Plantar fasciitis (also known as plantar fasciopathy or jogger’s heel) is a common painful disorder affecting the heel and underside of the foot. According to League (2009) 50% of patients will progress to bony heel spur if the problem is longstanding and at the origin of the fascia.
Plantar fasciitis got part of it’s name, ‘itis’, as it was believed to be an inflammatory condition. However, just like many other conditions this is argued about with studies observing microscopic anatomical changes indicating that plantar fasciitis is actually due to a non-inflammatory structural breakdown of the plantar fascia rather than an inflammatory process (Tahririan et al., 2014 and Yin et al., 2014). Due to debate, many in the academic community have stated the condition should be renamed plantar fasciosis.
The breakdown of the plantar fascia can be attributed to repetitive microtrauma (Monto, 2013 and Orchard, 2012). Microscopic examination of the plantar fascia often shows myxomatous degeneration, connective tissue calcium deposits and disorganized collagen fibres (Lareaur et al. 2014).
Standing and walking mechanically incorrectly (the Windlass mechanism) have been proposed as a contributing factor. This is thought to place excess strain on the calcaneal tuberosity leading to the problem (Yin et al., 2014).
Other studies have also suggested that plantar fasciitis is not actually due to inflamed plantar fascia, but may be a tendon injury involving the flexor digitorum brevis muscle located immediately deep to the plantar fascia (Orchard 2012).
Recommendation:
- Continuous 3mhz
- 3mhz 0.5-1.5 W/cm2
- 4-15 mins (10 is average)
- Frequency = 1x per day down to 1 x per week (3 per week is average)
- Session 1-24 (10 is average)
- Combine with =
- Ice
- Orthotics
- Night splints
- Home exercises (streaching)
- Dry needling
There are many reports in the literature that describe the physiological effects of therapeutic ultrasound. Published reports of only a few clinical trials have described conflicting conclusions. In 1996, Crawford and Snaith evaluated the therapeutic effects of US in the treatment of plantar heel pain, as compared with sham ultrasound. Both groups showed pain reduction (30% in the US group and 25% in the placebo group), but the results were not statistically significant. US remains the most common treatment routinely applied for plantar fasciitis and plantar heel pain (Konjen et al. 2015).
In 2004, Kaewpinthong showed that both US and shockwave therapy reduced levels of pain at 3, 6, and 12 weeks. In 2007, Cheing showed that both US and shockwave lead to a reduction in heel pain (9 sessions of ultrasound therapy) over a three week period.
In 2015 Konjen et al. performed US with a Sonoplus 591 Enraf Nonius unit at a frequency of 3MHz, intensity of 0.5-1 watt/cm2 , continuous mode, for 10 minutes. All sessions were administered by the same physical therapist; eighteen sessions were undertaken at a frequency of 3 sessions per week. Patient VAS pain scores showing significant reduction from the first week of treatment. Foot mobility function according to the PFPS mobility subscale also showed improvement at the end of treatment. These results supported the effectiveness of ultrasound therapy in the treatment of plantar fasciitis.
Akinoglu et al. (2017) looked at shockwave vs US and found that although both groups had improved scores, the improvements were clinically more meaningful in the ultrasound group at one month, which was statistically significant. Ultrasound treatment twice per week for three weeks (7 sessions) and home exercise (including plantar fascia and gastrocnemius stretching) twice a day for four weeks.
Grecco et al. (2013) again compared shockwave and US at 3 months VAS was improved more in the US group 65% v 70% at 12 months both were good improvements but shockwave was ahead 85% v 80% good outcome with good outcome defined as VAS score of 1/10 or less. They gave ten sessions of US with home exercise program including plantar fascia and gastrocnemius stretching.
Ulusoy et al. (2017) found ESWT and stretching statistically and clinically significantly superior to US after one month (success defined as 60% or more VAS improvement) to ultrasound and stretching (65% V 23.5%) for pain measured with VAS 5 sessions per week for 3 weeks (15 sessions) of continuous ultrasound (US) and home exercise including gastrocnemius and plantar fascia stretching.
Li et al. (2018) reviewed the available literature for various treatments for plantar fasciitis. They found US corresponded to significant pain reduction compared with placebo at 0 to 6 weeks MD = 2.33, 95% CrI: (1.10, 3.58). US also showed statistically significant superiority with regard to the short-term results vs placebo. However the pooled results (due to the wide 95% confidence intervals) of the network meta-analysis showed that ultrasound did not demonstrate significantly better outcomes than placebo over the short, intermediate, and medium terms. They concluded that although US worked it does not seem to be an optimal choice for reducing plantar fasciitis pain over the 3 time periods.
More recently Zeyana et al. (2021) performed a meta analysis including US and shockwave and said of the seven studies identified. No significant difference was found between ESWT and US for functional impairment, AOFAS scale score and pain in the first steps in the morning. Shockwave showed better long term results.