Background: We compared diagnostic ultrasound images of the plantar fascia with available patient histories for symptomatic patients previously diagnosed as having plantar fasciitis. Plantar fascia thickness and depth, the prevalence of perifascial hypoechoic lesions, and injury timelines in patients were reviewed. Methods: Images and histories for 126 symptomatic patients were collected from a patient database. We documented plantar fascia depth and thickness and the visualization of hypoechoic perifascial lesions. After image analysis, the obtained plantar fascia thickness measurements were compared with various patient attributes for possible relationships, including age, weight, and body mass index. In addition, plantar fascia thickness measurements were separated based on injury timeline as well as symptomatic/asymptomatic foot for patients with unilateral conditions to check for significant differences between subgroups. These were, in turn, compared with a control group of 71 individuals with no heel pain or diagnosis of plantar fasciitis. Results: Overall, mean ± SD symptomatic thickness (n = 148) was 6.53 ± 1.56 mm. Mean ± SD symptomatic depth (n = 136) was 13.36 ± 2.14 mm. For the control group, mean ± SD thickness was 3.20 ± 0.66 mm and depth was 10.30 ± 2.00 mm. Comparison of thickness based on injury timeline showed two significant differences: acute injuries (≤3 months) are significantly thicker than chronic injuries (>3 months), and only acute symptomatic thicknesses are significantly different from their asymptomatic thickness counterparts. Age, weight, and body mass index did not show significant correlations to thickness. Analysis of ultrasound images showed that 93% of symptomatic feet had hypoechoic lesions. Conclusions: Injury timeline and the presence of hypoechoic lesions may play important roles in patient discomfort, diagnosis, and treatment of plantar fasciitis.

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Background: Intense therapeutic ultrasound (ITU) is an innovative ultrasound-based therapy where sound waves are concentrated into select musculoskeletal tissue. These focused waves generate thermal coagula at a controlled depth and space while preserving surrounding tissues. A multicenter study was conducted evaluating the efficiency, safety, and patient tolerance of ITU for the treatment of chronic plantar fasciitis (CPF) pain. Methods: Seventy-four CPF patients, having failed conservative and/or minimally invasive treatment, participated in the study. Randomized participants either received 2 ITU treatments or 2 sham ITU treatments in addition to standard-of-care therapy. Plantar fascia pain was assessed pretreatment and at 4, 8, 12, and 26 weeks after treatment. Diagnostic ultrasonographic images were analyzed to examine hypoechoic, perifascial lesions whose volumes were calculated until week 12. Function and patient satisfaction were measured using self-reported outcome measures. Results: The treated group reported significant average pain reduction (–26%, –33%, –43%) and hypoechoic lesion volume (–33%, –53%, –68%) at weeks 4, 8, and 12 compared to baseline. Although the control/sham group reported insignificant pain changes at the same time points (–5%, +8%, and +2%) and increased hypoechoic lesion volume (+15%, +28%, +58%). Treated patients reported a significant increase in daily living activities (+28%, +42%, +47%, +40%) compared to the sham/control group (+0.12%, +12%, +3%, +21%). Patient satisfaction remained more than 80% at weeks 8, 12, and 26 for all treatment groups. Conclusion: ITU is an effective pain relief treatment for CPF, which is refractory to either conservative measures or minimally invasive treatments. Level of Evidence: Level II.

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Initial treatment of plantar fasciitis (PF), consisting of anti-inflammatories, stretching and in-shoe orthosis (heel pad, heel wedge, or arch support), leads to symptomatic resolution in over 90% of patients but takes 3-6 months. This study was conducted to test the effectiveness of a minimally invasive modality, intense therapeutic ultrasound (ITU), in accelerating the healing of chronic plantar fasciitis (PF). ITU uses high-frequency high-intensity focused ultrasound to create small thermal injury zones inside soft tissue without damage to surrounding structures. ITU has been shown to initiate a tissue repair cascade and promote collagen generation in dermal and musculoskeletal tissue and is FDA approved for use in non-surgical brow lifts [1,2]. The goal of this study was to determine if ITU when combined with standard therapy could speed the healing of chronic PF. Methods: 47 patients with chronic (greater than 3 months) heel pain due to PF were randomized to standard therapy (antiinflammatory pills, stretching, and gel heel cups) plus ITU ("ITU", n=33) or standard therapy plus sham ITU ("control", n=14) groups. ITU treatments were administered at enrollment and two-weeks later using a custom 3.3 MHz therapeutic ultrasound system (Guided Therapy Systems, Mesa, AZ). Sham treatment utilized the same protocol but with the energy set to 0 Joules. Treatment effect was assessed at 2, 4, 6, and 12 weeks after the initiation of treatment using diagnostic ultrasound and patient reported outcomes (PROMIS physical function computer adaptive test, PROMIS global health, Foot Function Index pain subscale, and a non-validated heel pain specific questionnaire). Ultrasound images were analyzed to determine the size of lesions within the PF. Both the sonographer and the study coordinator administering the patient reported outcome instruments were blinded to group assignment. Results: 38 patients completed the 12 week study (ITU: n=37, Control: n=11.). The ITU group reported a significantly greater reduction in heel pain scores [Mean 8.27, SD 4.69, P=0.027] compared to the control group [Mean 2.25, SD 5.92] (Figure 1). Ultrasound imaging showed an 81% decrease in perifascial lesion size in the treatment group, compared to a 26% increase in lesion size in the control group (Figure 2). Conclusion: Preliminary results of this clinical study of noninvasive ITU for the treatment of chronic PF showed that ITU treatment as compared to sham control lead to a larger and more rapid reduction of heel pain and perifascial lesion size. ITU holds promise as a potential therapy to accelerate the healing of chronic plantar fasciitis