Why? Ultrasound of the Foot. Ultrasound of the Foot. General Rules. Plantar Fascia. Plantar Fasciitis 18/09/2018

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Thomas Welch
5 years ago
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Plantar plate tears MTP joint synovitis Ganglia

Clinical examination One finger Focal pain?

examination Reporting Normal is rare Be descriptive

Plantar Fascia Strong connective tissue structure

support and dynamic shock absorption) Origin:

Middle, lateral and central band Lateral: insert

Peroneal brevis insertional tendinosis Central band

degeneration of the plantar fascia Microtrauma or

1 Ultrasound of the Foot Why? Ultrasound of the Foot Plantar fasciitis Plantar fascia fibromatosis Morton s neuroma Intermetatarsal bursitis Adventitial bursitis Plantar plate tears MTP joint synovitis Ganglia Gout Masses General Rules Anatomy, anatomy, anatomy Clinical examination One finger Focal pain? Time Linear transducer Comparison Extend the examination Reporting Normal is rare Be descriptive Diagrams & measurement Accurate/clear annotaion Plantar Fascia Strong connective tissue structure Maintains the longitudinal arch of the foot (static support and dynamic shock absorption) Origin: calcaneus Insertion: heads of metatarsal bones Middle, lateral and central band Lateral: insert onto base of 5 th MT Lateral plantar fasciitis vs. Peroneal brevis insertional tendinosis Central band most frequently injured Painful non-inflammatory degeneration of the plantar fascia Microtrauma or tears Risk factors High BMI Long periods of work related weight bearing Athletes with high impact on foot Morning most painful 1

US findings: Fushiform thickening Surrounding

Anechoic/hypoechoic defect relating to tears >4mm

fibrous proliferation of the plantar fascia

palmer fibromatosis in 65% of patients Cause

lobulated) hypoechoic masses arising from plantar

Maybe subtle focal fusiform thickening Typically

Fusiform enlargement of the interdigital nerve

tissue Located between the MT heads on the

intermetatarsal ligaments Most commonly affecting

to footwear Burning/tingling sensation Mulder s

joint together and under dynamic stress, release

2 US findings: Fushiform thickening Surrounding soft tissue edema Hypoechoic Heterogeous Anechoic/hypoechoic defect relating to tears >4mm Bony spur at origin Plantar Fibromatosis Bengin fibrous proliferation of the plantar fascia Forming nodules of various sizes Concomitant palmer fibromatosis in 65% of patients Cause Unknown Suggested: genetic predisposition and alteration to the collagen profile of the plantar fascia Plantar Fibromatosis Focal, oval (can be lobulated) hypoechoic masses arising from plantar fascia Disruption to normal internal structure Maybe subtle focal fusiform thickening Typically <2cm in length Minimal vascularity Multiple Fusiform enlargement of the interdigital nerve Pseudo-neuroma with the nerve wrapped in fibrotic tissue Located between the MT heads on the plantar aspect of the deep transverse intermetatarsal ligaments Most commonly affecting 2/3, 3/4 webspaces Female:Male ratio 5:1 Relate to footwear Burning/tingling sensation Mulder s click test Squeezing the foot bringing the MTP joint together and under dynamic stress, release the MTH then bring then back together Use the other hand to press from dorsal to volar between the MT spaces 2

$stress fracture Intermetatarsal$ of the transverse metatarsal ligament

3 Round or ovoid Hypoechic nodule Elongate to show nerve entering Typically noncompressible mushroom No hyperemia Dx Interstitial bursitis MT stress fracture Intermetatarsal Bursitis Located on the dorsal aspect of the transverse metatarsal ligament Common differential diagnosis for Morton s neuroma due to their similar location intermetatarsal space Intermetatarsal Bursitis Compressible Heterogeneous Hypoechoic/anechoic Various shapes/sizes Morton s neuroma and intermetatarsal bursitis can co-exist No colour flow Displace the nerve Adventitial Bursitis Inflammation of the adventitial bursa Develop at sites where subcutaneous tissue is exposed to high pressure and friction Usually overlies bony prominences or tendons Arises from merging of pre-existing small spaces in loose connective tissue : Pocket of fluid spaces in the s/c tissue Peripheral s/c hyperemia The Plantar Plate Fibrocartilagionous structure connects the base of the prox phalanx to the MT neck Supports the plantar aspect of the MTH and resists hyperextention of the MTP joint Risk factors High heeled shoes Acute hyperextension trauma Overuse 3

Plantar Plate Tear Hypoechoic or anechoid changes

of the plantar plate Maybe associated with

Persisitent hyperextension of the prox phalanx

Unilocular or multilocular cyst containing mucoid

Communicate with an adjacent joint or tendon

without septations Posterior enhancement Neck

Talo-Calcaneal jt Talo-Navicular jt space

Synovial hypertrophy and hyperemia Gout Commonest

characterized by hyperuricaemia and crytalization

structures such as bursae, tendons and soft

4 Plantar Plate Tear Hypoechoic or anechoid changes and discontinuity of the homogeneous appearance of the plantar plate Maybe associated with Synovitis of the MTPJ Flexor tenosynovitis Persisitent hyperextension of the prox phalanx Rupturing of plantar plate Hammer toe Ganglia Unilocular or multilocular cyst containing mucoid material surrounded by fibrous capsule Communicate with an adjacent joint or tendon sheath : Anechoic or hypoechoic masses With or without septations Posterior enhancement Neck Ganglia Common sites Cuneiform/ Metatarsals Talo-Calcaneal jt Talo-Navicular jt space Extensor tendon sheaths MTP Joint Synovitis Synovial hypertrophy and hyperemia Gout Commonest form of inflammatory arthritis Metabolic disorder characterized by hyperuricaemia and crytalization of uric acid in the joints, peri-articular structures such as bursae, tendons and soft tissues Gouty tophi wet sugar clumps Echogenic foci Heterogenous Hyperechoic/hypoechoic Peri-articular erosions 4

5 Foreign Bodies Hyperechoic fragments, usually linear Glass or metal produce acoustic shadowing Proximal and distal depth of FB from the skin 3 dimensions of the FB Abscesses surround FB appear heterogeneous, ill-defined, hypoechoic collection with peripheral vascularity Plantar Warts Cause by human papiloma virus Hypoechoic vascular lesion in the sole of the foot Giant Cell Tumour Of The Tendon Sheath Hypoechoic mass May be lobular Homogeneous or heterogenous Vascularity Commonly found in the digits Synovial Sarcoma Commonest soft tissue malignant tumours Age Occurs near tendons, tendon sheath, bursae, interosseus membranes Pain and tenderness 30% of cases show calcification Focal nodular Rounded or lobulated Solid, hypoechoic mass Irregular margins Heterogeneous or complex Increased vascularity Nerve Sheath Tumours Schwannomas arise from the Schwann cells surrounding nerves Hypoechoic fusiform mass with a dural tail 5

Imaging of Ankle and Foot pain

Imaging of Ankle and Foot pain Pramot Tanutit, M.D. Department of Radiology Faculty of Medicine, Prince of Songkla University 1 Outlines Plain film: anatomy Common causes of ankle and foot pain Exclude: