title: Sonographically guided deep plantar fascia injections: where does the injectate go?
abstract: OBJECTIVE
  To determine the distribution of sonographically guided deep plantar fascia injections in an unembalmed cadaveric model.
  
  
  METHODS
  A single experienced operator completed 10 sonographically guided deep plantar fascia injections in 10 unembalmed cadaveric specimens (5 right and 5 left) obtained from 6 donors (2 male and 4 female) aged 49 to 95 years (mean, 77.5 years) with a mean body mass index of 23.2 kg/m(2) (range, 18.4-26.3 kg/m(2)). A 12-3-MHz linear array transducer was used to direct a 22-gauge, 38-mm stainless steel needle deep to the plantar fascia at the anterior aspect of the calcaneus using an in-plane, medial-to-lateral approach. In each case, 1.5 mL of 50% diluted colored latex was injected deep to the plantar fascia. After a minimum of 72 hours, study coinvestigators dissected each specimen to assess injectate placement.
  
  
  RESULTS
  All 10 injections accurately placed latex adjacent to the deep side of the plantar fascia at the anterior calcaneus. However, the flexor digitorum brevis (FDB) origin from the plantar fascia variably limited direct latex contact with the plantar fascia, and small amounts of latex interdigitated with the FDB origin in 90% (9 of 10). In all 10 specimens, latex also covered the traversing first branch of the lateral plantar nerve (FBLPN, ie, Baxter nerve) between the FDB and quadratus plantae muscles. No latex was found in the plantar fat pad or plantar fascia in any specimen.
  
  
  CONCLUSIONS
  Sonographically guided deep plantar fascia injections reliably deliver latex deep to the plantar fascia while avoiding intrafascial injection. However, the extent of direct plantar fascia contact is variable due to the intervening FDB. On the contrary, the traversing FBLPN is reliably covered by the injection. Deep plantar fascia injections may have a role in the management of refractory plantar fasciitis, particularly following failed superficial perifascial or intrafascial injections, in cases of preferential deep plantar fascia involvement, or when entrapment/irritation of the distal FBLPN is suspected.
authors.affiliation: Mayo Clinic College of Medicine, Rochester, MN 55905 USA.
authors.forename: Eugene
authors.initials: E
authors.lastname: Maida
authors.forename: James C
authors.initials: JC
authors.lastname: Presley
authors.forename: Naveen
authors.initials: N
authors.lastname: Murthy
authors.forename: Wojciech
authors.initials: W
authors.lastname: Pawlina
authors.forename: Jay
authors.initials: J
authors.lastname: Smith
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002102:Cadaver; D005205:Fascia / Q000737:chemistry* / Q000000981:diagnostic imaging*; D005260:Female; D005528:Foot / Q000000981:diagnostic imaging*; D006801:Humans; D015552:Injections, Intralesional; D007840:Latex / Q000008:administration & dosage* / Q000737:chemistry*; D008297:Male; D008875:Middle Aged; D014018:Tissue Distribution; D018084:Ultrasonography, Interventional / Q000379:methods*
chemical_list: D007840:Latex
keywords: Baxter nerve; plantar fascia; plantar fascia injection; sonography