Calcific plantar fasciitis is an uncommon condition related to calcium hydroxyapatite deposition within the substance of the plantar fascia and can occur in chronic plantar fasciitis either as a sequel to trauma and secondary to a previous steroid injection [1], or in the context of rheumatic diseases such as systemic sclerosis [2].

Ultrasound is often the initial imaging modality of choice in plantar fasciitis; it typically shows increased thickness (> 4.0 mm) with loss of fibrillar structure at the insertion of the central compartment of the plantar fascia (Figure 1). A surrounding anechoic halo and an increased vascularity under Power Doppler ultrasound is not infrequent in plantar fasciitis [3]. A well-demarcated homogeneous hyperechoic focus with or without a weak posterior shadow is the characteristic ultrasound sign of the presence of a soft consistency calcification (Figure 2A).

The ultrasound-guided percutaneous lavage has already been performed with excellent results in terms of pain reduction and functional improvement in patients with calcific tendinopathy, such as in the rotator cuff and epicondylitis. This minimally invasive interventional procedure is inexpensive, presents no risks or adverse effects, and requires short treatment times in well-trained hands. However, to our knowledge, this method has not been reported in the treatment of calcific plantar fasciitis.

With the patient in the prone position, an adequate disinfection of the skin is carried out and a low dose of local anesthetic is injected with an ultra-thin needle (27/30 G × 15 mm). Alternatively, an anesthetic block of the posterior tibial nerve may be performed with the patient in the same position as previously described [4].

The procedure is performed under ultrasound guidance in long-axis view and in-plane, from posterior to anterior with a 21 G × 50 mm hypodermic needle. Once the plantar fascia has been reached with the tip of the needle, if operated under local anesthesia only, an hydrodissection of the superficial portion of the fascia is performed with a rapid-onset local anesthetic (e.g., lidocaine 1%–2%). Once anesthesia is achieved, the needle is advanced into the calcification to remove the deposits (Figure 2A). The saline solution is injected under pressure and continuously aspirated (Video 1) until all the calcified material has been collected in the syringe (Figure 2B).

At the end of the procedure, in case there is a dispersion of the calcific material, which could cause a postprocedural inflammation, or it is considered appropriate to inject an anti-inflammatory drug or a steroid, it is recommended to advance the needle through the fascia and deposit the drug between the plantar fascia and the muscle plane, to obtain a greater reduction in pain and disability as well as avoiding atrophy or necrosis of the heel fat pad [5].

Figure 1. Ultrasound Appearance of Plantar Fasciitis

Ultrasound appearance of plantar fasciitis: increased thickness and loss of fibrillar structures.

Figure 2. Ultrasound Guided Lavage Procedure

Needle is advanced within the calcification (arrow) (A). Washing continues until all the calcified material has collected in the syringe (B).

Video 1. Procedural Video

Once the needle is placed inside the calcification, the saline solution is injected under pressure and continuously aspirated until all the calcified material has collected in the syringe.
The video is available at https://doi.org/10.29760/APJP.202302/
PP.0002.

Recommended to advise the patient to avoid loading in the first days and to wear soft insoles (memory foam or gel) until healing, generally expected in a few weeks (Figure 3).

In conclusion, ultrasound-guided percutaneous lavage is an effective and safe, painless, and low-cost technique also in the treatment of calcific plantar fasciitis.

Figure 3. Ultrasound Appeareance After Treatment

One month after the ultrasound-guided percutaneous lavage.