F. Berkowitz,
Jessica
Plantar
MD
#{149} Ruben
Fasciitis:
clinical presentation of plantar 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 Tiweighted and coronal intermediate and T2-weighted images of symptomatic and asymptomatlc feet were obtained; additional sequences were used for symptomatic feet. Maximum thickness of the plantar fascia was significantly Increased (P < .0001) in patients with plantar faaciitis (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 fasclitls had areas of moderately increased signal intensity in the substance of the fascia. MR imfasciitis
may
sessment changes
provide an objective of the morphologic associated with plantar
ciitis,
as well
other
causes
Index malities, Radiology
terms:
as-
faa-
as assist in excluding of heel pain. 4642.24 #{149} Foot, abnor#{149} Foot, MR studies, 4642.1214
Fasciitis,
4642.24 1991;
MD
179:665-667
T
Rudicel,
#{149} Sally
MR
The
aging
Kier,
Imaging’
heel syndrome is characterized by chronic heel pain in the absence of a known traumatic event (1-3). Although several pathologic conditions may cause the clinical syndrome, plantar fasciitis is a frequent cause (3-11). The differenHal diagnosis includes calcaneal stress fractures, median calcaneal neuritis, tarsal tunnel syndrome, and other conditions that may cause heel pain similar to that of plantar fasciitis (3,6,8,12). When heel pain is bilateral, the seronegative arthritides warrant consideration because they may cause an enthesopathy at the plantar fascial insertion (1,5,9,13,14). HE painful
Conventional
radiographic
volunteers.
MATERIALS
Medical
College,
#{176}RSNA,1991
Valhalla,
NY
10595.
studies
of patients with painful heel syndrome are often unrewarding (2,4). The most common radiographic finding is a plantar calcaneal spur, although this finding probably represents the incidence of spur in the general population (3,4,6,9,14,15). Others have noted increased thickness of the heel fat pad and subfascial area in symptomatic feet (16). Calcaneal uptake at radionuclide scintigraphy is another frequent but nonspecific finding (5,12,15). As magnetic resonance (MR) imaging has been effective in diagnosing several pathologic conditions of the soft tissues of the ankle and foot (17-19), we sought to characterize the MR imaging feahires of plantar fasciitis, comparing MR imaging features of patients with the clinical diagnosis of plantar fasditis with those of age- and sexmatched controls and unmatched asymptomatic
I From the Departments of Radiology (J.F.B., R.K.) and Orthopedics (S.R.), Yale University School of Medicine, New Haven, Conn. Received August 31, 1990; revision requested October 3; revision received January 30, 1991; accepted February 14. Address reprint requests to J.F.B., Department of Radiology, New York
MD
AND
METHODS
Eight patients with unilateral (n 6) and bilateral (n = 2) heel pain were referred to the Department of Radiology by an orthopedist eases of the
(S.R.)
experienced
in din-
foot. There were seven wornen and one man. The patients ranged in age from 28 to 73 years (mean, 43 years). All patients reported heel pain, and all
demonstrated
the
physical
characteristics
of plantar fasciitis. Tenderness was elicited on palpation along the undersurface of the calcaneus in three heels, along the plantar fascia in five heels, and along the fascia and calcaneus in two heels. One patient with tenderness along the plantar fascia also demonstrated tenderness along the Achilles tendon. Both patients with bilateral heel pain were runners. The seven women ranged in weight from 135 to 200 lb (61-90 kg), with a mean weight of 160 lb (73 kg). The man weighed 185 lb (84 kg). plantar
Imaging
findings in the patients were those in nine asympto-
compared
with
matic
heels
controls group
and
of five sex- and age-matched six nonpainful heels in a
of five unmatched of heels imaged
number subject
depended
entirely
at the time
straints
matched
controls (mean,
46 years
controls. The in each control on time con-
of imaging.
matched
controls were men and one was an obese woman in whom both heels Eight of the nine patients
aged 29-33 58-year-old were studied. and all con-
years,
trols
were
The five
were women aged 3241 years; P < .7). Four un-
examined
at 1.5 T with
a super-
conductive system (Signa; CE Medical Systems, Milwaukee) with a 17-cm-bore transmit-receive extremity coil. One patient had both feet examined simultaneously in a 24-cm-bore transmit-receive head coil. Sagittal Ti-weighted spin-echo (SE) sequences
(400-600/20
time msec/echo time dual-echo SE sequences
30, 80) were aged
ic feet
with
performed the extremity
were
also
[repetition
msec])
and coronal
(1,700-2,200/20in all subjects
im-
coil. Symptomat-
studied
with
an axial
dual-echo sequence. Section thickness was 3 mm with 0-1.5-mm gaps between sections.
Field
of view
was
14-16
cm,
with a 256 X 256 or 192 X 256 matrix and one signal excitation. The thickness of the plantar fascia was measured on both sagittal and coronal images
at the
of the central aponeurosis torum brevis
occurred sertion
point
of maximal
component overlying muscle.
thickness
of the plantar the
flexor
Thin point
digi-
always
within 5 cm of the calcaneal inin the symptomatic ankles. In con-
Abbreviation:
SE
-
spin
echo.
665
,
trol heels, measurements were made at the point of maximal thickness or just anterior to the calcaneal insertion if the fancia was of uniform thickness. Any deviation from the normally uniform low signal
intensity
recorded. plantar
caneal brous
of
the
plantar
was
fascia
The presence or absence of calcaneal spurs, other osseous calabnormalities, subcutaneous fisepta,
Achilles
subcutaneous
tendon
hated. The study Investigation and informed all volunteers the research
edema,
abnormalities
-
and
were
tabu-
I
.
was approved
by the Human Committee at our hospital, consent was obtained from and patients imaged under protocol.
RESULTS The plantar fascia in both the agematched controls and the group of young male controls was of homogeneous low signal intensity with cither uniform thickness or minimal tapering along its course (Fig 1). A slight flaring of the fascia was often seen as its calcaneal insertion. The margins of the plantar fascia were well defined. Ti-weighted or intermediate images were used more often to measure the thickness of the plantar fascia, since tissue contrast was greater on these images and the margins of the fascia were easier to define. The mean thickness of the fascia on sagittal images in the agematched controls was 3.22 mm ± 0.44 (standard deviation) and the mean thickness on coronal images was 3.44 mm ± 0.53. For the young male controls, the mean thickness of the plantar fascia was 3.00 mm ± 0.82 in the sagittal plane and 3.00 mm ± 0.0 in the coronal plane. The plantar fascia in the 58-year-old obese volunteer measured 8 mm sagittally and 9 mm comonally in the left foot and 8 mm sagittally and 8 mm coronally in the right foot and demonstrated focal arcan of increased signal intensity. In symptomatic feet, the plantar fascia was significantly thickened (P < .0001)
compared
with
that
in both
the matched control group and the young male controls. The mean thickness of the plantar fascia was 7.40 mm
mm ± 1.17 sagittally and 7.56 ± 1.01 coronally in the symp-
tomatic feet (Fig 2). In all but one heel (nine of 10), the plantar fascia demonstrated various-sized areas of increased signal intensity within the fascia in the region of fascial thickening. Subcutaneous
seen
in nine
ic feet controls
666
fibrous
(60%)
of matched and three
#{149} Radiology
septa
were
of 15 asymptomatand unmatched (33%) of nine
b. Figure
1.
intermediate
weighted
Normal plantar fascia. (a) Sagittal (2,000/20) and (b) coronal Ti-
(600/20)
images
demonstrate
normal thin plantar fascia and overlying subcutaneous (curved arrow in b).
symptomatic
not imaged Calcaneal (27%)
the
(straight fibrous
and
five
(50%)
10 symptomatic
heels.
No abnormali-
ties
in the
marrow
were
S
arrows) septa
heels. The heel pad was in one symptomatic foot. spurs were noted in four
of 15 controls noted
of
of the
calcaneus. Subcutaneous edema present in only one symptomatic heel (Fig 3). Achilles tendinitis present in only one symptomatic ankle.
was was
The cause of plantar fasciitis has been attributed to mechanical stress on the plantar fascia resulting in microtears as well as fascial and perifascial inflammation (2,3,6,7,14). In mild cases, plantar fasciitis may cause pain only with exercise. Some more severely affected individuals find walking and standing uncomfortable It is not
surprising
that
plantar
fasciitis is a common cause of heel pain in runners and obese patients, presumably due to the trauma of mepetitive traction on the plantar fascia (2,3,7,8,11,14,15). The multilayered mosis is composed
components: emal. The
medial, dominant
plantar of three
aponeudistinct
central, and central portion
b. Figure
2.
Plantar
fasciitis.
(a) Sagittal
Ti-
weighted (600/20) image shows thickened plantar fascia (straight arrows) and calcaneal spur (curved arrow). (b) Coronal intermediate (2,200/20) image demonstrates thickened plantar fascia (arrow) with intrasubstance increased signal intensity on 2,000/20 images.
extends from its attachment along the medial calcaneal tubemosity, with the deep layer of the aponeumosis fanning into five tracts distally that
DISCUSSION
(20).
I
lat-
have
their
insertions
phalanges tenderness
calized
on the
(6). Acutely, of plantar
deep
in the
proximal
the pain and fasciitis are lo-
heel
pad
along
the insertion of the plantam aponeumosis at the medial calcaneal tuberosity (2-7,16). In more chronic stages, pain may extend more distally along the aponeumosis (6). In our patients, the morphologic changes in the plantam fascia were observed only in the central component. Treatment of plantam fasciitis is primanly conservative, employing rest,
immobilization, orthoses, flammatory exercises, jections
ice packs,
heel
pads,
oral
nonstemoidal anti-inmedications, stretching and occasional steroid in(2,6-8,20). Infrequently, sum-
June
1991
p
.,-
: /
I
C’,
I -.‘
.-
.
m
-‘.,
&
.
&
,
‘L
d
Figure
row)
3.
and
Subcutaneous
focally
(straight arrow) plantar fasciitis sagittal image. also present.
collagen be
proof
necrosis
hyperplasia
emphasized
was
not
as patients
ar-
fascia
on patients with pain (3,7,8,i 1,14). specimens have dem-
giofibroblastic must
(curved
plantar
are seen in a patient with on a 12-weighted (2,000/80) A plantar calcaneal spur is
gery is performed chronic refractory Surgical biopsy onstrated
edema
thickened
an-
(3,7).
that
obtained
were
and
in this
following
It
pathologic
study,
our
fractures
as a cause
patients
syndromes
(22). such
Nerve
of pain
in
entrapment
as tarsal
tunnel
syn-
drome or medial calcaneal neuritis are causes of painful heels but have clinical manifestations somewhat different from those of plantar fasciitis and were considered unlikely in our patients. Invasive procedures such as nerve conduction testing and selective nerve blocks, which could rule out these entities, were not performed in our patients. No patient demonstrated clinical evidence of semonegative arthritis, and serologic tests
were
not
in this
fascia
similar
to that
performed.
179
#{149} Number
3
seen
signal in our
of the
abnormality
6.
7.
8.
9.
10.
1 1.
12.
13.
14.
15. 16.
17.
18.
19.
20.
U
knowledge PhD, who
The authors gratefully acthe contribution of Robert Lange, provided statistical analysis.
References
2.
5.
patients.
Acknowledgment:
3.
Volume
thickening
and
This observation may mean that more chronic repetitive trauma to the plantar fascia secondary to obesity or age may result in changes similar to those seen in plantar fasciitis. Although this suggests that the observed morphologic changes are not specific to plantar fasciitis, it may be that the association of the thickening of the plantar fascia and intrasubstance increased signal intensity in the appropriate clinical setting will prove diagnostic of plantar fascii-
1.
This preliminary study comparing a small number of patients with asymptomatic controls demonstrates
bilateral
plantar
tis.
4.
study.
Further imaging of symptomatic individuals is warranted to confirm our conclusions. Imaging of one markedly obese 58-year-old woman without a history of heel pain demonstrated
nonopera-
tive regimens at the time of imaging. The diagnosis of plantar fasciitis was presumptive, but care was taken to rule out other diagnoses with similam clinical findings. Lack of abnormality within the calcaneus on MR images helped exclude calcaneal stress
that MR imaging can depict abnormalities of the plantar fascia in patients with clinical evidence of plantar fasciitis. Other authors have shown that signal intensity abnommalities and thickening of the Achilles tendon and signal intensity abnormality of the supraspinatus tendon of the shoulder correlate with degeneration, inflammation, and scarring (17,18,21). Similar pathologic changes in the plantar fascia would be expected to appear as thickening of the fascia with intrasubstance signal intensity abnormality, as was seen in our patients. Alterations in the morphologic characteristics and signal intensity of the plantam fascia were not seen in asymptomatic agematched controls or younger asymptomatic controls. Although correlation with other tissues may be suggestive, the exact histologic nature of the changes in the plantar fascia seen at MR imaging was not determined
Furey JG. Plantar fasciitis: the painful heel syndrome. J Bone Joint Surg [Am] 1975; 57:672-673. Hill JJ Jr. Cutting PJ. Heel pain and body weight. Foot Ankle 1989; 9:254-256. Leach RE, Seavey MS. Salter DK. Results of surgery in athletes with plantar fasciitis. Foot Ankle 1986; 7:156-161.
21.
22.
Williams PL, Smibert JG, Cox R, Mitchell R, Klenerman L. Imaging study of the painful heel syndrome. Foot Ankle 1987; 7:345-349. Sewell JR. Black CM, Chapman AH, Statham J, Hughes GRV, Lavender JP. Quantitative scintigraphy in diagnosis and management of plantar fasciitis (calcaneal periostitis): concise communication. J Nucl Med 1980; 21:633-636. Kwong PK, Kay D, Voner RT, White MW. Plantar fasciitis: mechanics and pathomechanics of treatment. Clin Sports Med 1988; 7:119-126. Snider MP, Clancy WG, McBeath AA. Plantar fascia release for chronic plantar fasciitis in runners. Am J Sports Med 1983; 11:215-219. Lutter LD. Surgical decisions in athletes’ subcalcaneal pain. Am J Sports Med 1986; 14:481-485. Vasavada PJ, DeVries DF, Nishiyama H. Plantar fasciitis: early blood pooi images in diagnosis of inflammatory process. Foot Ankle 1984; 5:74-76. Katoh Y, Chao EYS, Morrey BF, Laughman RK. Objective technique for evaluating painful heel syndrome and its treatment. Foot Ankle 1983; 3:227-236. Leach RE, Dilorio E, Harney RA. Pathologic hindfoot conditions in the athlete. Clin Orthop 1983; 177:116-121. Graham CE. Painful heel syndrome: rationale of diagnosis and treatment. Foot Ankle 1983; 3:261-267. Gerster JC. Plantar fasciitis and Achilles tendinitis among 150 cases of seronegative spondarthritis. Rheumatol Rehabil 1980; 19:218-222. Lester DK, Buchanan RJ. Surgical treatment of plantar fasciitis. Clin Orthop 1984; 186:202-204. Williams PL. The painful heel. Br J Hosp Med 1987; 38:562-563. Amis J, Jennings L, Graham D, Graham CA. Painful heel syndrome: radiographic and treatment assessment. Foot Ankle 1988; 9:91-95. Quinn SF, Murray WI, Clark RA, Cochran CF. Achilles tendon: MR imaging at 1.5 I. Radiology 1987; 164:767-770. Marcus DS, Reicher MA, Kellerhouse LE. Achilles tendon injuries: the role of MR imaging. J Comput Assist Tomogr 1989; 13:480-486. Kier R, McCarthy S, Dietz M, Rudicel S. MR imaging of painful conditions of the ankle. RadioGraphics 1991; 11:401-414. Torg JS, Pavlov H, Torg E. Overuse injuties in sport: the foot. Clin Sports Med 1987; 6:291-320. Kieft GJ, Bloem JL, Rozing PM, Obermann WR. Rotator cuff impingement syndrome: MR imaging. Radiology 1988; 166:211-214. Lee JK, Yao L. Stress fractures: MR imaging. Radiology 1988; 169:217-220.
Radiology
#{149} 667
Jessica
Plantar
MD
#{149} Ruben
Fasciitis:
clinical presentation of plantar 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 Tiweighted and coronal intermediate and T2-weighted images of symptomatic and asymptomatlc feet were obtained; additional sequences were used for symptomatic feet. Maximum thickness of the plantar fascia was significantly Increased (P < .0001) in patients with plantar faaciitis (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 fasclitls had areas of moderately increased signal intensity in the substance of the fascia. MR imfasciitis
may
sessment changes
provide an objective of the morphologic associated with plantar
ciitis,
as well
other
causes
Index malities, Radiology
terms:
as-
faa-
as assist in excluding of heel pain. 4642.24 #{149} Foot, abnor#{149} Foot, MR studies, 4642.1214
Fasciitis,
4642.24 1991;
MD
179:665-667
T
Rudicel,
#{149} Sally
MR
The
aging
Kier,
Imaging’
heel syndrome is characterized by chronic heel pain in the absence of a known traumatic event (1-3). Although several pathologic conditions may cause the clinical syndrome, plantar fasciitis is a frequent cause (3-11). The differenHal diagnosis includes calcaneal stress fractures, median calcaneal neuritis, tarsal tunnel syndrome, and other conditions that may cause heel pain similar to that of plantar fasciitis (3,6,8,12). When heel pain is bilateral, the seronegative arthritides warrant consideration because they may cause an enthesopathy at the plantar fascial insertion (1,5,9,13,14). HE painful
Conventional
radiographic
volunteers.
MATERIALS
Medical
College,
#{176}RSNA,1991
Valhalla,
NY
10595.
studies
of patients with painful heel syndrome are often unrewarding (2,4). The most common radiographic finding is a plantar calcaneal spur, although this finding probably represents the incidence of spur in the general population (3,4,6,9,14,15). Others have noted increased thickness of the heel fat pad and subfascial area in symptomatic feet (16). Calcaneal uptake at radionuclide scintigraphy is another frequent but nonspecific finding (5,12,15). As magnetic resonance (MR) imaging has been effective in diagnosing several pathologic conditions of the soft tissues of the ankle and foot (17-19), we sought to characterize the MR imaging feahires of plantar fasciitis, comparing MR imaging features of patients with the clinical diagnosis of plantar fasditis with those of age- and sexmatched controls and unmatched asymptomatic
I From the Departments of Radiology (J.F.B., R.K.) and Orthopedics (S.R.), Yale University School of Medicine, New Haven, Conn. Received August 31, 1990; revision requested October 3; revision received January 30, 1991; accepted February 14. Address reprint requests to J.F.B., Department of Radiology, New York
MD
AND
METHODS
Eight patients with unilateral (n 6) and bilateral (n = 2) heel pain were referred to the Department of Radiology by an orthopedist eases of the
(S.R.)
experienced
in din-
foot. There were seven wornen and one man. The patients ranged in age from 28 to 73 years (mean, 43 years). All patients reported heel pain, and all
demonstrated
the
physical
characteristics
of plantar fasciitis. Tenderness was elicited on palpation along the undersurface of the calcaneus in three heels, along the plantar fascia in five heels, and along the fascia and calcaneus in two heels. One patient with tenderness along the plantar fascia also demonstrated tenderness along the Achilles tendon. Both patients with bilateral heel pain were runners. The seven women ranged in weight from 135 to 200 lb (61-90 kg), with a mean weight of 160 lb (73 kg). The man weighed 185 lb (84 kg). plantar
Imaging
findings in the patients were those in nine asympto-
compared
with
matic
heels
controls group
and
of five sex- and age-matched six nonpainful heels in a
of five unmatched of heels imaged
number subject
depended
entirely
at the time
straints
matched
controls (mean,
46 years
controls. The in each control on time con-
of imaging.
matched
controls were men and one was an obese woman in whom both heels Eight of the nine patients
aged 29-33 58-year-old were studied. and all con-
years,
trols
were
The five
were women aged 3241 years; P < .7). Four un-
examined
at 1.5 T with
a super-
conductive system (Signa; CE Medical Systems, Milwaukee) with a 17-cm-bore transmit-receive extremity coil. One patient had both feet examined simultaneously in a 24-cm-bore transmit-receive head coil. Sagittal Ti-weighted spin-echo (SE) sequences
(400-600/20
time msec/echo time dual-echo SE sequences
30, 80) were aged
ic feet
with
performed the extremity
were
also
[repetition
msec])
and coronal
(1,700-2,200/20in all subjects
im-
coil. Symptomat-
studied
with
an axial
dual-echo sequence. Section thickness was 3 mm with 0-1.5-mm gaps between sections.
Field
of view
was
14-16
cm,
with a 256 X 256 or 192 X 256 matrix and one signal excitation. The thickness of the plantar fascia was measured on both sagittal and coronal images
at the
of the central aponeurosis torum brevis
occurred sertion
point
of maximal
component overlying muscle.
thickness
of the plantar the
flexor
Thin point
digi-
always
within 5 cm of the calcaneal inin the symptomatic ankles. In con-
Abbreviation:
SE
-
spin
echo.
665
,
trol heels, measurements were made at the point of maximal thickness or just anterior to the calcaneal insertion if the fancia was of uniform thickness. Any deviation from the normally uniform low signal
intensity
recorded. plantar
caneal brous
of
the
plantar
was
fascia
The presence or absence of calcaneal spurs, other osseous calabnormalities, subcutaneous fisepta,
Achilles
subcutaneous
tendon
hated. The study Investigation and informed all volunteers the research
edema,
abnormalities
-
and
were
tabu-
I
.
was approved
by the Human Committee at our hospital, consent was obtained from and patients imaged under protocol.
RESULTS The plantar fascia in both the agematched controls and the group of young male controls was of homogeneous low signal intensity with cither uniform thickness or minimal tapering along its course (Fig 1). A slight flaring of the fascia was often seen as its calcaneal insertion. The margins of the plantar fascia were well defined. Ti-weighted or intermediate images were used more often to measure the thickness of the plantar fascia, since tissue contrast was greater on these images and the margins of the fascia were easier to define. The mean thickness of the fascia on sagittal images in the agematched controls was 3.22 mm ± 0.44 (standard deviation) and the mean thickness on coronal images was 3.44 mm ± 0.53. For the young male controls, the mean thickness of the plantar fascia was 3.00 mm ± 0.82 in the sagittal plane and 3.00 mm ± 0.0 in the coronal plane. The plantar fascia in the 58-year-old obese volunteer measured 8 mm sagittally and 9 mm comonally in the left foot and 8 mm sagittally and 8 mm coronally in the right foot and demonstrated focal arcan of increased signal intensity. In symptomatic feet, the plantar fascia was significantly thickened (P < .0001)
compared
with
that
in both
the matched control group and the young male controls. The mean thickness of the plantar fascia was 7.40 mm
mm ± 1.17 sagittally and 7.56 ± 1.01 coronally in the symp-
tomatic feet (Fig 2). In all but one heel (nine of 10), the plantar fascia demonstrated various-sized areas of increased signal intensity within the fascia in the region of fascial thickening. Subcutaneous
seen
in nine
ic feet controls
666
fibrous
(60%)
of matched and three
#{149} Radiology
septa
were
of 15 asymptomatand unmatched (33%) of nine
b. Figure
1.
intermediate
weighted
Normal plantar fascia. (a) Sagittal (2,000/20) and (b) coronal Ti-
(600/20)
images
demonstrate
normal thin plantar fascia and overlying subcutaneous (curved arrow in b).
symptomatic
not imaged Calcaneal (27%)
the
(straight fibrous
and
five
(50%)
10 symptomatic
heels.
No abnormali-
ties
in the
marrow
were
S
arrows) septa
heels. The heel pad was in one symptomatic foot. spurs were noted in four
of 15 controls noted
of
of the
calcaneus. Subcutaneous edema present in only one symptomatic heel (Fig 3). Achilles tendinitis present in only one symptomatic ankle.
was was
The cause of plantar fasciitis has been attributed to mechanical stress on the plantar fascia resulting in microtears as well as fascial and perifascial inflammation (2,3,6,7,14). In mild cases, plantar fasciitis may cause pain only with exercise. Some more severely affected individuals find walking and standing uncomfortable It is not
surprising
that
plantar
fasciitis is a common cause of heel pain in runners and obese patients, presumably due to the trauma of mepetitive traction on the plantar fascia (2,3,7,8,11,14,15). The multilayered mosis is composed
components: emal. The
medial, dominant
plantar of three
aponeudistinct
central, and central portion
b. Figure
2.
Plantar
fasciitis.
(a) Sagittal
Ti-
weighted (600/20) image shows thickened plantar fascia (straight arrows) and calcaneal spur (curved arrow). (b) Coronal intermediate (2,200/20) image demonstrates thickened plantar fascia (arrow) with intrasubstance increased signal intensity on 2,000/20 images.
extends from its attachment along the medial calcaneal tubemosity, with the deep layer of the aponeumosis fanning into five tracts distally that
DISCUSSION
(20).
I
lat-
have
their
insertions
phalanges tenderness
calized
on the
(6). Acutely, of plantar
deep
in the
proximal
the pain and fasciitis are lo-
heel
pad
along
the insertion of the plantam aponeumosis at the medial calcaneal tuberosity (2-7,16). In more chronic stages, pain may extend more distally along the aponeumosis (6). In our patients, the morphologic changes in the plantam fascia were observed only in the central component. Treatment of plantam fasciitis is primanly conservative, employing rest,
immobilization, orthoses, flammatory exercises, jections
ice packs,
heel
pads,
oral
nonstemoidal anti-inmedications, stretching and occasional steroid in(2,6-8,20). Infrequently, sum-
June
1991
p
.,-
: /
I
C’,
I -.‘
.-
.
m
-‘.,
&
.
&
,
‘L
d
Figure
row)
3.
and
Subcutaneous
focally
(straight arrow) plantar fasciitis sagittal image. also present.
collagen be
proof
necrosis
hyperplasia
emphasized
was
not
as patients
ar-
fascia
on patients with pain (3,7,8,i 1,14). specimens have dem-
giofibroblastic must
(curved
plantar
are seen in a patient with on a 12-weighted (2,000/80) A plantar calcaneal spur is
gery is performed chronic refractory Surgical biopsy onstrated
edema
thickened
an-
(3,7).
that
obtained
were
and
in this
following
It
pathologic
study,
our
fractures
as a cause
patients
syndromes
(22). such
Nerve
of pain
in
entrapment
as tarsal
tunnel
syn-
drome or medial calcaneal neuritis are causes of painful heels but have clinical manifestations somewhat different from those of plantar fasciitis and were considered unlikely in our patients. Invasive procedures such as nerve conduction testing and selective nerve blocks, which could rule out these entities, were not performed in our patients. No patient demonstrated clinical evidence of semonegative arthritis, and serologic tests
were
not
in this
fascia
similar
to that
performed.
179
#{149} Number
3
seen
signal in our
of the
abnormality
6.
7.
8.
9.
10.
1 1.
12.
13.
14.
15. 16.
17.
18.
19.
20.
U
knowledge PhD, who
The authors gratefully acthe contribution of Robert Lange, provided statistical analysis.
References
2.
5.
patients.
Acknowledgment:
3.
Volume
thickening
and
This observation may mean that more chronic repetitive trauma to the plantar fascia secondary to obesity or age may result in changes similar to those seen in plantar fasciitis. Although this suggests that the observed morphologic changes are not specific to plantar fasciitis, it may be that the association of the thickening of the plantar fascia and intrasubstance increased signal intensity in the appropriate clinical setting will prove diagnostic of plantar fascii-
1.
This preliminary study comparing a small number of patients with asymptomatic controls demonstrates
bilateral
plantar
tis.
4.
study.
Further imaging of symptomatic individuals is warranted to confirm our conclusions. Imaging of one markedly obese 58-year-old woman without a history of heel pain demonstrated
nonopera-
tive regimens at the time of imaging. The diagnosis of plantar fasciitis was presumptive, but care was taken to rule out other diagnoses with similam clinical findings. Lack of abnormality within the calcaneus on MR images helped exclude calcaneal stress
that MR imaging can depict abnormalities of the plantar fascia in patients with clinical evidence of plantar fasciitis. Other authors have shown that signal intensity abnommalities and thickening of the Achilles tendon and signal intensity abnormality of the supraspinatus tendon of the shoulder correlate with degeneration, inflammation, and scarring (17,18,21). Similar pathologic changes in the plantar fascia would be expected to appear as thickening of the fascia with intrasubstance signal intensity abnormality, as was seen in our patients. Alterations in the morphologic characteristics and signal intensity of the plantam fascia were not seen in asymptomatic agematched controls or younger asymptomatic controls. Although correlation with other tissues may be suggestive, the exact histologic nature of the changes in the plantar fascia seen at MR imaging was not determined
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