Just to add to my last post.
I saw a patient today who I think illustrates benefits of using Diagnostic ultrasound exam in decision making for plantar heel pain.
It may interest those not using high res Diagnostic ultrasound and who are considering investing the time and money into this.
I find this one of the most useful diagnostic tools I use for people with MSK injury of foot and ankle and would encourage everyone in our profession to take its potential seriously. I feel that since gaining some competence in interpretation, US has had a big impact in my diagnostic abilities for many of the injuries I exam.
This patient had prior history of plantar heel pain (right foot) only dating from December 06.
Diagnostic ultrasound exam identified both mild degenerative and inflammatory change in Feb 2007 right foot not left .
Pain was not improved with use of foot orthoses after five months. At this point I supplied her with 3Mhz low power therapeutic US machine which she used at home TID for 10 minute sessions followed by tissue specific stretching.
Pain resolved with 4 weeks of revised treatment. There were no significant changes seen with US in thickness but inflammation indicted with power doppler (PDI) was absent.
In September 2008 she returned concerned regarding episodic left foot plantar heel pain, she had not used foot orthoses constantly since last visit but found pain resolved with use.
Today she returned reporting left foot plantar heel pain worsening past six weeks in spite of constant foot orthoses use.
IMAGES;
image 1 anotated.jpg
1 Left foot no pain Oct 07 - sag view - plantar fascia appears normal but large osteophyte deep to insertion of aponeurosis. Thickness measured within normal limits @ 4.5mm.
image 2 anotated.jpg
2 Left foot today, chronic pain – saggital view insertion thickened with slight hypoechoic areas visible
image 3 anotated.jpg
3 Similar view with power doppler (PDI) showing area of intense flow (arrowed) distal to enthesis.
image 4 anotated.jpg
4 Coronal view – slice at tip of enthesis similar evidence of intense flow.
image 5 anotated.jpg
5 Right foot symptomatic Oct 2007 – sag view showing fusiform thickening, slightly hypoechoic, and large osteophytes within and deep to body of aponeurosis. Slight flow was also detected at distal margins of enthesis (not shown here).
6 Right foot asymptomatic currently, note reduction in thickness from 2007 although still above normal limits (2.4 to 4.8mm at widest slice) – no flow with PDI.
This case is unusual and unique for me for 2 reasons; she is one of few pts I have examined with evidence of true fasciitis, (this coincides with only slight of signs of fasciosis seen as hypo-echoicity within fascia); she is the only person who I have examined at 14 months interval showing significant changes corresponding to symptoms on different feet.
What I feel the Diagnostic ultrasound exam identified was;
Initial right foot pain was possibly inflammatory rather than purely effects of degeneration. Right foot did not respond to foot orthoses (this fits the trend I am noticing of no resolution with foot orthoses when thickness exceeds 8mm).
Immediate post pain resolution thickness measurement was not reduced but evidence of inflammation was. Thickness was however significantly reduced at 14 months and pain continued absent provided foot orthoses used. This was interesting because it is the first comparative measurement I have made at such long interval. When I started using US I used to do comparative exam at 4 to 8 weeks following treatment success (usually foot orthoses custom or prefab) and noticed no significant changes in plantar fascia. I stopped doing this follow up exam with US because the trend seemed unequivocal.
This observation also started to make me think that the foot orthoses effect might not be related to effects on the fascia but possibly protection of parallel musculature. Prior discussions with Kevin Kirby on podarena around the notion of sub-periosteal inflammation associated with the fascia insertion (he believes this based on MRI evidence) remain a possibility though and this is beyond the limits of US to explore.
Also there is evidence of correlation in these images of significant asymmetric symptom improvement and worsening and the morphologic changes seen with US which have been associated with plantar heel pain.
In terms of treatment plan, it gives me instant and useful information to add to history, physical and gait exam.
More ambitiosly, I feel US may provide good information regarding the possibility, over time, of meaningful clinical audit revealing if plantar heel pain, with multifaceted potential causes, may be more accurately sub categorized and treated accordingly.
The lack of specificity which commonly plagues our diagnosis and treatment of plantar heel pain may also be confounding the value of existing studies because the study inclusion criteria could be too broad to be meaningful.
Although some studies use US as a diagnostic inclusion criteria, non that I have seen use PDI to differentiate inflammation from degeneration and non sub divide subjects according to measurement.
Any thoughts?
Cheers
Martin
The St. James Foot Clinic
1749 Portage Ave.
Winnipeg
Manitoba
R3J 0E6
phone [204] 837 FOOT (3668)
fax [204] 774 9918
www.winnipegfootclinic.com
Ultrasound guided dextrose injection for achilles tendonitis & plantar fasciitis
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