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Over recent yrs, I have picked up on more and more comments from clinicians using diagnostic ultrasound on its usefulness to help predict clinical responses to interventions for plantar fasciitis; certainly not that evidence based (yet), but none-the-less people are finding it useful clinically and anecdotally. I have been trying to get a better handle on this and drawing on other peoples experiences, but its been difficult to quantify those experiences.

A couple of studies have started to look at this:
Prognostic Value of Diagnostic Sonography in Patients With Plantar Fasciitis.
Ultrasound thickness correlates to improvement in plantar fasciitis
Ultrasound scanning for recalcitrant plantar fasciopathy. Basis of a new classification

I just got my hands on a copy of a book by Stephen L Barret DPM: Heel Pain, Healing the Heal which documents his own extensive experiences with plantar fasciitis (I won't get into the its not really "-itis" issue for now). More on book: Amazon.com; Amazon.uk; Book Depository; Fishpond.au). There were certainly a lot of useful clinical pearls in the book and some thought provoking opinions worthy of further consideration and development.

One I will raise here was the classification that he developed and uses to guide treatment options. I reached out to Stephen and he sent me a good copy of the table to use here:



The classification is based on thickness and hypoechoic signal seen on ultrasound and then staged based on duration; sort of what the clinicians I mentioned above have been saying is a useful prognostic indicator and guide to the nature of the treatment used.

While the classification has not been validated nor used in any clinical trial, it does raise of a lot of possibilities, especially on things like how well different categories of plantar fasciitis respond to the different treatments.

Some thoughts:
- what if a clinical trial on say, foot orthoses, for plantar fasciitis ended up by chance with a lot of feet, say, in category IIIC? Perhaps feet in that category do not respond too well to foot orthotics, so the study might conclude that orthotics are useless for plantar fasciitis and the results get extrapolated to all cases of plantar fasciitis. Whereas if most of the cases in the study were, say Category IB, they might have all responded brilliantly within a few weeks (or they might not) ...I trying to make a point.
- I never cease to be amazed as the quality of online advice given to, say, runners when they have plantar fasciitis (esp from non-clinicians) and that advice is one-size-fits all as it worked for me. They need to realize that plantar fasciitis is a diverse clinical entity and will need different clinical approaches depending on the staging.
- for eg, a recent paper on stretching vs strengthening for plantar fasciitis created quite a buzz in social media. Wouldn't it be nice to know the response rates to those interventions if the cases in the study were divided into the above categories? and which categories are more responsive to stretching and/or strengthening?

When I asked Stephen for a copy of the table to use here, in his reply be said

yep! What say you?

 

Great post Craig . Anything that can help to improve outcomes when treating pl fasciitis/osis is most welcome.