How To Detect Chronic Heel Pain With Musculoskeletal Ultrasound

Start Page: 66
This photo shows a plantar plate rupture of the second metatarsophalangeal joint.
Here one can see a fibroma of the central band of the fascia. Surgeons used ultrasound for a guided injection.
This ultrasound image shows a rheumatoid module.
This ultrasound image shows plantar fascia anisotropy, which occurs when a sound wave strikes an anatomic structure at an angle of less than 90 degrees.
Here one can see critical edge shadowing, an artifact that occurs around curved surfaces. The edge of the curved surface deflects the acoustic wave, resulting in a hyperechoic (black) signal.
Here is a heel cyst in a 52-year-old woman who has had heel pain for three months. The musculoskeletal ultrasound was able to diagnose the cyst, which was not clinically discernable.
This 48-year-old man presented with a two-year history of plantar fasciosis. As one can see, the ultrasound showed a normal plantar fascia as compared to the contralateral heel, which was asymptomatic.
This ultrasound image depicts plantar fasciosis with an abnormal central band. The upper limit of normal fascial thickness has been cited as 3 mm for the central band.
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Author(s): 
By John Tassone Jr., DPM

    Documentation of an ultrasound of the heel can be in a separate report or as a subset of the objective part of one’s notes. Either way, photos should accompany the written report. The assessment should include the measurements of all three bands of the symptomatic fascia and, in a unilateral case, the asymptomatic heel as a comparison. Along with the quantitative assessment, one should include a qualitative description as well and utilize proper terminology. Here are some of the more common terms:

    • Hyperechoic: increased echo or brightness on the screen

    • Hypoechoic: decreased echo or gray to dark on the screen

    • Anechoic: lack of echo or black on the screen

    • Fibrillar pattern: normal fiber pattern of tendon or ligament

    • Echotexture: general term referring to the internal architecture of the structure and the echo pattern seen

In Summary

    Musculoskeletal ultrasound is a powerful diagnostic tool. In a relatively short clinical time, one can obtain vital information to better diagnose and subsequently treat patients. What is paramount, however, is the need for proper education and training in its use. In addition to understanding the anatomy, one must also understand the physics, the artifacts inherent with imaging and the machine itself.
As we have seen, musculoskeletal ultrasound provides strong identification of the fascia but can also enable the clinician to assess soft tissue masses, tendinopathy and ligament injuries just as well. One may also utilize the ultrasound for guided injections and directed biopsies.

    Dr. Tassone is an Assistant Professor and Course Director for Medical Imaging at the Arizona Podiatric Medical Program at Midwestern University. He is a Diplomate of the American Board of Podiatric Orthopedics and Primary Podiatric Medicine, and a Diplomate of the American Board of Multiple Specialties in Podiatry. Dr. Tassone has a private practice in Glendale, Ariz.




References:

1. Barrett SL, Day SV, Pignetti TT, Egly BR. Endoscopic heel anatomy: analysis of 200 fresh frozen specimens. J Foot Ankle Surg 1995 Jan-Feb; 34(1):51-56.
Additional References
2. Wong SM, Griffeth J, Tang A, Hui A. The role of Ultrasonography in the Diagnoses and Management of Idiopathic Plantar Fasciitis, Rheumatology 2002: 41: 835-836.
3. Sabir N, Demirlenk S, Cubkeu S, Yagci B. Clinical Utility of Sonography in Diagnosing Plantar Fasciitis, J Ultrasound Med 1998: 24: 1041-1048.
4. Muglia V, Cooperberg P. “Artifacts,” www.rad.pulmonary.ubc.ca/USartifacts.
5. Dondelinger RF, Marcelis S, Daenen B, Ferrara M. Peripheral Musculoskeletal Ultrasound Atlas, New York, Thieme Medical Publishers: 1996. 6. Zagzebiski J. Essentials of Ultrasound Physics, St. Louis, Missouri, Mosby: 1996.




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