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Ultrasound therapy for plantar fasciitis

Discussion in 'General Issues and Discussion Forum' started by *sole_man*, Oct 28, 2005.

  1. *sole_man*

    *sole_man* Member

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    Hi, I am thinking of buying an ultrasound therapy unit to use in my practice. I keep reading conflicting data regarding the uses of 1mhz and 3mhz. I wondered if anyone has good expeience is the use of both. IdeallyI need some general rules eg- which for plantar fasciitis or which for deep and which for superficial. Hopefully someone can give me some advice based on experience rather than 6 weeks worth of research :) . Thanks.
  2. DAVOhorn

    DAVOhorn Well-Known Member

    Before you shell out for this piece of equipment speak to your local Physio dept on the benefits of Ultrasound to t/t soft tissue inflammation.

    I think you will find that they will persuade you of the merits of not buying one and its loss of favour as a modality of t/t for soft tissue inflammation.

    regards David
  3. Craig Payne

    Craig Payne Moderator

    I stand to be corrected on this, but wasn't there an RCT many years ago on ultrasound in PF and for half the machine was turned off and there was no difference between the groups.

    Despite being called "fasciitis", it is NOT an inflammatory process .... its degenerative process and should be called "fasciosis".
  4. DAVOhorn

    DAVOhorn Well-Known Member

    re loss of memory

    Dear Craig,

    your memory is not too shabby.

    There was also another test involving the use of Ultrasound and alternative heat sources eg hot water bottle.

    The hot water bottle and ultrasound had comparable outcomes. They both worked moderately. But the hot water bottle was a bit cheaper to buy.

    regards David
  5. kenstack

    kenstack Welcome New Poster

    US for plantar fasciosis

    Hey everyone-

    For what it's worth I have toiled for several years trying to treat this condition with modalities, primarily Ultrasound, to little avail. I would not recommend pruchasing one to help patients. The reimbursement for ultrasound treatment is also very poor as a FYI.

    If I could bring one thing up regarding this condition - I am a bit tired of having patients arrive for outpatient therapy and report they are doing their plantar fascia stretches as the doctor told them. I ask them to demonstrate and they are nothing more than a gastrocnemius muscle belly stretch (runner's standing stretch) and a soleus stretch (same technqiue with knee bent). What is so difficult about stretching the plantar fascia through some dorsiflexion and forefoot rotation?

    Ken Stack
    Physical Therapist
  6. Craig Payne

    Craig Payne Moderator

    I think the evidence is very clear on plantar fasical stretching:
    DiGiovanni BF, Nawoczenski DA, Lintal ME, Moore EA, Murray JC, Wilding GE, Baumhauer JF.
    Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study.
    J Bone Joint Surg Am. 2003 Jul;85-A(7):1270-7.
  7. kenstack

    kenstack Welcome New Poster

    Plantar fascia stretching

    My question was not one of exercise validity but one of clinical practice as I do not see plantar fascia specific stretching being prescribed. Perhaps it is a US problem.

  8. GarethNZ

    GarethNZ Active Member

    I was going to recommend the paper Craig noted...but scrolled down the thread and he's already posted it. There definitely was an improvement in VAS scales compared to muscle stretches.
  9. Berms

    Berms Active Member

    plantar "fasciosis"

    Hi Craig, I know I'm a little late with this thread... but I was really interested in your description of plantar fasciitis as a degenerative process rather than an inflammatory one. I understand that the fascia itself may undergo degenerative changes as a longterm result of the condition, but isn't an ongoing inflammatory response generated in the tissues by the constant microtrauma at the site of the fascial insertion to the calcaneal tubercle? And isn't the reason behind "first step" pain in the mornings a result of the overnight inflammatory response and pooling of fluids in the tissue spaces? :confused: I know this is what I was taught in my training, and the inflammation in the local tissues can be seen and palpated on feet in the clinical setting.
    Would like to hear more on your thoughts about this.

  10. Craig Payne

    Craig Payne Moderator

    Here is the reference:
    Plantar Fasciitis A Degenerative Process (Fasciosis) Without Inflammation
  11. Craig Payne

    Craig Payne Moderator

    this sentence in the abstract is somewhat inconsistent with the discussion in this thread:
    Plantar fasciitis treated with local steroid injection
  12. Hylton Menz

    Hylton Menz Guest

    Here at La Trobe, Dr Jill Cook has done extensive research into achilles and patellar tendinopathy which suggests that overuse syndromes of tendons are not inflammatory (see Time to abandon the tendonitis myth BMJ editorial). One of the current theories is that a degenerative process involving formation of new blood vessels (neovascularisation) may be responsible for the pain (ref). A similar process may be taking place within the plantar fascia.


  13. betafeet

    betafeet Active Member

    Hi All thought you would appreciate seeing a bit more of this paper, much cheaper than ultrasound;

    Specific Stretching Exercises Can Relieve Chronic Heel Pain Symptoms

    ROSEMONT, IL -- July 2, 2003 -- Exercises that specifically stretch the plantar fascia can relieve heel pain caused by an inflammation of the sole (plantar surface) of the foot following an injury of the tough, ligament-like sheet of tissue (fascia) that extends from the heel bone to the base of the toes.
    These findings are the result of an investigation performed by Benedict F. DiGiovanni, MD; Deborah A. Nawoczenski, PhD, PT; Marc E. Lintal, MSPT; Elizabeth A. Moore, MSPT; Joseph C. Murray, MSPT; Gregory E. Wilding, PhD; and Judith F. Baumhauer, MD, of the Department of Orthopaedics, University of Rochester, and the Department of Physical Therapy, Ithaca College - University of Rochester campus, Rochester, New York, and published in the July 2003 issue of The Journal of Bone and Joint Surgery.
    The investigators monitored a group of patients who had experienced persistent and often disabling heel pain for at least ten months. The patients first completed a survey that provided an account of their heel pain and background information that was then matched to the selection criteria of similar age, weight, and time spent standing on their feet. This was followed by an examination by an orthopaedic surgeon to confirm the diagnosis of plantar fascitis. All of the selected patients received prefabricated soft insoles and a three-week course of non-steroidal pain medication and were shown an educational video about plantar fascitis.
    The researchers then split the patients into two groups: Group A received instructions for a non-weight-bearing plantar fascia-stretching program, and Group B were taught a weight-bearing Achilles tendon-stretching regimen. After eight weeks of performing their respective exercises, the patients again evaluated their pain, function, and satisfaction with treatment outcome. The two groups showed significant differences with regard to pain, activity limitations, and satisfaction with results: the members of Group A (plantar fascia stretch) reported greater improvement and satisfaction than those in Group B (Achilles tendon stretch).
    The researchers, therefore, concluded that plantar fascia-stretching exercises are superior to the previously standard Achilles tendon-stretching exercises for relieving chronic heel pain. While the Achilles tendon- stretching exercise does have a beneficial result, as shown by improvement in the patients in Group B, it does not work directly on the plantar fascia and is normally performed after putting weight on the affected heel, which may increase inflammation. The plantar fascia-stretching exercise, on the other hand, "directly isolates the plantar fascia by recreating the windlass mechanism, or the tensioning of the plantar fascia by pulling the toes and ankle toward the shin," says Dr. DiGiovanni, an Orthopaedic Surgeon, and foot and ankle specialist. "The timing of the stretching exercises, before taking the first step in the morning and prior to standing after prolonged sitting, is also very important since it is felt to limit the cycle of repetitive micro-tearing and inflammation occurring with those first painful steps." Dr. DiGiovanni also notes, "the plantar fascia stretching program which has been created is especially promising since it is highly effective, straight- forward, and inexpensive." For these reasons, the researchers think the plantar fascia stretching program should be the stretching exercise emphasized during treatment, rather than the traditional Achilles tendon stretch.
    Dr. DiGiovanni and his colleagues recommend that patients with heel pain caused by plantar fascitis learn how to perform plantar fascia-stretching exercises. Patients are instructed to perform these exercises before getting out of bed in the morning by sitting on the side of the bed and crossing the affected leg over the other leg, resting the ankle on top of the thigh. Using the hand on the affected side, the patient places the fingers across the base of the toes on the bottom of the foot and pulls the toes toward the shin until he or she feels a stretch in the arch of the foot. The patient places the other hand on the sole of the foot to feel the tension and confirm that it is being stretched. Patients are also instructed to perform the stretch prior to standing after prolonged sitting or inactivity, such as after sitting for a meal.
    Patients who perform the Achilles tendon-stretching exercise do their first stretch immediately after getting out of bed in the morning. Standing facing a wall, the patient positions the affected foot behind the other leg and leans into the wall. Before stretching, the patient places a shoe insert under the affected foot to minimize excessive midfoot rotation and points the toes of the affected foot toward the heel of the front foot. The patient bends the front knee while keeping the back knee straight and the affected heel firmly on the floor.
    Both groups were told to hold each stretch for a count of ten and to repeat ten times, three times a day.
    Dr. DiGiovanni and his colleagues are just completing a two-year follow-up study on the effect of plantar fascia-stretching exercises on chronic heel pain. He also plans to explore the possibility that beginning such an exercise program earlier after the onset of heel pain can shorten the duration of symptoms. His goal is to provide a breakthrough in treatment for those who suffer ongoing heel pain.
    SOURCE: American Academy of Orthopaedic Surgeons

  14. E Gurskin

    E Gurskin Welcome New Poster

    I am also interested in advice on the validity of ultrasound therapy. Does the therapy ultimately ruin tissue?
  15. brownpods

    brownpods Welcome New Poster

    2 comments covering both topics-
    1. The use of Dexamethasone. This is a soluble short acting drug and I would not necessarily expect it to have a prolonged action or benefit, unless there is some other incidental mechanism acting such as `breaking the pain cycle`. But much more benign than a depot preparation. I recall Tim Kilmartin routinely using a series of 3 Dexamethasone injections when I visited his hospital some years ago, dont recall if he published any audit data which is his usual practice, so whether serial injections provide more lasting benefit than the sum of individual ones ?.
    2. Maybe PF is a degenerative condition but with inflammatory/neovascular elements occuring from time to time, even if not constantly ?, sounds reasonable. This can be verified, If you are trained in use of Dx Sonography its relatively easy to apply the Power Doppler mode and actually check for presence and extent of inflammation/neovascularity in real-time at any point in time.
    Brian Brown

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