CASE 117

By: Dr. Nizar Al-Nakshabandi MD, FRCPC

HISTORY: 49-year-old man feeling pain in the heel of the foot. Started to run 1 month ago.

What are your findings?

What is the differential diagnosis?

What are the causes?

FINDINGS:

T2 sagital fat sat of the ankle joint demonstrates marked thickening of the plantar fascia reaching 20 mm with evidence of high signal changes present at the attachment into the plantar calcaneal spur which is also an abnormal finding and enlarged.

There is evidence of high signal changes present in the sinus tarsi with obliteration of the sinus fat.

Furthermore, a Stieda process off the posterior aspect of the talus is seen with inflammatory changes seen surrounding it.

DIFFERENTIAL DIAGNOSIS:

·        Plantar fasciitis.

·        Sinus tarsi syndrome.

·        Inflamed Stieda process.

DIAGNOSIS:

Plantar fasciitis.

PEARLS AND DISCUSSION:

Plantar fasciitis is inflammation of the plantar fascia of the foot/heel and is considered a common cause of foot pain.

It is seen in runners.

It is a from of mechanical stress. It could also be due to degenerative causes. Commonly associated with seronegative spondyloarthropathy such as ankylosing spondylitis, psoriasis, and Reiter’s disease.

Plain films can demonstrate a plantar calcaneal spur, although this may be seen in asymptomatic patients. Ultrasound easily diagnoses it and demonstrates increased thickness of the fascia with increased flow. MRI as in our case demonstrates high signal intensity on T2-weighted images.

Radiology plays a remarkable role in the management of these cases. Ultrasound or fluoroscopic guided joint facial injection. Stretching of the plantar fascia has been shown to reduce the short-term and long-term plan.

Sinus tarsi syndrome occurs in patients who have repetitive ankle sprains hemorrhage and inflammation in the recess of the sinus tarsi causes scarring. Can be associated with gout. MRI will show high signal changes present with evidence of obliteration of the fat inside the sinus tarsi.

An inflamed Stieda process which is a tubercle arising from the posterior lateral aspect of the talus can cause posterior ankle impingement in these cases resection of the Stieda process should proved to be curative.

FURTHER READING:

1.      Narváez JA, Narváez J, Ortega R et-al. Painful heel: MR imaging findings. Radiographics. 2000;20 (2): 333-52. Radiographics

2.      Lee KB, Bai LB, Park JG et-al. Efficacy of MRI versus arthroscopy for evaluation of sinus tarsi syndrome. Foot Ankle Int. 2008;29 (11): 1111-6. 

3.      Cerezal L, Abascal F, Canga A et-al. MR imaging of ankle impingement syndromes. AJR Am J Roentgenol. 2003;181 (2): 551-9. AJR Am J Roentgenol