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Hyperemia in Plantar Fasciitis Determined by Power Doppler Ultrasound

Hyperemia in Plantar Fasciitis Determined by Power Doppler Ultrasound

[ research report ]

ANDREW M. MCMILLAN, PhD1,2 • KARL B. LANDORF, PhD1,2 • JULIE M. GREGG, PhD3 JASON DE LUCA, DMU3 • MATTHEW P. COTCHETT, BPod(Hons)1,2 • HYLTON B. MENZ, PhD1,2 Hyperemia in Plantar Determined by Power Doppler

lantar fasciitis is characterized by chronic inferior heel and terioration of collagen fibers, increased point tenderness at the calcaneal origin of the plantar . secretion of ground-substance proteins, The condition is exacerbated by weight bearing after periods focal areas of fibroblast proliferation, and increased vascularity.10,22 These find- of rest and typically resolves after 12 months with conservative ings are similar to those reported in the P 5 management. The prevalence of heel pain in the general population literature,11 in which neuro- is estimated to range from 3.6% to 7%,7,9 and has vascular in-growth has been suggested to be a likely pain mechanism.1 been shown to account for 10% of mus- gated. However, a range of tissue changes Within human musculoskeletal tis- culoskeletal conditions affecting the foot at the subcalcaneal have been sues, the close anatomical relationship and ankle.19 demonstrated in patients undergoing between blood vessels and nerves is well The underlying pathology of plantar surgery for longstanding symptoms. The known, and, as a consequence, nerves fasciitis has not been thoroughly investi- most commonly reported features are de- are often described as “accompanying” or “traveling with” their respective blood vessels.2 Accordingly, it is likely that STUDY DESIGN: Cross-sectional observational RESULTS: Hyperemia of the was TT TT neovascularization of connective tissue study. present in 8 of 30 participants with plantar fasciitis in disorders such as plantar fasciitis and OBJECTIVES: To investigate the presence and in 2 of 30 controls. The between-group dif- TT tendinopathy also involves concurrent of hyperemia in plantar fasciitis with ference for hyperemia, using a 4-point scale, was power Doppler ultrasound. statistically significant, with participants with plan- in-growth of nerve fibers, thereby in- tar fasciitis showing increased Doppler ultrasound creasing sensitivity to pain mediators at BACKGROUND: Localized hyperemia is an es- TT signal compared to controls (Mann-Whitney U, P the site of injury. In relation to plantar tablished feature of tendinopathy, suggesting that = .03). However, the majority of participants with fasciitis, although several histological neurovascular in-growth may contribute to - plantar fasciitis with evidence of hyperemia dem- 10,13,14,22 associated pain in some patients. The presence of onstrated very mild color changes, and only 3 were studies have reported evidence abnormal soft tissue vascularity can be assessed found to have moderate or marked hyperemia. of angiogenesis within the plantar fas- with Doppler ultrasound, and a positive finding can cia enthesis, these studies did not utilize assist with targeted treatment plans. However, very CONCLUSION: Mild hyperemia can occur with TT techniques that enabled identification of little is known regarding the presence of hyperemia plantar fasciitis, but most individuals will not ex- in plantar fasciitis and the ability of routine Dop- hibit greater soft tissue vascularity when assessed nerve fibers and, therefore, did not dem- pler ultrasound to identify vascular in-growth in the with routine Doppler ultrasound. Clinicians treating onstrate neural in-growth as a feature of plantar fascia near its proximal insertion. plantar fasciitis should not consider a positive the condition. However, concurrent in- Journal of Orthopaedic & Sports ® Downloaded from www.jospt.org at on August 1, 2014. For personal use only. No other uses without permission. Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved. Doppler signal as essential for diagnosis of the METHODS: This observational study included growth of neural and vascular structures TT condition but, rather, as a feature that may help to 30 participants with plantar fasciitis unrelated to has been shown to occur with Achil- refine the treatment plan for an individual patient. systemic disease and 30 age- and sex-matched les tendinopathy,2,4 J Orthop Sports Phys Ther 2013;43(12):875-880. and, considering controls. Ultrasound examination was performed Epub 11 October 2013. doi:10.2519/jospt.2013.4810 the fundamental relationship between with a 13- to 5-MHz linear transducer, and power tendon and the plantar fascia (both are Doppler images were assessed by 2 blinded TTKEY WORDS: heel pain, imaging, investigators. neovascularization dense, regular connective tissue), it is likely that accompanying nerve fibers are

1Department of Podiatry, Faculty of Health Sciences, La Trobe University, Melbourne, Victoria, Australia. 2Musculoskeletal Research Centre, Faculty of Health Sciences, La Trobe University, Melbourne, Victoria, Australia. 3Southern Cross Medical Imaging, La Trobe University Private Hospital, Bundoora, Victoria, Australia. This project was funded by the Musculoskeletal Research Centre, La Trobe University, Australia. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Dr Andrew McMillan, La Trobe University, Kingsbury Drive, Melbourne, Victoria 3108 Australia. E-mail: [email protected] Copyright ©2013 Journal of Orthopaedic & Sports Physical Therapy® t

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tar fasciitis related to spondyloarthritis reported no evidence of hyperemia in those with plantar fasciitis compared to 24 controls, indicating the need for ad- ditional research in this area. Therefore, the aim of this study was to investigate whether soft tissue hyper- emia is present in plantar fasciitis, using conventional ultrasound techniques. A secondary objective was to investigate changes in plantar fascia thickness, with emphasis on clinically useful diagnostic threshold values. METHODS FIGURE 1. A longitudinal sonogram of the plantar fascia at the calcaneal origin. thical approval for the study also present with neovascularization in In so doing, PDU is not affected by flow- protocol was granted by the La Trobe plantar fasciitis. direction artifacts (eg, aliasing), allowing EUniversity Human Ethics Commit- Doppler ultrasonography involves the a lower pulse-repetition frequency to be tee, and all participants gave written processing of echoes produced by mov- used, which improves sensitivity to slow- informed consent prior to enrollment. ing objects within the scanning field (eg, moving blood within small vessels.12,15 Ultrasound imaging was conducted at blood flow within a vessel). The under- Therefore, PDU has an advantage when the La Trobe University Private Hospital pinning principle is that moving objects assessing musculoskeletal tissues for evi- (Bundoora, Australia) between January reflect the ultrasound pulse at a fre- dence of abnormal vascular perfusion. 2011 and February 2012. quency different from that of the origi- In relation to plantar fasciitis, 1 study23 Participants with plantar fasciitis were nal transmission (known as the Doppler has shown a relationship between inferi- recruited from the local community (by effect), and a frequency shift is thereby or heel pain and hyperemia of the plantar newspaper advertising) and from other detected when the echo is received by fascia, using PDU. In that study, moder- heel-pain projects that had recently the transducer.12 Furthermore, the direc- ate to marked hyperemia was observed in concluded at the university. These par- tion of movement toward or away from 8 of 20 participants with plantar fasciitis, ticipants were required to have a history the transducer is also determined by the compared to no hyperemia in 20 controls of inferior heel pain for at least 8 weeks, nature of the frequency shift, with either (P<.01). These results support the find- with a minimum average pain severity a higher frequency or lower frequency de- ings of histological studies of hyperemia (during the past week) of 20 mm on a tected, respectively.12 The resulting image in plantar fasciitis, and suggest that Dop- 100-mm visual analog scale. Plantar fas- produced demonstrates these frequency pler ultrasound assessment should be ciitis was confirmed by ultrasound assess- shifts by assigning colors to the corre- considered when imaging patients with ment and considered present when the sponding display pixels, coded according inferior heel pain. However, that study plantar fascia was 4.0 mm or greater at to the direction and velocity of movement was susceptible to bias due to method- the calcaneal origin.16 Exclusion criteria (ie, moving objects are represented by ological limitations. For example, the for case participants included corticoste- Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at on August 1, 2014. For personal use only. No other uses without permission. Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved. color images).12 PDU image assessor was not blinded, and roid injection of the heel within the past In addition to color Doppler, a varia- control participants were not matched 3 months, posterior heel pain, systemic tion in Doppler-shift processing, known for age and sex. Considering these fac- inflammatory disease, , and a as power Doppler ultrasound (PDU), tors, it is possible that the presence of history of local surgery. Participants with can be undertaken to improve sensitiv- hyperemia in the plantar fasciitis group bilateral heel pain had only the most se- ity to slow blood flow and flow within might have been overestimated, and that verely affected foot scanned. Age- (3 very small or deep vessels.12 Rather than between-group differences in participant years) and sex-matched controls were color-encoding the frequency shift ac- characteristics (eg, there were twice as recruited by local newspaper advertise- cording to velocity and flow direction, many males in the control group) might ments and from the university campus. this process determines the power (or have influenced the study findings. Fur- These participants were required to have strength) of the Doppler shift according thermore, a recent study8 involving PDU no history of inferior heel pain within 5 to the concentration of moving objects.12 assessment of 9 participants with plan- years preceding enrollment, and were ex-

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43-12 McMillan.indd 876 11/18/2013 3:20:02 PM cluded if they had diabetes, systemic in- Participant Characteristics flammatory disease, or a history of local TABLE surgery/trauma. One foot for each con- and Ultrasound Findings* trol participant was randomly selected by using a computer-generated random Variable PF Control number sequence. Participants, n 30 30 Ultrasound examination was under- Age, y 57  10 57  10 taken with participants lying prone, with Women, n (%) 15 (50) 15 (50) their extended and feet resting Body mass index, kg/m2 31  5 29  4 over the edge of an examination table.16 Symptom duration, mo 16  14 NA All ultrasound images used for assess- Participants with symptom duration of 6 mo or less, n (%) 9 (30) NA ment were obtained in the sagittal plane. Pain on 100-mm VAS 55  23 NA Plantar fascia thickness was measured Plantar fascia thickness, mm 6.4  1.3 3.8  0.8 at a standard location, where the fascia Plantar fascia thickness of 4.0 mm or greater, n (%) 30 (100) 9 (30) crosses the anterior aspect of the inferior Negative for hyperemia (grade 1), n (%) 22 (73) 28 (93) calcaneal border (FIGURE 1).16 This mea- Grade 2 hyperemia, n (%) 5 (17) 2 (7) surement technique was performed with Grade 3 hyperemia, n (%) 2 (7) 0 Sante DICOM Editor Version 3.1.20 soft- Grade 4 hyperemia, n (%) 1 (3) 0 ware (Santesoft Ltd, Athens, Greece) and Positive for hyperemia (grade 2 or above), n (%) 8 (27) 2 (7) has been shown to have good intrarater Abbreviations: NA, not applicable; PF, plantar fasciitis; VAS, visual analog scale. reliability (95% limits of agreement: 0.5, *Values are mean  SD unless otherwise indicated. –0.7 mm).24 Assessment of the PDU signal within pulse-repetition frequency of 781 Hz, al- RESULTS the proximal plantar fascia was per- though 5 participants were assessed with formed by 2 blinded podiatrists (K.B.L. a higher pulse-repetition frequency (977 total of 30 participants with and H.B.M.) with substantial experience Hz) to reduce flash artifact.25 Doppler plantar fasciitis unrelated to sys- in assessing soft tissue images of the foot gain was optimized by manual elevation A temic disease and 30 age- and sex- and ankle. A 4-point ordinal scale was until the first indication of color (repre- matched controls (60 participants total) used to grade the presence of hyperemia, senting background noise) began to ap- were recruited (TABLE). All participants as originally proposed by Newman et al20 pear at the calcaneal enthesis or proximal with clinically evident plantar fasciitis and further described by Walther et al23 plantar fascia.23 The sonographers were had a plantar fascia thickness of 4.0 mm specifically for plantar fasciitis, on which aware of clinical history (ie, plantar fas- or greater (ie, no potential participant 1 represented normal tissue perfusion, 2 ciitis or not) during assessments. was excluded based on sonographic mea- mild hyperemia, 3 moderate hyperemia, The between-group difference for the surement of plantar fascia thickness). and 4 marked hyperemia with a conflu- extent of hyperemia (ordinal data) was Hyperemia of the plantar fascia was ent surrounding vascular blush. This analyzed by the Mann-Whitney U test. present in 8 of 30 participants with grading scale was recently shown to Correlations between the extent of hyper- plantar fasciitis and in 2 of 30 control have good correlation with a computer- emia, duration of symptoms, and pain se- participants (TABLE). The between- ized method that quantified tissue vas- verity were analyzed with Spearman rho. group difference for hyperemia using cularity by calculating the total number The between-group difference for plan- the 4-point scale was statistically sig- Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at on August 1, 2014. For personal use only. No other uses without permission. Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved. of color pixels in the region of interest tar fascia thickness was analyzed by the nificant, with those with plantar fasciitis (Spearman rho = 0.70, P<.01).6 To reach independent t test with 95% confidence showing increased PDU signal com- consensus on the grading of hyperemia, intervals. Correlations between plantar pared to controls (Mann-Whitney U, P the 2 assessors examined PDU images fascia thickness, body mass index (BMI), = .03). However, the majority of those together. and pain were analyzed with Pearson r. with plantar fasciitis with evidence of All ultrasound imaging was performed All analyses were undertaken with SPSS hyperemia demonstrated very mild col- by experienced musculoskeletal sonog- Version 19 software (SPSS Inc, Chicago, or changes (grade 2), and only 3 were raphers (J.M.G. or J.D.), with a variable- IL), and statistical significance was set at found to have moderate or marked hy- frequency (13- to 5-MHz), linear-array the conventional level of .05. Only 1 heel peremia (TABLE, FIGURE 2). For the plantar transducer (ACUSON Antares premium for each participant was scanned to meet fasciitis group, there was no correlation edition; Siemens AG, Munich, Germany). the independence assumption of statisti- between hyperemia and duration of PDU settings were standardized with a cal analysis.18 symptoms (Spearman rho = 0.01, P =

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FIGURE 3. Cross-sectional Doppler sonogram of the plantar fascia showing the lateral plantar artery and artifact at the inferior surface of the calcaneus. These features do not represent true hyperemia of the soft tissue.

Consistent with the findings of a sys- tematic review investigating diagnostic imaging for plantar fasciitis,16 our find- FIGURE 2. Longitudinal Doppler sonograms of the plantar fascia demonstrating (A) normal tissue perfusion ings show greater plantar fascia thick- (grade 1), (B) mild hyperemia (grade 2), (C) moderate hyperemia (grade 3), and (D) marked hyperemia (grade 4). ness in participants with plantar fasciitis compared to controls, and a strong as- .94) or pain severity (Spearman rho = the presence of hyperemia and duration sociation between plantar fascia thick- 0.03, P = .88). of symptoms or pain severity. ness greater than 4.0 mm and heel pain. The mean between-group difference This study revealed a more conser- However, further exploration of our data for plantar fascia thickness was statisti- vative relationship between plantar fas- revealed that 9 controls had plantar fas- cally significant, with the value in those ciitis and hyperemia compared to that cia thickness greater than 4.0 mm, and of with plantar fasciitis being 2.7 mm great- previously reported by Walther et al,23 in these, 7 had a BMI of 30 kg/m2 or greater. er than that for the control group (95% which 40% of participants with plantar Therefore, we suggest that clinicians us- confidence interval: 2.1, 3.2 mm; P<.01). fasciitis were graded with either mod- ing threshold values to confirm plantar For the plantar fasciitis group, there erate or marked vascularity. Moreover, fasciitis consider BMI as part of their was no statistical relationship between a correlation between hyperemia and assessment, and set a higher threshold plantar fascia thickness and pain levels symptom duration, a key finding de- value (eg, 5.0 mm) for patients who are (Pearson r = 0.11, P = .57). However, for scribed by Walther et al,23 was not found obese and a lower threshold value (eg, 4.0 the total cohort (n = 60), there was a sta- in the present study, despite 30% of mm) for patients who are not obese. tistically significant correlation between those with plantar fasciitis reporting a Regarding the pain mechanisms of plantar fascia thickness and BMI (Pear- symptom history equal to or less than 6 plantar fasciitis, the findings of the pres- son r = 0.44, P<.01). months (TABLE). These discrepancies may ent study support the notion that neu- stem from underlying methodological rovascular in-growth can occur with the DISCUSSION differences, including the absence of age condition, and that increased sensitiv- Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at on August 1, 2014. For personal use only. No other uses without permission. Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved. and sex matching in the study by Wal- ity to pain stimulus may occur via this he f aim o this study was to in- ther et al,23 variable interpretation by the pathway for some patients. In relation vestigate whether soft tissue hyper- assessors of the Newman grading scale, to Achilles tendinopathy, histological Temia is present in plantar fasciitis, or use of blinded image assessment (as studies have shown that nerve fibers are using conventional ultrasound tech- in the present study). However, we are intimately associated with fine blood niques. Our findings show that mild hy- confident that our conservative findings vessels in areas of soft tissue degenera- peremia can occur with plantar fasciitis, did not result from decreased ultrasound tion,4 indicating that hyperemia within but most individuals do not exhibit great- sensitivity, as we used a lower pulse-repe- the plantar fascia is likely to represent a er soft tissue vascularity when assessed tition frequency setting compared to that corresponding increase in nerve supply. with routine Doppler ultrasound. In ad- used by Walther et al23 (781 versus 1102 This has clinical implications regarding dition, for those with plantar fasciitis, we Hz), which improved sensitivity to low- the management of plantar fasciitis, and found no statistical relationship between frequency shift.25 suggests that some patients may respond

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43-12 McMillan.indd 878 11/18/2013 3:20:05 PM well to treatments targeting neurovascu- microvessels in this study. For example, findings may not represent the full lar pain mechanisms, such as injection participants were not required to adhere spectrum of vascular features associated of or agents with direct to activity restrictions on the day of scan- with the condition. sclerosing properties (eg, polidocanol). ning, pressure applied to the heel during Furthermore, the findings of this study ultrasound assessment was not moni- ACKNOWLEDGEMENTS: A.M.M. and M.P.C. have provide some explanation of the mecha- tored, and smoking status was not as- received Australian Postgraduate Award PhD nism by which corticosteroids, which sessed. These factors have the potential to scholarships. H.B.M. is currently a National exert angiostatic effects (eg, inhibition of alter perfusion within the plantar fascia, Health and Medical Research Council Senior endothelial cell proliferation and migra- and might have influenced our observa- Research Fellow (1020925). tion),21 have been shown to reduce pain3 tions of individual participants. Finally, and tissue swelling3,17 in plantar fasciitis while ultrasound images were assessed by over a 3-month period. blinded investigators, the sonographers REFERENCES In relation to image assessment, clini- were aware of the patient group, and this . 1 Alfredson H. The chronic painful Achil- cians and sonographers should be aware could have influenced the study findings. les and patellar tendon: research on basic of the normal vascular anatomy of the biology and treatment. Scand J Med Sci inferior heel and the potential artifacts CONCLUSION Sports. 2005;15:252-259. http://dx.doi. that can mimic hyperemia within this org/10.1111/j.1600-0838.2005.00466.x . 2 Alfredson H, Öhberg L, Forsgren S. Is vasculo- region. For example, the lateral plantar ild hyperemia can occur with neural ingrowth the cause of pain in chronic artery crosses the inferior heel superficial plantar fasciitis, but most indi- Achilles tendinosis? An investigation using ultra- to the plantar fascia and, therefore, could Mviduals will not exhibit greater sonography and colour Doppler, immunohisto- be incorrectly identified as neovascular soft tissue vascularity when assessed chemistry, and diagnostic injections. Surg Sports Traumatol Arthrosc. 2003;11:334-338. activity. As shown in FIGURE 3, this vessel with routine Doppler ultrasound. Clini- http://dx.doi.org/10.1007/s00167-003-0391-6 is particularly visible on PDU when as- cians treating plantar fasciitis should not . 3 Ball EM, McKeeman HM, Patterson C, et sessing the plantar fascia in cross-section, consider a positive Doppler signal essen- al. Steroid injection for inferior heel pain: a randomised controlled trial. Ann Rheum Dis. as it traverses in a mediolateral direction tial for diagnosis of the condition but, 2013;72:996-1002. http://dx.doi.org/10.1136/ from the tarsal tunnel to the lateral mid- rather, a feature that may help refine the annrheumdis-2012-201508 foot. The lateral plantar artery can also be treatment plan for an individual patient. . 4 Bjur D, Alfredson H, Forsgren S. The innervation seen on a longitudinal image, and should Among participants with plantar fasci- pattern of the human : studies of the normal and tendinosis tendon with mark- therefore be considered when assessing itis, we found no statistical relationship ers for general and sensory innervation. Cell the region in either plane. FIGURE 3 also between the presence of hyperemia and Tissue Res. 2005;320:201-206. http://dx.doi. demonstrates that increased PDU signal duration of symptoms or pain severity. org/10.1007/s00441-004-1014-3 t is commonly observed at the inferior cor- . 5 Buchbinder R. Clinical practice. Plantar fasciitis. N Engl J Med. 2004;350:2159-2166. http:// tical surface of the calcaneus, which is an KEY POINTS dx.doi.org/10.1056/NEJMcp032745 artifact caused by the difference in tissue FINDINGS: Mild hyperemia can occur with . 6 Chen H, Ho HM, Ying M, Fu SN. Correlation density (and therefore echogenicity) be- plantar fasciitis, but most individu- between computerised findings and Newman’s tween bone and the surrounding soft tis- als will not exhibit greater soft tissue scaling on vascularity using power Doppler ul- 23 trasonography imaging and its predictive value sue. Increased signal in this area should vascularity when assessed with routine in patients with plantar fasciitis. Br J Radiol. therefore be interpreted with caution and Doppler ultrasound. Among partici- 2012;85:925-929. http://dx.doi.org/10.1259/ typically does not represent true hyper- pants with plantar fasciitis, we found bjr/99342011 emia of the soft tissue.23 no statistical relationship between the . 7 Dunn JE, Link CL, Felson DT, Crincoli MG, Keysor Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at on August 1, 2014. For personal use only. No other uses without permission. Copyright © 2013 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved. JJ, McKinlay JB. Prevalence of foot and ankle The findings of this study should be presence of hyperemia and duration of conditions in a multiethnic community sample of interpreted with several methodologi- symptoms or pain severity. older adults. Am J Epidemiol. 2004;159:491-498. cal limitations in mind. This study was IMPLICATIONS: Clinicians treating plantar . 8 Feydy A, Lavie-Brion MC, Gossec L, et al. pragmatically designed to represent nor- fasciitis should not consider a positive Comparative study of MRI and power Dop- pler ultrasonography of the heel in patients mal clinical imaging environments, and Doppler signal essential for diagnosis of with spondyloarthritis with and without therefore was unable to definitively iden- the condition but, rather, a feature that heel pain and in controls. Ann Rheum Dis. tify the presence or absence of hyperemia may help refine the treatment plan for 2012;71:498-503. http://dx.doi.org/10.1136/ in plantar fasciitis (eg, compared to histo- an individual patient. annrheumdis-2011-200336 . 9 Hill CL, Gill TK, Menz HB, Taylor AW. Prevalence pathological assessment). Furthermore, CAUTION: This study involved a relatively and correlates of foot pain in a population- it is possible that uncontrolled biological, small sample of individuals with plantar based study: the North West Adelaide health environmental, and procedural factors fasciitis and utilized routine ultrasound study. J Foot Ankle Res. 2008;1:2. http://dx.doi. might have influenced the appearance of assessment techniques. Therefore, the org/10.1186/1757-1146-1-2

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10. Jarde O, Diebold P, Havet E, Boulu G, Vernois J. sis. J Foot Ankle Res. 2009;2:32. http://dx.doi. http://dx.doi.org/10.1371/journal.pone.0046625 Degenerative lesions of the plantar fascia: surgi- org/10.1186/1757-1146-2-32 22. Snider MP, Clancy WG, McBeath AA. Plantar cal treatment by fasciectomy and excision of 17. McMillan AM, Landorf KB, Gilheany MF, Bird fascia release for chronic plantar fasciitis in run- the heel spur. A report on 38 cases. Acta Orthop AR, Morrow AD, Menz HB. Ultrasound guided ners. Am J Sports Med. 1983;11:215-219. Belg. 2003;69:267-274. injection for plantar fasciitis: ran- 23. Walther M, Radke S, Kirschner S, Ettl V, Gohlke 11. Khan KM, Cook JL, Maffulli N, Kannus P. Where domised controlled trial. BMJ. 2012;344:e3260. F. Power Doppler findings in plantar fasciitis. is the pain coming from in tendinopathy? It may http://dx.doi.org/10.1136/bmj.e3260 Ultrasound Med Biol. 2004;30:435-440. http:// be biochemical, not only structural, in origin. Br 18. Menz HB. Two feet, or one person? Prob- dx.doi.org/10.1016/j.ultrasmedbio.2004.01.006 J Sports Med. 2000;34:81-83. lems associated with statistical analysis 24. Wearing SC, Smeathers JE, Yates B, Sullivan 12. Kremkau FW. Diagnostic Ultrasound: Principles of paired data in foot and ankle medicine. PM, Urry SR, Dubois P. Sagittal movement of and Instruments. 7th ed. St Louis, MO: Elsevier/ Foot. 2004;14:2-5. http://dx.doi.org/10.1016/ the medial longitudinal arch is unchanged Saunders; 2006. S0958-2592(03)00047-6 in plantar fasciitis. Med Sci Sports Exerc. 13. LeMelle DP, Kisilewicz P, Janis LR. Chronic 19. Menz HB, Jordan KP, Roddy E, Croft PR. Char- 2004;36:1761-1767. plantar fascial and fibrosis. Clin acteristics of primary care consultations for 25. Yang X, Pugh ND, Coleman DP, Nokes LD. Are Podiatr Med Surg. 1990;7:385-389. musculoskeletal foot and ankle problems in the Doppler studies a useful method of assessing 14. Lemont H, Ammirati KM, Usen N. Plantar UK. (Oxford). 2010;49:1391-1398. neovascularization in human Achilles tendinopa- fasciitis: a degenerative process (fasciosis) http://dx.doi.org/10.1093/rheumatology/keq092 thy? A systematic review and suggestions for without inflammation. J Am Podiatr Med Assoc. 20. Newman JS, Laing TJ, McCarthy CJ, Adler RS. optimizing machine settings. J Med Eng Technol. 2003;93:234-237. Power Doppler sonography of : as- 2010;34:365-372. http://dx.doi.org/10.3109/030 15. Martinoli C, Pretolesi F, Crespi G, et al. Power sessment of therapeutic response--preliminary 91902.2010.497892 Doppler sonography: clinical applications. Eur J observations. Radiology. 1996;198:582-584. Radiol. 1998;27 suppl 2:S133-S140. 21. Shikatani EA, Trifonova A, Mandel ER, et al. Inhi- 16. McMillan AM, Landorf KB, Barrett JT, Menz HB, bition of proliferation, migration and proteolysis MORE INFORMATION Bird AR. Diagnostic imaging for chronic plantar contribute to corticosterone-mediated inhibition WWW.JOSPT.ORG heel pain: a systematic review and meta-analy- of angiogenesis. PLoS One. 2012;7:e46625. @

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