CASE 17064 Published on 25.11.2020

Plantar fascia tear

Section

Musculoskeletal system

Case Type

Clinical Cases

Authors

Ricardo Pereira Dias, João Janeiro, João Leitão

Serviço de Imagiologia Geral, Centro Hospitalar Universitário de Lisboa Norte, Hospital de Santa Maria, Lisboa, Portugal

Patient

78 years, male

Categories
Area of Interest Musculoskeletal soft tissue ; Imaging Technique Ultrasound
Clinical History

A 78-year-old male patient suffering from chronic heel pain on weight-bearing experienced a sharp pain with snapping sensation in the plantar aspect of the right heel after prolonged walking. The patient walked with an antalgic gait and physical examination revealed local swelling at the calcaneal attachment of the plantar fascia.

Imaging Findings

Ultrasound (US) demonstrated a full-thickness tear of the plantar fascia at its calcaneal insertion with a 1,3 cm gap at the site of rupture filled with slightly hypoechoic liquid and tissue reflecting local haemorrhage, oedema and inflammation in the surrounding soft tissues. Retraction and heterogeneity of the ruptured plantar fascia were noted as well as a plantar calcaneal spur.

Discussion

Plantar fascia (PF) disorders result from overuse microtrauma and are aggravated by foot deformities, improper footwear, increased body mass index and weight-bearing physical activities [1]. PF tears are rare and can be divided into acute-on-chronic and acute tears [1,2]. In acute-on chronic cases, the PF tear result as complication of plantar fasciitis (previous steroid injections are a reported risk factor) and usually occur in the proximal fascia [1,3,4]. Acute tears are related to forcible plantar flexion of the foot in competitive athletes and commonly occur distal to calcaneal insertion of the PF[1. Imaging can assist in the diagnosis and rule out other heel pathology. A PF tear should be suspected in the case of sudden heel pain during a weight-bearing activity in a patient with a positive history of plantar fasciitis and/or local corticoid injection. Imaging is of utmost importance for confirming the diagnosis as well as determining the location and severity of the tear (partial or complete).
US findings of plantar fasciitis include increased calibre of the plantar fascia to over 4 mm; loss of reflectivity of the fascia; entheseal new bone formation, including spur formation (a non-specific finding); in severe cases, perifascial collections[1]. The US characteristics of PF tear include complete or partial interruption of the PF and hypoechoic tissue in the region of rupture due to inflammation/haemorrhage. US is superior to MRI in differentiating true fibre tears from oedema [4]. Furthermore, dynamic manoeuvres allow confirmation of a complete tear by demonstrating a gap between the torn parts of the PF[5]. MRI findings of acute PF tear are complete or partial interruption of the low signal of the PF and signal changes at the site of lesion including high signal on fluid-sensitive sequences and intermediate signal on T1-weighted sequences[1]. Plain radiographs add little to the diagnosis of plantar fascia tear but are helpful to rule out concomitant fractures or foot deformities[1,6].  
Demonstration of PF tears on imaging is important because treatment differs from plantar fasciitis.
Treatment is based on the severity of the tear and usually involves immobilization and thrombosis prophylaxis, nonsteroidal ant-inflammatory drugs, and physical therapy with a focus on eccentric training [2,6]. Surgical repair is performed only in a few cases of major tears [2,6].

PF tear should be considered in the presence of suggestive clinical history and physical examination. US is a reliable imaging modality to confirm and localize the injury.

Differential Diagnosis List
Complete plantar fascia tear
Plantar fasciitis
Calcaneal stress fracture
Plantar fibromatosis
Final Diagnosis
Complete plantar fascia tear
Case information
URL: https://www.eurorad.org/case/17064
ISSN: 1563-4086
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