self described their pain as worse or better than the author's judgment of their symptomatic distress. The senior author reviewed their facial expressions, examination, and their ability to function at home and at work. Additionally, this study did not reflect patients who may go onto surgery in the future, or who's plantar fascia thickness increased or
Conclusion
This prospective study confirmed the following
- 1.
Reports from previous investigations that the plantar fascia in symptomatic patients is significantly thicker on ultrasound than that in non-symptomatic patients.
- 2.
Plantar fascia thickness diminishes on ultrasound with successful treatment.
- 3.
Clinical treatment with injection and biomechanical correction has a salutary effect on plantar fascia thickness, which is measurable.
- 4.
Plantar fascia tenderness is truly at its worst toward the end of the day.
- 5.
Patient
Acknowledgement
The authors wish to express their gratitude to Donna Agan, Ed.D., for the statistical analysis of the data in this investigation.
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