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Treatment of proximal plantar fasciitis with ultrasound-guided steroid injection,☆☆,

https://doi.org/10.1053/apmr.2000.9175Get rights and content

Abstract

Tsai W-C, Wang C-L, Tang F-T, Hsu T-C, Hsu K-H, Wong M-K. Treatment of proximal plantar fasciitis with ultrasound-guided steroid injection. Arch Phys Med Rehabil 2000;81:1416-21. Objective: To investigate the efficacy of ultrasound-guided steroid injection for the treatment of proximal plantar fasciitis and to evaluate mechanical properties of the heel pad after steroid injection. Design: Proximal plantar fascia and heel pad were assessed with a 10-MHz linear array ultrasound transducer. Pain intensity was quantified with a tenderness threshold (TT) and visual analog scale (VAS). The transducer was incorporated into a specially designed device to measure mechanical properties of the heel pad. Evaluations were performed before injection and at 2 weeks and 3 months after injection. Setting: An outpatient clinic of a tertiary care center. Patients: Fourteen consecutive patients with unilateral proximal plantar fasciitis. Intervention: Ultrasound-guided injection of 7mg betamethasone and 0.5mL of 1% lidocaine into the inflamed proximal plantar fascia. Main Outcome Measures: VAS, TT, heel pad and plantar fascia thickness, and echogenicity of the proximal plantar fascia on sonogram were assessed. Mechanical properties included unloaded heel pad thickness, compressibility index, and energy dissipation ratio. Results: Both VAS score ± standard deviation (SD; 5.43 ± 2.03, 1.39 ± 2.19, 0.57 ± 1.40 at the 3 measurements, respectively) and TT ± SD (5.05 ± 1.42, 9.34 ± 1.84, 9.93 ± 1.98kg/cm2 at the 3 measurements, respectively) improved significantly (p <.001) after steroid injection. The mean thickness of the plantar fascia was greater in the symptomatic side than in the asymptomatic side before treatment (0.58 ± 0.13cm vs 0.40 ± 0.11cm, p <.001). The thickness had decreased significantly 3 months after injection (0.46 ± 0.12cm at 2 weeks, 0.42 ± 0.10cm at 3 months,p <.001). The hypoechogenicity at the proximal plantar fascia disappeared after steroid injection (p <.001). Mechanical properties of the heel pad did not change 3 months after steroid injection (p >.05). Conclusion: Ultrasound offers an objective measurement of the therapeutic effect on proximal plantar fasciitis. Accurate steroid injection under ultrasound guidance can effectively treat proximal plantar fasciitis without significant deterioration of the mechanical properties of the heel pads. © 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Section snippets

Subjects

Fourteen consecutive patients with unilateral plantar fasciitis, between the ages of 35 and 80, enrolled in the present study. Their physical characteristics are shown in table 1.

Table 1: Subject characteristics (n = 14)

CharacteristicValue
Gender (male:female)1:13
Lesion (right:left)6:8
Age (yr)48.4 ± 10.8
Height (cm)159.0 ± 7.1
Weight (kg)67.6 ± 10.2
Body mass index (kg/m2)26.87 ± 4.63

Values are reported as mean ± SD.

The diagnosis of plantar fasciitis depended on tenderness at the origin of the

Ultrasonographic findings

On sonograms, the heel has a sharp high-intensity interface at the skin surface, then a finite area of soft tissue of medium acoustic intensity, and then another sharp bright interface representing the calcaneal soft tissue junction (fig 3). The calcaneus was identified by observation of acoustic shadowing. The plantar fascia was recognized by its moderately echogenic, striated appearance with insertion on the calcaneus. The edges were well defined by 2 echogenic lines (fig 1A). The plantar

Discussion

The plantar fascia arising from the calcaneal tuberosity to the forefoot and spanning the longitudinal arch has been shown to be the most important structure for dynamic arch support.26, 27 Overuse and microtears from repetitive trauma are thought to contribute to plantar fasciitis. When the plantar fascia assumes a greater share of force than it can accommodate physiologically, plantar fasciitis may result. This overload may cause microtears in the fascia at or near the fascia-bone interface.28

Conclusion

Ultrasound is useful in enhancing the accuracy of steroid injection because it precisely localizes the lesion and needle placement. Instead of relying on subjective VAS and TT, it offers objective measurements of the therapeutic effect, including the decreased thickness and disappearance of hypoechogenicity in the plantar fascia. No deterioration of mechanical properties of the heel pads (including pad atrophy) occurred, which means that the fat pad was not adversely affected by a single

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    Reprint requests to Fuk-Tan Tang, Department of Physical Medicine & Rehabilitation, Chang Gung Memorial Hospital 5, Fu-Shin St, Gueishan, Taoyuan Hsien, Taiwan; e-mail: [email protected].

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