Sonography of plantar fibromatosis

OBJECTIVE: Plantar fibromatosis is a rare benign fibroproliferative disorder of the plantar fascia that can be evaluated on sonography. Our study details the sonographic appearances of plantar fibromatosis. MATERIALS AND METHODS: We conducted a retrospective review of the clinical presentation, sonographic appearances, and clinical progress in 14 patients (range, 35-85 years; mean age, 53.1 years;) with plantar fibromatosis. Sonography was performed using either a 13-5-MHz multidimensional or 12.5-MHz linear array transducer. The location, sonographic appearances, and size of the plantar fibromatosis nodules were noted and correlated with symptom duration and clinical outcome. RESULTS: A total of 25 fibromatosis nodules in 19 feet were examined. On sonography, plantar fibromatosis was seen as a discrete fusiform nodular thickening of the plantar fascia, separate from the calcaneal insertion. Approximately one third (36%) of lesions were bilateral, and one quarter (26%) were multiple. All lesions were located either medially (60%) or centrally (40%) in the fascia. Most were hypoechoic (76%), were well defined (64%), and showed no acoustic enhancement (80%) or intrinsic vascularity (92%). No correlation was found between the echogenicity and size of plantar fibromatosis nodules or duration of symptoms (p < 0.01). One quarter of the affected feet had coexistent thickening of the plantar fascia at the calcaneal insertion with no related symptoms. CONCLUSION: Although the sonographic appearances of plantar fibromatosis vary, the appearances are characteristic enough to allow a specific diagnosis to be made. No clear relationship was found among the sonographic appearances, duration of symptoms, or clinical outcome.     

The evalaution of the foot core system in individuals with plantar heel pain

ObjectiveTo compare foot posture, plantar sensation, plantar fascia thickness, intrinsic foot muscle performance, and abductor hallucis morphology in individuals with and without plantar heel pain (PHP).DesignCross-Sectional.SettingLaboratory.ParticipantsSixteen individuals with PHP and sixteen matched healthy participants.Main outcome measuresStatic foot posture, plantar sensation, plantar fascia thickness, intrinsic foot muscle performance and abductor hallucis morphology were evaluated. Foot posture was assessed with the Foot Posture Index-6. Abductor hallucis morphology and plantar fascia thickness were measured utilizing diagnostic ultrasound. Plantar foot sensation was assessed at the head of the first metatarsal and medial longitudinal arch using Semmes-Weinstein Monofilaments. Intrinsic foot muscle performance was assessed using the intrinsic foot muscle test (IFMT). Mann-Whitney U and independent t-tests were used to examine between group differences.ResultsIndividuals with PHP exhibited a more pronated foot posture and greater plantar fascia thickness at the proximal insertion compared to healthy controls. Plantar sensation thresholds were higher in the PHP compared to healthy controls at the head of the first metatarsal. There were no group differences in abductor hallucis morphology or IFMT performance.ConclusionsIndividuals with PHP exhibited a more pronated foot posture, thicker plantar fascia, and diminished plantar tactile sensation.     

Increased F-18 FDG uptake on positron emission tomography/computed tomography imaging caused by plantar fibromatosis

We detail the history and evaluation of a 68-year-old man who had head-to-toe PET/CT scanning that showed a focal area of increased FDG uptake in the left medial foot. This was thought to be recurrence of his melanoma. The patient was asymptomatic. He had a history of malignant melanoma of the right ear, which was removed in 2001. On biopsy, the foot lesion was diagnosed as plantar fibromatosis. Plantar fibromatosis is a benign fibroblastic condition, which can be indistinguishable from malignancy in head-to-toe PET/CT scans. Awareness of their potential appearance on PET and PET/CT will aid in the appropriate staging of oncology patients.     

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     

Plantar fascia release for chronic plantar fasciitis in runners

Plantar fascia release has been suggested to be of benefit for patients with symptoms of chronic unresponsive plantar fasciitis. However, results of this procedure have not been published. We performed 11 releases in 9 long-distance runners whose symptoms had been present for an average of 20 months and had not responded to nonsurgical treatment. The results of these operations were excellent in 10 feet and good in 1 foot at an average follow-up time of 25 months. Eight out of nine patients returned to desired full training at an average time of 4.5 months. Histologic examination of surgical biopsy specimens from these patients showed collagen necrosis, angiofibroblastic hyperplasia, chondroid metaplasia, and matrix calcification. Plantar fascia release was an effective procedure for these patients.     

Imaging of plantar fascia and Achilles injuries undertaken at the London 2012 Olympics

Plantar fascia and distal Achilles injuries are common in elite athletes. Acute athletic injuries of the plantar fascia include acute plantar fasciopathy and partial or complete tears. Underlying most acute injuries is a background of underlying chronic plantar fasciopathy. Injuries may affect the central or less commonly lateral portions of the fascia and acute tears are generally proximal. Athletic Achilles injuries may occur at the mid tendon or the distal insertion, and there may be an underlying chronic tendinopathy. Acute or chronic paratendinopathy may occur as a separate entity or combined with Achilles injury. In this article, the spectrum of athletic injuries of the plantar fascia and Achilles is described, illustrated by imaging findings from the London 2012 Olympic games.     

An update of B-mode echography in the characterization of nodular thyroid diseases. An echographic study comparing 7.5 and 13 MHz probes

PURPOSE: We investigated B-mode US capabilities in diagnosis and characterizing thyroid nodules and compared our personal findings with those of the few analytical studies in the literature. We also compared the diagnostic accuracy of conventional 7.5 MHz versus more recent 13 MHz transducers. MATERIAL AND METHODS: We examined 136 consecutive patients with a single thyroid nodule: they were 97 women and 39 men, age ranging 15-87 years (mean: 37.4). The patients were submitted to scintigraphy and laboratory tests first and then to US, fine-needle biopsy and/or histologic examination. The final diagnosis was made at cytology and/or histology: we had 98 follicular hyperplasias, 20 follicular adenomas and 18 carcinomas. We studied the presence/absence of the halo sign, cystic portions, microcalcifications; nodule margins and echogenicity relative to the thyroid gland were also studied. RESULTS: The presence of microcalcifications had the highest specificity for malignancy. The sensitivity of this parameter was higher with 13 MHz than with 7.5 MHz transducers. Relative to microcalcifications, absence of cystic portions and irregular margins, 13 MHz US had 64.7-89% accuracy. The halo sign and lesion echogenicity did not permit a reliable differential diagnosis between benign and malignant nodules with both 7.5 and 13 MHz transducers. The association of microcalcifications and irregular margins had the highest accuracy, scoring 86% at 7.5 MHz and 90.5% at 13 MHz. CONCLUSIONS: High frequency US is a sensitive tool for diagnosing thyroid nodes. Accurate analysis of the US signs can suggest the benign/malignant lesion nature, which must be integrated with color, power and pulsed Doppler findings.     

Plantar fasciitis in runners. Treatment and prevention

Plantar fasciitis is a common overuse injury found in runners. The plantar fascia, which is responsible for maintaining the integrity of the longitudinal arch, becomes irritated, inflamed or torn by repetitive stresses placed upon it. Commonly cited predisposers of plantar fasciitis are excessive pronation, a flat or cavus foot, tight Achilles tendon, type of training shoes worn, and errors in the training routine. Once the plantar fascia becomes irritated a myriad of conservative measures may be used, including everything from rest, ice and elevation to steroid injections and, if all else fails, surgery. In most cases conservative treatment of one kind or another will alleviate the symptoms of plantar fasciitis. However, it is essential to determine and correct the cause of the problem in order for the runner to resume normal activity levels. Controlling anatomical/biomechanical inefficiencies of the feet, stretching and strengthening exercises for the lower extremity, proper training shoes, and reasonable training routines will alleviate the symptoms of plantar fasciitis in a large percentage of sufferers. To prevent this injury, runners should be aware of the potential overuse injury and take precautionary measures, e.g. seek a biomechanical/anatomical evaluation from a qualified practitioner. The practitioner can then offer suggestions as to the specific steps the runner should follow to prevent the injury condition.     

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.     

Spontaneous rupture of the plantar fascia

In this study, rupture of the plantar fascia was seen in five feet, of which four had had plantar fasciitis. At the time of the injury, which is an acceleration type of motion, there is severe pain in the heel followed by the development of ecchymosis in the sole and toward the heel of the foot. With conservative symptomatic care, the acute symptoms as well as the plantar fasciitis symptoms subside, generally allowing full activity in 3 to 4 weeks.     

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.     

Bone scintigraphy predicts outcome of steroid injection for plantar fasciitis.

Plantar fasciitis is a common cause of foot pain and may be disabling. Although localized injection is painful, anesthetics or corticosteroids can relieve symptoms well. Bone scintigraphy can confirm the diagnosis. We hypothesized that blood-pool abnormalities could provide prognostic information on the response to such injections. METHODS: We devised scintigraphic criteria that graded the blood-pool abnormalities as being localized to the plantar enthesis, being localized to half the length of the aponeurosis, or involving the whole aponeurosis. We evaluated 24 patients with an established diagnosis of plantar fasciitis, 8 of whom had bilateral disease, leading to a total of 32 feet injected. RESULTS: After injection, pain was relieved either completely or nearly completely in 20 feet. The other 12 feet had short-term or no improvement, with persistent pain and loss of function at 4-5 wk after injection. Of the 20 feet responding to injection, 14 had focal hyperemia on blood-pool images and 6 had minimal extension into the proximal third of the plantar soft tissues. No patient with diffuse hyperemia in the plantar fascia had a response (5/12 feet). On the delayed images of the 20 responders, mild inferior calcaneal uptake was seen in 8 feet, moderate uptake in 6, and severe uptake in 6. These groups did not significantly differ (P > 0.05). The blood-pool studies had good reproducibility, with a kappa-value of 0.64. CONCLUSION: Critical evaluation of plantar blood-pool images provides prognostic information on the response to localized injection into the enthesis. Reporting such studies is simple and reproducible.     

Elevated plantar pressure in diabetic patients and its relationship with their gait features

PurposeHigh plantar pressure is a major risk factor for diabetic foot ulcers. The relationship between plantar pressure and foot mobility has been investigated in some studies. However, when the foot is in motion, foot mobility is only a small feature of the gait. Therefore, we investigated relationship between high plantar pressure and gait and also studied the motion of the trunk. In addition, we investigated the relationship between gait and patient characteristics to identify patients at high-risk of developing diabetic foot ulcers.MethodsThe relationships between elevated plantar pressure, gait features, and patient characteristics were analyzed. Plantar pressure distribution in the stance phase was divided on the four plantar segments. Elevated plantar pressure was defined as being more than the mean plus one standard deviation of the corresponding segment in non-diabetic subjects. Plantar pressure distribution was measured by an F-scan system, and gait features were measured using wireless motion sensors attached to the sacrum and feet. Patient characteristics were obtained from medical records or by interview.ResultsSmall roll and yaw motions of the body and yaw motion of the foot during the mid-stance phase were related to the elevated plantar pressure in 57 diabetic patients. Furthermore, these gait features were related to sensory neuropathy, diabetes duration, patient weight, toe-gap force, and ankle range of motion.ConclusionGiven our findings, it may be possible to prevent diabetic foot ulcers by increasing foot motion during the mid-stance phase. Passive exercise aimed at expanding ankle range of motion in patients with sensory neuropathy or long-standing diabetes may assist in achieving this.     

The pathomechanics of plantar fasciitis

Plantar fasciitis is a musculoskeletal disorder primarily affecting the fascial enthesis. Although poorly understood, the development of plantar fasciitis is thought to have a mechanical origin. In particular, pes planus foot types and lower-limb biomechanics that result in a lowered medial longitudinal arch are thought to create excessive tensile strain within the fascia, producing microscopic tears and chronic inflammation. However, contrary to clinical doctrine, histological evidence does not support this concept, with inflammation rarely observed in chronic plantar fasciitis. Similarly, scientific support for the role of arch mechanics in the development of plantar fasciitis is equivocal, despite an abundance of anecdotal evidence indicating a causal link between arch function and heel pain. This may, in part, reflect the difficulty in measuring arch mechanics in vivo. However, it may also indicate that tensile failure is not a predominant feature in the pathomechanics of plantar fasciitis. Alternative mechanisms including 'stress-shielding', vascular and metabolic disturbances, the formation of free radicals, hyperthermia and genetic factors have also been linked to degenerative change in connective tissues. Further research is needed to ascertain the importance of such factors in the development of plantar fasciitis.     

An investigation of the relationship between plantar pressure distribution and the morphologic and mechanic properties of the intrinsic foot muscles and plantar fascia

BackgroundThe purpose of this study was to investigate the relationship between plantar pressure distribution and the stiffness, thickness, and cross-sectional area of the plantar fascia (PF) and abductor hallucis (AbH), flexor hallucis brevis (FHB), and flexor digitorum brevis (FDB) muscles.MethodsThe present study included a total of 41 healthy females between the ages of 20 and 34 years. Plantar pressure during static standing position was measured using a pedobarography system (MatScan, Tekscan, Inc., South Boston, Massachusetts, USA). Peak pressure, mean pressure, maximum force (Max-F), contact area (Con-A), pressure time integral, and force time integral (FTI) were measured. The thickness, cross-sectional area and stiffness of the intrinsic foot muscles and PF were measured using an ACUSON S3000 Ultrasound System and a 9L4 probe (4–9 MHz) (Siemens Medical Solution, Mountain View, CA, USA). Shear Wave Velocity (SWV) of the intrinsic foot muscles and PF was measured using a customized software program (Virtual Touch Imaging and Quantification; Siemens Medical Solution).ResultsCon-A had a moderate correlation with the thickness and cross-sectional area of PF, AbH, FHB, and FDB. A fair to moderate correlation was found between heel Max-F and the thickness and cross-sectional area of PF, AbH, FHB, and FDB. There is no significant correlation between the SWV of the assessed tissues and plantar pressure distribution parameters. Body mass and BMI had a fair to good correlation with Mean-P, Con-A, heel Max-F, midfoot Max-F, metatarsal Max-F, FTI, thickness, and cross-sectional area of the PF and assessed musclesSignificanceThe results suggest that abnormal force, contact area, and higher body mass may cause hypertrophy of the PF and foot intrinsic muscles.     

Ultrasound evaluation of foot muscles and plantar fascia in pes planus

BackgroundMultiple intrinsic and extrinsic soft tissue structures that apply forces and support the medial longitudinal arch have been implicated in pes planus. These structures have common functions but their interaction in pes planus is not fully understood. The aim of this study was to compare the cross-sectional area (CSA) and thickness of the intrinsic and extrinsic foot muscles and plantar fascia thickness between normal and pes planus feet.MethodsForty-nine adults with a normal foot posture and 49 individuals with pes planus feet were recruited from a university population. Images of the flexor digitorum longus (FDL), flexor hallucis longus (FHL), peroneus longus and brevis (PER), flexor hallucis brevis (FHB), flexor digitorum brevis (FDB) and abductor hallucis (AbH) muscles and the plantar fascia were obtained using a Venue 40 ultrasound system with a 5–13 MHz transducer.ResultsThe CSA and thickness of AbH, FHB and PER muscles were significantly smaller (AbH −12.8% and −6.8%, FHB −8.9% and −7.6%, PER −14.7% and −10%), whilst FDL (28.3% and 15.2%) and FHL (24% and 9.8%) were significantly larger in the pes planus group. The middle (−10.6%) and anterior (−21.7%) portions of the plantar fascia were thinner in pes planus group.ConclusionGreater CSA and thickness of the extrinsic muscles might reflect compensatory activity to support the MLA if the intrinsic foot muscle function has been compromised by altered foot structure. A thinner plantar fascia suggests reduced load bearing, and regional variations in structure and function in feet with pes planus.     

Fibromatosis of the breast in a male patient

Fibromatosis of the breast is a rare soft tissue lesion that arises from the mammary tissue or the pectoral fascia. We present a case of fibromatosis in a 39-year-old male patient who developed a right lateral breast mass in several weeks without prior trauma or surgery. Ultrasound-guided core needle biopsy findings included differential diagnoses of nodular fasciitis and fibromatosis. The patient was referred to a breast surgeon and underwent excisional biopsy. Final pathology report confirmed fibromatosis. The patient tolerated the surgery well and will continue to follow up post-operatively for recurrence.     

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.     

Applicability of contrast‐enhanced ultrasound in the diagnosis of plantar fasciitis

Contrast‐enhanced ultrasound (CEUS) is used to visualize the microvascularization in various tissues. The purpose of this study was to investigate whether CEUS could be used to visualize the microvascular volume (MV) in the plantar fascia, and to compare the method to clinical symptoms and B‐mode ultrasound (US) in patients with plantar fasciitis (PF). Twenty patients with unilateral PF were included and were divided by US in insertional thickening (10), midsubstance thickening (5), and no US changes (5). The MV was measured simultaneously in both heels. Four areas in the plantar fascia and plantar fat pad were measured independently by two observers. Inter‐ and intra‐observer correlation analyses were performed. The asymptomatic heels showed a constantly low MV, and for the whole group of patients, a significantly higher MV was found in the symptomatic plantar fascia and plantar fat pad. Inter‐observer correlation as well as intra‐observer agreement was excellent. The MV in the plantar fascia and plantar fat pad can be measured reliably using CEUS, suggesting that it is a reproducible method to examine patients with plantar fasciitis.     

Fibromatosis of the breast in a 52-year-old man (2010: 10b)

Fibromatosis is a proliferation of fibroblastic and miofibroblastic cells that primarily originate from the fascia or aponeuroses of the abdominal wall. This entity has no potential metastatic risk, but can reappear locally. In rare cases it may develop in the breast, and it is extremely uncommon in the male breast. Fibromatosis of the breast presents clinical, mammographic and ultrasound signs of malignancy, and it can only be confirmed through histological analysis. We present the case of a 52-year-old man with a palpable and painless nodule in the right breast of 2 months' evolution with radiological signs of malignancy. The histological analysis determined that this was due to fibromatosis.