Tag Archives: plantar fasciitis

Prospective study of plantar fascia thickness correlated to efficacy of conservative treatment for plantar fasciitis using ultrasonography

by Gerald Kuwada, DPM, NMD1*pdflrg

The Foot and Ankle Online Journal 9 (3): 9

The thickness of the plantar fascia is measured using ultrasonography and has been correlated to either success or failure of conservative treatment depending on how thick the fascia is. The research hypothesis is that the thicker the plantar fascia in a patient diagnosed with plantar fasciitis, the higher the incidence of treatment failure. One hundred thirty six patients from our 4 clinics and 7 podiatric physicians made the clinical diagnosis of plantar fasciitis. The patients were divided into 2 groups for this study. Group 1 included all the patients that had a successful outcome with conservative treatment. Group 2 included all the patients who failed to improve after extensive conservative treatment. The mean for Group 1 plantar fascia thickness was .522 mm. Group 2 included 11.7% of feet and the mean plantar fascia thickness was 1.006mm. The range of plantar fascia thickness was .3mm to .97mm for Group 1. The range of plantar fascia thickness for Group 2 was .67mm to 1.22mm. Based on this study, 1.006 mm was measured to be the mean for Group 2 and may be a useful predictor of treatment outcomes.

Keywords: plantar fascia thickness, plantar fasciitis, ultrasonography, conservative treatment

ISSN 1941-6806
doi: 10.3827/faoj.2016.0903.0009

1 – FASA Family Wellness, Tumwater, WA
* – Corresponding author: drgeraldkuwada@hotmail.com


The thickness of the plantar fascia is measured using ultrasonography and has been correlated to either success or failure of conservative treatment depending on how thick the fascia is [1-13]. The research hypothesis is that the thicker the plantar fascia in a patient diagnosed with plantar fasciitis, the higher the incidence of treatment failure. Conservative treatment in this study includes injection therapy, physical therapy modalities like icing, stretching, prefabricated arch supports, massaging, over the counter anti-inflammatory medications, and orthotics. The null hypothesis states that no matter what the thickness of the plantar fascia it has no effect on success or failure of conservative treatment.

What are some of the etiologies of plantar fascia thickness? It has been suspected that inflammation of the fascia occurs. Other etiologies include degenerative changes to the fascia, micro-tearing and scarification of the fascia [14]. Since using ultrasonography, this has been a recent concept in treating plantar fasciitis. In the past, we had no idea there was a thickness issue. According to more recent studies, there is a possible correlation between the thickness of the plantar fascia and the success of conservative treatment [15]. A study published by this author in 1980 found a 90% success rate with conservative treatment and a 10% failure rate. Most of the patient’s in the 10% group elected to proceed with open fascial release to get complete pain relief [16]. Yet, several authors found that a plantar fascia thickness of greater than 4mm was considered thick [15].

Methods

One hundred thirty six patients from our 4 clinics and 7 podiatric physicians made the clinical diagnosis of plantar fasciitis. Each patient had their plantar fascia measured using ultrasonography and the thicknesses were recorded. There were a total of 197 feet with the diagnosis of plantar fasciitis. The success or failure of conservative treatment was recorded for all 136 patients. The feet were divided into 2 groups for this study. Group 1 included all the patients that had a successful outcome with conservative treatment. Group 2 included all the patients who failed to improve after extensive conservative treatment. There was no time limit regarding conservative treatment time. Thus, some patients took several months to complete their conservative treatment, whereas others took much longer. A majority of these patients in Group 2 eventually had endoscopic plantar fasciotomy or open fascial releases performed to eliminate their heel pain. The mean thickness of the plantar fascia was calculated for both groups. Using a T test 2 tailed type with a p value of .001 and 95% confidence intervals was calculated.

Results

The statistical analysis demonstrated that the two groups were significantly different at a p-value of .0001. Group 1 included 88.3% of feet (174/197). The mean for Group 1 plantar fascia thickness was .522 mm. Group 2 included 11.7% of feet and the mean plantar fascia thickness was 1.006mm. The range of plantar fascia thickness was .3mm to .97mm for Group 1. The range of plantar fascia thickness for Group 2 was .67mm to 1.22mm. Thus, the null hypothesis is rejected and our research hypothesis was accepted.

Discussion

This study corroborates the conclusion of several other studies supporting the concept that the plantar fascia thickness is important and may predict patient  conservative treatment outcomes [1-13]. However, the 4mm thickness or greater was not considered significantly thick in this study. Many of the patients in Group 2 had EPF or open fascial release performed. All the patients had no residual heel pain after their surgical sites healed. Others have reported that the plantar fascia in some patients will be thinner after corticosteroid injections [15]. The author plans on doing a study on this topic to determine if this is true or not. Will the thickness also play a role in determining whether the plantar fascia will thin after corticosteroid injections? Will the BMI also be a predictor of outcomes based on thickness of the plantar fascia?

One of the concerns of this study was the inability to control the accuracy of the various podiatric physician measurements of the plantar fascia. There is a steep learning curve in accurately measuring the plantar fascia thickness. This was not tested by having each physician measure the same plantar fascia of a dozen patients and determine accuracy of each podiatric physician.

It has been suggested that diabetes mellitus has a high correlation with increased plantar fascial thickening [15]. This study did not examine this relationship.

Lastly, despite the thickness of the plantar fascia, the patient diagnosed with plantar fasciitis needs to undergo conservative treatment to fulfill the standard of care. How extensive the care is will be determined by the podiatric physician and the patient. Furthermore, there will be exceptions to the findings and conclusions of this study. A patient may be within range of Group 1 yet fail improving after receiving conservative treatment.  Contrarily, a patient within Group 2 range completely  becomes asymptomatic after completing conservative treatment. This is plausible even though it did not occur in this study. Based on this study, 1.006 mm was measured to be the mean for Group 2 and may be a useful predictor of treatment outcomes.

References

  1. Tsai WC, Chiu MF, Wang CL, Tang FT, Wong, MK. Ultrasound evaluation of plantar fasciitis. Scand J Rheumatol. 2000; 29(4): 255-259. Doi: 10: 1080/030097400750041415.
  2. Wearing SC, Smeathers, Sullivan PM, Yates B, Urry SR, Dubois P. Plantar fasciitis: are pain and fascial thickness associated with arch shape and loading? Phys. Ther. 2007:87(8):1002-1008.
  3. Genc H, Saracoglu M, Nacir G, Erdem HR, Kacar M. Long term ultrasonographic follow-up of plantar fasciitis patients treated with steroid injection. Joint Bone Spine. 2005;72(1):61-65. Doi:10.1016/j.jbspin.2004.03006.
  4. Ozdemir H, Yilmaz E, Murat A, Karakurt L, Poyraz AK, Ogur E. Sonographic evaluation of plantar fasciitis and relation to body mass index. Eur J Radiol. 2005:54(3):443-447/ doi: 10.1016/j ejrad 2004.09.004.
  5. Sabir N, Demirlenk S, Yagei B, Karabulut N, Cubukcu S. Clinical utility of sonography in diagnosing plantar fasciitis. J Ultrasound Med. 2005;24(8):1041-1048.
  6. Wall KR, Harkness MA, Crawford A. Ultrasound diagnosis of plantar fasciitis. Foot Ankle. 1993;14(8):465-470.
  7. Akfirat M, Sen C, Gunes T. Ultrasonographic appearance of the plantar fasciitis. Clin Imaging. 2003;27(5):353-357. DOI: 10.1016/S0899-7071(02)00591-0.
  8. Cardinal E, Chhem RK, Beauregard CG, Aubin B, Pelletier M. Plantar fasciitis: sonographic evaluation. Radiology. 1996;201(1):257-259.
  9. Gibbon WW, Long G. Ultrasound of the plantar aponeurosis (fascia) Skeletal Radiol. 1999;28(1):21-26. Doi: 10.1007/s002560050467.
  10. Vohra PK, Kincaid BR, Japour CJ, Sobel E. Ultrasonographic evaluation of plantar fascia bands. A retrospective study of 211 symptomatic feet. J Am Podiatr Med Assoc. 2002;92(8):444-449.
  11. Hall RL, Erickson SJ, Shereff MJ, Johnson JE, Kneeland JB. Magnetic resonance imaging in the evaluation of heel pain. Orthopedics. 1996; 19(3):225-229.
  12. Kamel M, Kotob H. High frequency ultrasonographic findings in plantar fasciitis and assessment of local steroid injection. J Rheumatol. 2000;27(9):2139-2141.
  13. Karabay N, Toros T, Hurel C. Ultrasonographic evaluation in plantar fasciitis. J Foot Ankle Surg. 2007;46(6):442-446. doi: 10.1053/j.jfas.2007.08.006.
  14. Walther M, Radke S, Kirschner S, Ettl V, Gohlke F. Power Doppler findings in plantar fasciitis. Ultrasound Med Biol. 2004;30(4):435-440. Doi: 10.1016/j.ultrasmedbio.2004.01.006. PubMed Cross Ref
  15. Buchbinder R. Plantar Fasciitis. N Engl J Med 2004:350:2159-66.
  16. McMillan AM, Landorf KB, Barrett JT, Menz HB, Bird AR. Diagnostic Imaging for chronic plantar heel pain: a systematic review and meta-analysis. J Foot Ankle Res. 2009; 2: 32 published online 2009 Nov 13. Doi: 10.1186/1757-1146-2-32.
  17. Kuwada GT, Gormley J. A Retrospective Analysis of calcaneal spur removal and complete fascial release. J Foot Ankle Surg. 1980; 19: 218-222.

Post-surgical plantar fasciitis

by Priya P. Sundararajan , DPM¹pdflrg

The Foot and Ankle Online Journal 7 (2): 4

Current evidence suggest that plantar fasciitis is multi-factorial in etiology. The following report introduces an extended post-surgical nonweightbearing period (6-10 weeks) as a previously unknown cause of plantar fasciitis. Through a univariate statistical analysis, the present study compares the presence of heel pain in twenty patients who remained nonweightbearing for 2-6 weeks (group 1) and twenty patients who remained nonweightbearing for 6-10 weeks in the post-surgical period (group 2). Results indicate a statistically significant correlation (p<0.05) between patients who endured an extended postoperative nonweightbearing period (group 2) and the presence of plantar fascial symptoms in the immediate weightbearing period. Findings of the present study suggest that a stretching regimen should be initiated prior to ambulation for patients remaining nonweightbearing greater than six weeks post-surgery.

Key Words: Plantar fasciitis, postoperative, nonweightbearing, heel pain, surgery, fascia

ISSN 1941-6806
doi: 10.3827/faoj.2014.0702.0004


Address correspondence to: Priya Sundarararjan DPM,
Wilmington Veterans Affairs Hospital, 1601 Kirkwood Highway, Wilmington, DE 19805

¹ Director of Podiatric Surgical Services, Wilmington Veterans Hospital 302-994-2511 Email: Priya.Sundararajan@va.gov


Plantar fasciitis is one of the most common pedal pathologies requisitioning medical evaluation and treatment, which translates to over one million outpatient visits annually in the United States [1]. Though the pain associated with plantar fasciitis can be debilitating, the syndrome is characterized as self-limiting since approximately 90% of symptomatic patients find relief through conservative measures [2,3]. Plantar fasciitis is the result of multi-factorial etiologies from increased body mass index to ankle equinus [1,4]. The following retrospective analysis introduces the extended post-surgical nonweightbearing period as a previously unknown cause of plantar fasciitis.

Methods

A retrospective review of forty patients who underwent surgery between August 2010 and August 2011 was conducted. These patients remained nonweightbearing between 2 and 10 weeks in the postoperative period. Twenty patients who were completely offloaded between 2 and 6 weeks post surgery were consecutively enrolled in the study as group 1. Similarly, twenty patients who remained completely nonweightbearing between 6 and 10 weeks after surgery were consecutively enlisted as group 2. The six-week mark was considered the divide as most reconstructive surgeries involve offloading for more than 6 weeks. Additionally, all patients remained nonweightbearing between 2 and 10 weeks; thus 6 weeks is the mean week. Exclusion criteria included any prior complaint or treatment of plantar heel pain or any surgery involving the plantar fascia. Patients who bore weight in the heel or forefoot without a two-week nonweightbearing period were also excluded from the study.

All patients were questioned as to the areas of discomfort in the beginning two weeks of the post-surgical weightbearing (WB) period. Specifically, each patient was questioned as to the presence or absence of heel pain. The heel was anatomically defined as the area underlying the calcaneal tuberosity. The presence of postoperative heel pain during the initial weightbearing period was recorded and statistically evaluated with a univariate analysis. If the patient related to having heel pain when first bearing weight, they were instructed to perform at least 15 minutes of calf stretching exercises daily. Patients were monitored until complete resolution of symptoms.

Results

Twenty patients in each group yielded usable results. A description of groups 1 and 2 are depicted in Tables 1 and 2, respectively. A statistically significant difference (p=0.0002) in the presence of heel pain in the early weightbearing period was found between patients who remained nonweightbearing between 2 and 6 weeks (group 1) and those who remained nonweightbearing between 6 and 10 weeks (group 2). Noting that the presence and resolution of symptoms are “yes” and “no” questions, the mean was calculated by assigning “yes” to 1 and “no” to 0. In group 1, 15% of patients reported heel pain during the first two weeks of bearing weight on the operated limb (Table 1). Of these patients, 100% reported total resolution of symptoms within the first six weeks of the weightbearing period with conservative calf stretching exercises. In group 2, 70% of patients reported heel pain during the first two weeks of bearing weight on the operated limb (Table 2). All patients who reported heel pain in both groups related complete relief of symptoms to the heel of the operated extremity within six weeks using conservative modalities, primarily through regimented stretching exercises. However, one patient in group 2 (patient 15) who reported significant relief without total resolution of symptoms was additionally fitted with custom-molded orthotics. With a stretching exercise protocol and orthoses, the patient found complete resolution within 6 weeks of bearing weight.

Discussion

Plantar fasciitis is a complex pathology involving the ligament-bone interface at the inferior aspect of the calcaneal tuberosity [3]. As a primary supporter of the plantar arch, the plantar fascia minimizes transverse plane motion between the calcaneus and metatarsals [3]. Vertical forces from the body travel down the body and exert pressure flattening the medial longitudinal arch [5]. Subjected to significant traction as weight is transferred from the rearfoot to the forefoot, the plantar fascia accommodates the transfer with minimal disruption to the plantar arch [6]. Biomechanical studies simulating total fascial release demonstrate extensive arch deformation in stance and over 200% increase in stresses to the long plantar ligament [7]. Rapid fascial elongation occurs before midstance, hence patients with plantar fasciitis present with sharp pains between heel strike and midstance [6]. Furthermore, research has shown that with 90N of force, the plantar fascia will stretch 4% with the failure point being the clamps [8]. Such research confirms the integrity of the plantar fascia and indicates the majority of the pathology occurs at the fascial-calcaneal interface.

Factors

As demonstrated in the present study, post-static dyskinesia is a hallmark of plantar fasciitis [3]. Frequently, patients give a history of sharp pain with insidious onset when first bearing weight after recumbent periods. Typically patients complain of maximal pain with initial ambulation in the morning. Plantar fasciitis is caused by bearing weight after a state of relative inactivity [9]. In the static nonweightbearing state, the plantar fascia is void of tension and thus rests in a contracted state [9]. In the immediate weightbearing period following recumbency, the plantar fascia undergoes a rapid elongation up to 4%, thus the patient experiences sharp, stabbing pains with initial weightbearing [6,8]. When extrapolating the recumbent state from a few hours to several weeks, the fascia is in a state completely void of weightbearing tension. Consequently, patients applying pressure to the heel of a limb which has not carried weight for a significant period of time will likely exhibit symptoms of plantar fasciitis as demonstrated by the current study.

fasciitis1

Table 1 Heel pain in patients remaining nonweightbearing between 2 and 6 weeks (Group 1).

Previous research has demonstrated an increased incidence of plantar fasciitis in individuals experiencing weight gain in the cases of pregnancy or obesity [10]. The mechanical overload causes excessive strain to the arch supporting capacity of the plantar fascia resulting in microtears in the plantar fascia [3]. Histopathological analysis of fascial specimens in chronically symptomatic patients reveal fibroblastic proliferation and granulomatous tissue signifying the cyclic degeneration and limited inflammatory response sustained at the fascial origin [11]. MRI and ultrasound reviews indicate that the dorsal-plantar thickness of plantar fascia in symptomatic patients can increase to 10 mm in thickness, whereas normal plantar fascia is approximately 3 mm [12,13,14]. Though patients in the present study did not exhibit chronicity in their fascial symptoms, the weight gain generally associated with the post-surgical nonweightbearing period may have exacerbated plantar fascial symptoms demonstrated in the early ambulatory stage.

In addition to an elevated body mass index, studies have reported patients with limited ankle flexion to have an increased incidence of plantar fasciitis [10]. Patients with ankle equinus are unable to fully utilize the entire length of the plantar fascia since the heel is bearing less than its proportional weight [10]. Similarly, in the nonweightbearing state the ankle usually rests in some degree of plantarflexion, thus allowing the plantar fascia to contract [9]. When patients begin ambulation after an extended nonweightbearing period, they may experience an incapacitating plantar fascial pain as demonstrated by the current study. All patients exhibited acute manifestations of fasciitis; hence, time to resolution of symptoms was abbreviated in the present study compared to clinical patients demonstrating chronic symptoms. With persistence of plantar fasciitis, pain becomes recalcitrant throughout the day and night [15]. Research correlates the presence of rest pain and night pain with a high failure rate of conservative treatment and serves as an indication for surgical intervention [15].

fasciitis2

Table 2 Heel pain in patients remaining nonweightbearing between 6 and 10 weeks (Group 2).

Treatment

Preliminary treatment protocols for acute plantar fasciitis involve regimented stretching exercises. Plantar fasciitis has earned the reputation of being a self-limiting condition since most patients achieve resolution of symptoms with conservative treatment alone as supported by the present study [2,16]. Stretching protocols often focus on either the posterior compartment of the leg or the plantar fascia itself. Prospective studies demonstrate that regular stretching of either focal point decreases overall pain and pain experienced with initial ambulation [17]. Fascial stretching exercises involve dorsiflexion of the hallux and lesser digits which passively tensions the plantar fascia [3]. Calf stretching exercises work by actively tensing the gastrosoleal complex as well as the plantar fascia [4]. Over 80% of patients with plantar fasciitis demonstrate a concomitant equinus; consequently, equinus is characterized as an etiologic factor of plantar fasciitis [4]. Research has shown that calf stretching exercises result in increased ankle dorsiflexion which directly increases fascial stretch [18,19]. The effectiveness of calf stretching exercises alone is evident in the present study. Furthermore, one case in the current study supported the effectiveness of combining calf stretching exercises with custom molded arch supports as demonstrated by previous research [20].

Conclusion

To the author’s knowledge, the following statistical analysis is the first to introduce an extended post-surgical nonweightbearing period (6-10 weeks) as an etiology of plantar fasciitis. The data presented suggests a statistically significant correlation between the length of postoperative nonweightbearing period and the presence of plantar fascial symptoms in the early ambulatory stage. The lack of fascial tension in the recumbent state, post-surgical weight gain, and ankle plantarflexion may be factors which intensify plantar fasciitis. These compounding factors deserve further research to clarify their significance in post-surgical plantar fasciitis. The clinical implication of the present research suggests that practitioners should implement stretching protocols prior to initiating ambulation. Accordingly, surgeons may facilitate a smoother transition to return to activity by preventatively countering plantar fascial symptoms. The current study is limited in its capacity to determine the full nature of post-surgical plantar fasciitis by its inability to accurately access patient compliance to the nonweightbearing regimen and patient adherence to the prescribed stretching program. By correlating post-surgical plantar fasciitis in terms of ranges, the current study obviates the need to determine exact patient compliance to the nonweightbearing timeline. Moreover, the minute p-value (p=0.0002) indicates a strong correlation between a nonweightbearing postoperative period greater than six weeks and plantar fascial symptoms. In conclusion, the current study presents a new etiology and clinical scenario associated with plantar fasciitis which surgeons and practitioners may preventatively treat by implementing stretching protocols prior to ambulation for patients with a lengthened post-surgical nonweightbearing period.

References

  1. Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int. 2004;25 (5): 303-10. – Pubmed
  2. Wolgin M, Cook C, Graham C et-al. Conservative treatment of plantar heel pain: long-term follow-up. Foot Ankle Int. 1994;15 (3): 97-102. – Pubmed
  3. League AC. Current concepts review: plantar fasciitis. Foot Ankle Int. 2008;29 (3): 358-66. – Pubmed
  4. Patel A, Digiovanni B. Association between plantar fasciitis and isolated contracture of the gastrocnemius. Foot Ankle Int. 2011;32 (1): 5-8.  – Pubmed
  5. Bolgla LA, Malone TR. Plantar fasciitis and the windlass mechanism: a biomechanical link to clinical practice. J Athl Train. 2004;39 (1): 77-82.  – Pubmed
  6. Gefen A. The in vivo elastic properties of the plantar fascia during the contact phase of walking. Foot Ankle Int. 2003;24 (3): 238-44. – Pubmed
  7. Gefen A. Stress analysis of the standing foot following surgical plantar fascia release. J Biomech. 2002;35 (5): 629-37. – Pubmed
  8. Wright DG, Rennels DC. A study of the elastic properties of plantar fascia. J Bone Joint Surg Am. 1964;46 : 482-92.  – Pubmed
  9. Cole C, Seto C, Gazewood J. Plantar fasciitis: evidence-based review of diagnosis and therapy. Am Fam Physician. 2005;72 (11): 2237-42.  – Pubmed
  10. Riddle DL, Pulisic M, Pidcoe P et-al. Risk factors for Plantar fasciitis: a matched case-control study. J Bone Joint Surg Am. 2003;85-A (5): 872-7.  – Pubmed
  11. Singh D, Angel J, Bentley G et-al. Fortnightly review. Plantar fasciitis. BMJ. 1997;315 (7101): 172-5.  – Pubmed
  12. Berkowitz JF, Kier R, Rudicel S. Plantar fasciitis: MR imaging. Radiology. 1991;179 (3): 665-7. – Pubmed
  13. Grasel RP, Schweitzer ME, Kovalovich AM et-al. MR imaging of plantar fasciitis: edema, tears, and occult marrow abnormalities correlated with outcome. AJR Am J Roentgenol. 1999;173 (3): 699-701. – Pubmed
  14. Kier R. Magnetic resonance imaging of plantar fasciitis and other causes of heel pain. Magn Reson Imaging Clin N Am. 1994;2 (1): 97-107. – Pubmed
  15. Haake M, Buch M, Schoellner C et-al. Extracorporeal shock wave therapy for plantar fasciitis: randomised controlled multicentre trial. BMJ. 2003;327 (7406): 75. – Pubmed
  16. Davis PF, Severud E, Baxter DE. Painful heel syndrome: results of nonoperative treatment. Foot Ankle Int. 1994;15 (10): 531-5. – Pubmed
  17. Digiovanni BF, Nawoczenski DA, Lintal ME et-al. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg Am. 2003;85-A (7): 1270-7.  – Pubmed
  18. Flanigan RM, Nawoczenski DA, Chen L et-al. The influence of foot position on stretching of the plantar fascia. Foot Ankle Int. 2007;28 (7): 815-22.  – Pubmed
  19. Radford JA, Burns J, Buchbinder R et-al. Does stretching increase ankle dorsiflexion range of motion? A systematic review. Br J Sports Med. 2006;40 (10): 870-5. – Pubmed
  20. Pfeffer G, Bacchetti P, Deland J et-al. Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot Ankle Int. 1999;20 (4): 214-21. – Pubmed

Evaluation of the results of autologous blood injection in the treatment of refractory heel pain

By Muzamil Ahmad Baba1, B. A Mir2, M. A Halwai3, Arshad Bashir2, Shakir Rashid1, Omar Khursheed1, Qazi Manaan1pdflrg

The Foot and Ankle Online Journal 6 (10): 2

Background: Plantar heel pain is one of the most common problems of the foot treated by health care professionals. As the precise etiological diagnosis of a painful heel still remains unknown, this entity remains enigmatic and frustrating to both the physician and the patient. The present study was done to assess the efficacy of autologous blood injection in the treatment of refractory heel pain.
Methodology: Fifty patients (average age of 46.7 years), 18 (36%) males and 32 (64%) females with refractory heel pain of more than 6 months duration underwent autologous blood injection. Patients were clinically evaluated and reviewed with visual analogue scale (VAS) pain scores pre-procedure and post procedure at 6 weeks followed by a final follow up at 6 months.
Results: Our study showed a significant reduction in VAS scores which reduced from a mean score of 8 (range 6-10) to a mean score of 4 (range 2-9) at 6 weeks and 2(range 0-9) at 6 months.
Conclusion: Autologous blood injection can be used as a treatment modality in patients with heel pain.

Key words: Autologous blood, heel pain, plantar fasciitis

Accepted: September, 2013
Published: October, 2013

ISSN 1941-6806
doi: 10.3827/faoj.2013.0610.002

Address correspondence to: Muzamil Ahmad Baba (MS), Post graduate department of orthopaedics Govt. Hospital for Bone and Joint Surgery Barzullah, Srinagar Kashmir, 190005. Mobile 9086181281. Email: muzamilbaba79@yahoo.com

1Orthopaedic Resident, Post graduate department of Orthopaedics Govt. Hospital for Bone and joint surgery Srinagar Kashmir.
2Associate professor, Govt. Hospital for Bone and joint surgery Srinagar Kashmir.
3Professor and Head, , Govt. Hospital for Bone and joint surgery Srinagar Kashmir.


In 1922, Stiell stated that painful heel appears to be a condition which is seldom efficiently treated, for the simple reason that the causation is not exactly diagnosed.[1]

It was 40 years later that Lapidus and Guidotti, in their article “Painful heel”, stated that the name painful heel is used deliberately in preference to any other more precise etiological diagnosis, since the cause of this definitive clinical entity still remains unknown. This entity of painful heel still remains enigmatic and often frustrating to both the doctor and the patient.[2]

The exact cause of painful heel is uncertain. It is known that the degenerative changes with increasing age are the most constant findings in the elastic adipose tissue of the heel pad.[3- 5]

Aging also brings about a gradual reduction in collagen and water content as well as in elastic fibrous tissue. Woolnough called the entity “tennis heel”, and postulated that repeated traction with aging and repeated trauma, produces microscopic tears and cystic degeneration in the origin of the plantar fascia and the flexor digitorum brevis immediately beneath the plantar fascia.[4] Other theories include the windlass mechanism and the neurogenic causes.[5]

As the etiology of plantar fasciitis is unclear, diagnosis is usually based on clinical signs including: plantar heel pain when weight-bearing after a period of rest, pain that eases with initial activity, but then increases with further use as the day progresses, and pain on palpation.[6] The various treatment options for this condition includes rest, massage, stretching, ultrasound, extra-corporeal shock wave therapy, cold/ heat therapy, orthotics, anti-inflammatory medications, injection of corticosteroids and surgery in refractory cases.[7, 8]

The findings of existing clinical trials provide some support for the use of corticosteroid injection in the short term management of plantar fasciitis.9 However; a recent systematic review concluded that the effectiveness of this treatment has not been sufficiently established, indicating that further research is required. Local steroid injections can provide good short-term relief of symptoms, but are associated with complications such as the rupture of plantar fascia and fat pad atrophy.[10, 11]

Treatment with autologous blood injections acts by providing various cellular and humoral mediators like growth factors which result in healing and relief of pain without any risk of plantar fascia rupture and fat pad atrophy.[12] As autologous blood injection in heel pain is the least studied, we carried out this study to find out the efficacy of this form of treatment in cases of refractory heel pain in which other treatment modalities had failed thus acting as their own controls.

Material and Methods

In our study, 50 patients with refractory heel pain were included following informed consent and institutional review board approval. Inclusion criteria included all patients with unilateral symptoms of at least 6 months with failure to conservative treatment including stretching, orthotics, local steroid injections or other conservative treatment modalities. Exclusion criteria included patients with symptoms of less than 6 months duration, current skin or soft tissue infection at the site, systemic inflammatory diseases, patients with bilateral involvement and patients who had received a steroid injection or other intervention within 3 months period.

A record of the patient’s pain using a visual analogue scale (VAS) was obtained prior to the procedure using a range of 0 to 10, with 0 representing no pain and 10 the worst pain ever experienced. Two millimeters of autologous blood was drawn from the antecubital fossa of the patient. The heel along with the foot was prepared and draped and 2 ml of 2% lignocaine was infiltrated along the surface followed by insertion of a 23 G needle at the most tender point and the blood was slowly injected into the site of maximum pain. Patients were advised to follow up at 2 and 6 weeks and a final follow up at 6 months. All injections were performed by two senior orthopaedic surgeons. The VAS was recorded prior to the procedure and recorded again at 6 weeks and 6 months post injection follow-up.

Results

Between May 2010 to June 2012, 54 patients were included in the study having met the inclusion criteria. Out of these, 4 patients were lost to follow-up while 50 patients completed the study and were followed for a period of 6 months following the injection. There were 32 (64%) females and 18 (32%) males in our study. The age of the patients ranged from 26 to 63 with an average age of 46.7 years. The mean period of symptoms was 11 months (range 6 to 28 months).

Gender Side Age (years) Duration of symptoms (months)
Male= 18 (36%) Right= 17 (34%) <30= 2 (4%) 6 – 12= 11 (22%)
Female = 32 (64%) Left= 33 (66%) 30 – 50= 39 (78%) 12 – 18= 33 (66%)
>50= 9 (18%) 18 – 36= 6 ( 12%)

Table 1: Distribution of patients on basis of gender, age, laterality and duration of symptoms.

Visual analogue scale (VAS) score NO. OF PATIENTS (Total=50)
Pre procedure At 6 weeks At 6 months
0 – 3 0 12 (24%) 41 (82%)
4 -7 11 (22%) 33 (66%) 4 (8%)
8 – 10 39 (78%) 5 (10%) 5 (10%)

Table 2: The VAS scores prior to the treatment and at 6 weeks and final follow up at 6 months.

The left side was more frequently involved 33 (66%) as compared to 17 (34%) on right side. (Table 1)

In our patients, the median VAS pain score at pre procedure was 8 (range 6-10) which decreased to a mean of 4 (range 2- 9) at 6 weeks and a mean score of 2 (range 0 – 8) at 6 months. Statistical analysis revealed a significant decrease in the score (p<.001). (Table 2)

Out of 50 cases, 4 (8%) patients showed an initial improvement but had a recurrence of symptoms with minimal or no change in VAS scores at 6 months. Five (10%) of the cases failed to respond to the treatment. Statistically significant improvement was seen in rest of the 41 (82%) cases both at 6 weeks and 6 months follow-up. Among complications 11 (22%) patients reported an initial temporary increase in pain which resolved within 2 – 3 days, with 3 (6%) patients requiring shot term use of narcotics. There was no infection, neurovascular damage, plantar fascia rupture in our study group.

Discussion

Plantar heel pain is one of the most common foot complaints presenting to a healthcare professional.[13] Reliable incidence data is lacking in many countries including our country. In USA, its incidence has been estimated to be around 10% and accounts for over one million medical visits every year.[13, 14]

A clear etiology still remains unknown, but plantar fasciitis is reported as the most common cause and the terms are frequently used interchangeably in the literature. Conservative treatment is used for this condition in majority of the cases and surgery being used in cases with failed conservative treatment. Surgery carries the risk of nerve injury, infection, rupture of the plantar fascia, and failure to improve the pain.[15] Corticosteroid injections have been shown to be effective in improving symptoms however it has been associated with various complications such as rupture of plantar fascia, calcaneal osteomyelitis and fat pad atrophy.[10, 11]

No such complication occurred in our series. In our study 41 (82%) of the patients had an excellent outcome with only 5 (10%) patients showing no relief and 4 (8%) cases showing a recurrence at final follow up.

In a study of autologous blood injections in plantar fasciitis by Frontera, 80% cases responded to the treatment.[12] Other treatment options like extra-corporeal shock wave therapy (ESWT) have been tried recently, however there is contradictory evidence and recommendations for the efficacy of extracorporeal shockwave therapy (ESWT), as a treatment modality for plantar fasciitis.[16]

The introduction of autologous blood into an area of inflammation will initiate the inflammatory cascade and promote healing in an otherwise degenerative process such as tendinosis or fasciosis. Barrett, et al.[17] also reported on the use of injectable Autologous Platelet Concentrate (APC+) for the treatment of plantar fasciosis. The hypothesis was that by injecting APC+ into recalcitrant, symptomatic plantar fascia was thought to cause a reparative effect leading to a resolution of symptoms. He termed this technique plantar fasciorraphy. His study included 9 patients who enrolled in the study. Of the 9 patients enrolled, 6 patients reported complete relief of symptoms post injection. At one year post study, 7 (77.8%) of the 9 patients had complete relief of symptoms.

Conclusion

Autologous blood injection appears to be a viable and effective treatment in chronic heel pain. It appears to be safe, cost effective and effective form of treatment even in cases who do not respond to other treatment modalities.

References

1. Stiell WF. Painful heel. Practitioner 1922 108: 345.
2. Lapidus PW, Guidotti FP. Painful heel: report of 323 patients with 364 painful heels. Clin Orthop 1965 39: 178-186. [PubMed]
3. Canale TS, Beaty HJ, Murphy AG. Disorder of tendons and fascia. Campbell’s Orthopaedics. 11th ed. Philadelphia USA; 2008. P. 4815-4818.
4. Woolnough J. Tennis heel. Med J Aus 1954 2: 857-861. [PubMed]
5.  Lemont H, Ammirati K, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. JAPMA 2003 93: 234-237. [PubMed]
6.  Schepsis A, Leach R, Gorzyca J. Plantar fasciitis: etiology, treatment, surgical results, and review of the literature. Clin Orthop1991 266: 185-196. [PubMed]
7.  Crawford F, Thomson C. Interventions for treating plantar heel pain. Cochrane Database Syst Rev 2003 3: CD 000416. [PubMed]
8.  Landorf K, Menz H. Plantar heel pain and fasciitis. Clin Evid 2008 2: 1111. [PubMed]
9.  Tatli ZY, Kapasi S. The real risks of steroid injection for plantar fasciitis with a review of conservative therapies. Curr Rev Musculosketel Med 2009 2: 3-9. [PubMed]
10.  Sellman JR. Plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int 1994 15: 376-81. [PubMed]
11.  Acevedo JI, Beskin JL. Complications of plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int 1998 19: 91-97. [PubMed]
12.  Frontera RW, Silver KJ, Rizzo DT. Autologus blood injection in plantar fascitis. Essential Phy Med Rehab 2008 472-473.
13.  Dunn JE, Link CL, Felson DT, Crincoli MG, Keysor JJ, McKinlay JB. Prevalence of foot and ankle conditions in a multiethnic community sample of older adults. Am J Epidemiol 2004 159: 491-498. [PubMed]
14.   Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int 2004 25:303-310. [PubMed]
15.  Kauffman J.  (2006-09-21). Plantar Fascitis. MedlinePlus Medical Encyclopedia. National Institutes of Health.
16.  Rompe JD, Furia J, Weil L, Maffulli N. Shock wave therapy for chronic plantar fasciopathy. Br  Med Bull 2007 81-82: 183-208. [PubMed]
17.  Barrett S, Erredge S. Growth factors for chronic plantar fasciitis. Podiatry Today 2004 17: 37-42.

A Prospective Randomized Trial Using Four Treatment Modalities for the Treatment of Plantar Fasciitis

by Gerald T. Kuwada, DPM, NMD

The Foot and Ankle Online Journal 4 (8): 1

Introduction: A prospective randomized study was conducted to determine the efficacy of subjective pain reduction in patients with plantar fasciitis using four treatment modalities.
Methods: One hundred patients (62 females and 38 males) were randomly assigned into four groups (n = 25) to receive arch supports, ultrasound treatments, injection or orthotics.
Results: The ultrasound group had the highest average pain reduction of 3.97 after treatment and the highest number of patients who had pain relief after treatment at 81% or 21/25. Orthotics had the next highest average pain reduction followed by local Marcaine/Triamcinolone injection and arch supports. The orthotic group had more patients who had no pain after using the devices than any of the groups.
Conclusions: No single treatment modality provided complete heel pain relief after treatment. Combining modalities will likely help improve plantar fasciitis than just one modality alone. This study also implies that some patients will require more than just one treatment modality to eliminate the symptoms of plantar fasciitis and that each modality usually decreased heel pain in most patients.

Key words: Heel pain, plantar fasciitis.

Accepted: July, 2011
Published: August, 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0408.0001


One of the common foot problems in our society today is plantar fasciitis or plantar fasciopathy. One etiology that appears to be associated with this condition is obesity. Unfortunately, Americans are the heaviest people in the world and the obese American population is increasing at an alarming rate according to the Center of Disease Control (CDC). [1,2]

The obesity issue is epidemic in America resulting in a myriad of preventable diseases like diabetes, cardiovascular disease, and cancer resulting often in premature death and contributing to the most costliest health care system in the world at plus 2 trillion dollars annually. [3] The escalating cost of our health care system is a tremendous burden to our society already paying two trillion dollars for the Iraq and Afghanistan wars. Other etiologies for heel pain include trauma, arthritides, overuse injury, foot type, gait abnormalities, masses and tumors. In some cases the etiology is multifactorial. [4]

For the obese patient attempting to lose weight by exercise and caloric restriction, having plantar fasciitis makes the situation almost impossible to lose weight. The podiatric physician is faced with a challenging task of determining a viable treatment plan that gets the obese patient exercising with minimal to no pain.

Fortunately, there are many treatment modalities which may be viable for our obese patients as well as others. Ultrasound treatment is non invasive, easy to apply and comfortable for the patient. The high frequency sound stimulates the local tissues and increases the blood flow to the area alleviating inflammation. [4] Prefabricated and custom orthotics is another treatment recommendation. Studies have shown no significant difference between the orthotics and both have shown to consistently reduce heel pain. [4,5] Injection therapy is another useful modality that has been used to reduce inflammation in plantar fasciitis. In one study Triamcinolone with Lidocaine proved to be the most effective injection compared to 3 other types of medication and technique types. [6] For short term treatment low dye strapping has been found to be effective reducing plantar fascial pain. [7]

As clinicians we observe patients with rigid pes cavus and hyperpronated feet with plantar fasciitis. A study by Zammet and Payne showed that foot orthotics altered rearfoot functioning significantly but couldn’t correlate this to symptom reduction for plantar fasciitis patients. [8] In another study, a combination of treatments was found to reduce heel pain. The study showed that for at least 12 weeks temporary custom orthotics and stretching reduced heel pain in patients. [9] Medial arch supports reduced heel pain compared to low dye strapping in another study. Both of these treatment modalities were coupled with 9 ultrasound sessions in combination with 3 weeks of calf muscle stretching. [10] A retrospective study reviewed low dose radiotherapy on 273 patients with plantar fasciitis. They found that there was reduction in heel pain especially in patients 50 years or younger. They could not explain why this occurred but recommended this treatment modality for patients 50 years old or younger in acute cases of plantar fasciitis. [11]

Acupuncture and acupoint PC 7 significantly reduced heel pain compared to acupoint LI 4 which is considered to have analgesic properties. There were 27 patients receiving acupuncture to PC 7 and 25 patients in LI 4 patients. Each patient received 5 treatments for 2 weeks. [12] Low frequency electrical stimulation was paired with orthotics and stretching versus patients receiving just orthotics and stretching. The results revealed no significant difference between the 2 groups. However, both patient groups had reduction in heel pain after treatments. [13] Other non-surgical modalities include the use of radiotherapy, Botox injections, extra-corporeal shockwave therapy, platelet plasma injection and dynamic splinting all demonstrating effective heel pain reduction. [14-18]

This study is unique because it compares one modality against another avoiding a combination of treatments seen in many studies. While combining treatments may be necessary for recalcitrant plantar fasciitis it is unclear which treatment is really reducing heel pain. By isolating each modality, which one will provide the highest pain reduction in patients with plantar fasciitis? This prospective randomized study examines four common treatment modalities: arch support, injection, orthotics and ultrasound for the treatment of plantar fasciitis.

Methods

There were 100 patients diagnosed with plantar fasciitis randomly selected by the research assistant to receive one of 4 treatment modalities: ultrasound, functional rigid orthotics, over the counter arch supports, and injection. Each participant reviewed and signed consent form regarding this study. There were 25 patients in each treatment group. Each patient rated their pre treatment subjective pain rating based on a 0-10 scale. Zero equals no pain and 10 is the most severe pain the patient has ever experienced. After one month of treatment the patients pain rating was recorded for every patient in each group.

The ultrasound group received 6 treatments of 5 minutes to the painful heel at a cycle of 1.5 over a 2 week period. The arch support group were instructed to purchase an over the counter arch support to fit their feet. The injection group received one injection of .5ccs of Triamcinolone and 1cc of .5% plain Marcaine into the painful heel. The orthotic group was casted using the Root, et al., method and a biomechanical examination was also performed on each patient. [19] The positive casts and biomechanical measurements were sent to a professional orthotic laboratory for fabrication and the orthotic sent to our office for dispensation. The patient’s sex, height, weight and age were recorded. The groups BMI or body mass index average was calculated for each group. The average group height, weight and age were also calculated. The average subjective pain rating was calculated. The number of patients with 0/10 pain rating after treatment was recorded for each group. The number of patients whose subjective pain was reduced after treatment in each group was determined. The average pain rating reduction for each group was calculated by the pre-treatment group average pain and subtracted by the post treatment average pain rating for each group.

Results

There were 68 females and 32 males in this study. The ultrasound group had the highest average pain reduction of 3.97 after treatment and the highest number of patients who had less pain after treatment at 81% or 21/25.

The ultrasound group also had the lowest BMI average of 30.20. The orthotic group had the second highest subjective pain reduction average after treatment with 2.92. They had the third highest pain reduction patients with 64% or 17/25. The orthotics group had the highest number of patients who had no pain after treatment at 32% or 8/25. The ultrasound group had the second highest number with 20% or 5/25 after treatment. The orthotic group had the second lowest BMI average with 30.3. The injection group had the third highest pain reduction average after treatment with 2.74. The injection group had the second highest number of patients who improved after treatment with 72% 18/25. They had the second highest BMI average with 32. There were 7% of 2/25 patients who got complete pain relief after injection. The arch support group had the highest average BMI of 32.67. The arch support group had the lowest number of patients with no pain after treatment at 5% or 1/25. There were 9/25 or 35% patients who improved after treatment with arch supports. There were 10 patients who weighed over 300 lbs. Eight of 10 were female and the 2 were males. One male weighed 173 kg. (380 lbs.)

Table 1  Treatment group results.  Total subjects (n) = 100,  Female to male ratio = 62:38.  AVG. HT=average height (meters),  AVG WT = average weight (kilograms)  GRP=group, BMI= Body mass index.

Discussion

Based on the results of this study no one treatment provided complete heel pain relief after treatment. Ultrasound group had the overall highest number of patients who had less pain after treatment at 81% with injection second at 72% and orthotic group at 64%. The arch support had the lowest number with 35%.

Orthotic treatment had the highest number of patients at 32% who reported no pain after treatment. Whereas, the arch support group had only one patient rate 0/10 pain after treatment. This study implies that some patients will require more than just one treatment modality to eliminate the symptoms of plantar fasciitis. Surprisingly, an over the counter arch support provided some relief in 32% of the patients in the arch support group. Despite its non- specificity it was still helpful for some patients. Each of the treatment groups average BMI was over 30 indicating that most of the patients were overweight or obese. This study corroborates weight is an important factor in the etiology and treatment of this common foot diagnosis. In 1980 the author reported on a retrospective study of complete fascial release and overall results and complications. [20] There were no patients who weighed over 136 kg. (300 lbs.) in that patient population. The female to male ratio was 2:1 as in this study. The overall patient BMI was less than 30 for the patients who participated in the 1980 study. The CDC regards obesity a national health issue. Furthermore, the number one cause of death in women and men is now myocardial infarction linked to obesity. In this study there were 4 times more women than men ( 8 women to 2 men ) that weighed over 136 kg. (300 lbs.) Trying to lose weight by diet and exercise will be difficult for patients with plantar fasciitis. It will be a greater challenge for those who are over 136 kg. (300 lbs.)

Most of the treatments considered in this study are safe and effective in reducing heel pain. However, extra-articular corticosteroid injections has been implicated in adverse reactions including one death from necrotizing fasciitis, injection site cellulitis, atrophy of the fat pad, and tendon rupture. [21] Kim, et al., reported on a 2.4% incidence of plantar fascial rupture after receiving an average of 2.67 injections. [22] The injections consisted of .5ccs of dexamethasone plus .5ccs of Triamcinolone, and .5ccs of Xylocaine mixed with .5ccs of Marcaine. Thus far, there have been no reported cases of severe complications from Botox® injections and platelet plasma injections.

The author begins treatment for most patients with plantar fasciitis using ultrasound treatment, and arch supports initially. If there is residual heel pain, an injection is added to the treatment regimen. If there is still recalcitrant heel pain, orthotics is recommended. In about 87% of the patients diagnosed with plantar fasciitis there is heel pain reduction. Thirteen percent don’t improve or worsen after exhaustive conservative treatment and 90% of these patients proceed with complete fascial release with a 98% success rate. This is over 35 years of clinical experience and observation.

This study is unique because only one treatment modality was administered to each patient in their respective groups. Many of the studies used multiple treatment modalities with the treatment being investigated to determine if there was significant pain reduction to plantar fasciitis patients. The combining of treatments may show pain reduction but we cannot ascertain which treatment helped more than the others. The authors study clearly demonstrated that each modality decreased heel pain usually in most patients.

References

1. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among U.S adults 1999-2008. JAMA 2010 303: 235-241.
2. CDC REPORT for 2010. National Center for Chronic Disease Prevention and Health Promotion, CDC: Freedman, D.S on Obesity 2010, 73-78.
3. WHO Report 2010. WHO 2010 Geneva, Switzerland.
4. Healey K. Chen K. Plantar fasciitis: current diagnostic modalities and treatments. Clin Pod Med Surg 2010 7(3): 396-380.
5. Landorf KB, Keenan AM, Herbert RD. Effectiveness of different types of foot orthoses for the treatment of plantar fasciitis. JAPMA 2004 94: 542-549.
6. Baldassin V, Gomes CR, Beraldo PS. Effectiveness of prefabricated and customized foot orthoses made from low cost foam for noncomplicated plantar fasciitis: a randomized controlled trial. Arch Phys Med Rehab 2009 90: 701-706.
7. Kalaci A, Cakici H, Hapa O, Yanat N, Dogamaci Y, Sevinc TT. Treatment of plantar fasciitis using four different local injection modalities: A randomized, prospective clinical trial. JAPMA 2009 99: 108-113.
8. Zammet GV. Payne CB. Relationship between positive clinical outcomes of foot orthotic treatment and changes in rearfoot kinematics. JAPMA 2007 97: 207-212.
9. Drake M, Bittenbender G, Boyles RE. The short term effects of treating plantar fasciitis with a temporary custom foot orthosis and stretching. J Orthop Sports Phys Ther 2011 41: 221-231.
10. El Salam MS, Elhafz YN. Low-dye taping versus medial arch support in managing pain and pain related disability in patients with plantar fasciitis. Foot Ankle Spec 2011 4: 86-91.
11. Osborne HR, Allison GT, Hanna C. Treatment of plantar fasciitis by low dye taping an iontophoresis: Short term results of a double blinded, randomized placebo controlled clinical train of Dexamethasone and Acetic acid. BJSM 2006 40: 545-549.
12. Zhang SP, Yip TP, Li QS. Acupuncture treatment for plantar fasciitis: A randomized controlled trial with six months follow-up. Evid Based Complement Alternat Med 2009: 23.
13. Stratton M, McPoil TG, Cornwall MW, Patrick K. Use of low frequency electrical stimulation for the treatment of plantar fasciitis. JAPMA 2009 99: 481-488.
14. Hajtmanova E, Kinclova I, Kostkova L, Hajtman A, Pec M. Low dose radiotherapy in the treatment of plantar fasciitis. Klin Onkol 2010 23: 104-110.
15. Rawicki B, Sheean G, Fung VS, Goldsmith S, Morgan C, Novak I. Cerebral Palsy Institute. Botulinum toxin assessment, intervention and aftercare for pediatric and adult niche indications including pain: international consensus statement. Eur J Neurol 2010 Suppl 2: 122-134.
16. Metzner G, Dohnalek C, Agner E. High energy extracorporeal Shock Wave Therapy for the Treatment of Chronic plantar fasciitis. Foot Ankle Int 2010 31: 790-796.
17. Peerbooms JC, van Laar W, Faber F, Schuller HM, van der Hoeven H, Gosens T. Use of platelet rich plasma to treat plantar fasciitis: design of multi centre randomized controlled trial. BMC Musculoskeletal Disorders 2010 13:11: 69.
18. Sheridan L, Lopez A, Perez A, John MM, Willis FB, Shanmugam R. Plantar fasciopathy treated with dynamic splinting. A randomized controlled trial. JAPMA 2010 10:161-165.
19. Root ML, Orien WP, Weed JH. Normal and Abnormal Function of the Foot. Clinical Biomechanics Corp Los Angeles, 1977.
20. Kuwada GT, Gormley J. Retrospective ananlysis of calcaneal spur removal and complete fascial release for the treatment of chronic heel pain. JFS 1992 11: 166-169.
21. Brinks A, Koes BW, Volkers AC, Verhaar JA, Biema-Zeinstra SM. Adverse effects of extra-articular corticosteroid injections: a systemic review. BMC Musculoskeletal Disorders 2010 11:206.
22. Kim C, Cashollar MR, Mendicino RW, Catanzariti AR, Fuge L. Incidence of plantar fascia ruptures following corticosteroid injection. Foot Ankle Spec 2010 3: 335-337.


Address correspondence to: Gerald T. Kuwada DPM, NMD. 275 SW 41st street, Renton, WA 98057.
E-mail: drgeraldkuwada@qwestoffice.net
Office phone: 425-251-9174
Office fax: 425-251-0758

1  Private practice, 275 SW 41st street, Renton, WA 98057.

© The Foot and Ankle Online Journal, 2011

Investigating Plantar Fasciitis

by Valerie A.J. Potter, MBChB, BSc (Hons), MSc1

The Foot and Ankle Online Journal 2 (11): 4

Plantar fasciitis is a condition caused by inflammation of the plantar aponeurosis and is a common cause of heel pain. The diagnosis is clinical and investigations are generally not required. However, in certain cases such as an atypical presentation or where there is no response to treatment, the clinician may consider further investigation. This review article briefly introduces the condition and goes on to discuss the possible options for investigation. This includes evaluation and usefulness of such tests as blood evaluation, radiographs, ultrasound, bone scintigraphy, magnetic resonance imaging (MRI) and nerve conduction studies.

Key words: Plantar fasciitis, investigations, heel pain, MRI, ultrasound, bone scintigraphy, nerve conduction.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: October, 2009
Published: November, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0211.0004


Anatomy and etiology of plantar fasciitis

The plantar fascia of the foot refers to the deep fascia of the sole. It arises posteriorly from the calcaneus and divides into bands which divide to enclose tendons. The thick central part of this fascia forms the plantar aponeurosis which is arranged into bands of fibrous connective tissue. The plantar fascia has a number of roles, which include holding parts of the foot together, protecting the plantar surface of the foot from trauma and helping to support the foot’s longitudinal arch. ‘Plantar fasciitis’ refers to inflammation of the plantar aponeurosis. This is a relatively common clinical condition and cause of heel pain resulting from a degenerative process. The exact mechanism is poorly understood but thought to be multifactorial. Mechanical overload is believed to play a key role. [1] Risk factors include age, obesity, biomechanical abnormalities of the foot and particular occupation- related or recreational activities such as aerobics and running particularly in flat or worn shoes.

The chronic form of heel pain is now more commonly termed ‘plantar fasciosis’. Repetitive trauma and overuse leads to microtears, with cycles of tearing and healing causing the release of various chemical mediators. This is thought to lead to myxoid degeneration and weakness of the fascia as well as pain. [2] This is a degenerative fasciosis without inflammation. [3]

Plantar fasciitis can also be associated with various inflammatory systemic conditions such as gout and rheumatoid arthritis. An increased incidence exists in patients with certain HLA B27 sponyloarthropathies in which case the fasciitis often presents at a younger age and carries a poorer prognosis. [4]

Clinical features

Typically the patient presents with pain in one or both plantar aspects of the feet. This has usually been insidious in onset although occasionally can be acute. The pain may be poorly localized particularly initially, but then may become maximal at the origin of the fascia, to the medial calcaneal tuberosity. It tends to be worse in the morning when the foot is first put on the floor or following a period of rest and is relieved on movement during the day. However, it can again be exacerbated by increased weight-bearing activity such as running. It is often described as a ‘tearing’ pain. On inspection, the foot appears normal with either no or slight swelling. [5] Palpating the foot, the practitioner may elicit maximal tenderness at the aforementioned origin of the plantar fascia and pressure here reproduces the pain. Passive dorsiflexion of the toes and ankles can also cause pain by stretching the fascia.6 The clinician must also consider a differential diagnosis for heel pain. (Table 1)

Table 1 Differential diagnosis for plantar fasciitis.

Investigations in plantar fasciitis

The diagnosis of plantar fasciitis is a clinical one based on the history and examination. It is also usually self-limiting and managed conservatively. However, in particular circumstances such as atypical presentations or failing to respond to treatment, the clinician may wish to consider other tests to aid in the diagnosis and differential diagnosis of heel pain syndrome.

Blood tests

In most cases, these do not play a role in diagnosis although occasionally the clinician may wish to perform certain blood tests if considering a systemic condition or alternative cause. A raised erythrocyte sedimentation rate or C-reactive protein may indicate underlying inflammation or infection respectively. Likewise, testing for HLA B27 gene may be helpful if suspecting one of the HLA B27 spondyloarthropathies such as ankylosing spondylitis, psoriatic arthritis, reactive arthritis or enteropathic arthritis. Further examples include gout in which serum uric acid is usually raised and a diagnosis of Paget’s disease is supported by a raised alkaline phosphatase with a normal phosphate and calcium.

Plain radiograph

It is common for a plain lateral radiograph of the foot to be ordered, often to rule out a stress fracture, heel spurs, fractured spurs or some other bony cause of the patient’s heel pain. However, one study involving 215 heels concluded that routine radiographs are of limited use in the initial evaluation of adults presenting with non-traumatic heel pain and should be reserved for those who do not improve or have an unusual history or physical signs. This study also found that radiographs were normal in 17.2% and that incidental radiographic findings were observed in 81.4%; most commonly plantar calcaneal spurs and Achilles spurs (46.5%, 100 of 215). [7]

One may argue that these incidental findings could in some cases explain the patient’s symptoms although a heel spur does not have any diagnostic value. [8] The aforementioned study also found that only 2% of the patients in their study had abnormal findings that prompted further evaluation supporting the conclusion that radiographs are generally of limited use and hence not cost effective. [7]

Ultrasound

In difficult cases, the clinician may wish to request an ultrasound of the foot. A number of studies have sought to evaluate usefulness of this modality with respect to diagnosing plantar fasciitis. One such study found that in patients with plantar fasciitis, ultrasound may detect relatively small differences in plantar fascia thickness (2.9mm in patients with unilateral plantar fasciitis, 2.2mm for the contralateral heel and 2.5mm for the control group). [9] A similar conclusion was reached by a Cardinal, et al., who found that increased thickness of the fascia and hypoechoic fascia are sonographic findings of this condition. They concluded that ultrasound may be a valuable non-invasive technique for the diagnosis of plantar fasciitis. [10]

Bone Scintigraphy

Bone scintigraphy is an investigation which uses technetium-99m labelled diphosphonates. It is one of the most frequently performed of all radionuclide procedures. The isotope is injected into the patient intravenously and is then cleared from the blood and taken up by the skeleton. Blood flow and osteoblastic activity determine skeletal uptake. This mode of imaging is not specific but is very sensitive and so is useful in screening for many pathological conditions. It is often used to investigate potential malignant bony lesions but may be requested, as in the context of heel pain, to explore chronic foot pain which is not responding as expected. In cases of musculoskeletal trauma, radionuclide bone imaging is useful for identifying pathologic conditions for which radiographs may be non-diagnostic. [11] It is often used to rule out a stress fracture.
Several studies have sought to determine the value of this modality in the diagnosis of plantar fasciitis. One study compared ultrasonography and bone scintigraphy; both were found to be sensitive and specific diagnostic imaging investigations in this condition. This study found that both confirmed the clinical diagnosis in 25 of 27 heels. However, this again serves to highlight the accuracy of clinical diagnosis supporting the view that imaging is only rarely required. Comparing the two investigations, the differences in sensitivity and specificity were not statistically significant and given the relative ease and non invasiveness of ultrasonography, this would thus seem to be the choice of imaging to employ. [12] Another study found that focal uptake at the medial calcaneal tubercle was present in the majority of patients in their study who had been diagnosed with plantar fasciitis, thus confirming the diagnosis. [13] A third study came to the conclusion that scintigraphy is very useful in diagnosing plantar fasciitis and distinguishing it from other causes of a painful heel after imaging 15 patients with chronic heel pain; 10 demonstrated scan findings consistent with plantar fasciitis whilst 2 were found to have a calcaneal stress fracture. [14]

Magnetic resonance imaging

Magnetic resonance imaging (MRI) is a further possible investigation to perform in difficult cases and is useful in detecting tears or ruptures of the fascia. In plantar fasciitis the MRI may show a widened fascia with increased signal often with some reactive oedema in the adjac ent bone. [15] The normal thickness of the plantar fascia is 4mm; in plantar fasciitis this may be increased to 8mm. In cases of ruptures and tears this thickness can reach 10mm or more and additionally, the MRI will show intrafascial high signal intensity of the T2 weighted image. [16] One study found that maximal thickness of the plantar fascia was significantly increased in patients with plantar fasciitis and that feet with the condition had areas of moderately increased signal intensity in the substance of the fascia. [17]

Although therefore very useful, a study compared the diagnostic accuracy of ultrasound and MRI and found the two comparable and concluded MRI may be reserved for the more complex cases where the diagnosis is not clear. [18] Similarly, another paper found that although MRI is the modality of choice in the morphologic assessment of different plantar fascia lesions, sonography can also serve as an effective tool and may substitute MRI in the diagnosis of plantar fasciitis. [19]

Nerve conduction studies

This is used to look at the ability of electrical conduction of a nerve and so to diagnose nerve damage or dysfunction. It involves the placement of electrodes on the skin at intervals along the nerve in question; a low intensity electrical current is then applied to generate an impulse. Nerve conduction velocity can then be measured by recording the motor response of a muscle to the stimulation of its motor nerve. Nerve conduction studies are rarely required in the context of plantar fasciitis, but may be considered if the clinician is suspecting nerve entrapment as the cause of the patient’s pain. This may include tarsal tunnel syndrome or where an atypical presentation represents a mixed picture. For example, Chang, et al., found that sensory nerve conduction studies were a useful and objective tool in the diagnosis of medical calcaneal neuropathy and that there was an association between this neuropathy and plantar fasciitis. [20] In addition, Baxter’s neuropathy, which is referred to as entrapment of the first branch of the lateral plantar nerve can produce medial heel pain. This can be very similar to that caused by plantar fasciitis and is thought to account for up to 20% of heel pain. [21]

Conclusion

Plantar fasciitis is a common cause of heel and foot pain. In most cases, history and examination provide the diagnosis and treatment can be advised based on severity and duration of symptoms.

If there is doubt as to the cause, investigations, usually rarely indicated, can be considered. Imaging modalities and tests include x-rays, ultrasound, scintigraphy, MRI and nerve conduction studies. The main value of these are in confirming the clinical diagnosis of plantar fasciitis as diagnostic features on imaging do exist and in detecting other causes of the patient’s heel pain. [9] Plain radiography is generally unhelpful; ultrasound appears to be the most useful in difficult cases and has the additional advantages of speed and low cost. MRI, bone scintigraphy and nerve conduction studies are best reserved for when there is a strong clinical suspicious of an alternative diagnosis or when the patient’s heel pain is not responding after 3 months or more of treatment. [6]

References

1. Puttaswamaiah R, Chandran P: Degenerative plantar fasciitis: A review of current concepts. The Foot 17: 3 – 9, 2007.
2. Tsai WC, Wang CL, Tang FT, Hsu TC, Hsu KH, Wong MK: Treatment of proximal plantar fasciitis with ultrasound-guided steroid injection. Arch Phys Med Rehabil 81: 1416 – 1421, 2000.
3. Lemont H, Ammirati KM, Usen N: A degenerative process (fasciosis) without inflammation. J American Podiatric Medical Association 93: 234 – 237, 2003.
4. Foye PM, Stitik TP: Plantar fasciitis. Emedicine, 2008. Accessed 09/23/2009.
5. Amis J, Jennings L, Graham D, Graham CE: Painful heel syndrome: radiographic and treatment assessment. Foot Ankle 9: 91 – 95, 1988.
6. Duff G: Plantar fasciitis and heel pain. Reports on the rheumatic diseases 2: 1 – 4, 2004.
7. Levy JC, Mizel MS, Clifford PD, Temple HT:Value of radiographs in the initial evaluation of nontraumatic adult heel pain. Foot Ankle Int 27: 427 – 430, 2006.
8. Tanz SS: Heel pain. Clin Orthop 28: 169 – 178, 1963.
9. Ozdemira H, Yilmazb E, Murata A, Karakurtb L, Poyraza AK, Ogura E: Sonographic evaluation of plantar fasciitis and relation to body mass index. Eur J Radiology 54: 443 – 447, 2005.
10. Cardinal E, Chhem RK, Beauregard, CG, Aubin B, Pelletier, M: Plantar fasciitis: sonographic evaluation. Radiology 201: 257 – 259, 1996.
11. Love C, Din AS, Tomas MB, Kalapparambath TP, Palestro CJ: Radionuclide bone imaging: An illustrative review. Radiographics 23 (2): 341 – 358, 2003.
12. Kane D, Greaney T, Shanahan M, Duffy G, Bresnihan R, Fitzgerald O: The role of ultrasonogaphy in the diagnosis and management of idiopathic plantar fasciitis. Rheumatology 40: 1002 – 1008, 2001.
13. O’Duffy EK, Clunie GP, Gacinovic S, Edwards JC, Bomanii JB, Ell PJ: Foot pain: specific indications for scintigraphy. Br J Rheumatol 37: 442 – 447, 1998.
14. Intenzo CM, Wapner KL, Park CH, Kim SM: Evaluation of plantar fasciitis by three-phase bone scintigraphy. Clin Nucl Med 16: 325 – 328, 1991.
15. Ostlere S: Imaging the ankle and foot. Imaging 2003;15: 242 – 269.
16. Kline A: Plantar fascial rupture of the foot: a case report. The Foot and Ankle Online Journal 2 (5): 4, 2009.
17. Berkowtiz JF, Kier R, Rudicel S: Plantar fasciitis: MR imaging. Radiology 179: 665 – 667, 1991.
18. Abdel-Wahab N, Fathi S, Al-Emadi S, Mahdi S: High resolution ultrasonographic diagnosis of plantar fasciitis: a correlation of ultrasound and magnetic resonance imaging. International Journal of Rheumatic Disease 11: 279 – 286, 2008.
19. Sabir N, Demirlenk S, Yagci B, Karabutlut N, Cubukcu S: Clinical utility of sonography in diagnosing plantar fasciitis. J Ultrasound Med 24: 1041 – 1048, 2005.
20. Chang CW, Wng YC, Hou WH, Lee XX, Chang KF: Medial calcaneal neuropathy is associated with plantar fasciitis. The Journal of Foot and Ankle Surgery 118: 119 – 123, 2007.
21. Chundru U, Liebeskind A, Seidelmann F, Fogel J, Franklin P, Beltran J: Plantar fasciitis and calcaneal spur formation are associated with abductor digiti minimi atrophy on MRI of the foot. Skeletal Radiology 37: 505 – 510, 2008.


Address correspondence to: East Surrey Hospital, Canada Avenue, Redhill, Surrey, RH1 5RH, U.K.

Acute Stroke Unit, East Surrey Hospital, Canada Avenue, Redhill, Surrey, RH1 5RH, U.K. vpotter@doctors.org.uk

© The Foot and Ankle Online Journal, 2009

Plantar Fascial Rupture of the Foot: A case report

by Al Kline, DPM1  

The Foot and Ankle Online Journal 2 (5): 4

Plantar fascial rupture is rarely presented in the literature. Spontaneous rupture of the plantar fascia is commonly preceded by plantar fasciitis. A 60 year old male presents following an acute injury of his foot while playing softball. He presents with acute pain and ecchymosis to the plantar arch of the foot. Plantar fascial rupture was diagnosed clinically and confirmed on magnetic resonance imaging (MRI). This case discusses the clinical evaluation, MRI results and treatment of acute, spontaneous rupture of the plantar fascia. We also describe the MRI differences of plantar fasciitis and plantar fascial rupture.

Key words: Plantar fasciitis, plantar fascial rupture, heel pain, Magnetic resonance imaging

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: April, 2007
Published: May, 2009


Plantar fascial injuries are a common source of foot pain. Plantar fasciitis is the most common type of plantar fascial injury. The condition is characterized by small tears of the plantar aponeurosis that can cause inflammation and thickening of the plantar aponeurosis. The causes of injury are related most commonly to stress and strain. General injury to the plantar fascia can be divided into three categories: mechanical, degenerative and systemic. [1] Mechanical conditions such as pronation, forefoot varus and rearfoot valgus will often lead to increased tension and strain of the plantar aponeurosis. This may be exacerabated by increased activity and lack of proper shoe and in-step support. It is now widely accepted that degenerative changes can occur within the plantar fascia due to repetitive micro tears and peri-fascial edema termed plantar fasciosis. [2] This is characterized as a degenerative process of myxoid degeneration without inflammation. [2]

There are also a number of inflammatory systemic conditions that can cause plantar fasciitis. These include rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, Reiter’s syndrome, gout, Behcet’s Syndrome and systemic lupus erythematosus.3 In general, the etiology of arch and heel pain can be mulifactorial in nature. When tension along the plantar aponeurosis exceeds its inherent strength, an acute fascial rupture can result.

Case Report

A 60-year old healthy male presented to our office in acute pain. He presented with a limp. He stated that he had been having arch and heel pain of the right foot over the past month. He recently participated in a softball game. He states that while ‘sprinting’ to a base, he felt a ‘pop’ in his arch followed by acute pain and swelling. He immediately stopped playing and placed ice on the arch region of the foot. Clinical evaluation of the foot reveals an extremely tender plantar fascia with localized bruising or ecchymosis (Fig.1).

Figure 1  The plantar fascia shows bruising directly along the arch of the foot.  There is extreme point tenderness to this region.

Pain was palpable along the entire course of the plantar fascia and more pronounced along the central arch. The patient was sent for magnetic resonance imaging (MRI) confirmation to rule out plantar fascial rupture. Pain was palpable along the entire course of the plantar fascia and more pronounced along the central arch. The patient was sent for MRI confirmation to rule out plantar fascial rupture.

MR Imaging and Findings

MRI shows classic signs of fascial tear and rupture. Multiplanar, multisequence images were obtained showing increased thickness of the plantar fascia up to 10mm with convexed dorsal thickening. A classic fusiform appearance of the fascia is seen in the region of rupture.

The sagittal image also shows intrafascial high signal echo on T2 imaging consistent with plantar fascial disruption of the fibers. (Fig. 2)

Perifascial edema (arrow) is seen along the deeper musculature adjacent to the plantar aponeurosis. The coronal view on STIR or inversion recovery sequencing shows dramatic intrafascial edema and hemorrhage. Again, fusiform thickening of the musculature and plantar aponeurosis is appreciated. (Fig. 3)

Figure 2  T2 sagittal image shows a central thickening up to 10mm with enlargement and nodular thickening of the plantar aponeurosis.

Figure 3  STIR (inversion recovery image) coronal views also shows intrafascial edema and hemorrhage.

Axial imaging shows increased signal intensity on T1 and T2 imaging with appreciable intrafascial and perifascial edema. (Fig. 4 A and B)

 

Figure 4A and 4B  MR Axial imaging shows T1 image (A).  The T2 image shows increased perifascial, intrafascial and muscular edema. (B)

Treatment

Treatment of plantar fascia rupture depends on the extent of injury confirmed by MRI findings and activity level of the patient. Our patient was active for his age and his overall injury was acute and extremely painful. In this respect, we recommended the patient wear a non-weight bearing cast for 4 weeks.

We placed him on NSAIDS for 2 weeks during his casting period. His recovery after casting included local stretching and physical therapy. We also placed him in orthotics.

Discussion

The clinical presentation of acute plantar fascial rupture differs from plantar fasciitis. The pain of an acute rupture is located more distal to the insertion of the plantar fascia and bruising is commonly seen along the middle of the arch. Clinically, this is extremely tender to touch and the patient will have trouble walking. Most often, clinical evaluation, activity of the patient and onset of pain will help the practitioner determine the extent of injury and determine fascial strain or fasciitis from actual tear or rupture of the plantar fascia. Radiographic evaluation lacks the proper contrast resolution for proper differentiation of plantar fasciitis and fascial rupture. Fascial thickening and perifascial edema can be seen on enhanced soft tissue radiographic imaging. However, MR imaging is superior in differentiating acute plantar fasciitis, chronic plantar fasciitis from partial or acute plantar fascial rupture. MR imaging will determine the exact localization and extent of fascial injury. In this regard, the proportionate thickness and amount of edema will help the practitioner determine the proper course of treatment.

The attachment of the plantar fascia is best demonstrated on coronal images. The entire course of the aponeurosis is best seen on the sagittal images. Visualizing of the medial fascial band is best seen in the sagittal and coronal views. The lateral band is best observed with oblique imaging, although sagittal and coronal images can also be used. MR imaging studies also show a difference in findings when comparing fasciitis and fascial rupture. In plantar fasciitis, there is often thickening of the aponeurosis as seen on sagittal image without actual disruption of the fascial fibers. The appearance of the plantar fascia is usually thickened and uniform. In plantar fascial rupture, there is often a fusiform appearance of the aponeurosis.

There is also widespread abnormal high signal intensity infiltrating perifascial soft tissues consistent with local edema. The most consistent finding in acute partial or complete rupture of the plantar aponeurosis is fusiform thickening of the fascia with abnormal, intrafascial signal intensity. Theodorou, et al., studied MR imaging of 14 patients with partial or complete rupture of the plantar fascia revealing abnormal, fusiform thickening of the plantar aponeurosis in all patients. All patients showed abnormal absence of T1-weighted low signal intensity of the plantar aponeurosis at the site of complete rupture or partial loss of T1-weighted low signal intensity respectively. [1]

Treatment can vary on extent of injury and activity of the patient. In earlier studies and before MR imaging techniques, patients with rupture were often treated conservatively using crutches, ice packs, anti-inflammatory agents and foot straps. Diagnosis was simply made by presentation of acute symptoms such as severe localized swelling and acute tenderness. As the swelling diminished, there is often a palpable defect that is replaced by a hard mass that gradually became less tender. [4] Leach, et al., reported suspected partial ruptures in six long distance runners who were treated conservatively. Only one patient required surgery for persistent swelling, undergoing a fascial release. They reported full recovery of all the long distance runners back to their original pre-injury activity with no deleterious effects, even in the one surgical patient. Now, with the aid of MR imaging, diagnosis and treatment can be more specific to extent of injury.

This case highlights clinical and MRI findings in a patient with plantar fascial rupture following an acute injury while playing softball. A fusiform appearance of the fascia on MR imaging was consistent with plantar fascial rupture and the patient’s clinical presentation. In its largest point, the intrafascial edema can increase the thickness of the fascia to over 10 mm. The normal thickness of the plantar fascia is about 4 mm in thickness. In cases of plantar fasciitis, the thickness can increase to 8mm. Most fascial ruptures and partial tears show an increase in thickness of the fascia of 10mm or more with intrafascial high signal intensity of T2 weighted MR images.

In plantar fasciitis, the MR T2 weighted imaging or bright signal intensity is not actually seen within the fascia, but can be readily seen perifascially. If a bright signal is seen within the fascia, it will represent rupture of the fascial fibers confirming the diagnosis of plantar fascial rupture.

References

1. Theodorou, D.J., et al.: Plantar fasciitis and fascial rupture: MR imaging findings in 26 patients supplemented with anatomic data in cadavers. Radiographics. 20: S181- S197, 2000.
2. Lemont H, Ammirati, KM, Usen N: Plantar fasciitis: A degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc 93(3): 234 – 237, 2003.
3. Barrett SL, O’Malley R.: Plantar fasciitis and other causes of heel pain. American Family Physician 59 (8), 1999.
4. Leach R, Jones R, Silva T: Rupture of the plantar fascia in athletes. J Bone Joint Surgery 60A (4): 537 – 539, 1978.


Address correspondence to: Al Kline, DPM
3130 South Alameda, Corpus Christi, Texas 78404.

1 Adjunct Clinical Faculty, Barry University School of Podiatric Medicine. Private practice, Chief of Podiatry, Doctors Regional Medical Center. Corpus Christi, Texas, 78411.

© The Foot and Ankle Online Journal, 2009

Pain Scale for Plantar Fasciitis

by Buck Willis, PhD1 , Angel Lopez, DPM2 , Andres Perez, MD-DPM3 , Larry Sheridan, DPM4 ,Stanley R Kalish, DPM5

The Foot and Ankle Online Journal 2 (5): 3

Background: Plantar fasciitis (PF) is a common and debilitating pathology whose chief complaint is acute plantar heel pain. This pathology affects between 1 and 2 million Americans each year, but a specific descriptive pain/disability scale has not been available to measure the severity and/or changes in pain specific to this pathology. The purpose of this study was to examine the PF, Pain and Disability Scale (PFPS) and its ability to discriminate between pain from PF and other heel pain.
Methods: The PFPS survey includes a series of key questions that relate to symptoms and control questions for PF. It also includes visual analogue scale and questions to measure the effect the pain has on activities of daily living. This questionnaire was administered to 400 patients who had been diagnosed with either PF or another pathology causing heel pain (e.g. calcaneal bursitis). Patients’ mean age was 50 years ±16 (242 females and 158 males).
Results: There was a significant difference in scores from PF patients versus other heel pain patients when compared in a one-way analysis of variance (P 0.05) or ethnicity (P > 0.05).
Discussion: The survey was effective in measuring pain that is unique to PF through questions of mobility/function and activities of daily living, and it showed a significant difference between patients with other heel pain vs. PF. This could become an effective tool in diagnosis and assessment of pain unique to PF.

Key words: Plantar fasciitis, Pain and disability scale, heel pain

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: April, 2009
Published: May, 2009


Plantar fasciitis (PF) is considered to be one of the most common foot pathologies affecting 1 to 2 million Americans each year. [7,9-11] However, a descriptive pain/disability scale has not been available to measure severity and/or changes in pain specific to this pathology.

Current orthopaedic pain scales include a simple 10 point Visual Analogue Scale (VAS) [7,18] to the “Disabilities of Arm/Shoulder/Hand” and the “Levine-Katz Functional Survey,” which measure the effect and disabilities of upper extremity pain has during Activities of Daily Living (ADL).

An overall foot-health questionnaire has been developed, [1] but this survey measures the broad health status of one’s foot and would not show specific changes in pain from PF in accordance to ADLs. The VAS scores pain on a scale of 1 to 10 or 1 to 100 and has been effective in helping clinician’s measure pain. However, confounding variables affect these scores.

Differences in VAS scores between different dates may not be true barometer of the change in pain. The foot health status questionnaire [7,8] and the VAS [2,7,8,13,17,18] have been used in many studies, but other authors have searched for a better method to measure changes following treatment of PF. Rose, et al., examined this question using nerve conduction (medial calcaneal nerve and the posterior nerve) to gain further insight into patient’s true recovery from PF. [15]

The foot function index (FFI) [2,8] was compared in clinical settings with PF patients by Landorf and Radford. [8] Patients were recruited for two trials to examine the “minimal important difference” for the patients when comparing these pain scales. The results indicated the difference that would benefit clinician’s interpretation, but Landorf and Radford remarked that these pain scores themselves do not “Take into account the affect a disorder has on the patient’s life in general.” [8]

Effective Orthopaedic Rehab: Seven Steps to Complete Recovery was written as a supplemental book for athletic training students and measures pain in ADLs and the effect motion and movement may have on the pain. Reviewers of this scale felt that it was a more complete, analytical measurement of pain than would be acquired by a VAS. [19]

The validity and source of the questions used in this PF, Pain and Disability Scale (PFPS) survey came from examination and comparison to questions in other text books, recent manuscripts, and from the clinical practice of diagnosing and treating PF. [1,3,8,11,17-19] The PFPS has been compared and validated beside the foot function index, and the 100 point VAS is actually included in the PFPS. However, the PFPS gives a more detailed, analytical analysis of patients’ pain by also examining symptomatic questions used in the differential diagnosis and questions regarding pain in ADLs. The purpose of this study was to examine the PFPS survey’s ability to discriminate between pain from PF and other heel pain.

Methods

Four hundred patients who presented with acute heel pain were recruited at four different foot/ankle clinics. Each patient was clinically examined to diagnose and categorize PF versus another heel pain condition such as calcaneal bursitis or calcaneal fractures. (See differential diagnosis on Table 1 and demographics of the patients can be seen in Table 2.) All patients completed the PFPS and informed consent was obtained for each patient participating in this study. Ethical approval for this study was granted by the Copernicus Group IRB.

Table 1  Differential diagnosis in PF.

Table 2  Patient demographics.

The PFPS includes unique symptomatic questions in differentiating PF and control questions as well, which make scores of 0 or 100 points to be invalid. If a patient had recorded either of these scores the test would have been deleted from this study, but no such incidence occurred. The PFPS questions were internally validated with inclusion of the 100 point VAS and externally validated through orthopaedic text and podiatric publications. [1,6,8,16,18,19]

Data Analysis

After PFPS questionnaires were collected from patients at four foot/ankle clinics (This form is blinded to the patent’s name and only the Date of Birth was used for tracking as required under the Declaration of Helsinki). A one-way analysis of variance (ANOVA) with post-hoc t-tests were used to determine differences between gender or ethnicity. All statistical tests were performed at an alpha level of 0.05 using SPSS and Microsoft Excel software.

Results

There was a statistically significant difference in scores of PF patients vs. scores of other heel pain patients (P 0.05) or ethnicities (P > 0.05).

Table 3  Results (SD = standard deviation)

The mean difference between PF vs. other heel pain was more than 35 points and this is believed attributed to the fact that the PFPS includes questions uniquely symptomatic to PF like pain from the first steps in the morning and reduced morning pain from toe walking. (See Figure 1, questionnaire.) The purpose of this study was to examine the PFPS survey’s ability to discriminate between pain from plantar fasciitis (PF) and other heel pain.

Figure 1  Study Questionnaire:  PFPS Plantar Fasciitis Pain/Disability Scale (PDF)

Discussion

Current studies support the need for a pain scale that can uniquely assess pain exclusive to PF for diagnosis and assessment. [2,6,8,11,15,18] Landorf and Radford question the statistical significance in changes with the VAS because of the multiple confounding variables associated with that test. They determined that a “Minimally Important Difference” was based not on statistical values alone but changes in “the effect a disorder has on the patient’s life in general”. [8]

Bennett, et al., developed a questionnaire to measure overall foot health. [1] Their questionnaire examined four different domains of questions (with 107 participants). The “domains” (or categories) of questions were Pain, Function, Footwear, and General Foot Health. One functional question was “How much does your foot health limit you in walking” [1] which is ideal in measuring the overall foot health but is not symptom specific to PF.

Rose, et al., [15] suggest using nerve conduction to evaluate changes in PF but few podiatrists may have nerve conduction equipment in their office. The PFPS can be administered in almost any setting. The existing pain scales are effective in gauging overall pain, [1,2,8,13,17,18] but they lack the specific inclusion of symptomatic questions that will allow specific, objective, analytical measurement of change in symptoms unique to PF. The PFPS effectively showed the difference between PF patients vs. patients with other pathologies causing heel pain.

The PFPS will allow clinician’s more descriptive, exclusive analysis of PF pain for evaluation of treatment than the 100-pint VAS scale.

For example a young woman’s score VAS and PFPS drops from 70 to 60 which would be “statistically significant” but, it may not show “Minimally Important Difference”.8 However a comparison the current vs. previous PFPS tests of this patient, shows a changed Q#14 because she no longer prefers toe walking, and Q#15 which shows reduced pain from “Walking in the morning” and reduced pain from “Standing after watching a movie.” This would display a “Minimally Important Difference”8 and answer the need for a pain scale that can uniquely assess pain exclusive to PF for diagnosis and evaluation.2,6,8,11,15,18

In this study the PFPS has effectively discriminated pain unique to PF patients vs. heel pain caused by other foot pathologies. A future study should be conducted using this PFPS to measure changes in PF patients’ pain through a treatment regime, lasting several months. That would further validate the efficacy of this questionnaire in diagnosis and assessing pain unique to PF.

References

1. Bennett PJ, Patterson C, Wearing S, Baglioni T. Development and validation of a questionnaire designed to measure foot-health status. J Am Podiatr Med Assoc 88 (9):419 – 28, 1998.
2. Digiovanni BF, Nawoczenski DA, Malay DP, Graci PA, Williams TT, Wilding GE, Baumhauer JF. Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. J Bone Joint Surg 88A:1775 – 81, 2006.
3. Dmitri Luke BS. Plantar fasciitis: a new experimental approach to treatment. Med Hypotheses 59(1): 95 – 7, 2002.
4. Fishco WD, Goecker RM, Schwartz RI. The instep plantar fasciotomy for chronic plantar fasciitis. A retrospective review J Am Podiatr Med Assoc 90 (2): 66 – 69, 2000.
5. Guldemond NA, Leffers P, Sanders AP, Emmen H, Schaper NC, Walenkamp GH. Casting methods and plantar pressure: effects of custom-made foot orthoses on dynamic plantar pressure distribution. J Am Podiatr Med Assoc 96 (1): 9 – 18, 2006.
6. Intenzo CM, Wapner KL, Park CH, Kim SM. Evaluation of plantar fasciitis by three-phase bone scintigraphy. Clin Nucl Med 16 (5):325 – 8, 1991.
7. Landorf KB, Keenan AM, Herbert RD. Effectiveness of foot orthoses to treat plantar fasciitis: a randomized trial. Arch Intern Med. 166 (12):1305 – 10, 2006.
8. Landorf KB, Radford JA. Minimal important difference: values for the foot health status Questionnaire, Foot Function Index and Visual Analogue Scale. The Foot 18(1):15-19, 2008.
9. Lemont H, Ammirati KM, Usen N. Plantar fasciitis: A degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc 93 (3): 234 – 237, 2003.
10. Martin JE, Hosch JC, Goforth WP, Murff RT, Lynch DM, and Odom RD. Mechanical treatment of plantar fasciitis: A prospective study. J Am Podiatr Med Assoc 91(1): 55 – 62, 2001.
11. Marx, RC, Mizel, MS. What’s new in foot and ankle surgery. J Bone Joint Surg 90A: 928 – 942, 2008.
12. Ng A, Beegle T, Rockett AK. Atypical presentation of plantar fasciitis secondary to soft-tissue mass infiltration. J Am Podiatr Med Assoc 91 (2): 89 – 92, 2001.
13. Radford JA, Landorf KB, Buchbinder R, Cook C. Effectiveness of calf muscle stretching for the short-term treatment of plantar heel pain: a randomised trial. BMC Musculoskeletal Disord 19: 8: 36, 2007.
14. Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for Plantar fasciitis: a matched case-control study. J Bone Joint Surg Am. 2003 May;85-A(5):872-7. Erratum in: J Bone Joint Surg 85A (7):1338, 2003
15. Rose JD, Malay DS, Sorrento DL: Neurosensory testing of the medial calcaneal and medial plantar nerves in patients with plantar heel pain. J Foot Ankle Surg 42 (4):173 – 7, 2003.
16. Ross M. Use of the tissue stress model as a paradigm for developing an examination and management plan for a patient with plantar fasciitis. J Am Podiatr Med Assoc 92(9): 499 – 506, 2002.
17. Schepers T, Heetveld MJ, Mulder PG, Patka P. Clinical outcome scoring of intra-articular calcaneal fractures. J Foot Ankle Surg 47 (3): 213 – 8, 2008.
18. Walther M, Radke S, Kirschner S, Ettl V, Gohlke F. Power doppler findings in plantar fasciitis. Ultrasound Med Biol 30(4): 435 – 40, 2004.
19. Willis B. Effective orthopedic rehab: Seven steps to complete recovery, Chapter I, 10 – 15, Trafford publishing, Victoria BC, Canada, 2003.


Address correspondence to: Texas State University, Health Physical Education and Recreation, San Marcos, TX (at the time of this study)
Email: BuckPhD@yahoo.com

1 Dynasplint Systems, Inc. PO Box 92135 Austin, TX 78709. (512) 297-1833
2 Lopez Podiatry; Ft Worth, Texas 910 W North Side Dr Ft Worth, TX 76164. (817) 625-1103 .Dralldpm@aol.com
3 Orlando Foot and Ankle Clinic; Orlando, FL 3670 Maguire Boulevard, Suite 220 Orlando, FL 32803. (407) 423-1234 AnPerez63@hotmail.com
4 Kaiser Permanente, Musculoskeletal Services; Sacramento, CA 2025 Morse Avenue Sacramento, CA 95825. (916) 973-5899 larry.sheridan@kp.org
5 Atlanta Foot and Leg Clinic; Jonesboro, GA 6911 Tara Boulevard, Suite #104 Jonesboro, GA 30236 (770) 477-9535 Srkalish@bellsouth.net

© The Foot and Ankle Online Journal, 2009

Prevalence of Equinus in Patients Diagnosed with Plantar Fasciitis

by EM Wenzel, MT(ASCP), DPM1, Z Kajgana , DPM1, KD Kelley, DPM2 , KM Mason DPM, C Ped3,
JS Wrobel, DPM4, MS, DG Armstrong DPM, PhD5,6

The Foot and Ankle Online Journal 2 (3): 1

Background: Plantar fasciitis is one of the most common complaints seen in podiatric practice. Typically, the diagnosis is made based on clinical presentation and patient history. Biomechanics is believed to also contribute to the onset of this condition through a decreased ankle joint range of motion.
Methods: The design was a retrospective case-control study of patients with plantar fasciitis (n = 23) and a control group (n = 54). Medical records from the Scholl Foot Clinic at Rosalind Franklin University were abstracted for measurements for ankle joint dorsiflexion with the knee extended and flexed along with other patient variables.
Results: Patients diagnosed with plantar fasciitis did not have a significant decrease in ankle joint dorsiflexion (p = 0.8979). A significantly higher body mass index (BMI) was noted in patients diagnosed with plantar fasciitis as compared to the control group (34 +/- 7.99 v. 29 +/-5.81; p = 0.0046). Increased plantar fasciitis was also noted in cavus foot structure (p = 0.0323) and in women (p = 0.0147 for left and p = 0.0250 for right).
Conclusions: An increased BMI, cavus foot structure, and female gender were found to be associated with a diagnosis of plantar fasciitis.

Key words: Plantar fasciitis, cavus foot, BMI.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: February, 2009
Published: March, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0203.0001


Previous research has estimated that approximately two million Americans are annually affected by plantar fasciitis [1] and it is further estimated that up to 25% of all foot injuries are due to plantar fasciitis. [2]

Plantar fasciitis, the inflammation of the plantar aponeurosis (most often of the central portion), is commonly responsible for the symptoms of the heel, midfoot and forefoot pain. [1,3,4] Its diagnosis is usually made solely on history and physical examination despite the etiology of being poorly understood. [5,6]

It has been hypothesized that anatomical, biomechanical and environmental factors may influence the inflammation of the plantar aponeurosis. [7] Anatomical factors include weight, tarsal coalition, and fat atrophy, where as biomechanical and environmental factors include tight Achilles tendon and poor footwear or walking barefoot respectively. [8]

Furthermore, a plantarflexed ankle joint allows for the contraction of the fascial tissue which is stretched during the midstance possibly causing microtears which induce a reparative inflammatory response. [6] This latter consideration has led us to believe that the chief etiology might indeed be of a biomechanical nature (i.e. tight Achilles tendon), since a majority of runners have a tight Achilles tendon which leads to the plantarflexed ankle. [6]

Values for dorsiflexion of the ankle joint vary in the literature significantly and range from 0 degrees to 25 degrees.9 However, for the purpose of this study it was necessary to classify the minimum amount of motion that must occur at the ankle joint for a patient to be classified as having normal ankle joint range of motion and those with less being classified as having an equinus. While it has been found that static measures and dynamic measures are not well correlated, the most widely accepted values in the literature for static measurements, and for the purpose of this study, state that the minimum amount of dorsiflexion necessary at the ankle for the normal gait is 10 degrees of motion. [10,11,12,13,14,15]

We hypothesized that patients complaining of plantar fasciitis would have an increased incidence of equinus deformity as compared to a control group of patients who do not complain of symptoms relating to plantar fasciitis and who had no previous history of a plantar fasciitis diagnosis.

Methods

A retrospective study of patient records was performed at the Rosalind Franklin Student Clinics. The study protocol and procedures were approved by the University’s Institutional Review Board. Consecutive records from the archives were pulled from podiatric patients with a diagnosis code of plantar fasciitis, beginning before and up to March 3rd, 2005 resulting in 48 patient records. These were selected for review based upon complete record of the following criteria: age, height, weight, occupation, typical shoe gear, what elicited pain for the patient, whether radiographs were obtained and the findings, bilateral ankle joint range of motion (knee extended and flexed) and foot structure. Any chart with incomplete or missing data according to the criteria previously set forth was excluded resulting in a patient population of 23 (17 women and 6 men) with a mean ± standard deviation (SD) age of 49 ± 11 years (range 25 to 69 years).

A control group was formed from consecutive patient charts without a diagnosis code of plantar fasciitis or history of ankle joint trauma. These charts were reviewed and included upon complete notation of the following criteria: age, height, weight, occupation, typical shoe gear, bilateral ankle joint range of motion (knee extended and flexed) and foot structure.

Following chart review and exclusion criteria a group of 54 patients was formed to serve as the control group with a mean age of 49 ± 11 years (range 18 to 68 years).

Data analysis was performed using STATA (version 9.1, College Station, TX) to determine whether a significant difference existed in the prevalence of equinus between the plantar fasciitis group and the control group. Other variables were also analyzed to determine the interrelationship with plantar fasciitis including BMI, gender, shoe gear, foot structure, and occupation. For continuous predictor variables one-way analysis of variance (ANOVA) with Bartlett’s test for equal variance was used. For categorical predictor variables ANOVA with Scheffe’s Post Hoc test was utilized. For dichotomous predictor variables Fisher’s exact test was used.

Results

While a trend towards plantar fasciitis patients having decreased ankle dorsiflexion was expected, these findings were not significant (p = 0.8979) (Figs. 1 and 2).

Figure 1  Box Plot for Degrees of Dorsiflexion Knee Extended.

Figure 2  Box Plot for Dorsiflexion Knee Flexed.

Mean dorsiflexion ± SD of the left ankle was found to be -1.91 ± 7.44 with the knee extended and 5.96 ± 7.85 with the knee flexed. For the right ankle these values were -1.74 ± 6.12 knee extended and 6.57 ± 7.19 knee flexed (Table 1).

A significant difference was found to exist between the control group and the plantar fasciitis group in BMI (p = 0.0046); those being diagnosed with plantar fasciitis having an increase in BMI. (Fig. 3)

Figure 3  Box Plot for BMI.

A similar trend in respect to weight (p = 0.0394) was also noted. An increased incidence of plantar fasciitis was found in those patients with a cavus foot structure (p = 0.0323). An increase in plantar fasciitis was found in women (p = 0.0147 for left and p = 0.0250 for right) (Table 2). No correlation between the patients with plantar fasciitis and their occupation, shoe gear or age was found.

Discussion

In this retrospective study patients with equinus were in fact not found to have a significant difference in the formation of plantar fasciitis (p=0.8979) (Figures 1,2). A trend was noted in increased gastroc-soleal (32% greater) and gastrocnemius equinus (20% increase) as compared to the control group. Despite these trends a statistical significance was not found to exist disproving our initial hypothesis.

The etiology of equinus deformity has spawned much research into determining its associated causes and complications. Some that have been more anecdotal include increased weight, age, foot structure, sex, occupation, or poor shoe gear. Another theory has been that if an ankle joint that is already compromised by an abnormally limited range of motion, as in equinus formation, is then subjected to unusual stress or exertion, such as repetitive daily trauma to the surrounding structures, conditions such as plantar fasciitis are a probable result. [6]

Although its link to plantar fasciitis may seem obvious, there are few articles that directly state or have adequate statistical value to prove the link. Riddle, et al., state that equinus, BMI, and work related weightbearing are the most relevant risk factors in predicting plantar fasciitis. [1] However, in their more recent article on the same topic they state BMI as being the only contributory variable for a reduced Lower Extremity Functional Score. [16]

Other authors such as Warren found a higher incidence of equinus in those patients who had not had symptoms of plantar fasciitis. [17]

As obesity is an often cited cause of plantar fasciitis the weight and BMI calculations of the plantar fasciitis group were compared to the control group. [1] This was performed using the Centers for Disease Control and Prevention (CDC) guidelines for calculation and categorization: normal (BMI <25), overweight (25-<32), obese (32-<36), grossly obese (36-<40), and morbidly obese (greater than 40) based on the patient’s height and weight. [18] Data analysis revealed a significant difference existed between the two groups (p=0.0046) for BMI and also for weight (p=0.0394) supporting the theory that BMI and weight are predictive for the development of plantar fasciitis. (Fig. 3)

Gender has long been thought to play a role in the development of plantar fasciitis and women are considered to be the group most often affected with plantar fasciitis. [6]

Although this can be attributed to shoe gear difference when compared to the control group, a trend that did not reach significance could be seen in a larger number of women being afflicted with plantar fasciitis than the more evenly distributed gender of the control group (74% compared to 59%). This study revealed that women had a significant decrease in ankle joint dorsiflexion with the knee extended (p = 0.0147 for left and p = 0.0250 for right). The shoe gear of men versus women was analyzed and no significant finding could be noted. This supports the theory that decreased ankle joint dorsiflexion might be another contributory factor in plantar fasciitis development in women.

Foot structure is commonly noted a predictive factor in the formation of plantar fasciitis, pes planus being more susceptible to its formation. [7,8] In this study it was found that pes cavus feet actually had an increased incidence of plantar fasciitis than pes planus feet (p = 0.0323). Other factors such as age, occupation, and shoe gear were analyzed and no significant finding could be noted in the formation of plantar fasciitis.

There are several primary limitations for this study. First, since research was collected from previous medical chart data that was documented by students, there is a potential for evaluator variability. It is safe to assume that the ankle joint ranges of motion measurements for each patient were not done by the same person and there is a potential for differing amounts of force applied during dorsiflexion exam. [8] Since the students taking the measurements were supervised by experienced clinicians, any gross errors or miscalculations are less likely. Furthermore, Martin and McPoil state that in ankle dorsiflexion measurements, interrater reliability can be expected. [19]

Because patients self report their height and weight there is a potential under or overestimation of the BMI. Recent research however has shown that underestimation is more likely than overestimation in self reported groups. [20] This study was also limited by lack of consistent detail provided by the medical charts this study required, therefore resulting in a reduction in sample size from the initial group of patients diagnosed with plantar fasciitis. However, a larger sample size may have provided the power to detect differences in ankle joint dorsiflexion. A limitation related to the data analysis is that this study used the foot as a unit and rather than using a clustered analysis of feet.

Conclusion

The authors hypothesized that a greater incidence of equinus deformity could be found among patients with plantar fasciitis than in those without history of plantar fasciitis. Upon examination of the data it was found that this initial hypothesis could not be supported by the analysis. Females diagnosed with plantar fasciitis were found to have to have a significant decrease in ankle joint dorsiflexion with the knee extended. An increased BMI and weight as well as a cavus foot structure were the only variables that showed a significant increase among all patients diagnosed with plantar fasciitis as compared to the control group. Other variables such as occupation, age, and shoe gear were not found to be of statistical significance when compared to a control group.

The results of this study suggest that weight loss should be utilized as a primary conservative treatment for patients diagnosed with plantar fasciitis who have a higher than normal BMI and weight before surgical alternatives are employed. Further prospective study with a larger patient population is warranted ensuring consistent charting and including clinically measured height and weight data.

References

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Address correspondence to: KD Kelly, DPM PGY-2 resident in Podiatric Medicine and Surgery at the Central Alabama Veterans Health Care System in Montgomery, Alabama.
E-mail: Kristin.Kelley@va.gov

PGY-II Podiatry Resident, Forum Health/Western Reserve Care System Podiatric Residency Program
PGY-II Chief Podiatry Resident, Central Alabama Veterans’ Health Care System
Chair, Department of Biomechanics and Orthopedics
Director, Outcomes Research, Center for Lower Extremity and Ambulatory, CLEAR
Chair, Research; Assistant Dean; Professor of Surgery
Director, Center for Lower Extremity and Ambulatory Research, CLEAR

© The Foot and Ankle Online Journal, 2009