Diagnostic imaging for chronic plantar heel pain: a systematic review and meta‐analysis

Abstract

BackgroundChronic plantar heel pain (CPHP) is a generalised term used to describe a range of undifferentiated conditions affecting the plantar heel. Plantar fasciitis is reported as the most common cause and the terms are frequently used interchangeably in the literature. Diagnostic imaging has been used by many researchers and practitioners to investigate the involvement of specific anatomical structures in CPHP. These observations help to explain the underlying pathology of the disorder, and are of benefit in forming an accurate diagnosis and targeted treatment plan. The purpose of this systematic review was to investigate the diagnostic imaging features associated with CPHP, and evaluate study findings by meta-analysis where appropriate.MethodsBibliographic databases including Medline, Embase, CINAHL, SportDiscus and The Cochrane Library were searched electronically on March 25, 2009. Eligible articles were required to report imaging findings in participants with CPHP unrelated to inflammatory arthritis, and to compare these findings with a control group. Methodological quality was evaluated by use of the Quality Index as described by Downs and Black. Meta-analysis of study data was conducted where appropriate.ResultsPlantar fascia thickness as measured by ultrasonography was the most widely reported imaging feature. Meta-analysis revealed that the plantar fascia of CPHP participants was 2.16 mm thicker than control participants (95% CI = 1.60 to 2.71 mm, P < 0.001) and that CPHP participants were more likely to have plantar fascia thickness values greater than 4.0 mm (OR = 105.11, 95% CI = 3.09 to 3577.28, P = 0.01). CPHP participants were also more likely to show radiographic evidence of subcalcaneal spur than control participants (OR = 8.52, 95% CI = 4.08 to 17.77, P < 0.001).ConclusionThis systematic review has identified 23 studies investigating the diagnostic imaging appearance of the plantar fascia and inferior calcaneum in people with CPHP. Analysis of these studies found that people with CPHP are likely to have a thickened plantar fascia with associated fluid collection, and that thickness values >4.0 mm are diagnostic of plantar fasciitis. Additionally, subcalcaneal spur formation is strongly associated with pain beneath the heel.

Hyperemia in Plantar Fasciitis Determined by Power Doppler Ultrasound

“…However, we are confident that our conservative findings did not result from decreased ultrasound sensitivity, as we used a lower pulse-repetition frequency setting compared to that used by Walther et al 23 (781 versus 1102 Hz), which improved sensitivity to lowfrequency shift. 25 Consistent with the findings of a systematic review investigating diagnostic imaging for plantar fasciitis, 16 our findings show greater plantar fascia thickness in participants with plantar fasciitis compared to controls, and a strong association between plantar fascia thickness greater than 4.0 mm and heel pain. However, further exploration of our data revealed that 9 controls had plantar fascia thickness greater than 4.0 mm, and of these, 7 had a BMI of 30 kg/m 2 or greater.…”

“…Plantar fasciitis was confirmed by ultrasound assessment and considered present when the plantar fascia was 4.0 mm or greater at the calcaneal origin. 16 Exclusion criteria for case participants included corticosteroid injection of the heel within the past 3 months, posterior heel pain, systemic inflammatory disease, diabetes, and a history of local surgery. Participants with bilateral heel pain had only the most severely affected foot scanned.…”

“…Ultrasound examination was undertaken with participants lying prone, with their knees extended and feet resting over the edge of an examination table. 16 All ultrasound images used for assessment were obtained in the sagittal plane. Plantar fascia thickness was measured at a standard location, where the fascia crosses the anterior aspect of the inferior calcaneal border (FIGURE 1).…”

“…Plantar fascia thickness was measured at a standard location, where the fascia crosses the anterior aspect of the inferior calcaneal border (FIGURE 1). 16 This measurement technique was performed with Sante DICOM Editor Version 3.1.20 software (Santesoft Ltd, Athens, Greece) and has been shown to have good intrarater reliability (95% limits of agreement: 0.5, -0.7 mm). 24 Assessment of the PDU signal within the proximal plantar fascia was performed by 2 blinded podiatrists (K.B.L.…”

Imaging of plantar fascia and Achilles injuries undertaken at the London 2012 Olympics

“…Provided the insonating beam is directed perpendicular to the fascia, it appears as a striated echogenic structure, tapering smoothly from proximal to distal. Within 10mm of its origin, the central portion measures 3-4mm in thickness [1] [4].…”