Insertion Of Plantar Fascia Research Articles

Ultrasound of the Heel Improves Diagnosis-Tender Entheses in the Heel Region Rarely Corresponds to Inflammatory Enthesitis in Patients with Peripheral Spondyloarthritis.

Enthesitis is a key pathology in spondyloarthritis (SpA), but diagnosis may be clinically challenging. The objective of this study was to investigate the prevalence of ultrasound enthesitis lesions in tender entheses in the heel region in patients with peripheral SpA. In 27 patients with tenderness upon palpation at the Achilles tendon or the plantar fascia insertion, ultrasound assessment of the affected enthesis was performed using greyscale and color Doppler mode. Images were evaluated using the Outcome Measures in Rheumatology (OMERACT) scoring system for enthesitis, scoring presence/absence of hypoechogenicity, thickening, calcifications/enthesophytes, and erosions, and color Doppler activity semi quantitatively from 0 to 3. A total enthesitis sum score was calculated. A second examiner scanned 10 patients for inter-reader reliability. Ultrasound signs of inflammatory enthesitis (thickening/hypoechogenicity and/or Doppler activity) were found in 48%, and 19% showed Doppler activity—all in the Achilles enthesis. Inflammatory pathologies other than enthesitis (e.g., tendinitis, arthritis, bursitis) were identified in 26% of tender heels. The ultrasound OMERACT scoring system for enthesitis lesions showed excellent intra- and inter-reader agreement in a clinical setting. In conclusion, less than 50% of clinically tender entheses are related to inflammatory enthesitis when assessed by ultrasound. Ultrasound is useful for diagnosing other pathologies that may explain tenderness in the area.

Functional outcome of surgical management of calcaneal spur by excision and autologous platelet-rich plasma injection

The calcaneal spur is also known as an enthesophyte which is a bony outgrowth from the calcaneum at the plantar fascia insertion. Treatment aspect ranges from initial conservative methods, invasive techniques to surgical excision of the spur in cases which are not responding to any other alternative methods. This article aims in evaluating the functional outcome of calcaneal spur excision coupled with a dose of autologous platelet-rich plasma injection in recalcitrant cases of the calcaneal spur. A total of 42 cases of confirmed calcaneal spur cases were recruited for the study. All participants were offered with calcaneal excision with a dose of autologous platelet-rich plasma injection. All patients were evaluated preoperatively and post-operatively with VAS and FFI scores at the end of the 1, 3 and 6 months. The patients who received calcaneal spur excision along with a single dose of autologous platelet-rich plasma injection reported statistically significant pain relief at the end of 6 months while comparing with the pre-operative VAS score (p = 0.003) and FFI score showed a statistically significant functional outcome between both groups at the end of 6 months (p <0.001). Surgical removal of calcaneal spur along with a dose of an autologous platelet-rich plasma injection serve the better management for calcaneal spur and improves the functional quality of life.

Local injection of Platelet Rich Plasma for Plantar Fasciitis

Background: Plantar fasciitis can be defined as inflammation at the insertion of plantar fascia and is thought most commonly due to overuse injury. It usually presents as sharp shooting heel pain which is worse in the morning. The location of pain is usually plantar surface of the foot and pain may radiate proximally in long standing and severe cases. In mild cases of plantar fasciitis non steroidal anti-inflammatory drugs and activity modification may be sufficient. Severe cases may require interventions such as night splints and orthotic devices which works by reducing loading of plantar fascia. Recently local injection of autologous platelet rich plasma is used by many researchers with promising results.
 Aims and Objectives: This prospective cohort study was undertaken to analyze the functional and clinical outcome in patients with plantar fasciitis who were treated by autologous injection of platelet rich plasma.
 Materials and Methods: This was a prospective cohort study conducted in department of orthopedics of a tertiary care medical college located in an urban area. The patients diagnosed to be having plantar fasciitis were included in this study on the basis of a predefined inclusion and exclusion criteria. Patients were assessed for severity of pain by the Visual Analogue Score for pain and American orthopedic foot and ankle score (AOFAS). A VAS score of 0-3 was taken as pain relief and VAS score of 4-10 was considered as no pain relief. Whereas AOFAS scores of 90-100, 80-89, 60-79 and less than 60 were taken as excellent, good, fair and poor outcome respectively. All patients were treated by local injection of autologous platelet rich plasma. The patients were followed up at 4 weeks, 8 weeks and 12 weeks. During follow up visits the pain relief was assessed by VAS and AOFAS scores. For statistical purposed SSPS 21.0 software was used and p value less than 0.05 was taken as statistically significant.
 Results: A total of 60 patients were included in this study out of which there were 22 (36.67%) males and 38 (63.33%) females with a M:F ratio of 1:1.72. The most common affected age group was between the age of 41-50 years (35%) followed by 51-60 years (21.67%) and 31-40 years (20%). Twenty-seven (45%) patients were either overweight or obese. A statistically significant reduction in pain was documented at the time of follow up of 4 weeks. At the end of 12 weeks 58 (96.67%) patients experienced significant pain relief and only 2 (3.33%) patients had significant pain. Also, there was statistically significant difference between AOFAS scores at the time of presentation and at 4 weeks, 8 weeks and 12 weeks follow up visits.
 Conclusion: Injection of autologous platelet rich plasma for chronic plantar fasciitis is found to have promising results in terms of pain relief (reduced VAS score) and functional outcome (Improvement in AOFAS score).

O13 Back to the Future: attempting to distinguish between inflammatory and non-inflammatory back pain

Case report - IntroductionBack pain is highly prevalent, affecting 40% of the paediatric population, with non-inflammatory causes accounting for the majority cases. However, the presentation of inflammatory back pain can be non-specific and a high degree of suspicion is necessary, particularly with the presence of risk factors such as HLA B27 positivity and personal and family history of psoriasis, inflammatory bowel disease, and acute uveitis.Case report - Case descriptionA previously well 14-year-old Caucasian girl was referred due to persistent lower back pain, HLA B27 positivity, and a history of acute uveitis. She reports that her pain began around the time of a road traffic accident two years previously. The pain was persistent but varied in intensity, worsened throughout the day, on bending forwards, and during bumpy car journeys, and on occasion was mildly relieved by ibuprofen. She later also developed neck pain and right lateral thigh pain. Despite her pain she was able to continue walking and swimming but found that she had to stop trampolining and cycling. She had recently been treated for a painful, red eye with topical treatment.On examination she had full range of movement of her spine and tenderness over her sacroiliac joints and plantar fascia insertion points, as well as more widespread muscle tenderness. Her bloods demonstrated normal inflammatory markers and MRI of her lumbar spine, pelvis, and sacroiliac joints showed a subtle disc degeneration with bulge at L5/S1 without nerve root compression or evidence of inflammation.An MDT approach was taken to manage her pain, with input from occupational therapy, discussing pain processing, pacing, pain management strategies, and sleep hygiene, and physiotherapy including hydrotherapy and a home exercise programme. Despite these interventions, her pain progressed and resulted in further functional impairment. Following MDT discussion, an MRI, already repeated after her first appointment, was performed for the third time which on this occasion demonstrated bilateral sacroiliitis with subchondral sclerosis, erosions, and bone marrow oedema. A diagnosis of enthesitis-related arthritis was made and treatment with diclofenac and etanercept was initiated.Case report - DiscussionWith HLA B27 positivity and a history of acute uveitis, she was clearly at risk of developing inflammatory arthritis, but without evidence of inflammation on imaging or bloods, treatment with immunomodulatory drugs was not indicated. With a high prevalence of non-inflammatory musculoskeletal pain in adolescent females and the significant rate of persistent chronic pain into adulthood for untreated patients, early MDT input in this patient’s management was essential. While management of non-inflammatory pain is primarily driven by therapists, this case highlights the benefit of communication within the MDT and the important role of the medical team, in regularly reviewing the diagnosis, particularly where symptoms evolve or do not follow the expected clinical course.Case report - Key learning pointsIn the presence of risk factors for spondyloarthropathy, a diagnosis of non-inflammatory back pain needs to be regularly reviewed and evolving symptoms, clinical deterioration, and patient or parent concerns need to be addressed. Although important, HLA B27 positivity has an overall penetrance of less than 20% and therefore does not exclude a diagnosis of non-inflammatory back pain. However, when coupled with history of uveitis or significant family history, repeat imaging should be considered.

Optimizing surgery of metaphyseal-diaphyseal fractures of the fifth metatarsal: a cadaveric study on implications of intramedullary screw position, screw parameters and surrounding anatomic structures

AimsMany advocate screw fixation of fractures to the metaphyseal-diaphyseal junction of the fifth metatarsal base, better known as Jones fractures (JF), to facilitate quicker ambulation and return to sport. Maximizing screw parameters based on fifth metatarsal (MT5) anatomy, alongside understanding the anatomic structures compromised by screw insertion, may optimize surgical outcomes. This study aims to (1) correlate the proximity of JF to the peroneus brevis (PB) and plantar fascia (PF) footprints and (2) quantify optimal screw parameters given MT5 anatomy. Materials and methods3D CT-scan reconstructions were made of 21 cadaveric MT5s, followed by meticulous mapping of the PB and PF onto the reconstructions. Based on bone length, shape, narrowest intramedullary canal (IMC) diameter, and surrounding anatomy, two traditional debated screw positions were modeled for each reconstruction: (1) an anatomically positioned screw (AP), predicated on maximizing screw length by following the IMC for as long as possible, and (2) a clinically achievable screw (CA), predicated on maximizing screw length without violating the fifth tarso-metatarsal joint or adjacent cuboid bone. Fixation parameters were calculated for all models. ResultsThe PB and PF extended into the JF site in 29% and 43%, respectively. AP's did not affect PB and PF footprint but required screw entry through the cuboid and fifth tarso-metatarsal joint in all specimens. CA screw entry sites, avoiding the cuboid and fifth tarso-metatarsal joint, partially compromised the PB and PF insertions in 33% and 62% with a median surface loss of 1.6%%(range 0.2-3.2%) and 0.81%%(range 0.05-1.6%), respectively. Mean AP screw length was 64±3.6mm and thread length 49±4.2mm. Mean CA screw length was 48±5.8mm and thread length 28±6.9mm. ConclusionThis study underscores the challenges associated with surrounding MT5 anatomy as they relate to optimal JF treatment. Both the extent of JF as well as a clinically achievable positioned screw violate the PB and PF footprints – although the degree to which even partial disruption of these footprints has on outcome remains unclear. To minimize damage to surrounding structures, including the PB and PF footprint, while allowing a screw length approximately two thirds of the metatarsal length, the CA screw position is recommended. This position balances the desire to maximize pull out strength while avoiding cortical penetration or inadvertent fracture site distraction.

Plantar fascia enthesitis: Clinical, radiographic and ultrasound findings in patients with axial spondyloarthritis

Aim of the workTo assess the clinical, radiographic and sonographic presentation of plantar fascia in axial spondyloarthritis (ax-SpA) and to identify the radiographic and ultrasonographic signs most associated with clinical disease parameters. Patients and methodsThe study included 74 patients with ax-SpA. Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Functional Index (BASFI) and Ankylosing Spondylitis Quality of Life (ASQoL) were assessed. Clinical assessment of plantar fascia included the plantar fascia palpation pain severity on a visual analogic scale (VAS); and the enthesitis-specific scores: The Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) and the Spondyloarthritis Research Consortium of Canada (SPARCC) score. All patients were explored by lateral heel radiographs and musculoskeletal ultrasound (US) at plantar fascia insertions. ResultsThe mean age was 36 ± 11.4 years. Plantar fascia enthesis was painful in 17% of cases. Standard radiographs showed plantar fascia involvement in 37% and US in 71% of patients. The clinical involvement of plantar fascia correlated with BASDAI (p = 0.02), as well as BASFI (p = 0.03) and ASQoL (p < 0.0001). X-ray enthesophyte was the most related to plantar fascia pain palpation (p < 0.01), MASES(p < 0.001) and SPARCC(p < 0.05). US entheseal thickening was related with pain palpation (p < 0.001) and MASES (p < 0.05). US enthesophyte was related with palpation pain (p < 0.05). Bony erosion was related to SPARCC (p < 0.05). ConclusionPlantar fascia in ax-SpA is often asymptomatic and associated with disease activity and functional impairment. The presence of enthesophyte was the radiographic sign most associated with clinical enthesitic involvement. Entheseal thickening, enthesophyte and bony erosion were the sonographic signs most associated with enthesitic.

The Effect of Strassburg Sock Orthosis on Heel Pain and Quality of Life in Patient with Plantar Fasciitis Lesion

Introduction : Plantar fasciitis is the most common reason for heel pain and the result of some repetitive trauma in calcaneus. People with plantar fasciitis need to be treated through some stretching techniques for plantar fascia and calf muscles, and some anti-inflammatory treatments. Materials and Methods: In this randomized clinical trial study, 28 patients with plantar fasciitis were selected through convenience sampling method. Individuals with morning pain and tenderness in the insertion of plantar fascia were included, and were assigned in two control and experimental groups. Individuals with a history of surgery, dislocation, and fracture in the lower limb were excluded. Then, they were referred to technical orthopedic clinics for night splinting. The heel pain and quality of life were assessed through Visual Analogue Scale (VAS) and Foot Ankle Outcome Questionnaire, respectively, before treatment, and at the end of the first, fourth, and sixth weeks. The collected data were compared between the groups using independent t test with a significant level of P < 0.05. Results: Regarding pain, daily activity, and sport, there were significant differences between the control and experimental groups at the fourth and sixth weeks. In terms of foot and ankle problems and quality of life, there were significant differences between the control and experimental groups at the first, fourth, and sixth week Conclusion: The current study indicates that prefabricate orthotic may be effective in pain relief of the heel, improvement of daily activities, and doing sport over time. Ultimately, the use of this splint increases the quality of life and decreases foot and ankle problems in the people with plantar fasciitis.

Development of a Preliminary Ultrasonographic Enthesitis Score in Psoriatic Arthritis - GRAPPA Ultrasound Working Group.

To assess the performance of various sonographic elemental entheseal lesions in distinguishing between psoriatic arthritis (PsA) and controls to inform the development of a novel sonographic enthesitis score for PsA. A total of 100 age- and sex-matched individuals (50 PsA and 50 controls) were evaluated. Eleven entheseal sites were scanned bilaterally according to a standardized protocol by 2 sonographers. Based on the Outcome Measures in Rheumatology (OMERACT) definition of sonographic enthesitis, the following lesions were assessed: structural entheseal changes (hypoechogenicity), thickening, bone erosion, enthesophytes, calcification, and Doppler signal, in addition to bursitis and bone irregularities. The images were read by 2 readers blinded to the clinical information. A series of logistic regression models were used to find the optimal combination of entheseal sites and elementary lesions that distinguished PsA from controls. Mean age was 55 ± 10 years (59% males). The optimal model that distinguished PsA from controls included 5 elementary lesions (enthesophytes, Doppler signal, erosions, thickening, and hypoechogenicity) and 6 entheseal sites (patellar ligament insertions into the distal patella and tibial tuberosity, Achilles tendon and plantar fascia insertions into the calcaneus, common extensor tendon insertion into lateral epicondyle, and supraspinatus insertion into the superior facet of the humerus). The area under the receiver-operating characteristic curve for this model was 0.93 (95% CI 0.88-0.98). We identified potential elemental ultrasonographic abnormalities and entheseal sites that could distinguish PsA and controls. This information will contribute to the development of a new sonographic score for assessment of enthesitis in patients with PsA.

Coexistence of plantar calcaneal spurs and plantar fascial thickening in individuals with plantar heel pain.

To examine associations between plantar calcaneal spurs, plantar fascia thickening and plantar heel pain (PHP), and to determine whether tenderness on palpation of the heel differentiates between these presentations. Adults aged ⩾50 years registered with four general practices were mailed a Health Survey. Responders reporting foot pain within the last 12 months underwent a detailed clinical assessment. PHP in the past month was documented using a foot manikin. Plantar calcaneal spurs were identified from weight-bearing lateral radiographs and plantar fascia thickening (defined as >4 mm) from ultrasound. Tenderness on palpation of the plantar fascia insertion was documented. Associations between these factors and PHP were explored using generalized estimating equations. Clinical and radiographic data were available from 530 participants (296 women, mean [s.d.] age 64.9 [8.4] years), 117 (22.1%) of whom reported PHP. Plantar calcaneal spurs and plantar fascia thickening were identified in 281 (26.5%) and 501 (47.3%) feet, respectively, but frequently coexisted (n = 217, 20.4%). Isolated plantar calcaneal spurs were rare (n = 64, 6.0%). Participants with PHP were more likely to have a combination of these features compared with those without PHP (odds ratio 2.16, 95% CI 1.24, 3.77, P = 0.007). Tenderness on palpation of the heel was not associated with plantar calcaneal spurs or plantar fascia thickening, either in isolation or in combination, in those with PHP. Plantar calcaneal spurs and plantar fascial thickening are associated with PHP, but frequently coexist. Tenderness on palpation of the heel does not appear to differentiate between clinical presentations of PHP.

Finite element modelling of Plantar Fascia response during running on different surface types

Plantar fascia is a ligament found in human foot structure located beneath the skin of human foot that functioning to stabilize longitudinal arch of human foot during standing and normal gait. To perform direct experiment on plantar fascia seems very difficult since the structure located underneath the soft tissue. The aim of this study is to develop a finite element (FE) model of foot with plantar fascia and investigate the effect of the surface hardness on biomechanical response of plantar fascia during running. The plantar fascia model was developed using Solidworks 2015 according to the bone structure of foot model that was obtained from Turbosquid database. Boundary conditions were set out based on the data obtained from experiment of ground reaction force response during running on different surface hardness. The finite element analysis was performed using Ansys 14. The results found that the peak of stress and strain distribution were occur on the insertion of plantar fascia to bone especially on calcaneal area. Plantar fascia became stiffer with increment of Young’s modulus value and was able to resist more loads. Strain of plantar fascia was decreased when Young’s modulus increased with the same amount of loading.

The Peroneus Brevis and Plantar Fascia Insertions Are Related to Proximal Fifth Metatarsal Fractures

Category: Midfoot/Forefoot Introduction/Purpose: Proximal fifth metatarsal fractures (PFMF) are among the most common fractures in the foot and can be categorized into three fracture zones [1]. To investigate the fracture mechanism of PFMF in different zones, a better understanding of the anatomy of the bone and its surrounding soft tissues is required. Both the plantar fascia (PF) and the peroneus brevis (PB) tendon insertions are at the base of the fifth metatarsal, and may contribute to the pathophysiology of PFMF. However, the role of the PB and PF insertions in the pathogenesis of PFMF remains unclear. The purpose of this study was to accurately define the footprint of the PB and PF insertions of the base of the 5th metatarsal in relation to the different zones of PFMF. Methods: 21 cadaveric fifth metatarsal bones were harvested from cadaveric feet. All bones were freed of any remaining soft tissue adherence, except for the PB and the PF insertions. Three reference screws with a diameter of 1 mm were placed and secured on each bone with 2 screws distally and 1 screw proximally for registration. All bones were CT scanned to create a 3D bone reconstruction. Next, the insertions of the PB and PF and the reference screws of each bone were digitized and then mapped to its corresponding 3D bone model. In order to describe the three different fracture zones of the 5th metatarsal, an established coordinate system was made for each bone to simulate separate fracture zones (Figure a) based on Lawrence guideline [1]. The shape, location and surface areas of both insertions and their relation to the different fractures zones were determined (Figure b). Results: The insertion of the PB was oval shaped and located on the dorsal side of the base, with a mean surface area of 88.1 ± 46.4 mm2. The PF was oval shaped and situated around the tip of tuberosity, with a mean surface area of 150.7±53.5 mm2. The PB insertion was present in zone 1 fractures in 100% (21/21) of the 5th metatarsal models and 29% (6/21) of the models for zone 2 fractures. The PF insertion was involved in 100% (21/21) of the 5th metatarsal models for zone 1 fractures and 43% (9/21) of the models for zone 2 fractures. Conclusion: Results of this study demonstrate that the insertion of both the PB and PF are involved in all zone 1 PFMF and a significant percentage of zone 2 PFMF. The location of tendon insertions affect the forces exerted on the bone, which may indicate a relation of the insertions of both the PB and the PF with the fracture mechanism of many zone 1 and 2 PFMF. Moreover, in the treatment of these fractures, care should be taken to maintain or restore the anatomy of these insertions to maximize functional outcomes.

Plantar Fascia Release Through a Single Lateral Incision

Category: Hindfoot, Midfoot/Forefoot, Cadaver Study Introduction/Purpose: Plantar fascia release (PFR) and calcaneal slide osteotomy (CSO) are often components of surgical management for cavus deformities of the foot. In this setting, the PFR has traditionally been performed through an incision over the medial calcaneal tuberosity, while the CSO is performed through a lateral incision. Two separate incisions can potentially increase surgical morbidity. We hypothesized that the plantar fascia could be fully released from the same lateral based incision that is used for the CSO, obviating the need for a medial incision. Methods: Six cadaver feet were dissected. A medial sided dissection was performed to isolate the tibial, medial plantar, lateral plantar, and calcaneal nerves, and the origin of the plantar fascia. Next, an incision was made on the lateral aspect of the ankle inferior and parallel to the peroneus longus tendon. Dissection was carried to bone. A curved face osteotome was utilized to sweep the plantar fascia off the calcaneus just distal to its proximal insertion. A #10 scalpel was inserted into this space, parallel to the plantar fascia and was directed towards the plantar fascia insertion; it was then turned ninety degrees so that the blade was perpendicular to the plantar fascia. The ankle was dorsiflexed until a full release was achieved. A Stryker oscillating saw was used to create a CSO through the lateral incision. We then inspected the medial structures in their relationship to the PFR and CSO. Results: In all six cadavers, the plantar fascia was fully released from its origin at the medial calcaneal tuberosity through the lateral incision. There was no obvious damage to the medial and lateral plantar nerves with this lateral based PFR. The CSO made through the lateral incision reliably crossed the calcaneal branch of the tibial nerve in all specimens and the osteotomy was posterior to the lateral and medial branches of the tibial nerve. Conclusion: PFR through a lateral incision is a safe and reliable method as part of the surgical treatment for cavus deformities of the foot. We achieved a full PFR in each cadaver specimen. An added benefit is that PFR through a lateral incision avoids the morbidity of an additional surgical incision. Further, a calcaneal slide osteotomy performed through a lateral based incision reliably crosses the calcaneal branch of the tibial nerve. Both PFR and CSO can be safely performed through a lateral incision; however, care must be taken when completing the CSO to ensure that the medial neurovascular structures remain uninjured.

Optimal Fixation of Jones Fractures Sacrifices the Peroneal Brevis Tendon Insertion andthe Plantar Fascia

Objectives:Patients with Jones fractures (JF) frequently undergo operative management with intramedullary screw fixation. Screw insertion through the base of the fifth metatarsal potentially compromises attachment points of the plantar fascia (PF) and peroneal brevis tendon (PB), and appropriate screw length and diameter remains controversial. The aim of this study was to define the anatomy of the fifth metatarsal bone using CT modeling in order to provide better guidance regarding optimized screw insertion point, screw length, diameter, and thread length and, moreover, to give better insight in the possible compromise of the PB and PF when placing a screw.Methods:Following IRB approval, 21 cadaveric fifth metatarsal bones were harvested. Three reference screws (1mm diameter) were placed and secured on each bone, with 2 screws distally and 1 screw proximally, to act as a geographic register. All bones were CT scanned to create 3D reconstructions using modeling software (Rhinoceros, v5.0). The outer cortex, intramedullary canal and articular cortex of each bone were identified. Using a digitizer (MircoScribe, G2LX), the PB and PF insertions, alongside the reference screws, were mapped onto the corresponding specimen. The total length of the bone, the shape and diameter at the narrowest point of the intramedullary canal were also measured.. Optimal screw diameter and length were calculated in this position, and the impact of screw placement on the insertion sites of both the PB and PF was recorded.Results:The mean length of the bones was 74 ± 3.6mm, with the narrowest diameter of the intramedullary canal being 4.3 ± 0.7 mm. Ideal screw position was identified as parallel to the cuboid and coaxial with the intramedullary cortex, partially sacrificing the PB and PF insertions in 62% (13/21) and 33% (7/21)of specimens respectively, with an average sacrified area of 1.6 ± 0.8 mm of the PB and 1.3 ± 0.8 mm of the PF insertion. The ideal screw length was 48 ± 5.8 mm, with a minimal thread length of 28 ± 6.8 mm and a minimal diameter of 4.5 mm. The screw length:total bone length ratio was 0.64 (range .050-0.72).Conclusion:To maximize compression and pull-out strength, as well as minimize destruction of soft tissue insertions during screw placement for the treatment of JF, screws should be placed parallel to the cuboid and collinear with the intramedullary cortex—mitigating but not avoiding injury to the PB and PF. Average optimal length of the screw should cover 64% of the length of the bone, with a minimum 4.5 mm diameter and 50% thread length. Given variability in anatomy, however, screw choice should be tailored to the individual. Operative treatment of JF, a common foot injury, represent one of the more controversial surgical techniques in foot care today. Improving anatomic understanding of the implications of screw insertion will be paramount to maximizing functional outcomes.

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.

Ultrasound of the joints and entheses in healthy children.

Tendon insertion pathologies such as enthesitis and apophysitis in children can result from trauma, overuse syndrome and arthritis. Knowledge of the US appearance of normal joints by age might aid diagnosis of pathologies. We describe the age-related sonographic features of the elbows, knees and feet in healthy children, providing a reference for the normal appearance of tendon insertions, apophyseal cartilage and bursae. This is a prospective cross-sectional study of 30 healthy children. Children were grouped according to age: group 1 (4-9years, n = 11), group 2 (10-13years, n = 9) and group 3 (14-18years, n = 10). Children completed pain and function questionnaires and underwent a standardized joint examination by a pediatric rheumatologist. The common extensor, common flexor, quadriceps, patellar and Achilles tendons and plantar fascia insertions were evaluated with gray-scale and power Doppler ultrasound. The anterior elbow, suprapatellar and retrocalcaneal bursae were evaluated for fluid. We measured the apophyseal cartilage thickness at the enthesis. Correlation analyses examined associations between age and tendon thickness. We used ANOVA, with location as a repeated measure, to test for gender differences in cartilage thickness. Children had a median age of 12.4years and 55% were boys. All 360 entheses appeared normal on gray-scale imaging. There was a strong linear relationship between tendon thickness and age. Tendon vascularity was only present in young children (group 1), in 7/22 (32%) quadriceps tendons. Peri-tendinous power Doppler signal was seen at seven sites: two patellar, four quadriceps and one common flexor tendon, and all these children were in group 2. Suprapatellar bursal fluid <3mm was detected in 9/60 (15%) knees. Of the children in group 1, boys had thicker apophyseal cartilage than girls at the medial epicondyle, patellar poles and os calcis (P < 0.05). Tendon vascularity may be a normal finding in young children, and mild peri-tendinous vascularity is not uncommon in children 10-13years of age. Tendon thickness has a linear relationship with age; however cartilage thickness varies across sites and also differs as a function of gender.

SAT0387 Ultrasonographic and Clinical Assessment of Peripheral Enthesitis in Italian Patients with Psoriatic Arthritis, Psoriasis and Fibromyalgia –The ULISSE Study

BackgroundEnthesitis in Spondylarthropathy (SpA) is underestimated and often misdiagnosed. A recent paper suggests that tenderness at entheseal sites by itself is not useful in distinguishing between psoriatic arthritis (PsA) and...

OP0165 Whole-body MRI for assessment of enthesitis in psoriatic arthritis, axial spondyloarthritis and healthy subjects – a comparison with 7 clinical enthesitis indices

BackgroundTender entheses is a common disease manifestation in patients with psoriatic arthritis (PsA) and spondyloarthritis (SpA). Whole-body MRI (WBMRI) is a new imaging modality where patients are scanned from “head...

Immediate Clinical and Biomechanical Effects of Low-dye Taping in Patients with Plantar Heel Pain

Plantar heel pain is common musculoskeletal disorder of the foot related to sports activity. Treatment of the plantar heel pain is usually conservative including low-dye (LD) taping. We evaluated the immediate clinical and biomechanical effect of LD taping. 19 patients who had plantar heel pain with fat pad tenderness or tenderness on plantar fascia insertion area participated in this study. We assessed plantar pressure change with foot pressure analysis system, fat pad depth changes with ultrasonography, pain improvement with visual analogue scale before and after LD taping. Patient treated with LD taping showed the decrease in maximum peak pressure and pressure time integral, and there was not a significant difference between pre and post maximal velocity, average velocity, distance of center of pressure. Fat pad depth increase (mean 1.67 mm, p

Plantar Fascia: Imaging Diagnosis and Guided Treatment

Plantar fasciopathy is a common cause of heel pain. This article covers the imaging anatomy of the hindfoot, the imaging findings on ultrasound and magnetic resonance imaging (MRI) of plantar fasciopathy, plantar fibromas, trauma, Achilles tendonopathy, neural compression, stress fractures of the os calcis and other heel pad lesions. Thickening of the plantar fascia insertion more than 5 mm either on ultrasound or MRI is suggestive of plantar fasciopathy. Ultrasound is superior to MRI for diagnosis of plantar fibroma as small low signal lesions on MRI are similar to the normal plantar fascia signal. Ultrasound demonstrates low echogenicity compared with the echogenic plantar fascia. Penetrating injuries can appear bizarre due to associated foreign body impaction and infection. Achilles tendonopathy can cause heel pain and should be considered as a possible diagnosis. Treatment options include physical therapy, ECSWT, corticosteroid injection, and dry needling. Percutaneous US guided treatment methods will be described.

Early diagnostic Achilles tendinopathy in patients with psoriasis and arthralgia

Psoriatic arthritis belongs to a group of spondyloarthropaties that are characterised by, among other things, enthesopathy. The most typical enthesitis is heel pain related to inflammation of the Achilles tendon...