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Long‐distance running (LDR) can induce transient lowering of the foot arch, which may be associated with mechanical fatigue of the plantar fascia (PF). However, this has not been experimentally tested in vivo. The purpose of this study was to test our hypothesis that LDR induces transient and site‐specific changes in PF stiffness and morphology and that those changes are related to the lowering of the foot arch. Ten male recreational long‐distance runners and 10 untrained men were requested to run overground for 10 km. Before and after running, shear wave velocity (SWV: an index of soft tissue stiffness) and thickness of PF at three different sites from its proximal to distal end were measured using supersonic shear imaging and B‐mode ultrasonography. Foot dimensions including the navicular height were measured using a three‐dimensional foot scanner. SWV at the proximal site of PF and navicular height was significantly decreased in both groups after running, with a higher degree in untrained men (−21.9% and −14.1%, respectively) than in runners (−4.0% and −6.3%, respectively). The relative change (%Δ) in SWV was positively correlated with %Δnavicular height in both groups (r = .69 and r = .65, respectively). Multiple regression analysis revealed that %ΔSWV at the proximal site solely explained 72.7% of the total variance in %Δnavicular height. It is concluded that LDR induces transient and site‐specific decreases in PF stiffness. These results suggest that the majority of running‐induced lowering of the foot arch is attributable to the reduction of PF stiffness at the proximal site.

The aim of this study was to examine the influence of hormonal changes during the menstrual cycle on deep fasciae. A total of 29 women, 17 users, and 12 nonusers of hormonal contraceptives were examined clinically and by ultrasound, including shear wave elastography, at two phases of the menstrual cycle. The thickness and elasticity of the fascia lata, thoracolumbar fascia, and plantar fascia were measured, compared between hormonal contraceptive users and nonusers, and correlated with clinical data. There were statistically significant differences between users and nonusers of hormonal contraceptives: the thoracolumbar fascia was thicker in nonusers (P = 0.011), and nonusers had higher maximal and mean stiffnesses of the fascia lata (P = 0.01 and 0.0095, respectively). Generally, nonusers had a higher body mass index (BMI). The elasticity of the thoracolumbar and the plantar fasciae did not differ significantly between the groups. We found no correlation between thickness and elasticity in the fasciae. There were no statistically significant differences in hypermobility, cephalgia, or dysmenorrhea between users and nonusers of hormonal contraceptives. The results of this pilot study suggest that deep fasciae can be evaluated by shear wave elastography. Nonusers of contraceptives had greater stiffness of the fascia lata and higher BMI. Clin. Anat. 32:941-947, 2019. © 2019 Wiley Periodicals, Inc.

The purpose of this series is to review the appearance of plantar fibromatosis with high-resolution ultrasonography (US) and highlight a new imaging sign termed the "comb sign." A retrospective study was performed for patients with a clinical diagnosis of plantar fibromatosis. Charts of 43 patients (age range, 26-77 years; mean age, 54 years) were reviewed to gather patient demographics and symptoms. Several US characteristics were evaluated with emphasis on any new imaging features. A total of 57 plantar fibromas in 43 patients were examined. Plantar fibromatosis was seen as a lobular marginated oval nodule along the superficial plantar fascia involving the central or medial cord, often at the middle third (84%) of the plantar fascia, showing posterior acoustic enhancement (65%), mixed echogenicity (82%), and intralesional vascularity (53%). Slightly more than half (51%) of the lesions showed a previously unrecognized appearance, designated the comb sign. This sign was more commonly seen in the setting of larger fibromas (P < .05). Plantar fibromatosis is usually a clinical diagnosis that can be aided by a typical US appearance. Although the imaging characteristics are largely similar to prior literature, this series suggests that most show mixed echogenicity and posterior acoustic enhancement, and approximately half show internal vascularity. A new US sign, termed the comb sign, shows alternating bands of hypoechogenicity and isoechogenicity, particularly in larger plantar fibromas, and can help in further characterization.

Objectives: The aim of our study was to evaluate the incidence, prevalence, characteristics, disease associations, risk factors and outcome of clinical enthesitis in patients with PsA. Methods: The study included patients with PsA followed prospectively. Enthesitis was defined as the presence of at least one tender enthesis at one of the 18 entheseal sites of the Spondyloarthritis Research Consortium of Canada enthesitis index. Results: Between 2008 and 2014, 281 of 803 patients had enthesitis providing a prevalence of 35%. 192 patients developed enthesitis during the course of follow-up, with an annual incidence of 0.9%. Most of the patients had 1 (48.4%) or 2 (32.2%) tender entheseal sites and the mean (s.d.) number of sites per visit was 2.03 (1.6). The 3 most common sites were at the insertions of the Achilles tendons and plantar fascia on the calcaneus, and the lateral epicondyles (24.2%, 20.8% and 17.2%, respectively). More active disease (higher actively inflamed joint count, tenosynovitis and dactylitis), more pain and less clinical damage were associated with enthesitis. Higher BMI, more actively inflamed joints and younger age were risk factors for developing this condition. Enthesitis resolved in most patients without changing treatment. Conclusion: Clinical enthesitis is common with a period prevalence of 35% of PsA patients. It usually involves only 1 or 2 sites simultaneously. The most common tender sites are at the insertions of the Achilles tendon, plantar fascia and the lateral epicondyles. More active disease and more pain are associated with enthesitis. This article is protected by copyright. All rights reserved.

Several surgically corrective procedures are considered to treat Adult Acquired Flatfoot Deformity (AAFD) patients, relieve pain, and restore function. Procedure selection is based on best practices and surgeon preference. Recent research created patient specific models of AAFD to explore their predictive capabilities and examine effectiveness of the surgical procedure used to treat the deformity. The models' behavior was governed solely by patient bodyweight, soft tissue constraints, muscle loading, and joint contact without the assumption of idealized joints. The current work expanded those models to determine if an alternate procedure would be more effective for the individual. All procedures incorporated first a tendon transfer and then included one hindfoot procedure, the Medializing Calcaneal Osteotomy (MCO), and one of three lateral column procedures: Evans osteotomy, Calcaneocuboid Distraction Arthrodesis (CCDA), Z osteotomy, and the combination procedures MCO & Evans osteotomy, MCO & CCDA, and MCO & Z osteotomy. The combination MCO & Evans and MCO & Z procedures were shown to provide the greatest amount of correction for both forefoot abduction and hindfoot valgus. However, these two procedures significantly increased joint contact force, specifically at the calcaneocuboid joint, and ground reaction force along the lateral column. With exception to the lateral bands of the plantar fascia and middle spring ligament, the strain present in the plantar fascia, spring, and deltoid ligaments decreased after all procedures. The use of patient specific computational models provided the ability to investigate effects of alternate surgical corrections on restoring biomechanical function in these flatfoot patients. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1523-1531, 2017.

Destruction of the normal metatarsal arch by a long metatarsal is often a cause for metatarsalgia. When surgery is warranted, distal oblique, or proximal dorsiflexion osteotomies of the long metatarsal bones are commonly used. The plantar fascia has anatomical connection to all metatarsal heads. There is controversial scientific evidence on the effect of plantar fascia release on forefoot biomechanics. In this cadaveric biomechanical study, we hypothesized that plantar fascia release would augment the plantar metatarsal pressure decreasing effects of two common second metatarsal osteotomy techniques. Six matched pairs of foot and ankle specimens were mounted on a pressure mat loading platform. Two randomly assigned surgery groups, which had received either distal oblique, or proximal dorsiflexion osteotomy of the second metatarsal, were evaluated before and after plantar fasciectomy. Specimens were loaded up to a ground reaction force of 400 N at varying Achilles tendon forces. Average pressures, peak pressures, and contact areas were analyzed. Supporting our hypothesis, average pressures under the second metatarsal during 600 N Achilles load were decreased by plantar fascia release following proximal osteotomy (p

Purpose To determine intra- and interobserver reliability and precision of sonographic (US) scanning in measuring thickness of the Achilles tendon, plantar fascia, and heel fat pad in patients with heel pain. Methods Seventeen consecutive patients referred with heel pain were included. Two evaluators blinded to the diagnosis performed independently US scanning of both feet without any dialogue with the patient. The examiner left the room, and the next examiner entered. All patients had two US scans performed by each examiner. Two months later, the US images were randomly presented to the evaluators for measurements. Reliability and agreement were assessed by calculation of intraclass correlation coefficient (ICC), 95% limits of agreement (LOA), and typical error (TE). LOA was calculated as a percentage of the mean thickness of each structure to obtain a unitless parameter. Results We found excellent intratester reliability (ICC 0.78–0.98) and good intertester reliability using one measurement (ICC 0.72–0.91) and excellent (ICC 0.85–0.95) when using average of two measurements. The intratester agreements were good with LOA: 9.5–23.4% and TE: 3.4–8.4%. The intertester agreements were acceptable using one measurement with LOA: 16.1–36.4%, and better using two measurements with LOA: 14.4–33.2%. Conclusions US is a reliable technique of measurement in the daily clinic, and one single measurement is sufficient. In research, we recommend that the same observer performs the US measurements, if one single scanning is preferred; if more researchers are involved, the average measurement of two US scans is recommended. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound, 2016

Objectives The primary objective of this study was to determine whether the sonographic appearance of the plantar fascia is predictive of the treatment (ie, pain) response in patients receiving supportive therapy for proximal plantar fasciitis. This study was a secondary analysis of data obtained from a randomized controlled trial of ambulatory adults, which examined the efficacy of 3 different foot supports for plantar fasciitis. Methods Participants underwent diagnostic sonographic examinations of their heel at baseline and again at 3 months by a single experienced foot and ankle surgeon. Quantitative (eg, thickness) and qualitative (eg, biconvexity) characteristics of the fascia were recorded according to a standard protocol. Logistic regression models were used to identify predictors of the pain response. Results Seventy patients completed a baseline evaluation, and 63 patients completed a 3-month follow-up assessment. The pain response was not associated with the type of foot support (P> .05). The only significant indicator of an unfavorable response in the univariate and multivariate analyses was biconvexity of the plantar fascia on sonography at presentation (multivariate odds ratio, 4.76 [95% confidence interval, 1.16-19.5; P= .030). Furthermore, changes in self-reported pain over the 3-month study period were not accompanied by alterations in plantar fascia thickness over this time (r = .056; P = .671). Conclusions We conclude that patients who present with biconvexity of the plantar fascia may be less responsive to tier 1 treatment regimens that center around mechanical support of the plantar fascia. Furthermore, follow-up measurements of the fascia in this population should not weigh heavily in decisions such as return to play.

BACKGROUND: Diabetes mellitus is a metabolic disorder with involvement of the neurovascular and muscular system. Peripheral neuropathy (PN) is thought to be the principal cause of foot complications in type 2 diabetes mellitus (T2DM). However, foot evaluation using ultrasonography early in the course of diabetes has not gained due importance. The aim of the present study was to evaluate the thickness of intrinsic foot muscles, plantar skin, plantar fascia, and plantar fat pad in T2DM subjects with and without PN using musculoskeletal ultrasonography. METHODS: This study was conducted in 30 T2DM subjects with and without PN and 30 age-matched non-diabetes mellitus (NDM) subjects. After detailed clinical evaluation, high-frequency musculoskeletal ultrasonography was used to measure the thickness of the intrinsic foot muscles and plantar tissue thickness under the metatarsals. Data were analyzed using independent t-tests to compare T2DM groups with NDM subjects, and one-way ANOVA followed by Tukey's honestly significant difference test for between- and within-group analyses. RESULTS: There was a significant reduction in the thickness of the intrinsic foot muscles and plantar tissue in T2DM compared with NDM subjects (P

Objective To evaluate the distribution of enthesitis and the accuracy of physical examination with a dolorimeter for the detection of enthesitis in children, using ultrasound (US) assessment as the reference standard. Methods We performed a prospective cross-sectional study of 30 patients with enthesitis-related arthritis (ERA) and 30 control subjects. The following tendon insertion sites were assessed by standardized physical examination with a dolorimeter and US: common extensor on the lateral humeral epicondyle, common flexor on the medial humeral epicondyle, quadriceps at the superior patella, patellar ligament at the inferior patella, Achilles, and plantar fascia at the calcaneus. Results Abnormal findings on US were detected most commonly at the insertion of the quadriceps (30% [18 of 60 sites]), common extensor (12% [7 of 60]), and Achilles (10% [6 of 60]) tendons. The intrarater reliability of US (kappa statistic) was 0.78 (95% confidence interval [95% CI] 0.63–0.93), and the interrater reliability was 0.81 (95% CI 0.67–0.95). Tenderness as detected by standardized dolorimeter examination had poor positive predictive value for US-confirmed enthesitis. In comparison to controls, patients with ERA reported more pain and had lower pain thresholds at every site, including control sites (P < 0.001 for all comparisons). The interrater reliability of dolorimeter examination for detection of enthesitis was low (κ = 0.49 [95% CI 0.33–0.65]). Conclusion Compared to US, standardized dolorimeter examination for the detection of enthesitis in children has poor accuracy and reliability. The decreased pain threshold of ERA patients likely contributed to the limited accuracy of the physical examination findings. Further research regarding the utility of US for identifying enthesitis at diagnosis of juvenile idiopathic arthritis, accurately predicting disease progression, and guiding therapeutic decisions is warranted.

Spontaneous ruptures of the plantar fascia are uncommon injuries. They typically occur at its calcaneal insertion and usually represent a complication of plantar fasciitis and local treatment with steroid injections. In contrast, distal ruptures commonly result from traumatic injuries. We describe the case of a spontaneous distal rupture of the plantar fascia in a 48-year-old woman with a low level of physical activity and no history of direct injury to the foot, plantar fasciitis, or steroid 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.

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.

Objectives To evaluate the efficacy of autologous conditioned plasma (ACP) compared with extracorporeal shockwave (ESWT) and conventional treatments for plantar fasciitis. Design Randomized trial. Setting Sports medicine center in a tertiary care hospital. Patients Fifty-four subjects (age range, 29-71 years) with unilateral chronic plantar fasciitis with more than 4 months of symptoms. Methods Subjects randomized to 3 groups: 19 to ACP and conventional treatment (ACP group), 19 to ESWT and conventional treatment (ESWT group), and 16 to conventional treatment alone. Conventional treatment included stretching exercises and orthotics if indicated. Main Outcome Measurements Outcomes were pain-Visual Analog Scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, and ultrasound plantar fascia thickness assessed at baseline before treatment and at 1 month, 3 months, and 6 months after treatment. Results VAS, AOFAS ankle-hindfoot scale, and plantar fascia thickness improved in all groups. Significant VAS pain score improvements in the ACP group compared with conventional treatment at month 1 ( P = .037) and for the ESWT group compared with conventional treatment at months 1, 3, and 6 ( P = .017 , P = .022, and P = .042). The AOFAS ankle-hindfoot scale score improved in the ACP group at months 3 and 6 ( P = .004 and P = .013) and, for the ESWT group, at months 1 and 3 ( P = .011 and P = .003) compared with conventional treatment. Significant improvements in plantar fascia thickness were seen in the ACP group at months 1 and 3 compared with conventional treatments ( P = .015 and P = .014) and at months 3 and 6 compared with the ESWT group ( P = .019 and P = .027). No adverse events reported. Conclusions Treatment of plantar fasciitis with ACP or ESWT plus conventional treatments resulted in improved pain and functional outcomes compared with conventional treatment alone. There was no significant difference between ACP and ESWT in terms of VAS and AOFAS ankle-hindfoot scale improvements, although the ACP group demonstrated greater reductions in plantar fascia thickness.

Objectives To determine the distribution of sonographically guided deep plantar fascia injections in an unembalmed cadaveric model. Methods A single experienced operator completed 10 sonographically guided deep plantar fascia injections in 10 unembalmed cadaveric specimens (5 right and 5 left) obtained from 6 donors (2 male and 4 female) aged 49 to 95 years (mean, 77.5 years) with a mean body mass index of 23.2 kg/m(2) (range, 18.4-26.3 kg/m(2)). A 12-3-MHz linear array transducer was used to direct a 22-gauge, 38-mm stainless steel needle deep to the plantar fascia at the anterior aspect of the calcaneus using an in-plane, medial-to-lateral approach. In each case, 1.5 mL of 50% diluted colored latex was injected deep to the plantar fascia. After a minimum of 72 hours, study coinvestigators dissected each specimen to assess injectate placement. Results All 10 injections accurately placed latex adjacent to the deep side of the plantar fascia at the anterior calcaneus. However, the flexor digitorum brevis (FDB) origin from the plantar fascia variably limited direct latex contact with the plantar fascia, and small amounts of latex interdigitated with the FDB origin in 90% (9 of 10). In all 10 specimens, latex also covered the traversing first branch of the lateral plantar nerve (FBLPN, ie, Baxter nerve) between the FDB and quadratus plantae muscles. No latex was found in the plantar fat pad or plantar fascia in any specimen. Conclusions Sonographically guided deep plantar fascia injections reliably deliver latex deep to the plantar fascia while avoiding intrafascial injection. However, the extent of direct plantar fascia contact is variable due to the intervening FDB. On the contrary, the traversing FBLPN is reliably covered by the injection. Deep plantar fascia injections may have a role in the management of refractory plantar fasciitis, particularly following failed superficial perifascial or intrafascial injections, in cases of preferential deep plantar fascia involvement, or when entrapment/irritation of the distal FBLPN is suspected.

Objective To determine the efficacy of autologous platelet-rich plasma (PRP) compared with dextrose prolotherapy (DP) in patients with chronic recalcitrant plantar fasciitis (PF) Design A single-blinded, randomized, controlled study. Setting Department of Physical Medicine and Rehabilitation of a university hospital. Participants Twenty-one patients with a clinical diagnosis of chronic PF confirmed by diagnostic ultrasound (plantar fascia thickness >4 mm) were randomly assigned to the PRP group (n = 10) or the DP group (n = 11). Interventions Each patient received 2 injections into the plantar fascia through a peppering technique under ultrasound guidance at an interval of 2 weeks, either with 2 mL of autologous PRP or 2 mL of 15% dextrose/lidocaine solution. Main Outcome Measurements The outcome measures included the pain, disability, and activity limitation subscales, measured by means of the Foot Functional Index. Data were collected before the first injection, at 2 weeks (before the second injection), and at the 2- and 6-month follow-ups. Results All patients completed the follow-ups, with the exception of 1 patient in the PRP group. The mean Foot Functional Index total and subcategory score improvements were greater in the PRP group compared with the DP group (improvement with PRP vs DP, total: 30.4% vs 15.1%, pain: 29.7% vs 17.1%, disability: 26.6% vs 14.5%, activity limitation: 28.0% vs 12.4%). However, no statistically significant difference was noted at any follow-up. In the pain and disability subcategories, both groups showed significant improvements at the last re-evaluation. The PRP group also showed significant improvements in the disability and activity limitation subscales at the second re-evaluation. Conclusions Each treatment seems to be effective for chronic recalcitrant PF, expanding the treatment options for patients in whom conservative care has failed. PRP treatment also may lead to a better initial improvement in function compared with DP treatment.

The purpose of this study was to prospectively investigate the effect of sonographically guided corticosteroid injection on the clinical and radiologic responses in patients with proximal plantar fasciosis.Thirty-one consecutive patients with unilateral plantar fasciosis were enrolled. A 4-cm 21-gauge needle was positioned in a caudocranial oblique manner, and the needle was withdrawn to the near edge of the fascia so that the solution dispersed around the edge. Two milliliters (20 mg/mL) of lignocaine/prilocaine, 1%, and 0.5 mL (20 mg) of methylprednisolone acetate solutions were injected separately. The plantar fascia and fat pad thickness, fascial echogenicity, and perifascial edema were assessed with a 10-5 MHz linear array transducer. The American Orthopedic Foot and Ankle Society midfoot scale was used to assess function, alignment, and pain. The initial radiologic and clinical measurements were compared with data obtained not less than 6 weeks after the injections.A statistically significant decrease in the mean plantar fascia thickness was detected after treatment (P.0001). There was no statistically significant difference in the plantar fascia echogenicity before and after treatment (P = .11). A statistically significant decrease was found for perifascial edema (P.0001), and a statistically significant increase in American Orthopedic Foot and Ankle Society scores was detected (P = .0007). There was no decrease in fat pad thickness (P.1). Plantar fascia rupture was detected in 1 patient.Sonographically guided corticosteroid injection enables real-time imaging of the plantar fascia during needle insertion. A caudocranial oblique injection beneath the fascia may have an incremental value in the treatment response in patients with plantar fasciosis.

Although fasciae have long interested clinicians in a multitude of different clinical and paramedical disciplines, there have been few attempts to unite the ensuing diverse literature into a single review. The current article gives an anatomical perspective that extends from the gross to the molecular level. For expediency, it deals only with fascia in the limbs and back. Particular focus is directed towards deep fascia and thus consideration is given to structures such as the fascia lata, thoracolumbar fascia, plantar and palmar fascia, along with regional specializations of deep fascia such as retinacula and fibrous pulleys. However, equal emphasis is placed on general aspects of fascial structure and function, including its innervation and cellular composition. Among the many functions of fascia considered in detail are its ectoskeletal role (as a soft tissue skeleton for muscle attachments), its importance for creating osteofascial compartments for muscles, encouraging venous return in the lower limb, dissipating stress concentration at entheses and acting as a protective sheet for underlying structures. Emphasis is placed on recognizing the continuity of fascia between regions and appreciating its key role in coordinating muscular activity and acting as a body-wide proprioceptive organ. Such considerations far outweigh the significance of viewing fascia in a regional context alone.

Aim and Method: In a prospective study of nine men and eight women with suspected unilateral or bilateral plantar fasciitis, 23 symptomatic heels were examined by both high-resolution ultrasound and a preplanned limited sagittal magnetic resonance imaging (MRI) protocol to assess the different signs. Eleven healthy volunteers (22 heels) acted as controls. Results: The plantar fascia was thickened in symptomatic feet. The thickness of the plantar fascia in symptomatic feet was (3.0–7.0 mm; 4.9 ± 1.3) measured by ultrasound which was significantly thicker than in the control group (1.1–2.4 mm; 1.7 ± 0.06); P

The surgeon doing microsurgery will encounter problems related to the heel not only in terms of how to reinnervate the transferred tissue, but also in patients presenting with heel pain. While most heel pain is thought to be related to the plantar fascia arising from the calcaneus, conceptually heel pain can be of neural origin. The technique for documenting sensibility in the heel is described using the Pressure-Specified Sensory Device. Knowledge of calcaneal nerve sensibility can determine whether there is sufficient sensation to prevent ulceration, whether there is a nerve entrapment that would benefit from neurolysis, or whether there is a neuroma that would benefit from resection.

Objective The purpose of this study was to evaluate the utility of color B-mode imaging with contrast optimization in evaluating low-contrast lesions of the foot and ankle (Morton neuromas and plantar fasciitis). Methods The sonographic examinations of 49 consecutive patients with a diagnosis of plantar fasciitis or Morton neuroma imaged with both conventional gray scale imaging and color B-mode imaging with contrast optimization (Photopic; Siemens Medical Solutions, Mountain View, CA) were reviewed. In every patient, matched pairs of images obtained with conventional gray and color maps (Photopic) were acquired and stored as DICOM (Digital Imaging and Communications in Medicine) images on a sonographic workstation. Each image was assessed independently by 2 musculoskeletal radiologists trained in musculoskeletal sonography for overall image contrast (lesion to background), conspicuity of regional tissue boundaries, visualization of deep tissue boundaries, and how well the internal characteristics of the structure were visualized. Results Three-way analysis of variance showed that Photopic imaging resulted in statistically significantly improved overall image contrast, definition of regional soft tissue boundaries, including deep soft tissue boundaries, and depiction of the internal characteristics of the structure being examined. Conclusions Color imaging with contrast optimization improves overall image contrast and better defines deep soft tissue boundaries and the internal morphologic characteristics of Morton neuromas and the plantar fascia compared with conventional gray scale imaging.

Purpose To compare the effectiveness of sonographically guided and palpation-guided steroid injection for the treatment of proximal plantar fasciitis. Patients and Methods Twenty-five consecutive patients with unilateral proximal plantar fasciitis were recruited and randomly divided into a sonographically guided group (n = 12) and palpation-guided group (n = 13). Proximal plantar fascia was assessed with a 5- to 12-MHz linear-array transducer. Pain intensity was quantified using a “tenderness threshold” (TT) and a visual analog scale (VAS). Injection of 7 mg (1 ml) of betamethasone and 0.5 ml of 1% lidocaine into the inflamed proximal plantar fascia was performed under the guidance of sonography or palpation. Patients were evaluated clinically and sonographically before injection and at 2 weeks, 2 months, and 1 year after injection. VAS- and TT-measured pain intensity, thickness, and echogenicity of the proximal plantar fascia, as well as the recurrence of heel pain, were assessed. Results Both VAS- and TT-measured levels of pain improved significantly after steroid injection in both groups (p < 0.001). Also, the thickness decreased significantly after injection (p < 0.01 in the palpation-guided group; p < 0.001 in the sonographically guided group). The number of patients with hypoechogenicity at the proximal plantar fascia decreased after steroid injection in both groups (p < 0.01 for both groups). The recurrence rate of plantar fasciitis in patients of the palpation-guided group (6/13) was significantly higher than that of the sonographically guided group (1/12) (p < 0.05). Conclusions Steroid injection can be an effective way to treat plantar fasciitis, and injection under sonographic guidance is associated with lower recurrence of heel pain. © 2006 Wiley Periodicals, Inc. J Clin Ultrasound34:12–16, 2006

Objective To study the role of biomechanical factors and HLA-B27 in plantar fasciitis. Methods T1-weighted and T2 spectral presaturation with inversion recovery (fat suppressed) magnetic resonance imaging (MRI) sequences of the plantar fascia insertion and adjacent bone were performed on 28 patients with plantar fasciitis; 17 had spondylarthropathy (SpA)-associated disease, and 11 had mechanically induced disease. The relationship between the degree of bone edema, scored on a semiquantitative scale (from absent to severe), and the patient's HLA-B27 status was determined. Results On MRI, edema within the soft tissue at the enthesis was evident in both groups. Bone edema in the adjacent calcaneum was evident in 64.7% (11 of 17) of patients with SpA and in 45% (5 of 11) of those with mechanically induced disease (P = 0.441). HLA-B27 was identified in 9 (53%) of the patients with SpA but in none (0%) of those with mechanically induced disease. All 6 of the SpA patients with extensive bone edema but none of the 5 SpA patients with mild bone edema were HLA-B27 positive (P = 0.002). Conclusion The association of HLA-B27 with bone pathology in early enthesitis may have implications for a better understanding of the pathogenesis of SpA.

Disclosures: T. P. DeWald, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A right-hand-dominant 23-year-old male swimmer presented with persistent right shoulder pain, numbness, and paresthesia with radiation down the medial aspect of the right upper extremity. Patient stated that symptoms started gradually over a week and would only present during distances over 1,000 meters. Symptoms resolved when the athlete ceased activity. Setting: University Sports Medicine Clinic. Results or Clinical Course: Patient was treated conservatively with observation. Patient demonstrated normal physical examination. However, patient’s symptoms were reproduced with his right arm fully abducted and externally rotated and equivocal Adson’s test. Venous and arterial ultrasounds of the right upper extremity were obtained with no evidence of vessel obstruction. IR angiogram was then performed and did not show venous or arterial thoracic outlet syndrome. However, during provocative maneuver of extreme abduction and external rotation patient exhibited compression of the bilateral axillary arteries and circumflex humeral arteries. MRI of the right shoulder was negative for fat atrophy of teres minor and infraspinatus mucles. Electrodiagnostic studies did not demonstrate abnormalities in the axillary, ulnar, or median nerves with normal EMG of corresponding muscles. Patient resumed activity and continued to swim competitively with modification in training duration and regimen, demonstrating improvement in symptoms. The athlete will be evaluated for possible surgical decompression in the offseason. Discussion: Quadrilateral space syndrome is a rare condition arising from the compression of the axillary nerve and posterior circumflex humeral artery within the quadrilateral space. Ours is a unique case in which an athlete is demonstrating transient, ischemic quadrilateral space syndrome after long distance swimming. Muscle hypertrophy or fibrotic band formation have been implicated in pathology. Surgical decompression has proven to be successful in alleviating symptoms. Conclusions: Quadrilateral space syndrome should be considered as a differential diagnosis in young athletes with persistent shoulder pain and neuromuscular compromise as it can be missed.

Aim The aim of this study was to investigate the prevalence of limited joint mobility at the first metatarsophalangeal joint (MPJ) and dysfunction of the plantar fascia in people with diabetes mellitus and Charcot's neuroarthropathy and a control group. Methods Fifteen subjects with a history of mid-foot Charcot's neuroarthro pathy and 26 controls with sensory neuropathy but no Charcot's neuro arthropathy were recruited. Ranges of ankle and first MPJ dorsiflexion were measured for each participant. Plantar fascia function was assessed using Jack's test. Results The range of dorsiflexion at the first MPJ was significantly reduced in the subject group compared with the control group (51.2 vs. 64.8; P

Purpose The aim of this study was to describe the most common sonographic appearances of plantar fibromatosis, thus enabling sonographic diagnosis of this benign, focally invasive fibrous neoplasm. Methods The medical records, pathologic reports, and sonographic reports and images of 22 patients with palpable plantar masses were reviewed retrospectively. The sonographic findings were used to characterize those masses with respect to location, shape, size, and echogenicity. Sixteen patients were included in this study because of the proximity of their lesions to the plantar fascia; 6 patients were excluded because their lesions were metatarsophalangeal bursae or ganglia. Results The 20 feet examined in the 16 patients studied contained 43 distinct lesions, all located on the surface of the plantar fascia. Thirty-seven (86%) of the 43 were 20 mm long or less. Thirty-seven (86%) of the 43 lesions were elongated; the remaining 6 (14%) were round or oval. Twenty-five (68%) of the 37 elongated lesions had tapered ends, and the other 12 (32%) had rounded ends. Thirty-one (72%) of the 43 lesions were hypoechoic; 25 (81%) of these 31 measured as long as 10 mm. Ten (83%) of the 12 lesions that had mixed echogenicity were longer than 10 mm. Conclusions The lesions of plantar fibromatosis were characteristically located on the surface of the plantar fascia, sagittally elongated, most often less than 20 mm long, fusiform, and hypoechoic. Lesions longer than 10 mm often exhibited mixed echogenicity. The superficial location and appearance should strongly suggest plantar fibromatosis, although careful examination is required to exclude other possibilities, such as sarcoma. © 2001 John Wiley & Sons, Inc. J Clin Ultrasound 29:499–505, 2001.

We have evaluated the utility of ultrasonographic guidance for intervention in the musculoskeletal system. All interventional musculoskeletal procedures using ultrasonographic guidance performed at our institution from July 1998 through November 1999 were reviewed. Examinations were performed using either a linear or curved phased array transducer, based on depth and local geometry. The choice of needle was likewise optimized for specific anatomic conditions. One hundred ninety-five procedures were performed on 167 patients from July 1998 through November 1999. Thirty-one procedures had magnetic resonance correlation within 6 months beforehand. Excluding large-joint aspirations and injections, we found that 180 of the procedures were more readily performed using ultrasonography than any other imaging modality. These included therapeutic injections into tendon sheaths (biceps, flexor digitorum longus, posterior tibial, and iliopsoas), Morton's neuromas, plantar fascia, wrist ganglia, and tarsal tunnel cysts; peritendinous hamstring injections; and synovial cyst and muscle biopsies. In all cases, the target of interest was identified easily with ultrasonography, and needle position was documented readily. Also in all cases, aspiration or medication delivery to the site of interest was observed during real time and was documented on postprocedure images of the area. No significant complications (e.g., bleeding, infection, and neurovascular compromise) were encountered during or immediately after any procedure. Ultrasonography is a readily available imaging modality useful for guiding interventional procedures in the musculoskeletal system. The ability to document exact needle placement in real time confirms accurate placement of therapeutic injections, fluid aspiration, and soft tissue biopsies.

Fine linear extraarticular calcium deposits were found in X-rays of 7 of 52 patients with articular chondrocalcinosis (ACC). Seven Achilles tendons, seven quadriceps tendons, and one plantar fascia were affected. In a control group of comparable age and sex, without ACC but with generalized osteoarthritis, no calcifications were found in the tendons. On a biopsy specimen of Achilles tendon with such calcium deposits, X-ray diffraction showed that they had the characteristics of calcium pyrophosphate dilhydrate. Isolated small foci of crystals were observed on some segments of tendon bundles. The presence of fine linear calcifications on X-rays of the Achilles or quadriceps tendons may be a useful aid in the radiologic diagnosis of so-called articular chondrocalcinosis.