Ultrasound of the plantar aponeurosis (fascia)

Objective. To assess the plantar aponeurosis origin (plantar fascia) using high-resolution ultrasound. Design. 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). Results. 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. Conclusion. Ultrasound allows confirmation of the clinical diagnosis in plantar fasciitis and may provide information as to its etiology.     

Ultrasonographic appearance of the plantar fasciitis

PURPOSE: To study high frequency sonographic in the examination of plantar fasciitis (PF), which is a common cause of heel pain. MATERIALS AND METHODS: Our study was done with 25 PF (21 unilateral, 4 bilateral) and 15 control cases of similar age, weight and gender. In this study, the plantar fascial thickness (mainly), fascial echogenity and biconvexity were examined using 7.5 MHz linear phase array transducer. Perifascial fluid collection, fascial rupture and fascial calcification that are rarely seen were also examined. RESULTS: The fascial thickness ranges for the PF cases: for the symptomatic heels: 3.9-9.1 mm (mean: 4.75 +/- 1.52 mm), for the asymptomatic heels: 2.0-5.9 mm (mean: 3.37 +/- 1.0 mm) and for the control group: 2.1-4.7 mm (3.62 +/- 0.68 mm). The results were significantly different in Group I for symptomatic heels and the control group statistically for PF (P < .05). The echogenity of plantar fascia and biconvexity of plantar fascia were the major criteria for symptomatic heels. In three heels (10%), perifascial fluid was diagnosed, in three heels (10%) fascial calcification, in one heel (3%) partial fascial rupture. Subcalcaneal spur was encountered sonographically in both cases of Groups I and II. CONCLUSION: Ultrasonography (US) is the first step for PF, because of its easy and quick performance, availability and high sensitivity of diagnosis, low-cost and free radiation.     

Critical differences in lateral X-rays with and without a diagnosis of plantar fasciitis

Plantar fasciitis is a clinical diagnosis and is often combined with some form of imaging to validate the diagnosis. The clinical utility of lateral X-rays lies in the fact that they are relatively inexpensive and may contribute to ruling out other osseous causes of pain. In this study 106 (27 plantar fasciitis (PF) and 79 controls) plain non-weight bearing lateral X-rays were examined by a blind examiner to document the key features of the lateral X-ray between images of individuals with and without plantar fasciitis. As expected calcaneal spurs were observed in both groups (85% PF and 46% controls). However, plantar fascia thickness and fat pad abnormalities resulted in the best group differentiation (p<0.0001) with sensitivity of 85% and specificity of 95% for plantar fasciitis. It was concluded that the key radiological features that differentiate the groups were not spurs but rather changes in the soft tissues. If it is deemed necessary to confirm the diagnosis of typical plantar fasciitis with imaging, a lateral non-weight bearing X-ray should be the first choice investigation especially if these key features are noted.     

Sonographic evaluation of plantar fasciitis and relation to body mass index

PURPOSE: We have investigated the role of sonography in the diagnosis of plantar fasciitis. MATERIALS AND METHODS: This study evaluates 39 patients with plantar fasciitis and control group of 22 healthy volunteers. The plantar fascia thickness was measured 5 mm distal to the insertion of the calcaneus of plantar aponeurosis. Qualitative parameters such as decreased echogenity, biconvexity, perifascial fluid and calcification of plantar fascia were also noted. RESULTS: Mean plantar fascia thickness was measured 2.9 mm in patients with unilateral heel pain, 2.2 mm for contralateral normal heel and 2.5mm for control group. There was a statistically significant difference between heel with plantar fasciitis, contralateral normal heel and control groups (p=0.009 and 0.0001, respectively). Mean body mass index was 28 kg/m(2) in patients with heel pain and 25 kg/m2 in control group. Body mass index measurements were significantly different between plantar fasciitis and control groups. We found reduced plantar fascia echogenity in 16 cases (41%), calcaneal spur in 20 cases (51%), biconvex appearance in two cases (5.1%) and perifascial fluid in one case (2.5%). CONCLUSION: We conclude that in patients with plantar fasciitis, ultrasound may detect relatively small differences in plantar fascia thickness even in clinically unequivocal plantar fasciitis.     

Ultrasound elastography in the early diagnosis of plantar fasciitis

BackgroundThe purpose of this study was to investigate whether ultrasound (US) elastography is useful for the early diagnosis of plantar fasciitis.Material and methodsWe retrospectively reviewed US elastography findings of 18 feet with a clinical history and physical examination highly suggestive of plantar fasciitis but with normal findings on conventional US imaging as well as 18 asymptomatic feet.ResultSoftening of the plantar fascia was significantly greater in the patient than in the control group [Reviewers 1 and 2: 89% (16/18) vs. 50% (9/18), P= .027, respectively].ConclusionUS elastography is useful for the early diagnosis of plantar fasciitis.     

Chronic plantar fasciitis: acute changes in the heel after extracorporeal high-energy shock wave therapy--observations at MR imaging

PURPOSE: To prospectively evaluate with magnetic resonance (MR) imaging the acute changes in the heel associated with extracorporeal shock wave therapy (ESWT). MATERIALS AND METHODS: Institutional clinical study review board approved the study, and informed consent was obtained. MR imaging was performed within 24 hours before and after ESWT on 18 feet of 12 patients (eight women and four men; age range, 33-63 years; average, 49.9 years) with chronic plantar fasciitis. ESWT was applied to the most painful point on the plantar surface of the heel, with a total of 1500 shocks at 18 kV. The MR imaging protocol consisted of sagittal and coronal T1- and T2-weighted images with and without fat saturation. The images were reviewed to assess the post-ESWT changes in soft-tissue and bone marrow edema, the thickness of the proximal plantar fascia, and the presence of a heel spur. Paired t test was used for the statistical analysis. RESULTS: Soft-tissue edema, which was present in 16 (89%) of 18 heels before ESWT, had increased in severity in 12 (75%) heels after ESWT. Calcaneus bone marrow edema at the insertion site was observed in eight heels before ESWT. After ESWT, the extant of bone marrow edema had increased in one heel and had newly developed in another heel. The heel spur seen in nine (50%) feet was not affected by ESWT. In 17 (94%) heels, the proximal plantar fascia was abnormally thick, with thickness not significantly changed with use of ESWT (P > .05). CONCLUSION: Increase in soft-tissue edema is the most common acute response associated with ESWT.     

Ultrasound guided injection of platelet rich plasma in cases of chronic plantar fasciitis

Chronic plantar fasciitis (PF) is, by far, considered one of the commonest causes of foot complaints; constituting up to 15% of the foot symptoms that needs medical care in adult and active subjects.

Contrast enhanced gray-scale sonography in assessment of joint vascularity in rheumatoid arthritis: results from the IACUS study group

The purpose of this study way to assess the value of contrast enhanced gray-scale ultrasound (CEUS) in detection of vascularity in joints of patients with rheumatoid arthritis (RA) in a multicenter study of the International Arthritis Contrast Ultrasound (IACUS) study group. We assessed 113 joints in 113 patients (44 men, 69 women; mean age 51±14 years) with clinical diagnosis of RA. Gray-scale ultrasound (US), power Doppler US (PDUS) and CEUS, using a low mechanical index US technique, was performed. CEUS was done by bolus administration of the contrast agent SonoVue (Bracco, Milan, Italy) with a dosage of 4.8-ml SonoVue flushed with 10 ml saline. Detection of joint vascularity was performed for differentiation of active synovitis from inactive intra-articular thickening (synovitis/effusion). With the use of US and PDUS, active synovitis could be differentiated from inactive intra-articular thickening in 68/113 joints (60.1%), whereas CEUS enabled differentiation in 110/113 (97.3%) joints (p<0.0001). Thickness measurement of active synovitis was significantly improved after contrast administration (p=0.008). In conclusion, CEUS improves the differentiation of active synovitis from inactive intra-articular thickening. Since CEUS has shown an ability to improve assessment of vascularized synovial proliferation in RA affected joints, this technique may have further potential in monitoring therapy.     

Ultrasound scanning for recalcitrant plantar fasciopathy. Basis of a new classification

Objective

The treatment of recalcitrant plantar fasciopathy is often empirical. Imaging is usually in the form of radiographs, if undertaken at all. The aim of this study is to characterise the disease pattern in recalcitrant cases of plantar fasciopathy. This allows classification of the pathology, which in turn allows meaningful evaluation of current and future treatments.

Materials and methods

One hundred and twenty-five consecutive feet with symptoms of ‘plantar fasciitis’ lasting longer than 6 months (all of which had failed to improve with a stepwise conservative management protocol) had confirmed plantar fasciopathy on ultrasound scanning. The disease characteristics were evaluated based on the scan findings.

Results

Of the patients evaluated, 66 % had typical insertional disease. The remaining 34 % had atypical distal fascia disease; 22 % had mixed insertional and distal disease, and 12 % had pure distal disease. Patients with pure distal disease were found to have either distal thickening or discrete fibromata.

Conclusion

In this cohort of recalcitrant cases, ultrasound scans detected a high proportion of atypical non-insertional plantar fascia disease. This would not be detected without imaging studies, and therefore we recommend the use of ultrasound scanning in cases of recalcitrant plantar heel pain that have failed proper first-line management, in order to confirm the clinical diagnosis and to classify the disease as either insertional or non-insertional plantar fasciopathy (or mixed disease). Only in this way can treatments for this group of patients be systematically evaluated against different disease patterns to determine their effectiveness.     

Plantar fasciitis: MR imaging

The clinical presentation of plantar fasciitis may be mimicked by a number of other painful heel conditions. Thus, magnetic resonance (MR) imaging was used to develop objective morphologic criteria to establish a diagnosis of plantar fasciitis in eight patients. Sagittal T1-weighted and coronal intermediate and T2-weighted images of symptomatic and asymptomatic feet were obtained; additional sequences were used for symptomatic feet. Maximum thickness of the plantar fascia was significantly increased (P less than .0001) in patients with plantar fasciitis (sagittal, 7.40 mm +/- 1.17, and coronal, 7.56 mm +/- 1.01) compared with age- and sex-matched volunteers (sagittal, 3.22 mm +/- 0.44, and coronal, 3.44 mm +/- 0.53) and young male controls (sagittal, 3.00 mm +/- 0.8, and coronal, 3.00 mm +/- 0.0). Furthermore, nine of 10 feet with plantar fasciitis had areas of moderately increased signal intensity in the substance of the fascia. MR imaging may provide an objective assessment of the morphologic changes associated with plantar fasciitis, as well as assist in excluding other causes of heel pain.     

Long-term results of extracorporeal shockwave treatment for plantar fasciitis

BACKGROUND: Extracorporeal shockwave treatment has shown mixed short-term results for plantar fasciitis. However, the long-term results are not available. HYPOTHESIS: Long-term results of shockwave treatment are comparable with short-term results. STUDY DESIGN: Randomized controlled clinical trial; Level of evidence, 1. METHODS: This prospective study consisted of 149 patients (168 heels) with an established diagnosis of chronic plantar fasciitis, including 79 patients (85 heels) in the shockwave treatment group and 70 patients (83 heels) in the control group. In the shockwave group, patients received 1500 impulses of shockwaves at 16 kV to the affected heel in a single session. Patients in the control group received conservative treatment consisting of nonsteroidal anti-inflammatory drugs, orthotics, physical therapy, an exercise program, and/or a local cortisone injection. Patients were evaluated at 60 to 72 months (shockwave group) or 34 to 64 months (control group) with a 100-point scoring system including 70 points for pain and 30 points for function. The clinical outcomes were rated as excellent, good, fair, or poor. RESULTS: Before treatment, the groups showed no significant differences in the scores for pain and function. After treatment, the shockwave group showed significantly better pain and function scores as compared with the control group. The overall results were 69.1% excellent, 13.6% good, 6.2% fair, and 11.1% poor for the shockwave group; and 0% excellent, 55% good, 36% fair, and 9% poor for the control group (P < .001). The recurrence rate was 11% (9/81 heels) for the shockwave group versus 55% (43/78 heels) for the control group (P < .001). There were no systemic or local complications or device-related problems. CONCLUSION: Extracorporeal shockwave treatment is effective and safe for patients with plantar fasciitis, with good long-term results.     

Painful heel: MR imaging findings.

Heel pain is a common and frequently disabling clinical complaint that may be caused by a broad spectrum of osseous or soft-tissue disorders. These disorders are classified on the basis of anatomic origin and predominant location of heel pain to foster a better understanding of this complaint. The disorders include plantar fascial lesions (fasciitis, rupture, fibromatosis, xanthoma), tendinous lesions (tendinitis, tenosynovitis), osseous lesions (fractures, bone bruises, osteomyelitis, tumors), bursal lesions (retrocalcaneal bursitis, retroachilleal bursitis), tarsal tunnel syndrome, and heel plantar fat pad abnormalities. With its superior soft-tissue contrast resolution and multiplanar capability, magnetic resonance (MR) imaging can help determine the cause of heel pain and help assess the extent and severity of the disease in ambiguous or clinically equivocal cases. Careful analysis of MR imaging findings and correlation of these findings with patient history and findings at physical examination can suggest a specific diagnosis in most cases. The majority of patients with heel pain can be successfully treated conservatively, but in cases requiring surgery (eg, plantar fascia rupture in competitive athletes, deeply infiltrating plantar fibromatosis, masses causing tarsal tunnel syndrome), MR imaging is especially useful in planning surgical treatment by showing the exact location and extent of the lesion.     

Plantar calcaneal enthesophytes: new observations regarding sites of origin based on radiographic,MR imaging,anatomic, and paleopathologic analysis

OBJECTIVE: To determine the relationship between sites of calcaneal plantar enthesophytes and surrounding fascial and soft tissue structures using routine radiography, MR imaging, and data derived from cadaveric and paleopathologic specimens. DESIGN AND PATIENTS: Two observers analyzed the MR imaging studies of 40 ankles in 38 patients (35 males, 3 females; mean age 48.3 years) with plantar calcaneal enthesophytes that were selected from all the ankle MR examinations performed during the past year. Data derived from these MR examinations were the following: the size of the enthesophyte; its location in relation to the plantar fascia (PF) and flexor muscles; and the thickness and signal of the PF. The corresponding radiographs of the ankles were evaluated at a different time by the same observers for the presence or absence of plantar enthesophytes and, when present, their measurements. A third observer reviewed all the discordant observations of MR imaging and radiographic examinations. Two observers analyzed 22 calcaneal specimens with plantar enthesophytes at an anthropology museum to determine the orientation of each plantar enthesophyte. MR imaging of a cadaveric foot with a plantar enthesophyte with subsequent sagittal sectioning was performed to provide further anatomic understanding. RESULTS: With regard to MR imaging, the mean size of the plantar enthesophytes was 4.41 mm (SD 2.4). Twenty (50%) enthesophytes were located above the PF, 16 (40%) between the fascia and abductor digiti minimi, flexor digitorum brevis and abductor hallucis muscles, and only one (3%) was located within the PF. In three (8%) cases the location was not determined. The size of enthesophytes seen with MR imaging and radiographs was highly correlated (P<0.01). The interobserver agreement for all measurements was good (Pearson >0.8, kappa >0.9). Eleven of the 22 bone specimens had plantar enthesophytes oriented in the direction of the abductor digiti minimi and 11 oriented in the direction of the flexor digitorum brevis and PF. The cadaveric sections revealed different types of enthesophytes. CONCLUSIONS: Plantar calcaneal enthesophytes arise in five different locations: at the insertion sites of abductor digiti minimi and flexor digitorum brevis muscles; between the PF and these muscles; and, less frequently, within the PF and at the insertion site of the short plantar ligament.     

Pathologic and post-operative conditions of the plantar fascia: review of MR imaging appearances

Magnetic resonance (MR) imaging has emerged as an important noninvasive diagnostic imaging technique for assessment of foot pathology. This modality, owing to its multiplanar imaging capability and inherent superiority in contrast, has been shown to be more accurate and sensitive for detection of plantar fascia pathology than any other imaging method. One of the most important and recognizable causes of heel pain is plantar fasciitis. With the exception of plantar fasciitis, there has been little emphasis on imaging other conditions that affect this important structure. The objective of this review is to demonstrate, from a perspective of MR imaging, the many different pathologic conditions that affect the plantar fascia. Included in this review will be a discussion of normal anatomy as well as entities such as acute plantar fasciitis, chronic plantar fasciitis, traumatic rupture, normal post-surgical changes, pathologic post-fasciotomy conditions, infection, and fibromatosis. Received: 25 January 2000 Revision requested: 21 March 2000 Revision received: 3 April 2000 Accepted: 6 April 2000     

Foot pain after a plantar fasciotomy: an MR analysis to determine potential causes.

PURPOSE: The purpose of this work was to determine potential causes of foot pain in patients who have had a surgical release of the plantar fascia for treatment of fasciitis. METHOD: We studied 17 patients (15 women, 2 men; age range 22-59 years, mean 40 years) with foot pain after undergoing a fasciotomy. Fourteen unilateral and three bilateral procedures accounted for the 20 ankles evaluated. Mean duration after surgery was 22 months (range 3-53 months). Each patient was instructed to localize the pain to a region of the foot; classify the pain as new onset, persistent, or recurrent; and characterize it as to the action that produced the greatest pain. T1-weighted sagittal and dual-echo T2-weighted images in the sagittal, coronal, and axial planes were obtained in a 1.5 T magnet. The MR studies were evaluated for abnormalities of the plantar fascia, perifascial soft tissues, tendons, and osseous structures. RESULTS: The plantar fascia appeared thick in all ankles (mean 8.0 mm, range 6-12 mm). A total of 25 symptomatic sites were assessed. An acute plantar fascia rupture explained plantar symptoms in two feet. In another 16 feet (12 with plantar heel pain and 4 with nonspecific heel pain), 6 had documentation of acute plantar fasciitis and 9 demonstrated perifascial edema. Of the latter nine feet, five demonstrated abnormalities of the posterior tibialis, peroneus longus, and peroneus brevis tendons. The pain localized to the medial arch in six feet; five feet had abnormalities of the posterior tibialis tendon and one foot demonstrated edema in the flexor digitorum brevis muscle. The pain localized to the lateral midfoot in one foot, which had a cuboid stress fracture. CONCLUSION: The cause of foot pain in patients who had a plantar fasciotomy appeared to be multifactorial. Three likely causes of pain were identified: persistent or recurrent acute plantar fasciitis, pathology related to arch instability, and structural failure from overload.     

Ultrasound of the Foot and Ankle

For specific indications, ultrasound is an inexpensive and efficient alternative to magnetic resonance (MR) imaging of the ankle and foot. In addition to the tendons, the anterior joint, retrocalcaneal bursa, ligaments, plantar fascia, and soft tissues can be imaged with ultrasound. Tenosynovitis, tendon tears and tendinosis, joint effusions, intra-articular loose bodies, ganglion cysts, plantar fasciitis, and Morton neuromas can be demonstrated with ultrasound. In most cases, a focused ankle or foot ultrasound can be performed more rapidly and efficiently than magnetic resonance imaging. Direct correlation with the site of pain and rapid comparison with the asymptomatic ankle are possible with this modality. As pressure for cost containment continues, demand for ultrasound of the ankle and foot will likely increase.     

Plantar fibromatosis: ultrasonography results]

INTRODUCTION: Plantar fibromatosis, or Ledderhose's disease, is a fibrous proliferation arising within the plantar fascia end exhibiting typical clinical nodular features. The lesion appears as a firm single thickening or a nodule, occasionally painful, localized to the medial portion of the sole of the foot. This unusual condition has not been extensively studied with US and very little has been written about it. MATERIAL AND METHODS: In 1998-99, six patients with plantar fibromatosis were submitted to US with 13 MHz linear array and 20 MHz mechanical annular array probes. All patients were examined in prone recumbency with the probe positioned on the sole of the foot. Only some of them were subsequently submitted to surgery. RESULTS: Plantar fibromatosis exhibited an almost pathognomonic pattern and US proved to be a quick, noninvasive and cost-effective technique to confirm clinical diagnosis. The nodule is typically single and isoechoic, with maximum diameter of about 1 cm, inhomogeneous internal structure and few thin hyperechoic septa. The nodular fibrous proliferation adheres with the major axis along the plantar fascia; it exhibits clear-cut margins and US beam transmission is good. No calcifications or fluid collections are seen within the nodule. Color and power Doppler show no flow inside. CONCLUSIONS: US is an adequate tool for the study of plantar fibromatosis.     

High‐load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12‐month follow‐up

The aim of this study was to investigate the effectiveness of shoe inserts and plantar fascia‐specific stretching vs shoe inserts and high‐load strength training in patients with plantar fasciitis. Forty‐eight patients with ultrasonography‐verified plantar fasciitis were randomized to shoe inserts and daily plantar‐specific stretching (the stretch group) or shoe inserts and high‐load progressive strength training (the strength group) performed every second day. High‐load strength training consisted of unilateral heel raises with a towel inserted under the toes. Primary outcome was the foot function index (FFI) at 3 months. Additional follow‐ups were performed at 1, 6, and 12 months. At the primary endpoint, at 3 months, the strength group had a FFI that was 29 points lower [95% confidence interval (CI): 6–52, P = 0.016] compared with the stretch group. At 1, 6, and 12 months, there were no differences between groups (P > 0.34). At 12 months, the FFI was 22 points (95% CI: 9–36) in the strength group and 16 points (95% CI: 0–32) in the stretch group. There were no differences in any of the secondary outcomes. A simple progressive exercise protocol, performed every second day, resulted in superior self‐reported outcome after 3 months compared with plantar‐specific stretching. High‐load strength training may aid in a quicker reduction in pain and improvements in function.     

Sagittal movement of the medial longitudinal arch is unchanged in plantar fasciitis

BACKGROUND: Although a lowered medial longitudinal arch has been cited as a causal factor in plantar fasciitis, there is little experimental evidence linking arch motion to the pathogenesis of the condition. This study investigated the sagittal movement of the arch in subjects with and without plantar fasciitis during gait. METHODS: Digital fluoroscopy was used to acquire dynamic lateral radiographs from 10 subjects with unilateral plantar fasciitis and 10 matched control subjects. The arch angle and the first metatarsophalangeal joint angle were digitized and their respective maxima recorded. Sagittal movement of the arch was defined as the angular change between heel strike and the maximum arch angle observed during the stance phase of gait. The thickness of the proximal plantar fascia was determined from sagittal sonograms of both feet. ANOVA models were used to identify differences between limbs with respect to each dependent variable. Relationships between arch movement and fascial thickness were investigated using correlations. RESULTS: There was no significant difference in either the movement or maximum arch angle between limbs. However, subjects with plantar fasciitis were found to have a larger metatarsophalangeal joint angle than controls (P < 0.05). Whereas the symptomatic and asymptomatic plantar fascia were thicker than those of control feet (P < 0.05), significant correlations were noted between fascial thickness and peak arch and metatarsophalangeal joint angles (P < 0.05) in the symptomatic limb only. CONCLUSIONS: Neither abnormal shape nor movement of the arch are associated with chronic plantar fasciitis. However, arch mechanics may influence the severity of plantar fasciitis, once the condition is present. Digital flexion, in contrast, has a protective role in what might be a bilateral disease process.     

Evaluation of plantar fasciitis by three-phase bone scintigraphy

Fifteen patients complaining of chronic heel pain underwent three-phase Tc-99m MDP bone scintigraphy. Ten patients demonstrated abnormal scan findings consistent with plantar fasciitis (PF) and had responded to conventional therapy. Two patients were found to have calcaneal stress fractures, and one patient demonstrated a calcaneal spur that required no treatment. The remaining two patients had normal scans and did not appear clinically to have PF. The three-phase bone scan is therefore very useful in diagnosing PF and in distinguishing it from other etiologies of the painful heel syndrome.