Steroid injection for inferior heel pain: a randomised controlled trial.

BACKGROUND: Plantar fasciitis is a common cause of heel pain. The aim of this study was twofold: to compare steroid injection with placebo injection and to compare ultrasound guided with unguided steroid injection in the management of this condition. METHODS: 65 patients with inferior heel pain were recruited between November 2008 and June 2011. Heel pain was measured using a visual analogue scale (VAS) at baseline and follow-up 6 and 12 weeks after injection. RESULTS: 22 patients were randomised to ultrasound guided steroid injection, 21 patients to palpation guided steroid injection and 22 to ultrasound guided placebo injection. There was a significant difference in VAS scores between the groups at 6 and 12 weeks (p=0.018 and p=0.004, respectively). There was a 19.7 (95% CI 2.5 to 37.0) difference in mean VAS scores at 6 weeks between the ultrasound guided steroid group and the placebo group and a 24.0 (95% CI 6.6 to 41.3) difference between the unguided steroid group and the placebo group at 6 weeks. At 12 weeks, the mean difference was 25.1 (95% CI 6.5 to 43.6) and 28.4 (95% CI 11.1 to 45.7) respectively between both steroid injection groups and the placebo group. There was no difference in VAS scores following steroid injection between the ultrasound guided and the unguided groups at either time point. Plantar fascia thickness was significantly reduced after injection in both active treatment groups (p=0.00). CONCLUSIONS: In this study, steroid injection showed a clear benefit over placebo at 6 weeks and this difference was maintained at 12 weeks. Trial Registration No ISRCTN79628180 (www.controlled-trials.com).

The Belfast musculoskeletal ultrasound course.

OBJECTIVES: To conduct a training course in musculoskeletal ultrasound (MSUS) for rheumatologists in Northern Ireland with the aim of equipping the participants with a basic knowledge of the theoretical and practical aspects of MSUS as they are applied to rheumatology. METHODS: Between September 2007 and June 2008, 10 rheumatologists attended a course in basic MSUS that was delivered by 7 rheumatologists with experience in MSUS. The course consisted of five separate modules that included tutorials on MSUS, self-directed learning of scanning techniques and personal mentoring. Progress was monitored throughout the course by the use of personal logbooks. Competency was formally assessed using the Royal College of Physicians' Direct Operational Procedural Skills (DOPS) assessment and an exit examination. RESULTS: Five trainees completed the entire course and passed both the practical and written elements of the exit examination. All were deemed to have attained a basic level of competency in MSUS. The main obstacle to completion of the course was a lack of scanning practice and an inability to complete the required number of scans and DOPS assessments. Participants were more likely to fulfil the requirements of the course if they were employed full time in the regional rheumatology unit where the course was based. All participants reported high levels of confidence in their basic scanning skills at the conclusion of the course. They also felt that the training enhanced their clinical examination skills and their understanding of musculoskeletal anatomy. CONCLUSIONS: A basic MSUS training course can be successfully delivered using a modular design that takes account of the trainee's level of experience and their work schedule. Important elements of such a course should include personal mentoring and the recording of scanning activity using a logbook. Periodic assessment of the trainee's performance is a useful means to motivate learning. Basic training in MSUS should become an accepted part of the routine training of rheumatologists in the UK.

High-resolution ultrasonography of the first metatarsal phalangeal joint in gout: a controlled study.

OBJECTIVE: To compare high-resolution ultrasound (HRUS) with conventional radiography in the detection of erosions in the first metatarsophalangeal joints (1st MTPJs) of patients with gout and to identify the characteristic sonographic features of gout. METHODS: HRUS examination of the 1st MTPJs of both feet was performed by two independent sonographers. The presence of joint and soft-tissue pathology was recorded. x Ray examination of the feet was performed on the same day and reported by the same radiologist. RESULTS: 39 male patients with gout and 22 age-matched control subjects (14 with an inflammatory arthropathy and 8 disease free) were studied. The agreement on erosion between HRUS and x ray was poor, kappa = 0.229 (non-weighted), with McNemar's test being significant (p<0.001) indicating a large number of false negative x rays. 22 MTPJs in patients with gout had never been subjected to a clinical attack of acute gout. In these MTPJs, there were 10 erosions detected by HRUS and 3 erosions on x ray. HRUS features significantly more prevalent in the patients with gout were hard and soft tophus-like lesions (p<0.01) and the double contour sign (p<0.01). CONCLUSIONS: These data show that HRUS may assist in the management of gout in two ways: first, by aiding in the diagnosis by identifying the sonographic features that may be representative of the disease, and, second, by allowing the early detection of erosive joint damage and/or tophaceous deposits even in clinically silent joints.