1. Plantar heel pain: an update of its aetiology and diagnosis
Karl B. Landorf, Andrew M. McMillan, Hylton B. Menz
Department of Podiatry
Lower Extremity and Gait Studies (LEGS) Research Program
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2. Conflict of interest statement
All authors declare that there are no known conflicts of interest related to this project.

3. Introduction

5. What is it? Pathology is not well understood1
Traditionally accepted that it is due to stress of the fascia, which leads to microtears and inflammation
However, histopathology presents a different picture
Degenerative process (no inflammation)2
Suggested the term ‘plantar fasciosis’
Limitation – long standing cases and only focused on the plantar fascia
1 Wearing et al, Sports Med, 2006
2 Lemont et al, JAPMA, 2003

6. Nomenclature Plantar heel pain (PHP) Plantar fasciitis (PF)
Plantar fasciosis
*Plantar fasciopathy

7. Imaging

8. Plain film x-rays

9. Plain film x-rays Heel spurs are common in plantar heel pain
Correlation between spurs and plantar heel pain
However, is it the cause of heel pain?
Many have a spur but no pain
8-15% of asymptomatic population have spurs1
However, up to 65% of patients complaining of heel pain have signs of a plantar heel spur2
Spurs can fracture
1Shama & Kamansky, 1983
2Prichasuk et al, 1994

10. What causes heel spurs? Over 50% of 216 older people had heel spurs
Odds of having a plantar calcaneal spur increased with certain pathologies
e.g. 8x - obesity; 5x - heel pain; 3x - OA
However, unrelated to radiographic measures of foot posture
Menz et al. JFAR, 2008

11. Vertical compression?
Research supports the theory that plantar calcaneal spurs are an adaptive response to vertical compression of the heel rather than longitudinal traction of the plantar fascia?

12. Vertical compression hypothesis
Plantar heel spurs cannot be traction spurs
They do not develop within the plantar fascia
Spurs develop on the deep surface of the fascia
They can reform after fascial release
Spurs are a response to mechanical stress
Due to adaptive response to changes in loading or an attempt to change loading patterns to minimise further damage
Kumai & Benjamin, J Rheumatol, 2002

13. Abreu et al: Skeletal Radiol 2003.

14. Ultrasonography

15. Ultrasonography Proximal plantar fascia (PF vs control) 2.2 mm thicker
105x more likely to have thickness >4 mm
204x more likely to have hypochogenicity
If you want the complete methods and statistics including 95% CIs, please consult Andrew’s article in JFAR.

16. Courtesy of: Jason De Luca, Southern Cross Medical Imaging, Bundoora
Plantar fascia usually has a linear fibrillar appearance <4 mm.
Plantar fasciopathy has >4 mm thickness, decreased echogenicity and mild increased vascularity.
Courtesy of: Jason De Luca, Southern Cross Medical Imaging, Bundoora

17. Ultrasonography – Power Doppler
Is there a vascular component?

18. Vascularity – Walther et al. 20041 2 3 4

19. McMillan et al, unpublished
Case-control study
30 cases (with PF) and 30 controls
Investigated vascularity (hyperaemia) within the fascia using power Doppler
‘mild hyperaemia’ – PF cases 5x more likely to have vascular in-growth
No correlation between grade of hyperaemia and duration of symptoms

20. Magnetic Resonance Imaging (MRI)
Proximal plantar fascia (PF vs control)
3.4 mm thicker

21. T1 weighted MRI image demonstrates abnormal signal in and thickening of the proximal plantar fascia

22. Magnetic Resonance Imaging (MRI)
Are there any other changes?
Bone?

23. MRI: T2 fat suppressed sagittal image demonstrates abnormal signal in proximal plantar fascia as well as bone marrow oedema (thick arrow)
Fat suppressed T2 weighted MRI demonstrates abnormal signal in
proximal plantar fascia as well as bone marrow oedema (thick arrow)

24. Chimutengwende-Gordon et al Foot Ankle Int 2010
Axial STIR image demonstrating calcaneal bone marrow oedema
Sagittal STIR image demonstrating soft tissue and bone marrow oedema

25. Summary of imaging for PHP
X-rays
Spurs (check for # spurs)
Ultrasound
Thicker (> 4 mm thick), hypoechogenicity, mild vascularity
MRI
Increased thickness and signal, plus bone marrow oedema (stress reaction/stress #)

26. Future research

27. Conclusion Heel spurs are associated with PHP
The fascia is often degenerated
There can be swelling in and around the fascia
There can be bone marrow oedema
Therefore, there appears to be both fascia and bone pathology