Metatarsophalangeal joint extension changes ultrasound measurements for plantar fascia thickness

The use of ultrasound to gauge plantar fascial thickness and therefore predict a pathologic fascia is embedded.  

We all know that Ultrasound is a widely used tool especially in conjunction with plantar fasciitis because it provides an inexpensive, and noninvasive method for quantifying the plantar fascia with accuracy levels comparable to magnetic resonance imaging (MRI).

Several studies agree that a plantar fascia thickness over 4 mm via ultrasound is consistent with plantar fasciitis.

However, some researchers have argued that a lack of standardization in the measurement process for plantar fascia thickness makes it challenging to properly validate the 4 mm reference guideline.

One critical component for standardizing measurement procedures is a thorough characterization of the relationship between plantar fascia thickness and toe position.

This new study rings some warning bells!

Metatarsophalangeal joint extension changes ultrasound measurements for plantar fascia thickness,
Grenado et al, 
Journal of Foot and Ankle Research201811:20


Ultrasound is an inexpensive method for quantifying plantar fascia thickness, especially in those with plantar fasciitis. Ultrasound has also been used to assess the effectiveness of various treatments for plantar fasciitis by comparing plantar fascia thickness before and after an intervention period. While a plantar fascia thickness over 4 mm via ultrasound has been proposed to be consistent with plantar fasciitis, some researchers believe the 4 mm plantar fascia thickness level to be a dubious guideline for diagnosing plantar fasciitis due to the lack of standardization of the measurement process for plantar fascia thickness. In particular, no universal guidelines exist on the positioning of the metatarsophalangeal (MTP) joints during the procedure and the literature also has inconsistent protocols. The purpose of this study is to investigate and compare the influence of MTP joint extension on plantar fascia thickness in healthy participants and those with unilateral plantar fasciitis.


The plantar fascia thickness of forty participants (20 with unilateral plantar fasciitis and 20 control) was measured via ultrasound three times at three different MTP joint positions: 1) at rest, 2) 30° of extension from the plantar surface, and 3) maximal extension possible.


The plantar fascia became significantly thinner as MTP joint extension increased in both the plantar fasciitis group (p < 0.001) and the control group (p < 0.001). In the plantar fasciitis group, the involved plantar fascia was 1.2 to 1.3 mm thicker (p < 0.001) than the uninvolved side depending on the MTP joint position. In the control group, the difference in plantar fascia thickness between the two sides was less than 0.1 mm (p < 0.92) at any MTP joint position.


MTP joint position can influence the ultrasound measurement of plantar fascia thickness. It is recommended that plantar fascia thickness measurements be performed with the toes at rest. If MTP joints must be extended, then the toes should be extended maximally and then noted to ensure subsequent ultrasound procedures are repeated. Standardizing the position of the MTP joints is not only important for attaining the most accurate thickness measurement of the plantar fascia, but is also important to researchers who use plantar fascia thickness to determine the effectiveness of various plantar fasciitis interventions.

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Simon Bartold
Director of Bartold Clinical