MRI assessment of the plantar fascia in diabetic versus nondiabetic patients: How thick should it be?

Transcription

1 MRI assessment of the plantar fascia in diabetic versus nondiabetic patients: How thick should it be? Poster No.: C-2324 Congress: ECR 2010 Type: Scientific Exhibit Topic: Musculoskeletal Authors: C. Pierre-Jerome 1, V. Moncayo 1, U. Albastaki 2, J. H. Göthlin 2, M. Keywords: DOI: R. Terk 1 ; 1 Atlanta, GA/US, 2 Gothenburg/SE MRI, Plantar Fascia, Plantar Fascia Thickness /ecr2010/C-2324 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 15

2 Purpose 1) To assess the plantar fascia thickness (PFT) in the diabetic and the non-diabetic patients. 2) To correlate the PFT as a function of body weight and age in diabetic versus nondiabetic patients. Images for this section: Page 2 of 15

3 Fig. 1 Page 3 of 15

4 Methods and Materials We reviewed the MR images of 121 subjects -thirty six diabetic patients and 85 nondiabetic patients. Mean age of the population was 47 years (range years). There were seventy (70) females and 51 males. Images were acquired with and without fat saturation and with one additional series with contrast. The plantar fascia thickness (PFT) was assessed focally in two planes -sagittal and coronal- figs.1,2. A focal increased thickness of over 30% of the adjacent normal size was defined as pathological. The thickness was assessed only on the central portion of the fascia, being the thickest compared to the medial and lateral portions (1). Body mass index (BMI) was calculated for all participants. Based on the BMI, the population was divided into 3 groups:i) normal weight, II) overweight and III) obese. Based on age, the population was subdivided into three categories: I) young =under 35 years, II) middle-aged= years, and older= over 65 years. PFT was correlated with BMI and age. Perifascial edema and reactive marrow edema in the calcaneus were also assessed. Statistical analysis: T-test was used to compare the continuous variables (thickness in both populations). Chi-square tests were used to test whether the dichotomized variables (signal intensity within the fascia, signal intensity in the perifascial tissues, and marrow edema in the calcaneous) were associated with patient's diagnosis. The significance levels were set at 0.05 for all tests. The SAS statistical package V9.2 (SAS Institute, Inc., Cary, North Carolina) was used for all data managements and analyses. Page 4 of 15

5 Images for this section: Fig. 1: Fig.1 Measurement of the plantar fascia thickness close to its insertion in sagittal plane. The measurement was performed about 1 cm from the insertion point. Page 5 of 15

6 Fig. 2: Fig.2 Measurement of the plantar fascia thickness in coronal plane, at the level as in sagittal plane. Page 6 of 15

7 Results In the study population, there was a visible distance between the insertion point of the plantar fascia and the insertion point of the Achilles tendon at the calcaneus (fig.1). Diabetic patients (58%) were more likely to be obese than non-diabetic patients (30%), representing a trend with p=0.07. Body weight was not found to influence the prevalence of increased plantar fascia thickness (PTF) in either population. But in the diabetic population, there was a trend of significance for increased PFT in the obese patients compared with the normal weight patients, p= 0.1 (fig.2). Older age (87%) was significantly more likely to be associated with increased PTF than younger age (63%) in non-diabetic patients (p=0.01), but not in the diabetic patients, p=1.00. Male (88%) was significantly more likely to be associated with increased PFT than female (63%) in diabetic patients, p=0.04; but not in the non-diabetic patients, p=0.65. The PFT close to the insertion site was marginally significantly thicker in diabetic patients (0.46) compared with non-diabetic patients (0.40), p=0.07. Signal changes within the thickened fascia close to the insertion site was significantly more prevalent in diabetic patients than in non-diabetic patients, p=0.04 (figs.3,4) (2-4). Diabetic patients were found to have a higher prevalence of increased signal intensity in the perifascial tissues compared with non-diabetic patients, p= (fig.5) (5,6). There was a higher prevalence of bone marrow edema in the calcaneous bone of diabetic patients compared with non-diabetic patients, p=0.01 (fig.6). Page 7 of 15

8 Images for this section: Page 8 of 15

9 Fig. 1: Fig.1. Plantar Fascia. MR SET1W sagittal. Illustration of the normal plantar fascia (curved arrow) in an adult foot and its relationship with the Achilles tendon (straight arrow). In the adult foot, there is a clear separation, with periosteum, between the insertion of the Achilles tendon (straight arrow) and the insertion of the plantar fascia (curved arrow). The distance between the insertions of the two tendons is less in children and young adults. The distance increases with age. Fig. 2: Fig.2. Plantar Fascia and Body Weight. MR SE T2WFS sagittal image of a 45 y.o. diabetic patient with obesity. There is focal increase of the fascia thickness close to the insertion point (arrow). Page 9 of 15

10 Fig. 3: Fig.3. Diabetes and Plantar Fascia Tear. MR SET1W (right) and SE T2WFS (left)sagittal images. 54 y.o male,insulin-dependant diabetic with acute heel pain. The images reveal deformity and full-thickness tear of the plantar fascia (arrows). Note the mild deformity of the navicular bone. Fig. 4: Fig.4. Diabetes and Plantar Fasciitis. MR STIR(right)and SET1WFS with contrast(left)sagittal images of a 49y.o. female with diabetes and severe heel pain. Page 10 of 15

11 The images show acute plantar fasciitis with signal changes around the plantar fascia (arrows). Note the contrast enhancement around the fascia (left image). Fig. 5: Fig.5. Diabetes and increased signal in the Perifascial Tissues. MR SET2WFS sagittal image of a 39 y.o. female with diabetes. The image displays high signal intensity in the plantar flexor digiti minimi muscle adjacent to the fascia (arrow). Page 11 of 15

12 Fig. 6: Fig.6. Diabetes and Marrow Edema. MR STIR sagittal image of a 54 y.o male with insulin-dependent diabetes. There is marrow edema in the calcaneus (curved arrow) as well as in the distal tibia and in the talus. Note the insertion tear of the Achilles tendon (straight white arrow. Page 12 of 15

13 Conclusion 1. PFT was more influenced by age than by body weight in the diabetic population. 2. There was a higher prevalence of increased signals in the perifascial tissues in the diabetic patients compared with the non diabetic patients. 3. Bone marrow edema in the calcaneous bone was more frequently seen in diabetic patients compared with non-diabetic patients. References 1. Uzel M, Cetinus E et al. The influence of Athletic Activity on the Plantar Fascia in Healthy Young Adults. J Clinical Ultrasound (January 2006);vol.34,no.1: Theodorou DJ, Theodorou SJ, Kakitsubata Y et al. Plantar fasciitis and fascial rupture: MR imaging findings in 26 patients supplemented with anatomic data in cadavers. Radiographics 2000; 20:S181. Page 13 of 15

14 3. Huerta P, Matamoros GJM et al. Relationship of body mass index, ankle dorsiflexion, and foot pronation on plantar fascia thickness in healthy, asymptomatic subjects. J Am Podiatr Med Assc 2008 Sept-Oct; 98(5): Ozdemir H, Yilmaz E et al. Sonographic evaluation of plantar fasciitis and relation to body mas index. European J of Radiology 2005; 54: Barrett SJ, O'Malley R. Plantar fasciitis and other causes of heel pain. Am Fam Physician 1999;59 (8): Berkowitz JF, Kier R, Rudicel S. Plantar fasciitis: MR imaging. Radiology 1991;179(3): Personal Information Claude Pierre-Jerome,M.D.PhD Emory University School of Medicine Department of radiology, MSK division 59, Executive Park South 4th floor Atlanta, GA USA Tel: (work) (direct) cpierr3@emory.edu Page 14 of 15

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