This modality is both preciseand cost-effective.

Diagnostic andTherapeutic

Management ofHeel Pain Via Ultrasound-

Guided Injection

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Musculoskeletal ultrasound isa relatively new modalityfor podiatrists to aid in the

diagnosis and treatment of injury

and/or diseases of the foot and ankle.Advances in technology have al-lowed for the availability of muscu-loskeletal ultrasound units that arediagnostically cost-effective and ap-propriate for office practice. In lightof evidenced-based medicine becom-

ing more important, the diagnosticand therapeutic use of musculoskele-tal ultrasound is becoming aquintessential component of manypodiatric practices today.

Indications for the use of muscu-

By Praveen K. Vohra, DPM & Christopher J. Japour, DPM, MS

Continued on page 164

Welcome to Podiatry Management’s CME Instructional program. Our journal has been approved as a sponsor of Contin-uing Medical Education by the Council on Podiatric Medical Education.

You may enroll: 1) on a per issue basis (at $17.50 per topic) or 2) per year, for the special introductory rate of $99 (yousave $76). You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. In the nearfuture, you may be able to submit via the Internet.

If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earned cred-its. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake the test atno additional cost. A list of states currently honoring CPME approved credits is listed on pg. 170. Other than those entities cur-rently accepting CPME-approved credit, Podiatry Management cannot guarantee that these CME credits will be acceptable byany state licensing agency, hospital, managed care organization or other entity. PM will, however, use its best efforts to ensurethe widest acceptance of this program possible.

This instructional CME program is designed to supplement, NOT replace, existing CME seminars. Thegoal of this program is to advance the knowledge of practicing podiatrists. We will endeavor to publish high quality manuscriptsby noted authors and researchers. If you have any questions or comments about this program, you can write or call us at: Podia-try Management, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us at bblock@prodigy.net.

Following this article, an answer sheet and full set of instructions are provided (p. 170).—Editor

ObjectivesAfter reading this continuing ed-ucation article, the podiatric phy-sician will:

1) Recognize ultrasound im-ages of medial, central and later-al plantar fascia bands.

2) Identify ultrasound imagesof normal anatomic medial, cen-tral and lateral plantar fasciabands.

3) Identify abnormal anatomicultrasound images of medial,central and lateral plantar fasciabands.

4) Identify painful areas ofplantar fascia using ultrasoundimaging techniques.

5) Explain how to guide diag-nostic and therapeutic injectionof painful plantar fascia using ul-trasound imaging techniques.

6) Define ultrasound terminol-ogy: hypoechoic, hyperechoic.

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C L I N I C A L P O D I A T R YC L I N I C A L P O D I A T R Y

bats were listening to something be-cause even if blinded they couldfunction effectively. Not until 1938was his question answered when G.W. Pierce invented a sonic detectorthat could pick up very high frequen-cy vibrations of bats and convertthem into sound. The medical appli-cations of ultrasound on biologicalorganisms were initially discussed byexperimenters Robert Wood and Al-fred Loomis. They noted the effectsof high doses of ultrasound on thebody were as injurious as radiation.However, in lower doses, it was noted

to be a therapeutic agent.From 1947 to 1949, George Lud-

wig, a surgeon working at the NavalResearch Institute, collaborated withhis colleagues at Massachusetts Insti-tute of Technology and successfullyused ultrasound to detect gall stones.The 1950’s and 1960’s were to be-come important years for the furtherdevelopment and refinement of ul-trasound imaging, both in the UnitedStates and Japan. In the 1980’s Fran-cis Fry, with his co-worker ElizabethKelly, developed a computer-based,low-intensity ultrasound instrument

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loskeletal ultrasound of thefoot and ankle include identifying

and treating almost any soft tissuepathology of the foot and ankle in-cluding: plantar fasciitis, skin andsoft tissue lesions, foreign bodies,blood vessels and nerves, as well astendon and ligament pathology.

Historically, the first recorded in-terest in ultrasound occurred in 1793,when Lazzaro Spallanzini observedthe functioning of bats in completedarkness. Spallanzini theorized that

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Figure 1D: Symptomatic central band of plantar fasciashows black thickened space (labeled “1”) at the lateralaspect of the medial calcaneal tubercle with decreasedechogenicity. Distal plantar fascia, less thickened and lesssymptomatic (labeled “2”). Subcutaneous tissue repre-sented by white stippling above (plantar) to the centralband. Acoustic shadowing of the medial calcaneal tuber-cle is blackened labeled as “MCT”.

Figure 1B: Symptomatic plantar fascia shows black thick-ened space (labeled “1”) with decreased echogenicity. Dis-tal plantar fascia, less thickened and less symptomatic (la-beled “2”). Subcutaneous tissue represented by white stip-pling above (plantar) the medial band. Acoustic shadow-ing of the medial calcaneal tubercle blackened labeled as“MCT”.

Figure 1C: Asymptomatic central band of plantar fasciashows black less thickened space (labeled “1”) at the lat-eral aspect of the medial calcaneal tubercle with de-creased echogenicity. Distal plantar fascia, less thickenedand less symptomatic (labeled “2”). Subcutaneous tissuerepresented by white stippling above (plantar) to the cen-tral band. Acoustic shadowing of the medial calcaneal tu-bercle is blackened labeled as “MCT”.

Figure 1A: Normal, asymptomatic, medial band of plantar fas-cia shows fine blackened parallel echogenic lines with slightvariation in thickness or echogenicity: proximal plantar fascia(labeled “1”) and distal plantar fascia (labeled “2”). Subcuta-neous tissue represented by white stippling above (plantar)the medial band. Acoustic shadowing of the medial calcanealtubercle blackened labeled as “MCT”.

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eign bodies and fractures. Becausepartial ruptures are more difficult todiagnose and treat by the physicalexam, the musculoskletal ultrasoundhas become a valuable instrument invisualizing partial tears and directingthe proper course of therapy to pre-vent a complete rupture. Partial tearsor complete ruptures when scannedby diagnostic musculoskeletal ultra-sound will appear darker because

they are passing through a morefluid-filled area of trauma.

Identification of soft-tissue mass-es is yet another capability of diag-nostic musculoskeletal ultrasound. Asolid lesion will be hyperechoic orhave reflections inside it. Fluid-filledmasses, on the other hand, will haveno reflections within and be hypoe-choic. In a similar fashion, ligaments,which are mostly solid tissue by na-ture, will be hyperechoic, as will

for visualization of soft tissue thatwas used for detecting breast cancer.

The foot receives a tremendousamount of stress in the form of eithermicrotrauma, daily wear and tear, orovert gross trauma such as sprains,strains or tears. Like other parts ofour body, these excessive amounts ofstress cause pain and swelling. The re-sulting trauma and inflammationthen causes edema which presents asa collection of fluid to the affectedarea. Trauma and associated inflam-mation is the predominant patholog-ical condition that affects ligamentsand tendons. Athletic activity com-monly predisposes tendons to rup-ture from abrupt starts and stops.Chronic repetitive motion from thehome gym and tread mills common-ly predisposes the foot and ankle totrauma and inflammation. Metabolicfactors that predispose the tendon torupture include: aging, presence ofcalcifications, general or local steroidtherapy and metabolic conditionssuch as rheumatoid arthritis, SLE, Di-abetes, gout, syphilis, and arthritis.

For the foot and ankle, some ofthe more frequent applications ofmusculoskeletal ultrasound for thefoot and ankle are to detect:1 plantarfascia for inflammation and or tears;2

Achilles tendon tears or tendonitis;3

pedal ligament ruptures or sprains;3

capsulitis4 painful neuromas and5 for-

Ultrasound... blood vessel walls.Conversely, The lumens

of blood vessels will be hypoe-choic. Nerves on longitudinal andtransverse sections will be hypere-choic. Foreign bodies, usually solidstructures, will usually scan as hyper-echoic bodies with surrounding areasof inflamed tissue that appear hypoe-choic.

Given the ability of ultrasound todirectly examine foot pathology andto interact with the patient’s feed-back of pain, treatment with injec-tions and aspirations can be a moreexact science. For non-foot patholo-gy, musculoskeletal ultrasound is rou-tinely used to examine knees, hips,spine, and wrists. Common diag-noses established from an examina-tion might include carpal tunnel syn-drome, rotator cuff injury, as well astendon and ligament injury of thehips and knees.

Heel PainHeel pain is a routine diagnosis

presenting to many podiatric officesand clinics. The authors have foundmusculoskeletal ultrasound to be avaluable instrument to successfullydiagnose and treat plantar fasciitis.The syndrome of plantar fasciitis hasbeen referred to as heel spur syn-drome, medial arch sprain, calcanealperiostitis and calcaneodynia. Plantarfasciitis is a clinical syndrome with

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Figure 1E: Asymptomatic lateral band of plantar fasciashows black less thickened space (labeled “1”) at the lat-eral calcaneal tubercle with decreased echogenicity. Distalplantar fascia, less thickened and less symptomatic (la-beled “2”). Subcutaneous tissue represented by white stip-pling above (plantar) to the central band. Acoustic shad-owing of the lateral calcaneal tubercle is blackened la-beled as “LCT”.

Figure 1F: Symptomatic lateral band of plantar fasciashows black thickened space (labeled “1”) at the lateralcalcaneal tubercle with decreased echogenicity. Distalplantar fascia, less thickened and less symptomatic (la-beled “2”). Subcutaneous tissue represented by white stip-pling above (plantar) to the central band. Acoustic shad-owing of the lateral calcaneal tubercle is blackened la-beled as “LCT”.

Ultrasound hasbecome a valuable

instrument in visualizingpartial tears.

ination demonstrates tendernessupon palpation at the insertion ofthe plantar fascia into the calcanealtubercles or along the medial, centralor lateral bands ofthe plantar fascia.There may also besoft tissue swellingalong the medialarch or a palpablenodule within theplantar fascia. Thepalpable nodule inthe band of theplantar fascia usu-ally represents anold tear and can bereasonably differ-entiated from other soft tissue tu-mors or foreign bodies by using diag-nostic ultrasound. Additionally,using musculoskletal ultrasound,plantar fasciitis can be differentiated

from tarsaltunnel syn-drome andheel fat padatrophy pain,o t h e r w i s eknown asachillodynia.The afore-ment ionedare syn-dromes thatoccur in thesame generallocation ofthe heel.

The causeof plantar fas-cia pain canbe biome-chanical innature causedby microtearsof either theperiostium ormicrotears ofthe plantarfascia fromr e p e t i t i v et r a u m a .There hasbeen associa-tion betweenplantar fasci-itis and obesewoman, malerunners, andoccupationsthat requirelong periods

of standing. Flat feet can be a predis-posing cause of plantar fasciitis as theweakened ligamentous supports ofthe feet cause increased stress to the

plantar fascia, re-sulting in overuseand tears of theplantar fascia.

In a simi-lar manner, high-arched feet are lessable to absorb theground reactiveforces, stressingthe plantar fascia.The inflammationat the heel area, vi-sualized on ultra-

sound examination as a thickenedband of plantar fascia, represents thebody’s attempt to repair its damagedtissue (Figures 1A,1B,1C,1D,1E,1F ).Keep in mind that there are patientswith metabolic causes of plantarfasciitis/heel pain, such as those withthe seronegative arthridities. Thesepatients can present with bilateralsymptoms as well as have other con-stitutional symptoms.

Many non-surgical treatmentsduring the natural course of plantarfasciitis have been advocated; theyinclude: stretching exercises, ice, footstrappings/paddings; orthotic de-vices; non-steroid anti-inflammatorymedications; iontophoresis, andphonophoresis. For the severe debili-tating cases injection therapy andcast immobilization are often recom-mended. With recalcitrant heel pain,musculoskletal ultrasonography be-comes helpful because it enables thephysician to directly observe on amonitor plantar pedal soft tissueanatomy, and to formulate both a di-agnosis and treatment plan.1-4

Performing an initial ultrasoundstudy could avoid the need for othercostly diagnostic exams. Comparedto MRI and CAT scans, musculoskle-tal ultrasound is cost-effective anddoes not use high fields of magneticenergy or radiation. For the claustro-phobic patient it could be the diag-nostic modality of choice. X-ray,MRI, and CAT scans do not allow formotion studies while ultrasounddoes. When used properly muscu-loskeletal ultrasound can establishthe exact location and dimensions ofa pathology such as a tendon or liga-ment tear, neuroma or foreign body.

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common unilateral tendernessat the attachment of the plantar-

fascia to the medial calcaneal tuber-cle.

Occasionally patients may haveradiating pain to the medial malleo-lus, and when this occurs there maybe involvement of the medial cal-caneal nerve. Most patients haveexquisite morning pain when theyget out of bed and take their initialsteps or when they stand after gettingout of a chair. The pain is often se-vere enough to alter gait and the pa-tient will often stop walking or holdthe foot in an inverted or supinatedposition to alleviate the pain. Forboth groups, the pain gradually de-creases to a reasonably tolerable levelafter a few minutes of walking.

Plantar fasciitis on physical exam-

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Figure 3: Transverse placement of the ultrasound transducer onthe plantar surface of the foot plantar to the medial and later-al calcaneal tubercles. Notice that the ultrasound transducer isperpendicular to the long axis of the foot.

Figure 2: Longitudinal placement of the ultrasound transduceron the plantar surface of the foot. Notice that the ultrasoundtransducer is parallel to the long axis of the foot.

Performing an initialultrasound study couldavoid the need for othercostly diagnostic exams.

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tar fasciitis. Additionally, thismodality can be used in the treat-ment of other adjacent anatomicalsoft tissue structures. When a givenband of plantar fascia is palpated,the patient can directly verbalize tothe examiner the absence or pres-ence of pain while the patient’splantar fascia is visualized on theultrasound monitor.

Ultrasound has previously been

used to measure the thickness ofthe plantar fascia in patients withpainful heels, with researchers fo-cusing upon the medial band’s con-tribution to the patients’ symp-toms.5-7 Studies of the effectivenessof conservative modalities such aspadding, strapping, injections, footorthotic devices for the treatmentof heel pain show that between65% to 95% of patients obtain re-lief with time from a variety of con-servative therapies.8

Traditionally, the generalizedarea of plantar fascia discomfort is

palpated, beforeinjection, with-out knowing ex-actly the locationof the pathology.This is of clinicalconcern becausethe potentially af-fected area receiv-ing the injectioncould be partiallyor entirely missedbecause it is notvisualized. Ultra-sonography al-lows for the exactplacement andcontinuous moni-toring of the nee-dle because thepedal anatomy isvisualized. Hence,

In addition, because of the inter-active nature of musculoskeletal ul-trasound the soft tissue pathologycan be visualized at multiple tissueplanes so that artifact can be elimi-nated. The MRI and CT scans, onthe other hand, are dependent onthe one-time position of the footfor each plane scanned, so that ifthe foot is not in the best possibleposition, the soft tissue pathologymay be poorly visualized or com-pletely missed. Of course, there aredrawbacks to musculoskeletal ultra-sound. The major disadvantage isthat it is operator and machine-de-pendent. For the novice muscu-loskeletal ultrasound operator,there is a learning curve to consid-er. From the machine standpoint, alow-resolution transducer may pro-duce a false reading. Similarly, if ahigh-resolution transducer is usedand the wrong anatomical region isscanned, a false negative can occurbecause of the small focal area ofthe transducer.

Because there is direct patientinteraction with musculoskeletalultrasound, establishing a diagnosisand treatment can be done as withankle arthroscopy and the EPF pro-cedures. Ultrasonography, with itsdigital imaging processing and lin-ear array high-frequency transduc-ers, not only allows the examinerto visualize plantar fascia bandthickness, but can also guide injec-tion therapy for treatment of plan-

Ultrasound... the diagnosis and treat-ment of plantar fasciitis be-comes effective because theneedle is placed at the appropri-ate site. Ultrasound facilitates visu-alization of asymptomatic andsymptomatic plantar fascia, helpingto establish a diagnosis of plantarfasciitis.9-11 Results of previous ultra-sound studies demonstrate the av-erage thickness of symptomaticplantar fascia to be 5.6 millime-ters6,7 and 3.6 millimeters forasymptomatic plantar fascia.6 Ananatomic study of 200 fresh frozencadaver specimens showed a meanthickness of the medial, central andlateral bands of the plantar fasciameasured and were reported to berespectively 4.5 mm., 1.6 mm., and2.5 mm.12

Ultrasound Imaging PrinciplesUltrasonographic imaging is

based on the recorded echo oftransmitted sound waves from agiven object, e.g., tendon, bone,parenchyma, or foreign material.The sound wave is then reflectedback to a transducer. The echoesthat create the image arise fromacoustic impedance mismatches atthe interface between objects.When the sound waves encounteran object of high mass density (e.g.,bone), a high acoustic impedancemismatch is produced.5 Objects willappear hyperechoic or brighter onthe ultrasound. An object withlower mass density (e.g., air, blood,abscess, inflammation) will producea low acoustic impedance mis-match. Such an object will appearhypoechoic or black on the ultra-sound image.

For example, the acousticimpedance of bone is 7.80 x 106,whereas that of air is 4.0 x 102. Ob-jects that produce a high acousticimpedance mismatch typicallyhave a signal void beyond the ob-ject, called an acoustic shadow. Anacoustic shadow is caused by highlyattenuating structures, where agross acoustic mismatch is createdat the interface of the object. Theobject interferes with the transmis-sion of sound energy and leaves anacoustic void.13-15

Plantar fasciitis or tendonitis de-notes a local vascular proliferation,edema and increased tendon vol-

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Figure 4: Transverse ultrasound imaging plane of the cal-caneus. Region marked “A” is the medial calcaneal tuber-cle. Region marked “B” is the calcaneal sulcus. Regionmarked “C” is the lateral calcaneal tubercle. Regionmarked “D” is a band of plantar fascia.

Ultrasonography allowsfor the exact placement

and continuousmonitoring of the

needle.

culoskletal ultrasound also makes itideal for follow-up studies. These fol-low-up musculoskletal ultrasoundexams can monitor the healing of atendon or ligament after a giventreatment or therapy. It can also beused to evaluate the progression of alesion. In the case of plantar fasciitisor tendonitis it could be used to eval-uate the effectiveness of anti inflam-matory treatments because there isusually a related decrease in thethickness or volume of the associatedstructure.

There are many ultrasound de-vices on the market today. Therefore,it is important to select an ultrasounddevice that provides ample resolutionto allow visualization of intra sub-stance tears of tendon, ligament orfascia that could easily be missedwith devices that have lower resolu-tion. In selecting a machine to pro-vide ample resolution one must con-sider not only the frequency (MHz)of the transducer but also the num-ber of processing channels and theprogramming sophistication. ■

AcknowledgementsMike Yu, BS for photographs and

Anne Erickson, MA, CMI for medicalillustrations, both from Brooklyn VAMedical Center. Dr. Brian Kincaid,Sonographer,Tinley Park, IL,60477 .Francine Tidona, MLS and RobertHall, MLS for library assistance, bothfrom Brooklyn VA Medical Center.

References1 Miller S, Van Holsbeeck M, Boruta P,

et al: Ultrasound in the diagnosis of poste-rior tibial tendon pathology. Foot AnkleInt 17: 555, 1996.

2 Fornage BD, Rifkin MD: Ultrasoundexamination of tendons. Radio ClinNorth Am 26: 87, 1988.

3 Kainberger FM, Engel A, Barton P, etal: Injury of the Achilles tendon: diagnosiswith sonography. AJR Am J Roentgenol155: 1031, 1990.

4 Fornage BD, Rifkin MD: Ultrasoundexamination of hand and foot. RadiolClin North Am 26: 619, 1988

5 Rockett MS: The use of ultrasound inthe foot and ankle: J. Am. Podiatric Med.Assoc. 89 (7): 331-338, 1999.

6 Wall JR, Harkness MA, Crawford A:Ultrasound diagnosis of plantar fasciitis.Foot Ankle Int 14:465-70, 1993.

7 Cardinal E. Cjeri RK, Beuregard CG,Aubin B, Pelletier M: Plantar fasciitis sono-graphic evaluation: Radiology 201: 257-9,1996.

8 Japour CJ, Vohra R, Vohra P, ET AL.

Management of Heel Pain Syndrome withAcetic Acid Iontophoresis. JAPA 89(5):251,1999.

9 Sellman JR: Plantar fascia rupture as-sociated with corticosteroid injection:Foot Ankle 15: 376-81, 1994.

10 Brophy DP, Cunnane G, FitzgeraldO, Gibney RG: Technical report: ultra-sound guidance for injection of sole tissuelesions around the heel in chronic inflam-matory arthritis: Clin. Radiol 50: 120-2,1995

11 Anderson RB and Foster MP: Opera-tive treatment of subcalcaneal pain. FootAnkle 9: 317-323, 1969.

12 Barrett SL, Day SV, Pignetti TT, EglyBR. Endoscopic heel anatomy: analysis of200 fresh frozen specimens. J. Foot AnkleSurg. 34(1):51, 1995.

13 Fornage BD, Schernberg FL: Sono-graphic diagnosis of foreign bodies of thedistal extremities. AJR Am J Roentgeno147: 567, 1986.

14 Goodsitt MM: “The Basic Physics ofUltrasound Imaging”¸in Radiology: Diag-nosis-Imaging-Intervention, ed by JMTaveras, JT Ferrucci, p 51, JB Lippincott,Philadelphia, 1993.

15 Walter JP: Physics of high-resolu-tion ultrasound: practical aspects. RadiolClin North Am 23: 3, 1985.

16 Schepsis AA, Leach RF, Gorayca J:Plantarfasciitis etiology, treatment, surgi-cal results and review of the literature:Clin. Orthop Rel Sci 266: 185-96, 1991.

17 Kier R: Magnetic resonance imagingof plantar fasciitis and other causes of heelpain: Magn Reson Imaging Clin. N. Am:2: 97-107, 1994.

18 Rockett MS, Waitches G, SudakoffG, et al: Use of ultrasonography versusmagnetic resonance imaging for tendonabnormalities around the ankle. FootAnkle Int 19: 604, 1998.

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ume. Musculoskeletal ultra-sound in acute plantar fasciitis

or tendonitis demonstrate a de-creased echogenicity, hypoechoic,with blurred anatomy.

Musculoskeletal UltrasoundTechniques For The Foot

Patients are positioned with theirfeet placed at the edge of the exami-nation table. The medial, central, andlateral aspect of the heel at the inser-tion of the plantar fascia were palpat-ed to determine the location of themedial, central, and lateral bands ofthe plantar fascia. Acoustic gel is ap-plied to cover the head of the trans-ducer. The transducer is then placedon the plantar surface of the foot andthe focus is adjusted to the depth ofthe plantar fascia at its attachment tothe calcaneus. Ultrasound scanningduring dynamic dorsiflexion of thetoes is performed to stretch the plan-tar fascia, allowing its margins to bedelineated. Images are then recordedon both VHS video and emulsionfilm using a multi-image camera.Longitudinal placement of the trans-ducer head on the plantar aspect ofthe foot (Figure 2) allows for lateralview of the plantar fascia. Transverseplacement of the ultrasound trans-ducer (Figure 3) is also obtained to as-sist/confirm the location of the plan-tar fascia medial, central and lateralbands (Figure 4).

Once the inflamed thickenedband(s) are isolated the injection isadministered at the symptomaticarea. The plantar fascia injection con-sists of lidocaine plain(2%), 1cc; Mar-caine plain (0.5%),1cc; and Dexam-etasone 4mg./ml.,0.25cc. An Unnaboot is then applied to the foot andthe patient is asked to remove it after5 to 7 days. Patient response to thistreatment is positive with reductionin pain.

SummaryUltrasound evaluation of the

plantar fascia followed by guided in-jection should be used when plantarfascia symptoms persist or when clin-ical presentation is atypical.4,16-18

By knowing the location of thesymptomatic plantar fascia band, thepractitioner will be better able toguide injections and manage thera-py. The non invasive nature of mus-

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Praveen K. Vohra, DPM is in pri-vate practice in Plainfield, IL.

Christopher J. Japour, DPM, MS(Corresponding Author) is Chief ofthe Podiatry Service, Department ofSurgery/Outpatient Services (11C),Danville Veterans Affairs MedicalCenter in Danville, IL. This article wassubmitted while he was AttendingPodiatrist, Department Of Surgery(112), Veterans Administration Medi-cal Center in Brooklyn, NY.

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B) low, brightC) high, darkD) high, bright

7) A signal _________ behind anobject of _________ density pro-duces an acoustic shadow.

A) void, lowB) void, highC) echo, lowD) echo, high

8) Selection of the proper ultra-sound machine is very impor-tant: to provide ample resolutionone must consider:

A) The frequency of thetransducerB) The number of processingchannels of the ultrasounddeviceC) The programmingsophistication of theultrasound deviceD) All of the above

9) Selecting the appropriate ul-trasound device to be used is animportant consideration for as-suring ample resolution. Ampleresolution is a must allowingclear detection of:

A) plantar fasciaB) boneC) intra substance tears oftendon, ligament, fasciaD) a and b

10) Symptomatic plantar fasciausually appears __________ onthe screen.

A) thickened and hypoechoicB) thickened andhyperechoicC) thin and hypoechoicD) thin and hyperechoic

1) Ultrasound imaging uses_________ to create an image.

A) radio wavesB) microwavesC) sound wavesD) water waves

2) Acoustic impedance or_________ mismatches receivedby the transducer are analyzedby the computer’s microproces-sor and produce images on thescreen.

A) electricalB) lightC) soundD) all of the above

3) Dense anatomical materialsuch as ______ will produce a_______ acoustic mismatch.

A) bone, lowB) bone, highC) abcess, highD) abcess, low

4) Low density anatomical mate-rial such as ______ will produce a_______ acoustic mismatch.

A) bone, lowB) bone, highC) blood, highD) blood, low

5) Hypoechoic images have a_______ impedance (acousticmismatch) and appear _________

A) low, darkB) low, brightC) high, darkD) high, bright

6) Hyperechoic images have a_______ impedance (acousticmismatch) and appear _________

A) low, dark

11) To locate the bands of theplantar fascia the transducershould be positioned __________along the plantar aspect of thefoot:

A) transverse onlyB) longitudinally onlyC) obliquely onlyD) a and b

12) Dorsiflexion of the toes dur-ing ultrasound evaluation of theplantar fascia is important :

A) to delineate the plantarfasciaB) to prevent foot crampingduring the examC) to identify the calcaneusD) a and b

13) The best approach to simul-taneously image both the medialcalcaneal tubercle and lateralplantar calcaneal tubercle is:

A) placement of the ultra-sound transducer longitudi-nallyB) placement of the ultra-sound transducer transverselyC) placement of the ultra-sound transducer obliquelyD) all of the above

14) At the medial aspect of themedial calcaneal tubercle, onecan expect to find:

A) medial plantar fascia bandB) central plantar fascia bandC) lateral plantar fascia bandD) a and c

15) At the lateral aspect of themedial calcaneal tubercle, onecan expect to find:

A) medial plantar fascia band

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170 PODIATRY MANAGEMENT • APRIL/MAY 2003

B) central plantar fascia bandC) lateral plantar fascia bandD) a and c

16) At the lateral calcaneal tubercle, one can ex-pect to find:

A) medial plantar fascia bandB) central plantar fascia bandC) lateral plantar fascia bandD) a and c

17) The important osseous anatomic “landmark” transversely viewed on ultrasound and lo-cated between the medial calcaneal tubercleand the lateral calcaneal tubercle is the:

A) anterior process of the calcaneusB) posterior calcaneal facetC) calcaneal sulcusD) os trigonum

18) Ultrasonography allows for the exact place-ment and continuous monitoring of the needlefor plantar fasciitis. How will the needle appearon the screen?

A) hypo-echoic and darkB) hyper-echoic and brightC) hypo-echoic and brightD) hyper-echoic and dark

19) Ultrasonic evaluation of symptomatic plan-tar fascia confirms the diagnosis of plantar fasci-itis. The average reported thickness of symp-tomatic plantar fascia is :

A) 3.6 millimetersB) 5.6 millimetersC) 7.6 millimetersD) 9.6 millimeters

20) The average reported thickness of asymp-tomatic plantar fascia is:

A) 3.6 millimetersB) 5.6 millimetersC) 7.6 millimetersD) 9.6 millimeters

E X A M I N A T I O N

(cont’d)

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You can now enroll at any time during the yearand submit eligible exams at any time during yourenrollment period.

PM enrollees are entitled to submit ten examspublished during their consecutive, twelve–monthenrollment period. Your enrollment period beginswith the month payment is received. For example,if your payment is received on September 1, 2001,your enrollment is valid through August 31, 2002.

If you’re not enrolled, you may also submit anyexam(s) published in PM magazine within the pasttwelve months. CME articles and examinationquestions from past issues of Podiatry Man-agement can be found on the Internet athttp://www.podiatrym.com/cme. All lessonsare approved for 1.5 hours of CE credit. Please readthe testing, grading and payment instructions to de-cide which method of participation is best for you.

Please call (631) 563-1604 if you have any ques-tions. A personal operator will be happy to assist you.

Each of the 10 lessons will count as 1.5 credits;thus a maximum of 15 CME credits may beearned during any 12-month period. You may se-lect any 10 in a 24-month period.

The Podiatry Management Magazine CMEprogram is approved by the Council on PodiatricEducation in all states where credits in instruction-al media are accepted. This article is approved for1.5 Continuing Education Contact Hours (or 0.15CEU’s) for each examination successfully completed.

PM’s CME program is valid in all statesexcept Kentucky and Pennsylvania.

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Over, please

Please print clearly...Certificate will be issued from information below.

Name _______________________________________________________________________Soc. Sec. #______________________________Please Print: FIRST MI LAST

Address_____________________________________________________________________________________________________________

City__________________________________________________State_______________________Zip________________________________

Charge to: _____Visa _____ MasterCard _____ American Express

Card #________________________________________________Exp. Date____________________

Note: Credit card payment may be used for fax or phone-in grading only.

Signature__________________________________Soc. Sec.#______________________Daytime Phone_____________________________

State License(s)___________________________Is this a new address? Yes________ No________

Check one: ______ I am currently enrolled. (If faxing or phoning in your answer form please note that $2.50 will be charged to your credit card.)

______ I am not enrolled. Enclosed is a $17.50 check payable to Podiatry Management Magazine for each exam submitted. (plus $2.50 for each exam if submitting by fax or phone).

______ I am not enrolled and I wish to enroll for 10 courses at $99.00 (thus saving me $76 over the cost of 10 individual exam fees). I understand there will be an additional fee of $2.50 for any exam I wish to submit via fax or phone.

Note: If you are mailing your answer sheet, you must completeall info. on the front and back of this page and mail with yourcheck to: Podiatry Management, P.O. Box 490, East Islip,NY 11730. Credit cards may be used only if you are faxing orphoning in your test answers.

TESTING, GRADING AND PAYMENT INSTRUCTIONS(1) Each participant achieving a passing grade of 70% or

higher on any examination will receive an official computer formstating the number of CE credits earned. This form should be safe-guarded and may be used as documentation of credits earned.

(2) Participants receiving a failing grade on any exam will benotified and permitted to take one re-examination at no extra cost.

(3) All answers should be recorded on the answer formbelow. For each question, decide which choice is the best an-swer, and circle the letter representing your choice.

(4) Complete all other information on the front and back ofthis page.

(5) Choose one out of the 3 options for testgrading: mail-in,fax, or phone. To select the type of service that best suits yourneeds, please read the following section, “Test Grading Options”.

TEST GRADING OPTIONSMail-In GradingTo receive your CME certificate, complete all information

and mail with your check to:Podiatry Management

P.O. Box 490, East Islip, NY 11730There is no charge for the mail-in service if you have already

enrolled in the annual exam CPME program, and we receive this

E N R O L L M E N T F O R M & A N S W E R S H E E T

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171

Continuing

Medical Education

exam during your current enrollment period. If you are not en-rolled, please send $17.50 per exam, or $99 to cover all 10exams (thus saving $76 over the cost of 10 individual exam fees).

Facsimile GradingTo receive your CPME certificate, complete all information and

fax 24 hours a day to 1-631-563-1907. Your CPME certificate willbe dated and mailed within 48 hours. This service is available for$2.50 per exam if you are currently enrolled in the annual 10-examCPME program (and this exam falls within your enrollment period),and can be charged to your Visa, MasterCard, or American Express.

If you are not enrolled in the annual 10-exam CPME pro-gram, the fee is $20 per exam.

Phone-In GradingYou may also complete your exam by using the toll-free

service. Call 1-800-232-4422 from 10 a.m. to 5 p.m. EST, Mon-day through Friday. Your CPME certificate will be dated thesame day you call and mailed within 48 hours. There is a $2.50charge for this service if you are currently enrolled in the annual10-exam CPME program (and this exam falls within your enroll-ment period), and this fee can be charged to your Visa, Master-card, or American Express. If you are not currently enrolled, thefee is $20 per exam. When you call, please have ready:

1. Program number (Month and Year)2. The answers to the test3. Your social security number4. Credit card information

In the event you require additional CPME information,please contact PMS, Inc., at 1-631-563-1604.

Enrollment/Testing Informationand Answer Sheet

✄

LESSON EVALUATION

Please indicate the date you completed this exam

_____________________________

How much time did it take you to complete the lesson?

______ hours ______minutes

How well did this lesson achieve its educational objectives?

_______Very well _________Well

________Somewhat __________Not at all

What overall grade would you assign this lesson?

A B C D

Degree____________________________

Additional comments and suggestions for future exams:

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

EXAM #5/03Ultrasound

(Vohra/Japour)

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

Circle:

172 www.podiatrym.comPODIATRY MANAGEMENT • APRIL/MAY 2003

E N R O L L M E N T F O R M & A N S W E R S H E E T (cont’d)

LESSON EVALUATION

Please indicate the date you completed this exam

_____________________________

How much time did it take you to complete the lesson?

______ hours ______minutes

How well did this lesson achieve its educational objectives?

_______Very well _________Well

________Somewhat __________Not at all

What overall grade would you assign this lesson?

A B C D

Degree____________________________

Additional comments and suggestions for future exams:

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

EXAM #4/03Down Syndrome

(Caselli)

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

Circle:

Contin

uing

Medica

l Edu

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