Watch your step: Painful conditions of the plantar region of the foot

Transcription

1 Watch your step: Painful conditions of the plantar region of the foot Poster No.: C-640 Congress: ECR 2009 Type: Educational Exhibit Topic: Musculoskeletal Authors: F. C. Miranda, R. D. Carneiro, L. A. Rosemberg, C. H. Longo, H. P. Guidorizzi, R. Y. Fernandes, D. C. B. Santos, N. J. T. Kim, M. B. G. Funari; São Paulo/BR Keywords: MRI, foot, Plantar Pain DOI: /ecr2009/C-640 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 57

2 Learning objectives Review the anatomy of the plantar compartment of the foot. Describe the imaging findings of painful conditions arising from or extending into the plantar region of the foot. Background Pain in the plantar region of the foot is a symptom with high prevalence, specially in athletes and runners. It can be caused by numerous entities (inflammatory, vascular, cancer, trauma, among others) that can be evaluated by different imaging methods, from radiography to magnetic resonance imaging (MRI), which has excellent contrast resolution and multiplanar capacity. Imaging findings OR Procedure details Plantar Anatomy Page 2 of 57

3 Fig.: 1: Distal Phalanges2: Middle Phalanges3: Proximal Phalanges4: Metatarsal Bones5: Medial Cuneiform Bone6: Intermediate Cuneiform Bone7: Lateral Cuneiform Bone8: Cuboid9: Navicular10: Talus11: Calcaneus Page 3 of 57

4 Fig.: The plantar region is divided in four layers from superficial to deep:first layer: abductor hallucis, flexor digitorum brevis, abductor digit minimisecond layer: quadratus plantae, lumbricals, flexor digitorum longus tendons, flexor hallucis longus tendonsthird layer: flexor hallucis brevis, adductor hallucis, flexor digiti minimi brevisfourth layer: interossei plantaris, the peroneus longus tendon, tibialis posterior tendon1: Abductor hallucis muscle, 2: flexor hallucis brevis muscle, 3: flexor hallucis longus tendon, 4: flexor digitorum longus tendon, 5: quadratus plantae muscle, 6: flexor digitorum brevis muscle, 7: lumbrical muscles and the tendons of the flexor digitorum longus and brevis, 8: flexor digiti minimi muscle, 9: abductor digiti minimi muscle, 10: adductor hallucis muscle. Fig.: The plantar fascia consists of a central aponeurosis, lateral and medial components:c = CalcaneusDB = Digital BandsCC = Central ComponentLC = Lateral ComponentMC = Medial Component Sesamoiditis Painful inflammatory condition. Caused by repetitive injury to the plantar aspect of the foot. MR imaging findings include decreased or normal signal intensity on T1W and increased signal intensity on STIR / T2W Fat Sat images. The findings are similar to those caused by a stress response, existing some overlap between these conditions. Involvement of both sesamoid bones favors a diagnosis of sesamoiditis. Page 4 of 57

5 Fig.: Medial sesamoid marrow is hypointense on coronal T1W image and hyperintense on coronal T2W Fat Sat image. Note the adjacent soft-tissue edema. Bone marrow and adjacent soft-tissue enhancement. Morton's Neuroma More often in middle-aged woman. Perineural fibrosis. Pain at the base of the web space radiating to the toes. Worsened by wearing shoes and walking. Most common site is the third web space. Low to intermediate signal on T1W and T2W. Late enhancement. Fig.: Drawing of a coronal view of the inferior and superior intermetatarsal spaces. 1: Deep Transverse Metatarsal Ligament, 2: Neurovascular bundle, Metatarsal heads 1-5 (M1-M5) Page 5 of 57

6 Fig.: Teardrop-shaped Morton's neuroma - iso-signal on T2W Fat Sat and hyposignal on T1W - between the third and fourth metatarsal head, with enhancement. Bursitis Inflammatory process of the intermetatarsal bursae between the metatarsal heads. Caused by trauma, infection, inflammatory and rheumatogic diseases. On MRI it is important to identify the liquid collection (hypersignal on T2W/STIR and hyposignal on T1W) and peripheral enhancement. Fig.: The intermetatarsal bursae is located on the dorsal compartment of the foot, above the deep transverse metatarsal ligament, differentiating from the diagnosis of Morton s neuroma, which is located in the plantar compartment. Page 6 of 57

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8 Fig.: Hour-glass distended intermetatarsal bursae between the third and fourth metatarsal heads - hypersignal on T2W Fat Sat, hyposignal on T1W and peripheral enhancement. Page 8 of 57

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10 Fig.: Hour-glass distended intermetatarsal bursae between the third and fourth metatarsal heads - hypersignal on T2W, hyposignal on T1W and peripheral enhancement. Exceptionally this inflamed bursae extends below deep transverse metatarsal ligament. Plantar Vein Thrombophlebitis Uncommon condition of unknown origin. Related to previous surgery, trauma, paraneoplasic conditions and hypercoagulative states. May mimic plantar fasciitis. Symptoms include sudden pain in the plantar region with soft-tissue edema. Pain is located on the course of the main plantar veins. Imaging findings include: dilated vessel, peri-venular edema, post-gadolinium intraluminal defect. Page 10 of 57

11 Fig.: 1. Lateral plantar veins and artery2. Medial plantar veins and artery3. Plantar metatarsal veins and artery4. Digital proper veins and artery5. Hallux Digital proper veins and artery Page 11 of 57

12 Fig.: Dilated medial plantar vein with intraluminal defect as showed on T1W Gd in different planes. On T2W the perivenular edema (hypersignal) is well seen. No significant signal on T1W. Fat Pad Necrosis Follows fat signal intensity on all sequences similar to lipoma. May contain fibrosis and septations suggesting an atypical lipoma or liposarcoma. Predominantly located over presure points or bony protuberances in the body. Page 12 of 57

13 Fig.: Focal obliteration of the medial plantar fat pad with heterogeneous hypersignal on T2W, hyposignal on T1WI with anelar / heterogeneuous enhancement. Plantar Fasciitis Most common cause of heel pain. Low-grade inflammatory disorder of the fascia. In most cases results from increased load. May be a part of systemic disorders: rheumatoid arthritis, seronegative spondyloarthropathies and gout. Most frequently affects the origin of the plantar fascia from the calcaneal tuberosity. Intermediate to high signal in the normally low signal plantar fascia. Most commonly involves the medial band plantar fascia near the calcaneal attachment. May have reactive edema in the calcaneus and surrounding soft tissue edema. Page 13 of 57

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15 Fig.: Thickening and increased signal in the central component of the plantar fascia with surrounding soft tissue edema and marrow edema in the calcaneal origin. Page 15 of 57

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17 Fig.: Medial view of the right foot (sagital) revealing inflammation of the plantar fascia. Plantar Fibromatosis Most frequently between the ages of 30 and 50 years. Bilateral involvement in 40%. Concomitant palmar fibromatosis in 35%. Affects most commonly the medial component of the plantar aponeurosis Manifests as one or multiple firm, fixed, fascial nodules. MRI findings include a poorly defined, infiltrative mass with heterogeneous signal intensity equal to or less that of skeletal muscle on T1W and T2W. Fig.: Nodule with intermediate signal on all sequences arising from the mid-third of the plantar fascia. The mass shows little enhancement. Page 17 of 57

18 Fig.: Nodule with intermediate signal on all sequences arising from the distal-third of the plantar fascia. Fascial Rupture Usually located at the posterior insertion of the fascia. Most often observed in patientes who have sustained forceful plantar flexion. Fig.: Retracted plantar fascia with discontinuity of its calcaneal insertion. Avascular necrosis Bone death due to ischemia. Can be classified as obstructive, compressive or physical disruption (trauma) of vessels. Most commonly occurs during the second decade of life. Female predominance. MRI findings include hypointense signal of subchondral sclerosis on T1W and hyperintensity on T2W / STIR. Page 18 of 57

19 Fig.: T1W hyposignal and T2W hypersignal geographic line delineating a fragment of avascular necrosis in the head of the first metatarsal. There is linear enhancement concordant with granulation tissue around necrosis. Trauma: Stress Fracture In the metatarsal bones are common in runners, ballet dancers, gymnasts, millitary recruts and in the occasional tourist. The middle or distal portion of the second, third and fourth metatarsal shafts are most often involved. Radiographs, CT may be negative. MR shows soft tissue and marrow edema +/- fracture line. Page 19 of 57

20 Fig.: Mid-third medial cortical thickening of the second metatarsal associated with marrow edema (T2W hypersignal) and periosteal reaction around the bone ( well seen on post-contrast). Page 20 of 57

21 Fig.: Incomplete fracture line (T1W linear hyposignal) in the base of the fifth metatarsal with marrow edema ( T2W hypersignal and T1W hyposignal). Adjacent soft tissue edema. Page 21 of 57

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23 Fig.: Transverse fracture line (T1W linear hyposignal) in the mid-third of cuboid with marrow edema ( T2W hypersignal and T1W hyposignal) and adjacent soft tissue edema. Fig.: Transverse fracture line (T1W linear hyposignal) in the anterior process of calcaneous with marrow edema (T2W hypersignal and T1W hyposignal). Tenosynovitis Inflammation of the tendon and tendon sheath. May be caused by inflammatory disease, infection or mechanical irritation. MRI findings include fluid in the tendon sheath and synovial thickening. Contrast enhancement of the synovia typically occurs. Page 23 of 57

24 Fig.: Subtle hypersignal on T2W and hyposignal on T1W in the flexor tendon of the halux. Liquid (T2W hypersignal) within the tendon sheath. On post-contrast images there is significant enhancement of tendon sheath. Ganglionic Cyst Cystic lesions filled with gelatinous fluid. Can be multiloculated and may have a narrow communication or neck with an adjacent joint or tendon sheath. Appear well defined on MRI. Hypointense on T1W and hyperintense on T2W. No internal enhancement is observed. Page 24 of 57

25 Fig. Acute Osteomyelitis Acute inflammatory process of the bone secondary to infection with pyogenic organisms. Staphylococcus aureus is the most common bacteria involved. On MRI, evidence of marrow edema and, with the use of gadolinium, hyperemia, in a infected bone can be shown within hours of symptom onset. Page 25 of 57

26 Fig.: Coronal T2W Fat Sat shows marrow edema in the base of the third metatarsal, associated with a collection between the flexor tendons. The collection is well demarcated on T1W Gd on the coronal and axial planes, as well as on the T2W sagital images. Tumors: Hemangioma Benign lesions classified as capillary, cavernous, or venous vascular proliferations. May occur in patients from 20 to 60 years of age. Lobulated mass with fatty septae. Phleboliths and fluid-fluid levels. Variable in MR appearance and may demonstrate low, intermediate, or high signal intensity on T1W. There is usually some increase in signal intensity on T2W or STIR sequences. Page 26 of 57

27 Fig.: Expansive lesion with predominantly hypersignal on T2W and hyposignal on T1W. Located in the deep plantar musculature. Calcinosis Cutis Calcium deposits in the skin due to local and/or systemic factors. Solitary or multiple painless, periarticular masses. Classified into 4 major types according to etiology: dystrophic, metastatic, iatrogenic and idiopathic. MRI findings include heterogeneous hypersignal on T2W and heterogeneous hyposignal on T1W. Page 27 of 57

28 Fig.: T1W, T2W and T1W Gd in the axial plane demonstrate an expansive lobulated lesion with marked hyposignal and mainly peripheral heterogeneous enhancement. Fig.: T1W shows the lesion around the fifth metatarsal bone, which is intact. Page 28 of 57

29 Fig.: On the X-ray: solid calcified matrix of the lesion. Page 29 of 57

30 Images for this section: Fig. 1: 1: Distal Phalanges2: Middle Phalanges3: Proximal Phalanges4: Metatarsal Bones5: Medial Cuneiform Bone6: Intermediate Cuneiform Bone7: Lateral Cuneiform Bone8: Cuboid9: Navicular10: Talus11: Calcaneus Page 30 of 57

31 Fig. 2: The plantar region is divided in four layers from superficial to deep:first layer: abductor hallucis, flexor digitorum brevis, abductor digit minimisecond layer: quadratus plantae, lumbricals, flexor digitorum longus tendons, flexor hallucis longus tendonsthird layer: flexor hallucis brevis, adductor hallucis, flexor digiti minimi brevisfourth layer: interossei plantaris, the peroneus longus tendon, tibialis posterior tendon1: Abductor hallucis muscle, 2: flexor hallucis brevis muscle, 3: flexor hallucis longus tendon, 4: flexor digitorum longus tendon, 5: quadratus plantae muscle, 6: flexor digitorum brevis muscle, 7: lumbrical muscles and the tendons of the flexor digitorum longus and brevis, 8: flexor digiti minimi muscle, 9: abductor digiti minimi muscle, 10: adductor hallucis muscle. Page 31 of 57

32 Fig. 3: The plantar fascia consists of a central aponeurosis, lateral and medial components:c = CalcaneusDB = Digital BandsCC = Central ComponentLC = Lateral ComponentMC = Medial Component Fig. 4: Medial sesamoid marrow is hypointense on coronal T1W image and hyperintense on coronal T2W Fat Sat image. Note the adjacent soft-tissue edema. Bone marrow and adjacent soft-tissue enhancement. Fig. 5: Drawing of a coronal view of the inferior and superior intermetatarsal spaces. 1: Deep Transverse Metatarsal Ligament, 2: Neurovascular bundle, Metatarsal heads 1-5 (M1-M5) Page 32 of 57

33 Fig. 6: Teardrop-shaped Morton's neuroma - iso-signal on T2W Fat Sat and hyposignal on T1W - between the third and fourth metatarsal head, with enhancement. Fig. 7: The intermetatarsal bursae is located on the dorsal compartment of the foot, above the deep transverse metatarsal ligament, differentiating from the diagnosis of Morton s neuroma, which is located in the plantar compartment. Page 33 of 57

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35 Fig. 8: Hour-glass distended intermetatarsal bursae between the third and fourth metatarsal heads - hypersignal on T2W Fat Sat, hyposignal on T1W and peripheral enhancement. Page 35 of 57

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37 Fig. 9: Hour-glass distended intermetatarsal bursae between the third and fourth metatarsal heads - hypersignal on T2W, hyposignal on T1W and peripheral enhancement. Exceptionally this inflamed bursae extends below deep transverse metatarsal ligament. Fig. 10: 1. Lateral plantar veins and artery2. Medial plantar veins and artery3. Plantar metatarsal veins and artery4. Digital proper veins and artery5. Hallux Digital proper veins and artery Page 37 of 57

38 Fig. 11: Dilated medial plantar vein with intraluminal defect as showed on T1W Gd in different planes. On T2W the perivenular edema (hypersignal) is well seen. No significant signal on T1W. Page 38 of 57

39 Fig. 12: Focal obliteration of the medial plantar fat pad with heterogeneous hypersignal on T2W, hyposignal on T1WI with anelar / heterogeneuous enhancement. Page 39 of 57

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41 Fig. 13: Thickening and increased signal in the central component of the plantar fascia with surrounding soft tissue edema and marrow edema in the calcaneal origin. Page 41 of 57

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43 Fig. 14: Medial view of the right foot (sagital) revealing inflammation of the plantar fascia. Fig. 15: Nodule with intermediate signal on all sequences arising from the mid-third of the plantar fascia. The mass shows little enhancement. Fig. 16: Nodule with intermediate signal on all sequences arising from the distal-third of the plantar fascia. Page 43 of 57

44 Fig. 17: Retracted plantar fascia with discontinuity of its calcaneal insertion. Page 44 of 57

45 Fig. 18: T1W hyposignal and T2W hypersignal geographic line delineating a fragment of avascular necrosis in the head of the first metatarsal. There is linear enhancement concordant with granulation tissue around necrosis. Page 45 of 57

46 Fig. 19: Mid-third medial cortical thickening of the second metatarsal associated with marrow edema (T2W hypersignal) and periosteal reaction around the bone ( well seen on post-contrast). Page 46 of 57

47 Fig. 20: Incomplete fracture line (T1W linear hyposignal) in the base of the fifth metatarsal with marrow edema ( T2W hypersignal and T1W hyposignal). Adjacent soft tissue edema. Page 47 of 57

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49 Fig. 21: Transverse fracture line (T1W linear hyposignal) in the mid-third of cuboid with marrow edema ( T2W hypersignal and T1W hyposignal) and adjacent soft tissue edema. Fig. 22: Transverse fracture line (T1W linear hyposignal) in the anterior process of calcaneous with marrow edema (T2W hypersignal and T1W hyposignal). Page 49 of 57

50 Fig. 23: Coronal T2W Fat Sat shows marrow edema in the base of the third metatarsal, associated with a collection between the flexor tendons. The collection is well demarcated on T1W Gd on the coronal and axial planes, as well as on the T2W sagital images. Page 50 of 57

51 Fig. 24: Subtle hypersignal on T2W and hyposignal on T1W in the flexor tendon of the halux. Liquid (T2W hypersignal) within the tendon sheath. On post-contrast images there is significant enhancement of tendon sheath. Page 51 of 57

52 Fig. 25: Axial T1W, T2W Fat Sat and T1W Fat Sat Gd demonstrate a cystic lesion in the hallux tendon sheath.sagital T1W Fat Sat Gd shows peripheral enhancement and its lobulated aspect.note the homogeneous hypersignal on coronal T2W Fat Sat. Page 52 of 57

53 Fig. 26: Expansive lesion with predominantly hypersignal on T2W and hyposignal on T1W. Located in the deep plantar musculature. Fig. 27: T1W, T2W and T1W Gd in the axial plane demonstrate an expansive lobulated lesion with marked hyposignal and mainly peripheral heterogeneous enhancement. Page 53 of 57

54 Fig. 28: T1W shows the lesion around the fifth metatarsal bone, which is intact. Page 54 of 57

55 Fig. 29: On the X-ray: solid calcified matrix of the lesion. Page 55 of 57

56 Conclusion Many disorders produce discomfort in the plantar region of the foot and the cause may be difficult to establish based solely on clinical findings. MR imaging, with its excellent contrast resolution and multiplanar imaging capacity, is useful in the detection of numerous soft-tissue, as well as bone and joint processes that occur in this portion of the foot. Radiologists should be familiar with the differential diagnosis and MR imaging features of these disorders. Personal Information References Ashman CJ, Klecker RJ, Yu JS. Forefoot Pain Involving the Metatarsal Region: Differential Diagnosis with MR Imaging. Radiographics 2001; 21: Berkowitz JF, Kier R, Rudicel S. Plantar Fasciitis: MR Imaging. Radiology 1991; 179: Goodwin DW, Salonen DC, Yu JS, Brossmann J, Trudell DJ, Resnick DL. Plantar Compartments of the Foot: MR Appearance in Cadavers and Diabetic Patients. Radiology 1995; 196: Morrison WB, Schweitzer ME, Wapner KL, Lackman RD. Plantar Fibromatosis: A Benign Aggressive Neoplasm with a Characteristic Appearance on MR Images. 1994; 193: Robbin MR, Murphey MD, Temple HT, Kransdorf MJ, Choi JJ. Imaging of Musculoskeletal Fibromatosis. Radiographics 2001; 21: Rosenberg ZS, Beltran J, Bencardino JT. From the RSNA Refresher Courses. MR Imaging of the Ankle and Foot. Radiographics 2000; 20: S153-S179. Siegal DS, Wu JS, Brennan DD, Challies T, Hochman MG. Plantar vein thrombosis: a rare cause o plantar foot pain. Skeletal Radiology 2008; 37: Taylor JAM, Sartoris DJ, Huang GS, Resnick DL. Painful Conditions Affecting the First Metatarsal Sesamoid Bones. Radiographics 1993; 13: Theodorou DJ, Theodorou SJ, Kakitsubata Y, Lektrakul N, Gold GE, Roger B, Resnick D. Plantar Fasciitis and Fascial Rupture: MR Imaging Findings in 26 Patients Supplemented with Anatomic Data in Cadavers. Radiographics 2000; 20: S181-S197. Theumann NH, Pfirrmann CWA, Chung CB, Mohana-Borges AVR, Haghighi P, Trudell DJ, Resnick D. Intermetatarsal Spaces: Analysis with MR Bursography, Anatomic Correlation, and Histopathology in Cadavers. Radiology 2001; 221: Tuite MJ. MR Imaging of the Tendons of the Foot and Ankle. Seminars in Musculoskeletal Radiology 2002; 6: Page 56 of 57

57 Woertler K. Soft Tissue Masses in the Foot and Ankle: Characteristics on MR Imaging. Seminars in Musculoskeletal Radiology 2005; 9: Yu JS. Pathologic and post-operative conditions of the plantar fascia: review of MR imaging appearances. Skeletal Radiology 2000; 29: Page 57 of 57