Cupping with neural glides for the management of peripheral neuropathic plantar foot pain: a case study.

Background/purpose: Plantar foot pain of neural origin is a challenging diagnosis to identify and treat. The purpose of this paper is to illustrate the novel way in which cupping was utilized in conjunction with neural glides to better diagnose and manage a patient who presented with symptoms of peripheral neuropathic plantar foot pain. Case description: A 65-year-old male presented to physical therapy with the diagnosis of plantar fasciitis by an orthopedic surgeon. The presentation included a diffuse area of pain toward the medial border of the foot with a peripheral neuropathic pain description. Cupping was used to identify pain in the saphenous nerve distribution and aided in resolving symptoms with the concomitant use of lower quarter neural glides. Outcome: At discharge and 1-year follow-up, the patient had a full resolution of symptoms and a return to prior level of function. Self-report outcomes included the numeric pain rating scale and the lower extremity functional scale. Discussion: This case is the first to describe the use of cupping combined with neural glides in the diagnosis and management of peripheral neuropathic pain from the saphenous nerve that was previously diagnosed as plantar fasciitis. The proposed mechanisms behind this treatment are also reviewed. Conclusion: In patients that present with symptoms of plantar fasciitis, testing neural glides combined with cupping may be warranted to confirm or refute the presence of a peripheral neuropathic pain source. Further studies are necessary to determine the mechanisms and further utility of the combined interventions in well controlled trials. Level of Evidence: Level IV.

3D printing individualized heel cup for improving the self-reported pain of plantar fasciitis.

BACKGROUND: To explore the therapeutic effect and the biomechanical mechanism of 3D printing individualized heel cup in treating of plantar heel pain. METHODS: The clinical effect was evaluated by plantar pressure analysis and pain assessment in participants. Its biomechanical mechanism of protecting the plantar heel was explored using finite element simulation. RESULTS: The individualized heel cup could support and protect the osseous structure and soft tissue of plantar heel while walking and jogging, as well as significantly reduce the self-reported pain after being worn for 4 weeks. The nylon heel cup could alter the load concentration of the heel as well as decrease the load affected on plantar fascia and calcaneus bone. It also provided an obvious support for heel pad. CONCLUSION: To summarize, the 3D printed individualized heel cup can be used as an effective method for the treatment of plantar heel pain.

Plantar fasciitis: A review of treatments.

Plantar fasciitis is the most common cause of heel pain in the United States. Many treatments are available and differ in efficacy and cost. This article discusses the theorized causes for plantar fasciitis and various treatments.

The plantar calcaneal spur: a review of anatomy, histology, etiology and key associations.

The plantar calcaneal spur (PCS) is a bony outgrowth from the calcaneal tuberosity and has been studied using various methods including cadavers, radiography, histology and surgery. However, there are currently a number of discrepancies in the literature regarding the anatomical relations, histological descriptions and clinical associations of PCS. Historically, authors have described the intrinsic muscles of the foot and/or the plantar fascia as attaching to the PCS. In this article we review the relationship between the PCS and surrounding soft tissues as well as examining the histology of the PCS. We identify a number of key associations with PCS, including age, weight, gender, arthritides, plantar fasciitis and foot position; these factors may function as risk factors in PCS formation. The etiology of these spurs is a contentious issue and it has been explained through a number of theories including the degenerative, inflammatory, traction, repetitive trauma, bone-formers and vertical compression theories. We review these and finish by looking clinically at the evidence that PCS causes heel pain.

Analysis of Pressure Pain Hypersensitivity, Ultrasound Image, and Quality of Life in Patients with Chronic Plantar Pain: A Preliminary Study.

OBJECTIVES: To evaluate widespread pressure pain in patients with chronic plantar heel pain compared with that in healthy controls and to investigate the differences in ultrasound imaging and quality of life between these two groups. METHODS: A total of 22 patients (11 female) with chronic plantar heel pain and the same number of healthy patients, matched according to age and gender, were included in this pilot study. Pressure pain thresholds (PPTs) were bilaterally assessed over the calcaneus bone, the plantar fascia, the first and fifth metatarsals, the soleus muscle, the second metacarpal, and the zygapophyseal joint of C5-C6. Plantar fascia thickness was measured via ultrasound imaging. In addition, quality of life and physical function were assessed using the Short-Form 36 (SF-36) questionnaire and the Foot and Ankle Ability Measure (FAAM) questionnaire, respectively. RESULTS: Analysis of covariance (ANCOVA) results showed significant differences in the PPTs at all points between the groups (P < 0.001), but not between sides. The PPTs were significantly lower in the patients than in the controls at all sites (P < 0.05). The results showed significant increases in fascia thickness at the calcaneus insertion (group: F = 74.172, P ≤ 0.001; side: F = 8.920, P ≤ 0.001) and the middle fascia point (group: F = 133.685, P = <0.001; side: F = 11.414, P = <0.001) on ultrasound in the patient group compared with the matched control group. The analysis also revealed that the patient group had a significantly lower score on every subscale of the SF-36 and FAAM questionnaires (all P < 0.001), except for the mental component, compared with the matched control group. DISCUSSION: Patients suffering from chronic plantar heel pain showed widespread and bilateral hypersensitivity, increased thickness of the plantar fascia in the affected foot, and deterioration in quality of life and physical functioning compared with matched controls.

Classification of Calcaneal Spurs and Their Relationship With Plantar Fasciitis.

Calcaneal spurs, as a cause of plantar fasciitis, are currently debatable. A prospective study was performed to classify calcaneal spurs according to the findings from an investigation of the relationship between calcaneal spurs and plantar fasciitis. Thirty patients with calcaneal spurs and plantar heel pain underwent calcaneal spur removal and endoscopic plantar fasciotomy. The relationship between the classification of calcaneal spurs and plantar fasciitis was evaluated by endoscopic findings, clinical symptoms, radiographic images, and biopsy findings. The visual analog scale for pain and the American Orthopedic Foot and Ankle Society ankle-hindfoot scores for functional evaluation were used preoperatively and postoperatively, respectively. The mean follow-up period was 24 months. Two separate types of calcaneal spurs were recognized. Type A calcaneal spurs were located superior to the plantar fascia insertion, and type B calcaneal spurs were located within the plantar fascia. Magnetic resonance imaging results showed a more severe plantar fasciitis grade in type B calcaneal spurs preoperatively. Histologic examination showed that the numbers of granulocytes per image in type B spurs were significantly increased compared with those in type A spurs. Statistically significant improvements were found in the mean visual analog scale and American Orthopedic Foot and Ankle Society scores and magnetic resonance imaging results in both groups. The amount of change in the visual analog scale score and American Orthopedic Foot and Ankle Society score, the number of granulocytes per image, and calcaneal spur length showed a high association with the classification of the calcaneal spurs. Calcaneal spurs were completely removed and did not recur in any of the patients on radiographic assessment during the follow-up period. Calcaneal spurs can be classified into 2 distinct types that are indicative of the severity of plantar fasciitis.

Correlation between the outcome of extracorporeal shockwave therapy and pretreatment MRI findings for chronic plantar fasciitis.

BACKGROUND: The purpose of this study was to investigate the relationship between magnetic resonance imaging (MRI) findings before extracorporeal shockwave therapy (ESWT) and the treatment outcome of ESWT. METHODS: This study examined 50 feet with chronic plantar fasciitis. The scores before ESWT and after a six-month follow-up were investigated using the Japanese Society for Surgery of the Foot (JSSF) Ankle-Hindfoot Scale and the Visual Analog Scale (VAS). MRI before ESWT was used for image evaluation. MRI revealed thickening of the plantar fascia (PF), and an investigation was conducted regarding the findings of a high-signal-intensity area (HSIA) inside the PF, edema near the PF, and bone marrow edema (BME) of the calcaneus. RESULTS: The average JSSF score and VAS score improved significantly at follow-up. In total, 44 feet were noted in the improved group. MRI revealed that the average amounts of PF thickening did not significantly differ between the improved group and the non-improved group. HSIA, edema near the PF, and BME were observed in 36, 41, and 11 feet in the improved group, respectively; and 2, 4, and 2 feet in the non-improved group, respectively. CONCLUSIONS: An HSIA in the PF predicted symptom improvement more easily than other MRI findings. LEVEL OF EVIDENCE: IV.

Primary Care Management of Plantar Fasciitis.

Plantar fasciitis (PF) is present in 10% of the population and is the most common cause of plantar heel pain. PF is painful, can alter daily activities and presents as a sharp pain localized to the plantar foot and medial heel. The underlying etiology involves microtrauma to the plantar fascia, specifically at its insertion point on the calcaneus. Successful management of plantar fasciitis is typically achieved with the conservative therapy approaches discussed.

Overuse injuries of the foot: imaging presentations of common pathologies.

Overuse injuries of the foot are common, resulting in frequent visits to the primary care physician and orthopaedic surgeon. Radiologic workup often ensues. Morton's neuroma, plantar fasciitis and Haglund's syndrome are three such entities with classic MRI appearances.

Platelet-rich plasma application in the management of chronic tendinopathies.

Platelet-rich plasma (PRP) may represent a new therapeutic option for chronic tendinopathies. Platelets release various cytokines and growth factors which promote angiogenesis, tissue remodeling, and wound healing. We made an extended literature review of the use of PRP in chronic tendinopathies: epicondylitis, rotator cuff, patellar and calcaneal tendinopathies, and plantar fasciitis. Medline, Embase and Google Scholar were used (until July 31, 2012). Clinical studies on PRP and tendinopathies published in English and French language peer-reviewed journals were included. Articles with a high level of evidence were given special consideration. Despite the proven efficacy of PRP on tissue regeneration in experimental studies, there is currently scanty tangible clinical evidence with respect to its efficacy in chronic tendon disorders. The few studies that have been performed appear unlikely to be comparable. Randomized controlled studies with appropriate placebo groups are needed to determine the real effectiveness of PRP for treating chronic musculoskeletal injuries.

Anatomical features of plantar fasciitis in various age cohorts: Based on magnetic resonance imaging.

BACKGROUND: Due to the lack of further studies on the influence of age factors on plantar fasciitis, this study evaluates the characteristic observation points of magnetic resonance imaging in various age cohorts of patients with plantar fasciitis to help diagnosis. METHODS: A retrospective analysis of 160 cases of plantar fasciitis patients and normal subjects (who have the disease unrelated to plantar fasciitis) who have undergone an MRI examination in our institution. The two groups were separately divided into young adult subjects (36 to 44 years old), middle age adult subjects (45 to 59 years old), and older adult subjects (60 to 79 years old). Data was gathered regarding plantar fascia thickness, the coronal length of the plantar fascia at the calcaneal origin, the signal intensity of plantar fascia and surrounding structures, and the presence or absence of plantar calcaneal spurs, all of which were assessed objectively by the investigators. RESULTS: There were statistical differences in the thickness of plantar fascia between two groups of three age cohorts (Older adult patients: 0.59 ± 0.09 cm; Middle age adult patients: 0.49 ± 0.09 cm; Young adult patients: 0.47 ± 0.05 cm) (all p < 0.001). In addition, there were also statistical differences in the high signal intensity changes of the plantar fascia and surrounding soft tissues between two groups of three age cohorts (all p < 0.001). In older adult plantar fasciitis patients, with regard to plantar calcaneal spur discovery, there was a statistical difference between the two groups (Chi-square = 12.799. df = 1. p < 0.001). CONCLUSION: In plantar fasciitis cases where a diagnosis is difficult, abnormalities in the soft tissue surrounding the plantar fascia in patients of low age are noteworthy. In older adult patients, the discovery of plantar calcaneal spurs with abnormal thickening of plantar fascia deserves attention, and abnormal MRI findings are more manifest. But the final diagnosis should be based on the medical history. LEVEL OF EVIDENCE: Level 3.

3-Tesla magnetic resonance imaging evaluation of posterior tibial tendon dysfunction with relevance to clinical staging.

The posterior tibial tendon (PTT) is the most important dynamic stabilizer of the medial ankle and longitudinal arch of the foot. PTT dysfunction is a degenerative disorder of the tendon, which secondarily involves multiple ligaments, joint capsules, fascia, articulations, and bony structures of the ankle, hindfoot, midfoot, and forefoot. When the tendon progressively attenuates, the patient develops a painful, progressive collapsed flatfoot or pes planovalgus deformity. This comprehensive review illustrates the 3-Tesla magnetic resonance imaging (3T MRI) features of PTT dysfunction. In addition, the reader will gain knowledge of the expected pathologic findings on MRI, as they are related to clinical staging of PTT dysfunction.

Clinical measures of foot posture and ankle joint dorsiflexion do not differ in adults with and without plantar heel pain.

Foot posture and ankle joint dorsiflexion have long been proposed to be risk factors for plantar heel pain, however body mass may be a confounder when investigating these factors. The aim of this study was to determine if clinical measures of foot posture and ankle joint dorsiflexion differ in adults with and without plantar heel pain after accounting for body mass. This was a cross-sectional observational study that compared 50 participants with plantar heel pain to 25 control participants without plantar heel pain who were matched for age, sex and body mass index. Foot posture was assessed using the Foot Posture Index and the Arch Index. Ankle joint dorsiflexion was assessed with a weightbearing lunge test with the knee extended and with the knee flexed. No significant differences (P < 0.05) were found between the groups for foot posture, whether measured with the Foot Posture Index or the Arch Index. Similarly, no significant differences were found in the weightbearing lunge test whether measured with the knee extended or with the knee flexed. Clinical measures of foot posture and ankle joint dorsiflexion do not differ in adults with and without plantar heel pain when body mass is accounted for. Therefore, clinicians should not focus exclusively on foot posture and ankle dorsiflexion and ignore the contribution of overweight or obesity.

Postoperative MR imaging of the foot and ankle: tendon repair, ligament repair, and Morton's neuroma resection.

This review article describes the postoperative magnetic resonance (MR) findings relating to surgery after tendon repair, ligament repair, and Morton's neuroma resection. The normal postoperative tendon is commonly thickened, showing signal changes that are most pronounced 3 to 6 months after surgery. Two years after tendon suture, the signal intensity should be low on T2-weighted images. The focus of the postoperative MR imaging after ankle repair is to detect the normal condition after the various surgical procedures (e.g., Broström, Watson-Jones, Evans, or Chrisman-Snook). The repaired ligament has to be visible, low signal intense on T2-weighted MR images, and the shape should be homogeneous. A high rate (26%) of so-called Morton's neuroma recurrences is seen in asymptomatic individuals after Morton's neuroma resection. Postoperatively, intermetatarsal bursitis MR abnormalities are more commonly encountered in symptomatic intermetatarsal spaces than in asymptomatic intermetatarsal spaces.

Effect of Dextrose Prolotherapy on Pain Intensity, Disability, and Plantar Fascia Thickness in Unilateral Plantar Fasciitis: A Randomized, Controlled, Double-Blind Study.

OBJECTIVE: The aim of the study was to evaluate the efficacy of dextrose prolotherapy in the treatment of chronic resistant plantar fasciitis through comparison with a control group. DESIGN: In this double-blind, randomized, controlled study, the patients were divided into two groups. The prolotherapy group (n = 30) was administered 5 ml of 30% dextrose, 4 ml of saline, and 1 ml of 2% lidocaine mixture (15% dextrose solution) and the control group was given 9 ml of saline and 1 ml of 2% lidocaine mixture twice at a 3-wk interval. During the 15-wk follow-up period, pain intensity was measured using the visual analog scale during activity and at rest. The foot function index was used to measure pain and disability. The plantar fascia thickness was measured by ultrasonography. The measurements were undertaken before treatment and at posttreatment weeks 7 and 15. RESULTS: Improvements in visual analog scale during activity, at rest, foot function index (all subgroups), and plantar fascia thickness measured at the 7th and 15th weeks were significantly higher in the prolotherapy group compared with the control group (P < 0.001). CONCLUSIONS: Dextrose prolotherapy has efficacy up to 15 wks and can be used as an alternative method in the treatment of chronic resistant plantar fasciitis.

The Relationship between Calcaneal Spur Type and Plantar Fasciitis in Chinese Population.

Plantar heel pain is a common disease with a high incidence in different races. It significantly reduced the quality of life of patients. However, the cause of PHP is still controversial and there were varieties of physiological factors associated with PHP. The most common pathological factor in the population was plantar fasciitis. Some existing research studies had found a correlation between calcaneal spurs and plantar fasciitis, and this study had found the correlation in Chinese population. It is invaluable not only to understand the relationship between different types of plantar calcaneal spurs and plantar fasciitis but also to identify the most appropriate treatment strategies. A total of 71 patients with calcaneal spurs were chosen from the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University. All 71 patients had completed X-rays and MRI scans; then, surgeons had removed their plantar calcaneal spurs. After surgery, all patients were followed up for 12 months; their prognosis was tested by the VAS and AOFAS scores. Type II (29, 40.8%) had the highest incidence in Chinese population, followed with type I (24, 33.8%) and type III (18, 25.4%). Preoperative VAS scores showed that type II (7.72 ± 1.10) was significantly higher than the other two types (P < 0.001). Postoperative VAS scores of type II were higher than those of type I and type III (P < 0.001). Postoperative AOFAS scores of type II were the lowest (P < 0.001). Researchers had proved that type II was more likely to cause PF.

A Radiographic Study of Biomechanical Relationship between the Achilles Tendon and Plantar Fascia.

BACKGROUND: Previously, scholars have concluded that the Achilles tendon and the plantar fascia were closely biomechanically related, although there is little clinical evidence of the relationship between the two. To investigate the biomechanical relationship between the Achilles tendon and the plantar fascia, the author used standing lateral ankle radiographs of patients with insertional Achilles tendonitis to determine the biomechanical relationship between the Achilles tendon and plantar fascia. METHODS: The author collected standing lateral ankle radiographs from patients with insertional Achilles tendonitis who accepted surgical treatment in the author's hospital from March 2009 to July 2018. According to whether there were bone spurs on the posterior side of the calcaneus, patients were divided into group A (spur present on the posterior side) and group B (spur not present on the posterior side). The positive rates of spurs on the plantar side of the calcaneus were determined in group A and group B. The chi-square test was used to compare the measurement results between the two groups. RESULTS: In group A, 13 heels were positive for calcaneal bone spurs, and the positive rate was 65.0%. In group B, 3 heels were positive for plantar calcaneal spurs, and the positive rate was 12%. Among all 16 patients with positive plantar calcaneal spurs, 13 had posterior calcaneal spurs (accounting for 81.3%), and 3 had negative results, accounting for 18.7%. There was a significant difference between the results in groups A and B (P < 0.05). CONCLUSION: There is a relationship between posterior calcaneal spurs and plantar calcaneal spurs in patients with insertional Achilles tendonitis, which can be inferred as resulting from the increasing tension in the biomechanically complex relationship between the Achilles tendon and the plantar fascia.

Biomechanical and anatomic factors associated with a history of plantar fasciitis in female runners.

OBJECTIVE: To compare selected structural and biomechanical factors between female runners with a history of plantar fasciitis and healthy control subjects. DESIGN: Cross-sectional. SETTING: University of Delaware Motion Analysis Laboratory, Newark, Delaware; and University of Massachusetts Biomechanics Laboratory, Amherst, Massachusetts. PARTICIPANTS: Twenty-five female runners with a history of plantar fasciitis were recruited for this study. A group of 25 age- and mileage-matched runners with no history of plantar fasciitis served as control subjects. INTERVENTIONS: The independent variable was whether or not subjects had a history of plantar fasciitis. MAIN OUTCOME MEASURES: Subjects ran overground while kinematic and kinetic data were recorded using a motion capture system and force plate. Rearfoot kinematic variables of interest included peak dorsiflexion, peak eversion, time to peak eversion along with eversion excursion. Vertical ground reaction force variables included impact peak and the maximum instantaneous load rate. Structural measures were taken for calcaneal valgus and arch index during standing and passive ankle dorsiflexion range of motion. RESULTS: A significantly greater maximum instantaneous load rate was found in the plantar fasciitis group along with an increased ankle dorsiflexion range of motion compared with the control group. The plantar fasciitis group had a lower arch index compared with control subjects, but calcaneal valgus was similar between groups. No differences in rearfoot kinematics were found between groups. CONCLUSION: These data indicate that a history of plantar fasciitis in runners may be associated with greater vertical ground reaction force load rates and a lower medial longitudinal arch of the foot.

Comparison of ultrasound-, palpation-, and scintigraphy-guided steroid injections in the treatment of plantar fasciitis.

BACKGROUND: The aim of the study was to compare the efficacies of steroid injections guided by scintigraphy, ultrasonography, and palpation in plantar fasciitis. METHODS: A total of 35 heels of 27 patients were randomly assigned to three steroid injection groups: palpation-guided (pg), ultrasound-guided (ug), and scintigraphy-guided (sg). Patients were evaluated for pain intensity before the injections and at the last follow-up of 25.3 months with a 100-mm visual analog scale (VAS). RESULTS: There were significant improvements in plantar fascia thickness, fat pad thickness, and VAS. Among the three groups of ug-pg, ug-sg, and pg-sg there were no statistically significant differences after treatment (P = 0.017, MWU = 36.5; P = 0.023, MWU = 29.5; and P = 0.006, MWU = 13, respectively). CONCLUSIONS: The ug, pg, and sg injections were effective in the conservative treatment of plantar fasciitis. We are of the opinion that steroid injections should be performed, preferably with palpation or ultrasonographic guidance.

Radial extracorporeal shock wave device appearance does not influence clinical outcomes: A randomized controlled trial.

OBJECTIVE: To determine whether the appearance of a radial extracorporeal shock wave device affects clinical outcomes in chronic plantar fasciitis. STUDY DESIGN: Randomized controlled parallel assessor-blinded clinical trial. MATERIAL AND METHODS: A total of 135 patients were assigned to 3 groups: group I, standard radial extracorporeal shock wave device; group II, standard radial extracorporeal shock wave device modified to give a more sophisticated appearance; group III, standard radial extracorporeal shock wave device modified to give a more austere appearance. The radial extracorporeal shock waves emitted by the 3 devices were identical. Primary outcome was foot function, measured with the Foot Function Index. Secondary outcomes were pain at different times, measured with a visual analogue scale, and plantar fascia thickness, measured with ultrasound. RESULTS: All variables decreased significantly from baseline assessment, in all 3 groups and at all time-points: 1, 2, 4 and 14 months after the last session (p < 0.001). There were no significant differences between groups for any of the variables assessed. CONCLUSION: Device appearance had no statistically significant influence on clinical outcomes in patients with chronic plantar fasciitis treated with radial extracorporeal shock wave therapy.