Elsevier

Clinical Radiology

Volume 64, Issue 9, September 2009, Pages 931-939
Clinical Radiology

Pictorial Review
Getting to the heel of the problem: plantar fascia lesions

https://doi.org/10.1016/j.crad.2009.02.020Get rights and content

Heel pain is a frequent disabling symptom. Clinical diagnosis is often difficult with a large range of possible diagnoses. Lesions of the plantar fascia form an important group. We present a review describing the common lesions of the plantar fascia, including plantar fasciitis, plantar fascia rupture, plantar fibromatosis, and plantar xanthoma, and illustrate them with appropriate magnetic resonance imaging (MRI) and ultrasound imaging. We also address foreign-body reactions, enthesopathy, and diabetic fascial disease.

Introduction

The plantar fascia is a thick, multilayered, inelastic band of fibrous tissue that courses along the plantar surface of the foot. It contains medial, central, and lateral components. The term “plantar fascia” often refers to the large central component. This attaches to the medial tuberosity of the Os calcis and extends anteriorly becoming broader and thinner. In the region of the metatarsal heads, the plantar fascia divides into five processes, one for each of the toes. Each of these processes divides opposite the metatarsophalangeal articulation into two strata, superficial and deep. The superficial stratum of each process is connected to the dermis by skin ligaments (retinacula cutis). These ligaments reach the skin of the ball of the foot proximal to, and in the floors of the furrows that separate the toes from the sole. The deeper stratum divides into two slips that embrace the side of the flexor tendons of the toes. The lateral and medial portions of the plantar aponeurosis are thinner than the central portion, and cover the sides of the sole of the foot. Some authors refer only to two branches omitting the medial, but referring to the central as the medial. In this article, the three-branch approach will be used.

The primary function of the plantar fascia is to act as a bowstring and maintain the longitudinal arch of the foot.

Section snippets

Normal imaging anatomy

The normal plantar fascia is easily visualized using magnetic resonance imaging (MRI) or ultrasound. On plain radiography, the fascia can be seen between layers of surrounding fat, but its internal structure is not defined. Bony spur formation at the fascial origin is also seen on plain radiographs, but the presence of a spur does not necessarily indicate fascial disease. The normal plantar fascia is seen on MRI as a thin band with low signal intensity on all pulse sequences (Fig. 1). It is

Lesions of the plantar fascia

The principle plantar fascia lesions are: plantar fasciitis, plantar fascia rupture, plantar fibromatosis, and plantar xanthoma. We will also address foreign-body reactions, enthesopathy, and diabetic fascial disease.

Conclusion

Plantar fascia lesions are responsible for a fair proportion of disabling heel pain. We have presented a review illustrated with MRI and ultrasound imaging in an attempt to highlight the variety of possible plantar fascial lesions. Although both imaging methods excel at imaging the plantar fascia, ultrasound has the added ability of allowing guided treatment at the time of imaging.

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