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Long-Term Outcome of Low-Energy Extracorporeal Shock Wave Therapy for Plantar Fasciitis: Comparative Analysis According to Ultrasonographic Findings

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Objective To investigate the long-term effect of low-energy extracorporeal shock wave therapy (ESWT) for plantar fasciitis (PF) according to ultrasonography (US) findings. Methods Thirty feet of 25 patients with clinical diagnosis of PF were enrolled and divided into two groups (Apparent-US and Uncertain-US) according to US findings, such as plantar fascia thickening or hypoechogenicity. Inclusion criteria were symptom duration >6 months and a fair or poor grade in Roles-Maudsley score (RMS). ESWT (0.10 mJ/mm2, 600 shocks) was given once a week for 6 weeks. Numeric rating scale (NRS) and RMS were evaluated prior to each ESWT session, at short-term follow-up (one week after all ESWT sessions) and long-term follow-up telephone interview (mean 24 months after ESWT). Good and excellent grade in RMS were considered as treatment success. Results Repeated measure ANOVA demonstrated that NRS significantly decreased with time after ESWT up to the long-term follow-up (time effect, p<0.001) without group-time interaction (p=0.641), indicating that ESWT equally decreased pain in both groups. Overall success rate was 63.3% (short-term follow-up) and 80.0% (long-term follow-up). In comparative analysis between groups, success rate of Apparent-US and Uncertain-US at short-term follow-up was 61.9% and 66.7%, respectively, and 85.7% and 66.7%, respectively, at long-term follow-up. Conclusion If other causes of heel pain are ruled out through meticulous physical examination and ultrasonography, low-energy ESWT in PF seems to be beneficial regardless of US findings. In terms of success rate, however, long-term outcome of Apparent-US appears to be superior to Uncertain-US.
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Long-Term Outcome of Low-Energy
Extracorporeal Shock Wave Therapy for Plantar
Fasciitis: Comparative Analysis According to
Ultrasonographic Findings
Jong-Wan Park, MD1, Kyungjae Yoon, MD, PhD1, Kwang-Soo Chun, MD1,
Joon-Youn Lee, MD1, Hee-Jin Park, MD2, So-Yeon Lee, MD2, Yong-Taek Lee, MD, PhD1
Departments of 1Physical and Rehabilitation Medicine, 2Radiology, Kangbuk Samsung Hospital,
Sungkyunkwan University School of Medicine, Seoul, Korea
Objective To investigate the long-term effect of low-energy extracorporeal shock wave therapy (ESWT) for plantar
fasciitis (PF) according to ultrasonography (US) findings.
Methods Thirty feet of 25 patients with clinical diagnosis of PF were enrolled and divided into two groups
(Apparent-US and Uncertain-US) according to US findings, such as plantar fascia thickening or hypoechogenicity.
Inclusion criteria were symptom duration >6 months and a fair or poor grade in Roles-Maudsley score (RMS).
ESWT (0.10 mJ/mm2, 600 shocks) was given once a week for 6 weeks. Numeric rating scale (NRS) and RMS were
evaluated prior to each ESWT session, at short-term follow-up (one week after all ESWT sessions) and long-term
follow-up telephone interview (mean 24 months after ESWT). Good and excellent grade in RMS were considered
as treatment success.
Results Repeated measure ANOVA demonstrated that NRS significantly decreased with time after ESWT up to
the long-term follow-up (time effect, p<0.001) without group-time interaction (p=0.641), indicating that ESWT
equally decreased pain in both groups. Overall success rate was 63.3% (short-term follow-up) and 80.0% (long-term
follow-up). In comparative analysis between groups, success rate of Apparent-US and Uncertain-US at short-term
follow-up was 61.9% and 66.7%, respectively, and 85.7% and 66.7%, respectively, at long-term follow-up.
Conclusion If other causes of heel pain are ruled out through meticulous physical examination and
ultrasonography, low-energy ESWT in PF seems to be beneficial regardless of US findings. In terms of success rate,
however, long-term outcome of Apparent-US appears to be superior to Uncertain-US.
Keywords Plantar fasciitis, Extracorporeal shock wave therapy (ESWT), Ultrasonography, Treatment outcome
Annals of Rehabilitation Medicine
Original Article
Ann Rehabil Med 2014;38(4):534-540
pISSN: 2234-0645 • eISSN: 2234-0653
http://dx.doi.org/10.5535/arm.2014.38.4.534
Received January 16, 2014; Accepted April 22, 2014
Corresponding author: Yong-Taek Lee
Department of Physical and Rehabilitation Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro,
Jongno-gu, Seoul 110-746, Korea
Tel: +82-2-2001-2283, Fax: +82-2-2001-1284, E-mail: yongtaek1.lee@gmail.com
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/
licenses/by-nc/3.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright © 2014 by Korean Academy of Rehabilitation Medicine
Comparative Analysis According to Ultrasonographic Findings
535
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INTRODUCTION
Plantar fasciitis (PF) is the most common cause of heel
pain and accounts for 11% to 15% of all foot symptoms
requiring medical care [1-3]. The standard treatments
of PF are conservative measures including insoles, shoe
modification, physical therapy, stretching exercises and
nonsteroidal anti-inflammatory drugs (NSAIDs). Further
approaches include corticosteroid injections [4-8]. For
intractable cases, surgical release of the plantar fascia
may be considered. Extracorporeal shock wave therapy
(ESWT) has been increasingly used as a safe alternative
treatment option for these, since many published papers
have reported a beneficial effect [9-15].
The diagnosis of PF has been typically based on clinical
history and the finding of localized tenderness [14]. Re-
cently, ultrasonography (US) has received increased at-
tention for its diagnostic capabilities, since many studies
have reported the thickening and hypoechoic changes of
the plantar fascia as characteristic features of PF [16-19].
Thus, nowadays diagnosis of PF is often made based on
both clinical and US findings. However, only clinical find-
ings have been used for the diagnosis of PF in the major-
ity of previous outcome studies for ESWT. Based on these
studies, the United States Food and Drug Administration
approved ESWT for the treatment of clinically diagnosed
chronic intractable PF.
To our knowledge, no study has addressed the outcome
of ESWT involving patients with clinically diagnosed PF
but whose US abnormality was uncertain. The present
study was undertaken to investigate the therapeutic effect
of low-energy ESWT in these patients and to compare the
results with clinically diagnosed and US confirmed PF.
MATERIALS AND METHODS
Subjects
Between 2008 and 2013, 70 patients (96 feet) with
chronic refractory PF were enrolled. Diagnosis of PF was
made based on the clinical findings of the patients’ his-
tory and physical examination. As an additional tool, US
evaluation was performed to confirm the PF and rule out
other diseases. Among them, 25 patients (30 feet) met
the inclusion and exclusion criteria. Inclusion criteria
were as follows: PF of at least 6 months in duration, lack
of pain relief by standard treatments including NSAIDs,
insoles, shoe modification, physical therapy and stretch-
ing exercises; completion of the ESWT protocol; grade
of poor or fair in the Roles-Maudsley score (RMS) before
the treatment (Table 1); and availability for long-term (at
least 7 months after ESWT) follow-up telephone inter-
views. Exclusion criteria were history of previous steroid
injections, tarsal tunnel syndrome, polyarthritis and
rheumatic disease, previous surgery of the foot, lumbar
spine disc herniation, trauma and pregnancy. The en-
rolled patients were divided into two groups according to
US findings. Patients who met one of the Korean US diag-
nostic criteria for PF [20] were classified in the Apparent-
US group and those who did not were classified in the
Uncertain-US group (Fig. 1). Korean US diagnostic cri-
teria for PF are plantar fascia thickness >3.8 mm (Fig. 2),
difference of plantar fascia thickness between the symp-
tomatic and asymptomatic foot >1.0 mm and hypoecho-
genicity in plantar fascia (Fig. 3).
Fig. 1. Uncertain ultrasonographic finding that does not
meet any of the Korean ultrasonographic diagnostic cri-
teria for plantar fasciitis as detailed in the text.
Table 1. Roles-Maudsley score
Point Interpretation
Excellent 1 No pain, full movement and activity
Good 2 Occasional discomfort, full movement
and activity
Fair 3 Some discomfort after prolonged activity
Poor 4 Pain-limiting activities
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Sonographic evaluation
Two musculoskeletal radiologists evaluated the plantar
fascia of patients using a HDI 5000 (Philips Medical Sys-
tems, Bothell, WA, USA) and LOGIQ E9 (GE Healthcare,
Milwaukee, WI, USA) imaging devices equipped with a
variable frequency linear 6 to 15 MHz probes. Patients
were in prone position during examination with their feet
hanging free over the end of the bed and their ankles dor-
siflexed to 90o. Both sides were evaluated and compared
with each other. Plantar fascia thickness was measured at
its thickest point and echogenicity was assessed around
the medial tubercle of the calcaneus.
ESWT protocol
No local anesthesia was applied. ESWT was performed
using an Evotron electrohydraulic type apparatus (Swi-
Tech Medical AG, Kreuzlingen, Switzerland) by one
musculoskeletal physiatrist. Patients reclined in a prone
position and their ankles were stabilized. The probe was
chosen between EvoTrode R05 (penetration depth, 5−30
mm) and R20 (penetration depth, 25−45 mm) according
to the depth of plantar fascia on US. The point of maximal
heel tenderness was palpated and marked with a skin
marker. US jelly was applied to the heel and low-energy
ESWT (0.10 mJ/mm2, 600 shocks) was given once a week
for 6 weeks. The frequency of shock was 1 Hz. We tried to
distribute the shock waves evenly over the whole of the
tender area by adjustment of the probe.
Clinical assessment
Pain intensity was measured before each ESWT ses-
sion, and at short-term follow-up and long-term follow-
up (telephone interview) using an 11-point pain intensity
numerical rating scale (NRS), where 0 is no pain and 10
is worst possible pain. Short-term follow-up was con-
ducted one week after completion of all ESWT sessions.
Subsequently, long-term follow-up telephone interview
was performed a mean of 24 months after ESWT (range,
7−42 months). RMS was also assessed before the first
treatment, and at short-term and long-term follow-ups
(Table 1). Overall success rate and success rate of each
study group were calculated at short-term and long-term
follow-ups. We defined a RMS grade of good or excellent
as treatment success.
Statistical analyses
Independent t-test and repeated measure ANOVA test to
compare and analyze the effect of low-energy ESWT be-
tween apparent-US and uncertain-US groups. The relation-
ship among plantar fascia thickness, age, symptom duration
and pain scores (NRS) were evaluated using Pearson cor-
relation coefficient. All analyses were performed with the
SPSS ver. 18.0 (SPSS Inc., Chicago, IL, USA). A p-value <0.05
was considered statistically significant.
Fig. 2. Apparent ultrasonographic abnormal finding
shows a plantar fascia thickness >3.8 mm.
Fig. 3. Apparent ultrasonographic abnormal finding
shows hypoechogenicity in the plantar fascia.
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RESULTS
Table 2 shows baseline characteristics. All variables
were not significantly different between Apparent-US and
Uncertain-US group, except plantar fascia thickness. The
results of repeated measure ANOVA test demonstrated
that the subjective pain was significantly decreased with
time up to long-term follow-up (mean 24 months after
ESWT) (time effect, p<0.001). However, there was no sig-
nificant group-time interaction (p=0.641 for interaction),
which means ESWT equally decreased subjective pain in
both groups (Fig. 4). The pain score at short-term follow-
up (one week after completion of all ESWT sessions) and
long-term follow-up did not show significant difference
between the two groups. These findings also indicated
that there was no significant difference in the effect of
lower-energy ESWT between two groups. In our study,
overall success rate of ESWT was 63.3% at the short-term
follow-up and 80.0% at the long-term follow-up. In inter-
group comparison, success rates at short-term follow-up
were similar between Apparent-US (61.9%) and Uncer-
tain-US (66.7%). At the long-term follow-up, those were
85.7% and 66.7%, respectively (Table 3). There was no
significant correlation between plantar fascia thickness
on US, age, pain scores at each assessment and symptom
duration.
DISCUSSION
Subjective pain started to decrease from 1 week after
first treatment session and continued to improve with
time up to mean 24 months. Using our definition of suc-
cess, overall success rate at short-term follow-up (one
week after completion of all ESWT sessions) and long-
term follow-up (mean 24 months after ESWT) was 63.3%
and 80.0%, respectively. These results are comparable
to previous reports that most patients improve within
2 weeks [21] and symptoms continued to improve with
time to 6 months [22]. These findings are also consistent
with other randomized control trials [10,11,23,24] and a
previous study that reported long-term symptom relief
after ESWT [25].
US is often used for the diagnosis of PF by direct mea-
surement of the thickness and observing echogenicity
of the plantar fascia. Several studies [16-18,26-29] have
consistently demonstrated a marked increase in plantar
Table 2. Basic characteristics according to ultrasonographic findings
Variable Apparent-US (n=21) Uncertain-US (n=9) Total (n=30) p-valuea)
Sex (male:female) 3:18 4:5 7:23
Lesion side (right:left) 8:13 4:5 12:18
Age (yr) 0.220
Mean (SD) 52.7 (9.8) 47.3 (12.6) 51.1 (10.8)
Range 25−72 21−61 21−72
Symptom duration (mo) 0.281
Mean (SD) 19.8 (13.8) 13.9 (12.7) 18.0 (13.6)
Range 6−36 6−48 6−48
Plantar fascia thickness (mm) <0.001
Mean (SD) 4.4 (0.8) 3.0 (0.6) 4.0 (0.1)
Range 3.5−6.1 2.0−3.7 2.0−6.1
Initial NRS 0.614
Mean (SD) 6.1 (2.3) 6.6 (2.4) 6.3 (2.3)
Initial RMS (poor:fair) 16:5 6:3 22:8
Follow-up (mo) 0.500
Mean (SD) 24.5 (10.8) 21.4 (12.6) 23.6 (11.2)
Range 7−41 7−42 7−42
Apparent-US, apparent ultrasonographic abnormal group; Uncertain-US, uncertain ultrasonographic group; SD, stan-
dard deviation; NRS, numeric rating scale; RMS, Roles-Maudsley score.
a)Independent samples t-test.
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fascia thickness in symptomatic feet compared to as-
ymptomatic sides. As a general rule, increased thickness
(>4 mm) and decreased echogenicity of plantar fascia
are considered as consistent US findings in PF [28,29]. In
Korean, Yoon et al. [20] reported that increased thickness
(>3.8 mm), difference of thickness between symptomatic
and asymptomatic sides (>1.0 mm) and hypoechogenici-
ty of plantar fascia were clinically meaningful US findings
of PF. In the present study, we used these Korean criteria
as the reference value for the determination of Apparent-
US and Uncertain-US.
Repeated measure ANOVA revealed no significant
group-time interaction (p=0.641 for interaction). In addi-
tion, the pain scores at short-term and long-term follow-
ups did not show a significant difference between the
study groups. These findings suggest that ESWT equally
improve subjective pain in both study groups regardless
of presence or absence of apparent abnormalities on US,
which are consistent with prior finding that plantar fascia
thickness does not influence the outcome of ESWT [25].
However, the present results are contrary to the common
understanding that plantar fascia thickness influences
treatment outcomes [14]. Plantar fascia thickness can be
marked increased in PF [17,18] and substantially reduced
after ESWT, showing a correlation with pain reduction
[30,31].
Several considerations about the main problem with
US may to some extent explain such conflicting results.
Operator-dependent technique and factors, such as lack
of standardization of measurement points or machine
settings, may affect the measured thickness value and
appearance of plantar fascia, and make it difficult to de-
termine reference values for designation of Apparent-
US or Uncertain-US [32]. Indeed, large differences in
the mean plantar fascia thickness were measured in the
previous studies, in which the mean values varied from
2.9−8.1 mm in patients with PF. Ranges of plantar fascia
thickness in patients with PF were 3.2−6.8 mm in one
study [26] and 4.3−8.1 mm in another [27]. Yet another
study reported a mean plantar fascia thickness of 2.9 mm
in patients with unilateral heel pain [17]. Additionally, US
evaluation of hypoechoic changes in the plantar fascia
Fig. 4. Repeated measure ANOVA test demonstrates that
pain score decreases with time up to long-term follow-
up (mean 24 months after ESWT) (time effect, p<0.001)
without significant group-time interaction (p=0.641 for
interaction). The pain scores at short-term follow-up
(one week after completion of all ESWT sessions) and
long-term follow-up do not show significant difference
between the study groups. ESWT, extracorporeal shock
wave therapy; NRS, numeric rating scale; Apparent-US,
apparent ultrasonographic abnormal group; Uncertain-
US, uncertain ultrasonographic group.
Table 3. Success rate at short-term and long-term follow-ups according to ultrasonographic findings
Follow-up Apparent-US (n=21) Uncertain-US (n=9) Total (n=30)
Short-term
Success rate (%) 61.9 66.7 63.3
Excellent 1 0 1
Good 12 6 18
Long-term
Success rate (%) 85.7 66.7 80.0
Excellent 3 1 4
Good 15 5 20
Apparent-US, apparent ultrasonographic abnormal group; Uncertain-US, uncertain ultrasonographic group.
Comparative Analysis According to Ultrasonographic Findings
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was reported to display surprisingly low agreement [33],
which could be attributed to the fact that the definition
of echogenicity is dependent on the adjacent muscle,
but there is no adjacent muscle for comparison when
examining the plantar fascia with US. For these limita-
tions, variations may exist among US examinations of the
plantar fascia. Thus, proper and careful interpretation of
findings is necessary when using US in routine clinical
practice. Nevertheless, US is important to rule out other
causes of heel pain or to establish the diagnosis of PF.
One limitation of the present study is the small number
of patients studied. In addition, it has been reported that
body mass index [34], walking hours per day, diabetes
mellitus, and documented psychological disorder affect
treatment outcome [25], but we did not consider these
factors since this information was not available.
In conclusion, if other causes of heel pain are ruled out
and diagnosis of PF is established through meticulous
physical examination and US, low-energy ESWT appears
to be beneficial regardless of US finding. In terms of suc-
cess rate, however, long-term outcome of patients with
apparent US abnormalities in plantar fascia appears to be
superior to those with uncertain US findings.
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article
was reported.
ACKNOWLEDGMENTS
The authors thank Ms. Miyeon Lee, Medical Informa-
tion Library in Kangbuk Samsung Hospital for her advice
about statistical analyses used in the study.
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... 13,15,16 Changes in the activation patterns of tibi- J KPT the precise mechanism has not been determined and the outcomes vary depending on the dosage and treatment regimes, the rationale for this effectiveness is to stimulate soft tissue healing, reduce calcification, inhibit pain receptors, and induce denervation. 25,26 In addition, extracorporeal shock waves could increase maximal dorsi flexion and a dorsiflexion/ plantar flexion torque ratio in patients with plantar fasciopathy. 27 These improvements contribute to quality of life, 27 static and dynamic balance. ...
... As a general rule, increased thickness over 4 mm is considered sonographic characteristics of PF [25]. However, previous studies of patients with PF in the literature showed large variations in mean plantar fascia thickness, ranging from 2.9 to 8.1 mm [26]. In our study, baseline plantar fascia thicknesses in ESWT and the sham-ESWT groups were 3.6 ± 0.7 mm and 4.1 ± 1.1 mm, respectively, and increased during the ESWT sessions and decreased below the baseline value in the follow-ups. ...
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The efficacy and safety of extracorporeal shock wave therapy (ESWT) on chronic plantar fasciitis (PF) in patients with axial spondyloarthritis (axSpA) remain unclear. To investigate the efficacy and tolerability of ESWT in patients with PF in axSpA. In this double-blind, randomized controlled trial, 22 axSpA patients with PF who had heel pain above 5 according to visual analog scale (VAS) over 3 months were randomly divided into 2 groups: ESWT and sham-ESWT. Both groups received a total of three treatments at 1-week intervals. All patients were assessed by the VAS, heel pressure algometry, Foot Function Index (FFI), and plantar fascia ultrasonography (thickness and morphology) at baseline, 1 week after each session, 4th and 8th week after the last therapy. The mean ± SD ages of the ESWT and sham-ESWT groups were 43.8 ± 8.2 and 48.5 ± 7.6 years, respectively. Significant time effects between the time points were observed in both groups in terms of VAS, pressure algometry, and FFI. There was a statistically significant decrease in pain, an increase in perceived pressure algometry values, and an improvement in activity restriction in the ESWT group compared to the sham-ESWT group. There was not a change in the plantar fascia thickness before and after the intervention in both groups. No side effects were observed during the treatment and follow-up. ESWT appears to be a safe and well-tolerated physical therapy modality for improving chronic refractory heel pain due to PF in patients with axSPA. This trial was registered to The Australian New Zealand clinical trial with the registration number ACTRN12618001954213. The enrollment began in 15/12/2018 and data collection stopped in 29/05/2020.
... We specifically measured thickness of the plantar fascia 1 cm away from the insertion at the calcaneum (17). According to literature, we considered a thickness more than 3.8 mm consistent with a status of plantar fasciitis (18,19). The sonographic thickness of the contralateral plantar fascia was also recorded. ...
... Second, in cases of plantar fasciitis as well, US findings, such as the thickness of the plantar fascia, did not always correlate with clinical status and vice versa. Previous studies have reported high sensitivity and specificity values of US based on a cutoff value of 4 mm for the diagnosis of plantar fasciitis [6,7]; however, there have also been contrasting results that only 42.7% to 60% of patients with plantar fasciitis exhibited thickening of the plantar fascia to more than 4 mm on US and some research suggests the mean plantar fascia thickness is 2.9 mm in cases of plantar fasciitis [35][36][37]. Our results demonstrated that a cutoff value of 3.8 mm for the plantar fascia thickness yielded a sensitivity of 48.6% and specificity of 90.6% with less accurate diagnostic value (AUC 0.63). ...
Article
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No consensus exists concerning the diagnostic role or cutoff value of the Achilles tendon thickness on ultrasonography (US) for the diagnosis of insertional Achilles tendinopathy. This study sought to assess the diagnostic utility of US measurement of the thickness and echogenicity of the Achilles tendon for the insertional Achilles tendinopathy in patients with heel pain, and to compare the results with those of the plantar fascia for the plantar fasciitis. We conducted US examinations in consecutive patients who presented with unilateral or bilateral heel pain at the foot clinic of a single tertiary hospital from February 2016 to December 2020. Each US evaluation assessed the thickness and echogenicity of the insertion area of the Achilles tendon and plantar fascia. We retrospectively compared these parameters between patients with insertional Achilles tendinopathy or plantar fasciitis and normal controls and analyzed the diagnostic utility of these parameters. Based on clinical diagnosis, 44 feet were diagnosed with insertional Achilles tendinopathy, 109 feet were diagnosed with plantar fasciitis, and 32 feet were classified as normal. There was a significant difference in the thickness of the plantar fascia between the plantar fasciitis and normal control groups (p = 0.032). There was also a significant difference in the echogenicity of the plantar fascia between the plantar fasciitis and normal groups (p < 0.001). However, there was no significant difference in the thickness of the insertional area of the Achilles tendon between the insertional Achilles tendinopathy and normal groups (p = 0.132). There was a significant difference in the echogenicity of the insertional area of the Achilles tendon between the insertional Achilles tendinopathy and normal groups (p < 0.001). US measurement of the thickness of the insertional area of the Achilles tendon might not reflect the clinical status of insertional Achilles tendinopathy, unlike that of plantar fasciitis.
... 20,30,32 For further assessment of symptom development, the 4-point Roles and Maudsley scale (1 ¼ excellent; 2 ¼ good; 3 ¼ acceptable; 4 ¼ poor) was used. 35,42 All symptomatic patients performed a previously described home-based physical therapy treatment program with eccentric and isometric exercises. 15 Patients who had already begun noninvasive therapies (such as shock wave therapy) were allowed to continue these therapies throughout the study duration. ...
Article
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Background The diagnosis and monitoring of Achilles tendinopathy with imaging are challenging. There is a lack of studies comparing the diagnostic accuracy of magnetic resonance imaging (MRI), brightness mode ultrasound (B-mode), and power Doppler ultrasound with recent technologies such as ultrasound tissue characterization (UTC) and shear wave elastography (SWE). Purpose To assess whether SWE and UTC, which offer quantitative values, show a superior diagnostic accuracy and capacity to detect structural improvement in Achilles tendinopathy compared with MRI, B-mode, or power Doppler. Study Design Cohort study (diagnosis); Level of evidence, 2. Methods Patients with insertional (n = 28) and midportion (n = 38) Achilles tendinopathy were evaluated at baseline and 6-month follow-up using MRI, B-mode, power Doppler, SWE, and UTC. Asymptomatic controls (n = 37) were evaluated at T 0 . Diagnostic accuracy was analyzed based on a quantitative receiver operating characteristic (ROC) analysis with quantitative cutoff values (anteroposterior diameter, Öhberg score, UTC echo type, Young modulus) and by semiquantitative Likert scale–based assessment of experienced physicians. Results For diagnosing insertional Achilles tendinopathy, semiquantitative MRI and power Doppler were most favorable (diagnostic accuracy, 95%), while the cross-sectional area of MRI revealed 89% accuracy in the ROC analyses (area under the curve [AUC], 0.911; P < .001). For diagnosing midportion Achilles tendinopathy, semiquantitative MRI and B-mode were most favorable (diagnostic accuracy, 87%), while UTC echo types 3 and 4 revealed 86% and 87% accuracy, respectively, in the ROC analyses (AUC, 0.911 and 0.941, respectively; P < .001). However, for quantitative and semiquantitative evaluation of diagnostic accuracy in both insertional and midportion Achilles tendinopathy, there was no significant difference in favor of one imaging modality over the others. Compared with baseline, only SWE showed a significant change at the 6-month follow-up ( P = .003-.035), but there were only fair to poor monitoring accuracies of 71% (insertion) and 60% (midportion). However, compared with the other modalities, the monitoring accuracy of SWE was significantly higher ( P = .002-.039). Conclusion There was no statistically significant difference in favor of one imaging modality over the others, but MRI revealed the highest overall diagnostic accuracy for the diagnosis of both insertional and midportion Achilles tendinopathy.
... 20 Personal assessment was scored by the patient with a 6-point Likert-type scale (1 = completely recovered, 2 = much improved, 3 = somewhat improved, 4 = hardly improved, 5 = not improved, 6 = worse) and the actual status with a 4-point Roles and Maudsley Scale (1 = excellent, 2 = good, 3 = acceptable, 4 = poor). 27,31 Participants were randomly assigned to the 3 groups before the first appointment by an independent person, using sealed numbered envelopes. Patients were blinded to the dedicated therapy groups. ...
Article
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Background Extracorporeal shock wave therapy (ESWT) is a widely considered treatment option for Achilles tendinopathy. Line-focused ESWT is a novel technique treating a larger tendon area than point-focused ESWT. Monitoring capacities of clinical symptoms with ultrasound under ESWT treatment are unknown. Hypothesis Point- and line-focused ESWT have a superior outcome than placebo ESWT. ESWT leads to morphological tendon changes detectable with ultrasound. Study Design Single-blinded placebo-controlled randomized contolled trial. Level of Evidence Level 1. Methods The study was conducted in 3 cohorts, namely ESWT point (n = 21), ESWT line (n = 24), and ESWT placebo (n = 21). Victorian Institute of Sports Assessment–Achilles (VISA-A) score was measured before the intervention (T0), after 6 weeks (T1), and after 24 weeks (T2). All cohorts performed daily physiotherapy for 24 weeks and received 4 sessions of point-focused, line-focused, or placebo ESWT in the first 6 weeks. Ultrasound was performed with B-mode, power Doppler, shear wave elastography (SWE) at T0 and T2 and with ultrasound tissue characterization (UTC) at T0, T1, and T2. Data were analyzed with a mixed analysis of variance and t test. Results There was a significant VISA-A improvement over time for all groups ( P < 0.001). ESWT point had the strongest VISA-A score improvement +23 (ESWT line: +18; ESWT placebo: +15), but there was no significant interaction between time and any of the groups: F(4, 116) = 1.393; P = 0.24. UTC, power Doppler, and B-mode could not show significant alterations over time. SWE revealed a significant increase of elastic properties for ESWT point in the insertion ( t = −3.113, P = 0.03) and midportion ( t = −2.627, P = 0.02) over time. Conclusion There is a significant VISA-A score improvement for all study groups without a statistically significant benefit for ESWT point or ESWT line compared with ESWT placebo. Tendon adaptation could only be detected with SWE for ESWT point. Clinical Relevance The present study could not detect any statistically relevant effect of ESWT compared to placebo. SWE is able to demonstrate tendon adaptation.
Article
Background: Various conservative treatment methods can be administered in the early stages of plantar fasciitis (PF). The aim of the treatment is to enable the patient to return to the physical activity as soon as possible. Aim: In this study it was aimed to compare efficacies of Extracorporeal Shockwave Therapy (ESWT) and Low-Level Laser Therapy (LLLT) on patients with PF. Design: A local prospective cross-sectional study SETTING: Department of Physical Medicine and Rehabilitation Outpatient Clinic of Sakarya University, Faculty of Medicine POPULATION: Patients aged 18-70 years, having ongoing heel pain for at least 3 months, and not using oral and/or parenteral corticosteroids in the last 6 months. Methods: A total of 40 patients with PF included in the current study. Visual Analog Scale (VAS), Roles and Maudsley Score (RMS), American Orthopedic Foot and Ankle Association Score (AOFAS) and Foot Function Index (FFI) questionnaire were performed for all patients. ESWT and LLLT groups comprised of 22 (55%) and 18 (45%) patients, respectively. Results: We found significant improvements in scores based on the VAS, RMS, AOFAS, FFI in patients with PF and it was sustained for 3 months (p = 0.001, for all scores). While decrease in scores based on the VAS and FFI in LLLT group was statistically more significant compared to ESWT group (p = 0.014, p = 0.013), there was statistically less significant decrease in scores on the AOFAS in LLLT group than that of ESWT group (p = 0.032). Conclusions: The results of this study indicated significant improvements in terms of pain, functional status and daily life activities following the administration of either of the treatments. Furthermore, LLLT was found to be significantly more effective for alleviating pain than ESWT in the treatment of PF.
Article
Background: Plantar fasciitis (PF) is a common cause of heel pain. Among the several conservative treatment options, Extracorporeal Shock Wave Therapy (ESWT) is considered the standard treatment. However, recent studies suggest that PF may be sustained by a myofascial impairment proximal to the pain area with a biomechanical disequilibrium of the entire limb and pelvis. Aim of the study: By combining the concepts of Fascial Manipulation and ESWT, the purpose of this study was to evaluate the effectiveness of the ESWT on myofascial points in a sample of subjects with PF. Study design: Open label randomized controlled clinical trial. Setting: Outpatient clinic. Methods and population: Patients with PF were randomly assigned to an Experimental treatment Group (EG), treated with focused ESWT on myofascial points, and a Control Group (CG), treated with the focused ESWT traditional approach on the medial calcaneal tubercle. Every patient underwent a 3-session program and follow-up after 1 and 4 months. Outcome measures included the Foot and Ankle Outcome Score (FAOS) and the Italian Foot Functional Index (17-iFFI). Results: Thirty patients were enrolled in the study. Four patients of the CG dropped out the study, therefore twenty-six patients were included in the final analysis. Improvement in 17-iFFI and FAOS scores was observed in both groups starting from the third treatment and confirmed at the 1-month and 4-month follow-ups, with earlier improvement in the score values observed in the EG. Conclusions: ESWT on myofascial points could provide an interesting alternative with better outcomes in terms of time needed for recovery compared to traditional ESWT for the conservative management of PF.
Article
Resumen Objetivos Evaluar la eficacia de la electrólisis percutánea intratisular en pacientes con tendinopatía rotuliana. Estrategia de búsqueda Se realizó una búsqueda bibliográfica de artículos publicados hasta diciembre de 2019 en las siguientes bases de datos: Scopus, Web of Science, Elsevier, Science Direct, PEDro, PubMed, Cochrane Library y Google Académico. Selección de estudios Se seleccionaron 13 artículos, los cuales fueron evaluados mediante la escala Critical Review Form-Quantitative Studies y la Escala Oxford. Resultados Se seleccionaron 13 artículos con una muestra total de 438 sujetos y una media por encima de nueve en la Critical Review Form-Quantitative Studies. Tras revisar todos los estudios se puede observar cómo todos los pacientes mejoran tras la aplicación del tratamiento. Se observaron diferencias estadísticamente significativas (p < 0,05) o mejoras en la escala VISA-P, Blazina, medición basal, escala EVA y escala de Roles y Maudsley. El número de sesiones empleadas con electrólisis percutánea intratisular es inferior si se compara con otras técnicas con datos estadísticamente significativos entre grupos. Conclusiones La aplicación de la técnica electrólisis percutánea intratisular en pacientes con tendinopatía rotuliana parece ser eficaz con efectos positivos en cuanto a dolor y funcionalidad.
Article
Background: Plantar fasciitis is a common cause of heel pain. Monitoring therapy effects is challenging with conventional B-mode ultrasound. Shear wave elastography (SWE) provides important diagnostic information beyond B-mode, with typically lower tissue stiffness in symptomatic plantar fascia. Up to now little is known about SWE features for therapy monitoring in plantar fasciitis. We evaluated the clinical effects of a 3-month physical therapy based treatment and its influence on B-mode and SWE ultrasound findings in patients suffering from plantar fasciitis, correlating ultrasound findings to score-based symptom development. Methods: Prospective, IRB-approved clinical study in plantar fasciitis patients undergoing a 3-month physical therapy based treatment. Measurement time points were before (T0), after 1 (T1) and 3 (T2) months of treatment, consisting of clinical orthopedic (FFI, AOFAS-Score) and multimodal radiologic sonographic examinations (B-mode/SWE) using a high-resolution linear 18-MHz probe. Results: A total of 33 patients with 43 symptomatic plantar fascia were included. We found a significant (P<0.001) clinical score improvement (AOFAS +14, FFI-Pain -21, FFI-Function -18) between T0 and T2. Mean initial thickness (T0) of symptomatic plantar fascia was 4.2 (±1.2) mm, compared to 3.2 (±0.7) mm at the asymptomatic contralateral side (P<0.001). No significant thickness changes were seen at T1 (4.2±1.1 mm) and T2 (4.5±1.3 mm), even though clinical scores improved significantly. Mean initial stiffness (T0) of symptomatic plantar fascia was 59.57 (±43.3) kPa, compared to 83.23 (±47.3) kPa at the asymptomatic contralateral side (P<0.001). In contrast to B-mode ultrasound, SWE values increased significantly between T0 (59.6±43.3 kPa), T1 (82.6±47.3 kPa) and T2 (102.5±47.2 kPa) (P<0.001-0.009), with positive correlations for AOFAS/FFI-Pain/Function scores (r=0.285-0.473, P<0.001-0.002). Conclusions: A physical therapy based treatment relieves plantar fasciitis symptoms during a 3-month period. In line with symptom reduction, stiffness (Young's-moduli) of plantar fascia increased significantly, while B-mode ultrasound revealed no measurable changes during the healing process. Shear wave elastography was able to quantify plantar fascia pathologies and their recovery under therapy.
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To evaluate the sonographic findings of plantar fasciitis. Both feet of 15 patients who had a clinical diagnosis of plantar fasciitis were evaluated with ultrasound (US) by using a 7.0-MHz linear-array transducer. Heel pain was unilateral in 11 patients and bilateral in four. Sagittal sonograms were obtained, and the thickness of the plantar fascia was measured at its proximal end near its insertion into the calcaneus. Other observations included hypoechoic fascia, fiber rupture, perifascial fluid collections, and calcifications. Both feet of 15 healthy volunteers were also evaluated as a control group. Plantar fascia thickness was significantly increased in the heels in patients with plantar fasciitis (3.2-6.8 mm; mean, 5.2 mm +/- 1.13) compared with their asymptomatic heels (2.0-4.0 mm; mean, 2.9 mm +/- 0.70) (P < .0001) and compared with the heels of the patients in the control group (1.6-3.8 mm; mean, 2.6 mm +/- 0.48) (P < .0001). The proximal plantar fascia of 16 (84%) symptomatic heels were diffusely hypoechoic compared with none of the patients' asymptomatic heels and only one heel of a patient in the volunteer group. No fascia rupture, perifascial fluid collection, or calcifications were identified. Increased thickness of the fascia and hypoechoic fascia are sonographic findings of plantar fasciitis. US may be a valuable noninvasive technique for the diagnosis of plantar fasciitis.
Article
Babcock MS, Foster L, Pasquina P, Jabbari B: Treatment of pain attributed to plantar fasciitis with botulinum toxin A: A short-term, randomized, placebo-controlled, double-blind study. Am J Phys Med Rebabil 2005;84:649–654. Objective: To investigate the effect of botulinum toxin A on associated pain and functional impairment of refractory plantar fasciitis. Design: This is a randomized, double-blind, placebo-controlled study of 27 patients (43 feet) with plantar fasciitis. Block randomization was performed using computer software. In patients with bilateral symptoms of comparable severity, botulinum toxin A was injected in one foot and saline in the other foot. The treatment group received a total of 70 units of botulinum toxin A divided into two sites per foot. One of the two sites was the tender area in the medial aspect of the heel close to the calcaneal tuberosity (40 units), and the other was in the arch of the foot between an inch anterior to the heel and middle of the foot (30 units). The placebo group received the same volume of normal saline. Main outcome measures included: Pain Visual Analog Scale, Maryland Foot Score, Pain Relief Visual Analog Scale, and pressure algometry response. Patients were assessed before injection, at 3 wks, and at 8 wks. Results: The study revealed statistically significant changes in the treatment group. Compared with placebo injections, the botulinum toxin A group improved in all measures: Pain Visual Analog Scale (P < 0.005), Maryland Foot Score (P = 0.001), Pain Relief Visual Analog Scale (P < 0.0005), and pressure algometry response (P = 0.003). No side effects were noted. Conclusions: Botulinum toxin A injection for plantar fasciitis yields significant improvements in pain relief and overall foot function at both 3 and 8 wks after treatment.
Article
Objective: To investigate the sonographic features of plantar fasciitis (PF). Methods: High-resolution ultrasound was used to measure the thickness and echogenicity of the proximal plantar fascia and associated heel pad thickness for 102 consecutive patients with PF (unilateral: 81, bilateral: 21) and 33 control subjects. Results: The mean thickness of the plantar fascia was greater on the symptomatic side for patients with bilateral and unilateral PF than on the asymptomatic side for patients with unilateral PF, and also control subjects (5.47±1.09, 5.61±1.19, 3.83±0.72, 3.19±0.43 mm, respectively, p<0.001). A substantial difference in thickness between the asymptomatic side of patients with unilateral PF and control subjects was also noted (p=0.001). The heel pad thickness was not show different between control subjects and patients with PF. The incidence of hypoechoic fascia was 68.3% (84/123). Other findings among the patients from our test group included intratendinous calcification (two cases), the presence of perifascial fluid (one case), atrophic heel pads (one case), and the partial rupture of plantar fascia (one case). Conclusion: Increased thickness and hypoechoic plantar fascia are consistent sonographic findings in patients exhibiting PF. These objective measurements can provide sufficient information for the physician to confirm an initial diagnosis of PF and assess individual treatment regimens.
Article
Plantar fasciitis is one of the most common complaints of chronic rearfoot heel pain seen by primary care providers. The etiology and differential diagnosis are numerous, as are treatment options. This article includes a definition of plantar fasciitis, anatomy, predisposing factors, physical examination techniques, differential diagnosis, and conservative nonsurgical treatment options. Plantar fasciitis may be acute, but is more often a chronic condition that is directly related to physical activity. The most common complaint is intense heel pain with the first step from bed in the morning and initial step after resting. This pain subsides with time, but returns in the evening after prolonged standing. (C) 2002 American College of Sports Medicine
Article
To evaluate the intra- and interrater reliability of ultrasonographic measurements of the thickness and echogenicity of the plantar fascia. Eleven patients (20 feet), who complained of inferior heel pain, and 26 volunteers (52 feet) were enrolled. Two sonographers independently imaged the plantar fascia in both longitudinal and transverse planes. Volunteers were assessed twice to evaluate intrarater reliability. Quantitative evaluation of the echogenicity of the plantar fascia was performed by measuring the mean gray level of the region of interest using Digital Imaging and Communications in Medicine viewer software. Sonographic evaluation of the thickness of the plantar fascia showed high reliability. Sonographic evaluations of the presence or absence of hypoechoic change in the plantar fascia showed surprisingly low agreement. The reliability of gray-scale evaluations appears to be much better than subjective judgments in the evaluation of echogenicity. Transverse scanning did not show any advantage in sonographic evaluation of the plantar fascia. The reliability of sonographic examination of the thickness of the plantar fascia is high. Mean gray-level analysis of quantitative sonography can be used for the evaluation of echogenicity, which could reduce discrepancies in the interpretation of echogenicity by different sonographers. Longitudinal instead of transverse scanning is recommended for imaging the plantar fascia.
Article
The aim of this study was to assess the reliability of peri-fascial oedema as a sonographic criterion for selecting the most appropriate treatment (ultrasound-guided corticosteroid injection or ultrasound-guided extracorporeal shock wave therapy) of idiopathic plantar fasciitis (IPF). Sixty-four patients with a clinical diagnosis of unilateral refractory IPF, treated conservatively for at least 8 weeks, were studied with high-resolution ultrasound (HRUS). Pain intensity was evaluated with a visual analogue scale (VAS). HRUS was used to confirm IPF and identify the presence of peri-fascial oedema. Patients with an HRUS diagnosis of IPF were grouped according to the presence (A) or absence (B) of peri-fascial oedema and then randomly allocated to treatment with corticosteroid injection (1) or extracorporeal shock wave therapy (2). Clinical and HRUS follow-up was performed 6 weeks after treatment. HRUS confirmed IPF in 68,97% of patients and identified peri-fascial oedema in 53.33%. Clinical and sonographic improvements were observed in 87.5% and 37.5% of patients in subgroups A1 and A2, respectively, and in 35.71% and 92.85% of those in subgroups B1 and B2, respectively. The presence of peri-fascial oedema may represent an effective criterion for guiding treatment decisions towards HRUS-guided corticosteroid injection.
Article
Unlabelled: Plantar fasciitis can be a chronic and disabling cause of foot pain in the adult population. For refractory cases, extracorporeal shock wave therapy (ESWT) has been proposed as therapeutic option to avoid the morbidity of surgery. We hypothesized that the success of extracorporeal shock wave therapy in patients with chronic plantar fasciitis is affected by patient-related factors. A retrospective review of 225 patients (246 feet) who underwent consecutive ESWT treatment by a single physician at our institution between July 2002 and July 2004 was performed. Subjects were included only if they had plantar fasciitis for more than 6 months and failure to response to at least 5 conservative modalities. Patients were evaluated prospectively with health questionnaires, Roles and Maudsley scores, and American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores at regular intervals. Follow-up was 30.2 +/- 8.7 months post procedure. Multivariable analysis was performed to assess factors leading to successful outcomes. Success rates of 70.7% at 3 months and 77.2% at 12 months were noted in this population. Previous cortisone injections, body mass index, duration of symptoms, presence of bilateral symptoms, and plantar fascia thickness did not influence the outcome of ESWT. The presence of diabetes mellitus, psychological issues, and older age were found to negatively influence ESWT outcome. Whereas many factors have been implicated in the development of plantar fasciitis, only diabetes mellitus, psychological issues, and age were found to negatively influence ESWT outcome. Level of clinical evidence: 2.
Article
To assess the plantar aponeurosis origin (plantar fascia) using high-resolution ultrasound. The sonographic appearance of the plantar fascia in asymptomatic volunteers was compared with the appearance in: (1) clinical idiopathic plantar fasciitis, (2) inflammatory arthropathy without clinically active plantar fasciitis and (3) Achilles tendon or ankle ligament injury. Patients. There were 48 asymptomatic volunteers (96 heels), 190 patients with idiopathic plantar fasciitis (297 heels), 35 with rheumatoid factor negative spondyloarthropathy (70 heels), 17 with rheumatoid arthritis (34 heels), 62 with clinical Achilles tendinitis (93 heels) and 17 with instability secondary to previous ankle ligament injury (17 heels). Compared with the asymptomatic volunteers, the symptomatic plantar aponeurosis demonstrated significant thickening in patients with clinically unilateral (P<0.001) and bilateral (P<0.001) idiopathic plantar fasciitis as well as in patients with spondyloarthropathy (P<0.001). However, the plantar aponeurosis on the asymptomatic side in patients with unilateral idiopathic plantar fasciitis (P<0.2), rheumatoid arthritis (P<0.2) and ankle injury (P<0.1) demonstrated no significant thickening. In patients with idiopathic plantar fasciitis, abnormal plantar aponeurosis echogenicity was seen in 78% and subcalcaneal bone spurs in 24%. Peritendinous edema was present in 5% of all symptomatic heels, subcalcaneal bone erosion in 4% and intratendinous calcification in 3% of heels. Retrocalcaneal bursitis was present in 7% of patients with idiopathic plantar fasciitis, 40% with spondyloarthropathy and 19% with rheumatoid arthritis. Ultrasound allows confirmation of the clinical diagnosis in plantar fasciitis and may provide information as to its etiology.
Article
Fifteen centers for orthopaedic treatment of the foot and ankle participated in a prospective randomized trial to compare several nonoperative treatments for proximal plantar fasciitis (heel pain syndrome). Included were 236 patients (160 women and 76 men) who were 16 years of age or older. Most reported duration of symptoms of 6 months or less. Patients with systemic disease, significant musculoskeletal complaints, sciatica, or local nerve entrapment were excluded. We randomized patients prospectively into five different treatment groups. All groups performed Achilles tendon- and plantar fascia-stretching in a similar manner. One group was treated with stretching only. The other four groups stretched and used one of four different shoe inserts, including a silicone heel pad, a felt pad, a rubber heel cup, or a custom-made polypropylene orthotic device. Patients were reevaluated after 8 weeks of treatment. The percentages improved in each group were: (1) silicone insert, 95%; (2) rubber insert, 88%; (3) felt insert, 81%; (4)stretching only, 72%; and (5) custom orthosis, 68%. Combining all the patients who used a prefabricated insert, we found that their improvement rates were higher than those assigned to stretching only ( P = 0.022) and those who stretched and used a custom orthosis ( P = 0.0074). We conclude that, when used in conjunction with a stretching program, a prefabricated shoe insert is more likely to produce improvement in symp-toms as part of the initial treatment of proximal plantar fasciitis than a custom polypropylene orthotic device.
Article
To investigate the value of ultrasonography in the diagnosis of plantar fasciitis and changes in plantar fascia following ultrasound guided local steroid injection. Twenty patients with a clinical diagnosis of plantar fasciitis and 20 healthy subjects were studied prospectively. Ultrasound examination was performed using an ATL Apogee 800 and linear array 11 MHz transducer. The affected heel was injected with 15 mg triamcinolone hexacetonide and 2 ml of 2% lidocaine. Ultrasound examination was performed at time of clinical evaluation, again immediately after injection, and at 1, 6, and 30 weeks later. The thickness, echogenicity, and marginal appearance of plantar fascia were measured. Ultrasonographic measurement of plantar fascia showed a significant increase in symptomatic heels (range 4.8-6.5, mean 5.8 +/- 2.06 mm) compared with healthy subjects (range 1.8-3.4, mean 2.4 +/- 0.64 mm) (p < 0.001). A significant decrease in the thickness of plantar fascia was observed 1 week after local steroid injection (range 2.1-3.5, mean 2.3 +/- 0.91 mm). Complete relief of symptoms and signs was further observed at 6 and 30 weeks. Ultrasonographic examination of plantar fascia is easy and quick to perform. Ultrasound procedure should be considered early in diagnosis and management of heel pain. Ultrasound guided local steroid injection proved safe and effective in the treatment of plantar fasciitis.