Abstract

Objectives: In this review, we discuss the efficacy of minimally invasive injection therapies for the treatment of plantar fasciitis (PF) using ultrasound (US)-guidance compared to landmark-guided or alternative imaging modalities.

Materials and methods: A systematic review was conducted in accordance with the Cochrane methodology from April 2023 to August 2023. A multisystem search was performed including PubMed, Ovid Embase, Web of Science, and Scopus for English published articles. Branched logic was used to include articles containing terms regarding PF, US and injections. Two authors screened studies for eligibility, and any disagreements were resolved through discussion with a third reviewer. Risk-of-bias assessments were performed.

Results: The search identified 2,068 publications; six studies were included in the review, comparing various local delivery techniques for the treatment of PF. All studies compared US- to landmark-guided local steroid injections, with one study also comparing scintigraphic-guidance. In the short- to mid-term, there was a significant improvement using all delivery methods with only one study that utilized an angle-adjustable device to aid in needle placement with US guidance showing statistical improvement compared to landmark-guided injections.

Conclusion: This systematic review demonstrates that pain outcomes are comparable between US-guided and landmark-guided injections for PF. However, US-guided techniques may offer additional practical advantages, such as improved visualization of anatomy, potentially enhancing safety and patient confidence. Clinicians should consider these procedural benefits in conjunction with efficacy outcomes when making treatment decisions.

Introduction

Plantar fasciitis (PF) is a common and often debilitating condition characterized by inflammation of the plantar fascia, a thick band of connective tissue that supports the arch of the foot.[1,2] The majority of patients typically experience heel pain along the origin of the plantar fascia at the medial calcaneal tubercle.[3] Risk factors for developing PF are multifactorial and include obesity, excessive foot pronation, pes planus, high-heel arch (pes cavus), reduced ankle dorsiflexion (e.g., tight heel cord), or through repetitive microtrauma (e.g., prolonged standing or running).[3,4] Although the diagnosis can be made clinically, selected imaging modalities may aid in establishing the correct diagnosis including magnetic resonance imaging (MRI), diagnostic ultrasound (US), plain radiographs and scintigraphy.[4-7] Plantar fasciitis is typically a self-limiting condition with favorable outcomes. Nearly 80% of patients experience resolution of symptoms within one year.[4,8-11] To date, a variety of conservative treatments for PF have been described including activity modification, orthotic devices and night splints, physical therapy, anti-inflammatory drugs, and extracorporeal shock-wave therapy (ESWT), and injection therapies with limited high-quality randomized-controlled trials (RCTs).[12-15]

Patients with chronic, refractory PF persisting for more than six months may be considered for minimally invasive injection therapies or surgery aimed at alleviating pain and/or improving functional outcomes. Minimally invasive injections for the treatment of PF include corticosteroids, dry-needling, botulinum toxin A (BoNT-A), and platelet-rich plasma (PRP).[15-17] These focal injection therapies have been carried out using varying techniques for delivery of treatment utilizing landmark-, US-, and scintigraphy-guided approaches.[18-21]

In recent years, high-frequency US has emerged as a valuable diagnostic and interventional tool in the field of musculoskeletal medicine allowing for real-time imaging, dynamic evaluation of soft-tissue structures, limited radiation exposure, and accurately guiding interventional procedures.[19,22] In this review, we discuss the efficacy of minimally invasive injection therapies for the treatment of PF using US-guidance compared to landmark-guided or alternative imaging modalities.

Material and Methods

Search Strategy

A systematic review was conducted in accordance with the Cochrane methodology. The literature search was carried out between April 2023 and August 2023. Review guidelines were established prior to performing the search. A multisystem search was performed (PubMed, Ovid Embase, Web of Science, and Scopus) for English published articles. We utilized branched logic to include articles containing terms regarding PF (Plantar Fasciitis OR Plantar Fascia OR Plantar Fasciopathy OR Heel OR Heel Pain) AND (Ultrasound OR Ultrasonography OR Sonography OR Ultrasound-Guided)) AND ((Ultrasound-Guided Injection OR Injection OR Corticosteroid Injection OR Plantar Fascia Injection OR Corticosteroid) OR (Saline Solution OR Placebo OR Local Anesthetics OR OrthoBiologics OR Platelet-Rich Plasma OR Whole Blood OR Mesenchymal Stem Cells OR Amnion OR Adipose Tissue OR Fat Injection OR Dextrose OR Botulinum Toxins OR Fasciotomy OR Tenotomy OR Tenex OR Prolotherapy OR Electrolysis OR High-Energy Shock Waves OR Palpation OR Anatomic Landmarks OR Physical Therapy). Two researchers screened studies for eligibility, and any disagreements were resolved through discussion with a third reviewer.

Outcome Measures

The main outcome for this systematic review was to evaluate the efficacy of the US-guided intervention in alleviating pain compared to an alternative injection modality. There were insufficient/unavailable studies for the comparison of injection accuracy.

Data Abstraction

Data abstraction was completed by a standardized approach for each study. In our data abstraction, we included the following fields where appropriate: first author, study objective, study design, country location of the study, age in terms of years of the participants, eligibility criteria outlined by the study, number of cases and controls, and results of the study. The outcomes reported in these studies included the efficacy of the injection treatment, the delivery method, and patient-reported outcome measures. A summary of the included studies is presented in Table 1.

Table 1. Characteristics of studies included

Table 1. Continued

Table 1. Continued

Assessment of Study Quality

The revised Cochrane Risk-of-Bias Tool for Randomized Trials (RoB 2) was utilized to assess the studies included in our systematic review. The RoB 2 is a comprehensive and widely adopted tool designed to assess the risk of bias in RCTs included in systematic reviews and meta-analyses. The tool covers five primary domains: bias arising from the randomization process, bias due to deviations from intended interventions, bias due to missing outcome data, bias in measurement of the outcome, and bias in selection of the reported result. Each domain is assessed through a series of signaling questions that guide reviewers in evaluating the risk of bias for each included study. The incorporation of the RoB 2 tool allows for a nuanced examination and appraisal of RCTs and aids in determining whether a study is at risk of “low”, “some concerns”, or “high risk” for bias.

Results

Overview

Initially, a total of 2,068 articles were identified to include our search terms: 644 articles from PubMed, 505 articles form Ovid Embase, 464 articles from Web of Science, 455 articles from Scopus, and two systematic review bibliographies. There were 617 duplicate records which were removed prior to screening. A total of 1,452 articles were screened across all databases. Of them, 1,420 were excluded based on their title and abstract. A total of 29 articles underwent a full text review for eligibility. Out of these articles that had a full text review, 24 articles were excluded, as they had the wrong intervention, wrong study design (such as case report or case series or open letter to the editor), incomplete data, or did not include a comparison group. Six studies were ultimately included for final review after meeting the established criteria (Figure 1).

Figure 1. PRISMA flow diagram illustrating identification, screening, eligibility, and inclusion of studies.

Risk of Bias Assessment

Out of the six studies, all were assessed using the RoB 2. The summary of these evaluations is shown in Tables 1 and 2. Six trials compared different techniques (US, palpation, scintigraphy) to guide local steroid injections for the treatment of PF.[19,21,23-26]

Table 2. Quality Assessment using the Revised Cochrane Risk-of-Bias Tool for Randomized Trials (RoB 2)

One of the earlier studies by Kane et al.[19] compared US-guided versus palpation-guided injections of 23 patients (28 heels) who failed at least eight weeks of conservative treatment. The authors evaluated the Visual Analog Scale (VAS) and the Heel Tenderness Index (HTI) scores from baseline to follow-up (median = 14.3 weeks). Fourteen heels were assigned to receive US-guided injections, 10 heels were allocated to the palpation-guided injection group, and four heels did not receive any injections. Both the US- and palpation-guided injections led to significant improvements in the mean VAS scores [39.6 ± 9.2 (US) vs. 41.5 ± 8 (palpation)] and HTI [1.35 ± 0.2 (US) vs. 1.3 ± 0.4 (palpation)]. While both groups experienced a significant improvement in the mean VAS and HTI scores, there was no significant difference by either mode of delivery. The RoB 2 was judged to be ‘high-risk’ for bias given lack of clear participant or assessor blinding. There were also baseline patient characteristic imbalances which could produce additional source of biases.[27]

Ball et al.[26] compared US-guided steroid injections to placebo injections, as well as, landmark-guided steroid injections. Sixty-five patients with PF were followed at 6 and 12 weeks with no difference in VAS scores following steroid injection between the US-guided and unguided groups at either time point. At six weeks post-treatment, the mean VAS scores were 33.1 ± 28.4 for the US-guided steroid injection group, 30.3 ± 27.3 for the unguided steroid injection group, and 50.9 ± 31.4 for the placebo group. By 12 weeks, the VAS scores were 28.4 ± 24.9, 28.2 ± 24.8, and 53.8 ± 33.8, respectively. The RoB 2 was noted to be of ‘some concern’ given potential bias in lack of reporting adverse events for patients that dropped out of the US-guided steroid group.[26,27]

In a study by Chen et al.,[24] patients with PF (n=33) received either device-assisted US-guided or palpation-guided steroid injections. An angle-adjustable device was used to aid needle position along with US-guidance. At three months of follow-up, the device-assisted group had higher tenderness threshold (TT) (9.02 T 1.38 vs. 7.18 T 2.11 kg/cm² ; p = 0.007), lower VAS score (1.88 T 2.13 vs. 3.63 T 2.60; p = 0.046), and lower hypoechogenicity incidence in the plantar fascia (3/16 vs. 9/16; p = 0.033) compared to the palpation-guided group. The RoB 2 assessment was deemed to be ‘high risk’ for bias given multiple factors including no clear mention of randomization method, assessor, or participant blinding.

Tsai et al.[25] compared the effectiveness of US-guided versus palpation-guided steroid injections for the treatment of proximal PF. Twentyfive patients underwent treatment evaluating VAS scores and TT up to one-year follow up after injection. In both groups, VAS- and TT-measured levels of pain improved significantly after steroid injection (p < 0.001). The RoB 2 assessment was judged to be ‘high risk’ for bias given multiple factors including lack of clear randomization, and lack of participant or assessor blinding.

Yucel et al.[21] compared the efficacy of US-, palpation-, and scintigraphy-guided injections. Twenty-seven patients (35 heels) were randomly assigned to the treatment groups after failed conservative treatment. The VAS was evaluated from baseline to follow-up (median: 25.3 months).

There were no statistically significant differences observed among the three groups (US-palpation guided, US-scintigraphy guided, and palpation-scintigraphy guided) after treatment, with p-values of 0.017 (MWU = 36.5), 0.023 (MWU = 29.5), and 0.006 (MWU = 13), respectively. The RoB 2 assessment was considered to be ‘high risk’ for bias due to lack of blinding for participants and outcome assessors, as well as, selection bias and no clear mention of randomization sequence.[27]

In the most recent study, Saba and El-Sherif[23] performed a prospective study in which 21 patients with PF received a local corticosteroid injection either with landmark- or palpation-guidance. At Weeks 2 and 4 of follow-up, outcome measures were statistically significant in VAS for pain, Plantar Fasciitis Pain/Disability Scale, and US evaluation assessment of PF thickness and echogenicity for both groups; however, there was no statistically significant difference between groups. The RoB 2 assessment was considered to be ‘high risk’ for as there was no clear mention of randomization, as well as, lack of blinding of participants and outcome assessors.

Discussion

In this systematic review, we discuss the efficacy of US-guided injections compared to different techniques to deliver local medications. Of the six reviewed studies involving 173 heels of 165 participants, all compared US-guided steroid injections to palpation-guided steroid injections,[19,21,23-26] with one study by Yucel et al.[21] also comparing scintigraphy-guided steroid injections. All studies showed improvement with treatment of local corticosteroid injections; however, with the exception of the study by Chen et al.[24] using device-assisted US-guidance, there was no statistically significant difference in efficacy based on injection technique.

Plantar fasciitis is the most common cause of chronic heel pain.[28] Multiple risk factors may contribute to chronic PF including obesity, repetitive overuse, excessive loading, structural foot deformities, or tight heel cords and foot muscles.[16] Chronic degenerative processes may, indeed, contribute more to plantar ‘fasciosis,’ rather than, inflammatory ‘fascititis’.[29] Clinical presentation is often unilateral; however, up to 30% of patient may experience bilateral symptoms.[28] The diagnosis of PF can be made with a thorough history and physical examination with various imaging modalities that can assist in further evaluation.[4-7] In the setting of recalcitrant chronic PF which does not resolve or respond to conservative measures, minimally invasive injection therapies may be considered.

Several factors may have contributed to the improved clinical outcomes between the groups. One likely scenario is the local dispersion of the injectate providing benefit which would not require precise placement of the needle. A common consideration while injecting the PF, particularly with corticosteroids, is the concern for fat pad atrophy or PF rupture. In one study, up to 10% of patients injected with corticosteroid suffered from PF rupture.[30,31] In the study performed by Tsai et al.,[25] there was no disruption of the PF noted up to one-year following injection. Another possibility is the systemic effects of corticosteroids providing improvement in treatment.

While there was no superiority in the use of US-guided procedures, the use of US as both a diagnostic and interventional modality may enhance the clinical decision-making process in patient management.[32] By accurately visualizing the surrounding structures, such as neurovascular anatomy, practitioners can avoid unintentional complications or trauma while providing precise needle placement. Ultrasound provides real-time feedback on the distribution of medication within the target tissue. Clinicians may also be able to tailor injections to each patient’s specific anatomy and condition, adjusting the injection technique, medication, and dose accordingly to maximize the therapeutic benefits while minimizing unwanted effects. Compared with other imageguided procedures, US offers several advantages, including lower relative cost, absence of ionizing radiation, real-time imaging capability, and portability.[22]

Nonetheless, there are some limitations that should be acknowledged. All the studies include the low quality of evidence, as most included RCTs were judged to have a high risk of bias. Key sources of bias included inadequate blinding of participants and assessors, unclear randomization methods, and small sample sizes, all of which could affect the reliability of the reported results. Additionally, studies largely reported only short- to mid-term outcomes, with limited or no data on long-term efficacy or recurrence rates. Functional outcomes, including mobility and quality-of-life measures, were infrequently evaluated.

In conclusion, this systematic review demonstrates that pain outcomes are comparable between US-guided and landmark-guided injections for PF. However, US-guided techniques may offer additional practical advantages, such as improved visualization of anatomy, potentially enhancing safety and patient confidence. Taken together, clinicians should consider these procedural benefits in conjunction with efficacy outcomes when making treatment decisions.

Citation:
Gharib M, Kasitinon D, Kowalske A, Özçakar L, Jain NB. Efficacy of plantar fascia injections under ultrasound guidance versus landmark and scintigraphic guidance: A systematic review. Arch ISPRM 2026;1(1):31-40. https://doi.org/10.5606/archisprm.2026.33.

N.B.J., L.Ö.: Dea/concept, control/supervision; N.B.J., M.G.: Design, analysis and/or interpretation; M.G., A.K.: Data collection and/or processing; A.K., M.G., D.K.: Literature review; M.G.: Writing the article; M.G., N.B.J., L.Ö.: Critical review; N/A.: References and fundings.

The authors declare that there are no conflicts of interest with respect to the research, authorship, and/or publication of this article.

The authors declare that there are no conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability
The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.

AI Disclosure
The authors declare that artificial intelligence (AI) tools were not used, or were used solely for language editing, and had no role in data analysis, interpretation, or the formulation of conclusions. All scientific content, data interpretation, and conclusions are the sole responsibility of the authors. The authors further confirm that AI tools were not used to generate, fabricate, or ‘hallucinate’ references, and that all references have been carefully verified for accuracy.

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