Abstract
Purpose
This study aimed to evaluate the diagnostic importance of ultrasonic imaging by assessing the thickness of the plantar fascia (F) and fat pad (FP) at different locations in the plantar region for the diagnosis of plantar fasciitis. Furthermore, the study sought to determine the correlation between angular measurements derived from direct radiography and measurements obtained via ultrasound imaging.
Methods
The study measured the intermetatarsal angle(IMA), 1st metatarsophalangeal angle(MTPA), 1st interphalangeal angle(IPA), and medial longitudinal arch angle(MLAA) in weight-bearing foot radiographs of 94 patients (23 males and 71 females) with unilateral plantar fasciitis. The control group comprised asymptomatic feet from the same individuals. Fat pad and plantar fascia thicknesses were assessed with ultrasonic imaging(USG) at three different points. A proportion was established between fascia(F) and fat pad(FP) thicknesses. The study examined the correlations between USG and direct radiography measurements, both within and between groups.
Results
A statistically significant difference was observed between the study group and the control group in various measurements. These include IMA measurements, plantar fascia thickness, and F/FP ratio measured at the calcaneal tubercle, as well as fascia thickness, fat pad thickness, and F/FP ratio measured in the midpoint of the medial arch (p = 0.024; p = 0.001; p = 0.001; p = 0.001; p = 0.008; p = 0.001 p<0.05 respectively). A significant correlation was discovered in the study group between F/FP measures in the calcaneal tubercle and MLAA.
Conclusion
Our study revealed a noteworthy correlation between plantar fasciitis and an increase in plantar fascia thickness, an increase in the plantar fascia/fat pad ratio, and a decrease in the fat pad thickness measured at three distinct points. In our study, it was seen that the diagnosis of plantar fasciitis can be made with USG alone, which is a fast, cost-effective and easy-to-apply method by evaluating the thickening of the plantar fascia, the reduction in fat pad thickness, and their relative proportions.
Level of evidence
Level III, Cross-Sectional Prospective Observational Study.
1
Introduction
Plantar fasciitis(PF) is a foot condition characterized by pain on the plantar surface of the foot and makes it difficult to walk . It is observed in 3.6–11.1 % of the population , . Although pes planus, pes cavus, obesity, and overuse are considered among the predisposing factors, the exact causes of the disease have not been completely established . The etiopathology of this condition commonly involves the degeneration of the plantar fascia. Its relationship with the calcaneal spur has been investigated in radiologic evaluations, however, recent investigations have not shown a definitive correlation. Edema was seen in the plantar fascia, extending from the calcaneus to the metatarsal heads, in investigations conducted using USG and MRI. Additionally, the thickness of fat in the heel was discovered to change based on the etiology . Radiologic imaging is frequently used in the diagnosis of plantar fasciitis to determine the etiology. Foot radiographs, USG and MRI are often employed diagnostic procedures. While foot deformities such as pes planus and pes cavus that disrupt plantigrade compression can be evaluated in foot radiographs, the thickness and edematous changes of the plantar fascia can be better evaluated in USG and MRI .
USG is a method that can be used in the diagnosis of plantar fasciitis and to observe changes in the plantar fascia after treatment. Its main advantages are rapid and efficient outcomes, reproducibility, absence of radiation exposure and low cost compared to MRI ,, . The plantar fascia is a fibrous structure that originates from the calcaneus and inserts at the metatarsal heads. Edema, degenerative changes in the plantar fascia and thinning of the heel fat pad can be seen on USG , . The elastic structure of the heel deteriorates when the fat pad diminishes. The decrease in shock absorption can be considered a predisposing factor for plantar fasciitis , . Our study aimed to assess the correlation between radiologic measurements in foot radiography and changes in plantar fascia and fat pad thickness from three different points in USG for diagnosing plantar fasciitis. Additionally, we aimed to evaluate the relationship between these measurements and their impact on clinical scores. In this way, it was aimed to establish a diagnostic guide for the use of USG, which is an easier, faster, and cheaper method in the diagnosis of plantar fasciitis, by correlating the data between USG and direct radiographs. Therefore, the objective is to diagnose plantar fasciitis in a more convenient and cost-efficient manner by utilizing USG, a faster and less expensive alternative to the time-consuming and costly approach of MRI for differential diagnosis in patients who cannot be diagnosed through clinical means.
2
Materials and methods
The study was designed as a prospective observational study after obtaining local ethics committee approval (protocol number 2020/413, decision number 2020–19–12). Patients who experienced pain in unilateral heel and sole between 2020 and 2021 underwent physical examination and imaging to rule out various potential causes such as posterior tibial tendon insufficiency, achilles tendinopathy, boxter neuritis, calcaneal stress fracture, tarsal tunnel syndrome, and heel fat pad atrophy syndrome.
The study was conducted on a sample of 94 participants who were diagnosed with unilateral plantar fasciitis between 2020 and 2021. The study group consisted of the feet of 94 patients who had complaints, while the control group consisted of the symptom-free feet of the same 94 patients. The gender, age, BMI(Body Mass Index), side of the complaint, comorbidities, time elapsed until the outpatient clinic presentation, treatments received for PF until the outpatient clinic presentation, and other orthopedic pathologies in the ipsilateral extremity of the individuals included in the study are shown in Table 1 .
Table 1
Demographic Findings.
| Age | Mean±SD | 48.23 ± 10.20 |
|---|---|---|
| Median (Min-Max) | 49 (24−76) | |
| Sex; n (%) | Female | 71 (%75.5) |
| Male | 23 (%24.5) | |
| Height (m) | Mean±SD | 1.64 ± 0.08 |
| Median (Min-Max) | 1.6 (1.5−1.9) | |
| Weight (kg) | Mean±SD | 79.98 ± 12.57 |
| Median (Min-Max) | 79.5 (56−118) | |
| BMI (kg/m²) | Mean±SD | 29.95 ± 4.53 |
| Median (Min-Max) | 29.6(19.8−41.3) | |
| Duration (week) | Mean±SD | 52.47 ± 82.87 |
| Median (Min-Max) | 24(2−500) | |
| Side | Right | 51(%54.3) |
| Left | 43(%45.7) | |
| Treatment | No | 39(%41.5) |
| Yes | 55(%58.5) | |
| Injection | 2(%3.6) | |
| ESWT | 4(%4.3) | |
| Orthotics | 28(%51.9) | |
| NSAID | 46(%85.2) | |
| Comorbidity | No | 42(%44.7) |
| Yes | 52(%55.3) | |
| DM | 13(%25.0) | |
| HT | 16(%30.8) | |
| CAD | 4(%7.7) | |
| LDH | 5(%9.6) | |
| Cancer | 2(%3.8) | |
| Goiter | 7(%13.5) | |
| Others | 20(%38.5) | |
| Ipsilateral extremity disease | None | 72(%76.6) |
| Gonarthrosis | 12(%12.8) | |
| HR | 3(%3.2) | |
| HV | 4(%4.3) | |
| Meniscopathy | 3(%3.2) |
The study assessed the intermetatarsal angle (IMA), 1st metatarsophalangeal angle (MTPA), 1st interphalangeal angle (IPA), and medial longitudinal arch angle (MLAA) in weight-bearing foot radiographs and USG measurements of patients with unilateral plantar fasciitis. The unaffected feet of the same patient group were used as the control group. The patients underwent clinical evaluation using AOFAS and FFI scores. Patients who had bilateral plantar fasciitis, fractures resulting from prior trauma, a history of surgery, pathologic fractures, or rigid deformities such as pes equinovarus sequelae were excluded from the study.
The ultrasound was conducted by a skilled physician who has experience in USG imaging. The patients were positioned face down with their feet hanging over the edge of the stretcher. Using USG, fat pad and fascia thicknesses were measured 2 mm distal to the attachment point of the plantar fascia at the level of the calcaneal tubercle ( Fig. 1 ) and at the midpoint of the medial arch ( Fig. 2 ). Additionally, fat pad thickness was measured at the level of the first metatarsal head contact point with the ground ( Fig. 3 ).
USG image 1: fascia and fat pad measurement from 2 mm distal to the calcaneal tubercle.
USG image 2: Fascia and fat pad measurement from medial arch midpoint.
USG image 3: Fat pad thickness measurement from the plantar aspect of the 1st metatarsal head.
The angles of IMA, MTPA, IPA, and MLAA were measured by a skilled physician who was different from the physician who conducted the USG examination on the weight-bearing foot radiographs of the patients ( Figs. 4–5 ).
Weight-bearing foot AP radiograph and IMA, MTPA, and IPA angle measurements.
Weight-bearing foot lateral radiographs and MLAA angle measurements.
2.1
Statistical analysis
NCSS (Number Cruncher Statistical System) 2007 (Kaysville, Utah, USA) program was used for statistical analysis. The study data was evaluated using descriptive statistical methods, including mean, standard deviation, median, frequency, percentage, minimum, and maximum. The conformity of the quantitative data to the normal distribution was assessed by the Shapiro-Wilk test and graphical analysis. The dependent group t test was used for intra-group comparisons of normally distributed quantitative variables. The Wilcoxon signed-ranks test was used for intra-group comparisons of quantitative variables that did not exhibit a normal distribution. The McNemar concordance test and diagnostic screening tests were used to compare qualitative data. Intraclass correlation coefficient (ICC) compatibility correlation was used between radiography and USG values.
3
Results
In the study group, AOFAS results ranged between 45 and 90 with a mean value of 72.13 ± 10.99, while in the control group, AOFAS results ranged between 95 and 100 with a mean value of 98.99 ± 2.01(p = 0.001, p < 0.01). In the study group, FFI values ranged between 28 and 230 with a mean of 119.91 ± 42.95, while in the control group, FFI values ranged between 0 and 25 with a mean of 8.77 ± 5.49(p = 0.001, p < 0.01) ( Table 2 ).
Table 2
Evaluation of functional scoring between groups.
| Study group | Control group | p | ||
|---|---|---|---|---|
| AOFAS | Mean±SD | 72.13 ± 10.99 | 98.99 ± 2.01 | ‘0001 |
| Median (Min-Max) | 75.5 (45−90) | 100 (95−100) | ||
| FFI | Mean±SD | 119.91 ± 42.95 | 8.77 ± 5.49 | ‘0001 |
| Median (Min-Max) | 118.5 (28−230) | 7 (0−25) |
‘Paired Sample T Test
IMA measurements were 0.54 ± 2.30 degrees higher in the control group compared to the study group, and this difference was statistically significant(p = 0.024; p < 0.05). The control group had a statistically significant decreased mean thickness of the plantar fascia assessed at the calcaneal tubercle, with a difference of 0.48 ± 7.58 mm compared to the study group(p = 0.001; p < 0.01).
The mean F/FP ratio measured in the calcaneal tubercle was 0.06 ± 1.38 units lower in the control group compared to the study group, and this difference was statistically significant (p = 0.001; p < 0.01). The control group exhibited a statistically significant decrease of 1.16 ± 1.80 mm in mean fascia thickness at the midpoint of the medial arch compared to the study group(p = 0.001; p < 0.01). The control group exhibited a statistically significant increase of 0.45 ± 2.02 mm in fat pad thickness at the midpoint of the medial arch compared to the study group(p = 0.008; p < 0.01). The F/FP ratio at the midpoint of the medial arch was 0.50 ± 0.91 units lower in the control group compared to the study group, and this difference was statistically significant(p = 0.001; p < 0.01). There were no statistically significant differences in the measurements of the MTPA, IPA, MLAA, calcaneal fat pad, and 1st metatarsal head fat pad among the groups of patients(p > 0.05) ( Table 3 ). Upon evaluation of these findings, it was noted that the thickness of the plantar fascia increased in both the calcaneal tubercle and the medial arch midpoint, the fat pad thickness decreased and the proportional distribution of the fascia relative to the fat pad increased in patients with plantar fasciitis compared to the control group.
Table 3
Comparison of data measured on direct radiography and USG between groups.
| Study group | Control group | p | Difference | ||
|---|---|---|---|---|---|
| IMA | Mean±SD | 7.67 ± 2.60 | 8.22 ± 3.06 | 0.024 | −0.54 ± 2.30 |
| Median (Min-Max) | 7.5(1.9−14.3) | 7.6(1.8−16) | −0.3(−5.7−6) | ||
| MTPA | Mean±SD | 16.20 ± 7.30 | 17.18 ± 7.30 | 0.066 | −0.98 ± 5.10 |
| Median (Min-Max) | 16.2(1.4−43.1) | 16.7(0.4−43.7) | −0.8(−20.3−17.5) | ||
| IPA | Mean±SD | 14.25 ± 5.04 | 13.37 ± 4.92 | 0.088 | 0.87 ± 4.90 |
| Median (Min-Max) | 14.2(1.1−31.7) | 14(0.8−24) | 0.2(−12−17) | ||
| MLAA | Mean±SD | 37.41 ± 7.33 | 37.84 ± 7.72 | 0.317 | −0.43 ± 4.12 |
| Median (Min-Max) | 37.1(20.1−54.9) | 38(20.5−56.4) | −0.7(−11.2−11.7) | ||
| CALCANEAL FASCIA | Mean±SD | 6.65 ± 2.00 | 6.17 ± 7.81 | 0.001 | 0.48 ± 7.58 |
| Median (Min-Max) | 6.8(2.4−12) | 5.4(2−79) | 1.2(−70.4−5.1) | ||
| CALCANEAL FAT PAD | Mean±SD | 8.36 ± 2.62 | 8.86 ± 2.96 | 0.064 | −0.49 ± 2.56 |
| Median (Min-Max) | 8.7(1.9−16.5) | 9.1(1.7−15.4) | −0.6(−7.4−6.8) | ||
| CALCANEAL F/FP | Mean±SD | 0.90 ± 0.48 | 0.84 ± 1.37 | 0.001 | 0.06 ± 1.38 |
| Median (Min-Max) | 0.8(0.2−3) | 0.6(0.2−13.4) | 0.1(−12.5−1.6) | ||
| MEDIAL ARCUS FASCIA | Mean±SD | 7.28 ± 2.21 | 6.11 ± 1.97 | 0.001 | 1.16 ± 1.80 |
| Median (Min-Max) | 7.7(1.7−12.7) | 6.3(1.4−11.4) | 1.2(−3.5−5.4) | ||
| MEDIAL ARCUS FAT PAD | Mean±SD | 4.22 ± 1.86 | 4.67 ± 2.02 | 0.008 | −0.45 ± 2.02 |
| Median (Min-Max) | 3.9(1.3−11.9) | 4.1(2.1−13.3) | −0.3(−8.7−8.4) | ||
| MEDIAL ARCUS F/FP | Mean±SD | 1.96 ± 0.90 | 1.46 ± 0.64 | 0.001 | 0.50 ± 0.91 |
| Median (Min-Max) | 1.9(0.4−4.9) | 1.4(0.3−3.9) | 0.4(−1.8−4.2) | ||
| 1.METATARSAL HEAD FAT PAD | Mean±SD | 2.55 ± 0.74 | 2.44 ± 0.81 | 0.060 | 0.11 ± 0.74 |
| Median (Min-Max) | 2.5(1.1−5.1) | 2.3(0.9−6.2) | 0(−3−2.2) |
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