- The origin on the calcaneum encounters most of the weight bearing stress and is where plantar fascitis occurs.
- Assess longitudinally, with the probe on the plantar aspect of the heel.
- Ensure you sweep across through the entire width of the origin.
- Follow the plantar fascia distally towards the toes.
TIP: Most plantar fascitis occurs medially at the calcaneal origin.
WHAT TO LOOK FOR
- Hypoechoic thickening at the calcaneal origin.
- Vascularity (none should be visible)
- Nodular thickening of the mid and distal plantar fascia bands (plantar fibromatosis)
Normal plantar fascia origin on the calcaneum. Tension enthesophytes are common here. Follow the fibres anteriorly through the arch.
Metatarso-phalangeal joints & extensor tendons.
- Joint effusions (Simple/complex)
- Synovial thickening and vascularity.
- Tendonopathy and smooth gliding of the tendons when passively mobilised.
TIP: Clawing of the toes, may indicate plantar plate or MTPJ degeneration.
|Assess the extensor tendons dynamically for pathology. Check the underlying joints (with minimal probe pressure) for effusions.|
- The plantar plate is a ‘labrum-like’ supportive apparatus on the plantar aspect of the MTPJ arising from the base of the proximal phalanx.
- Assess in longitudinal with the toe in slight extension.
- Slide from medial to lateral at each joint to assess the entire width of each plantar plate.
WHAT TO LOOK FOR
- Check for tears (hypoechoic clefts) and calcification.
TIP: The 2nd plantar plate is more prone to degenerative changes than the others.
The plantar plate is seen arising from the base of the proximal phalanx on the plantar aspect. You should gently extend the toe to visualise fully.
MORTONS NEUROMA (interdigital neuroma) and INTER-METATARSAL BURSA
- A Morton’s neuroma is a neurofibroma of the common plantar digital nerve due to repetitive insult to the nerve.
- More commonly the inter-metatarsal bursa is thickened (+/- fluid). This protrudes out the plantar aspect between the metatarsal heads, impinging upon the nerve duplicating the symptoms of a Morton’s neuroma.
- The bursa may occasionally be identified from the dorsal aspect however a plantar approach with dynamic assessment is preferable.
Anatomy of the forefoot. Plantar aspect, demonstrating the relkative position of the tendons, joints, nerves and bursae. (note that there are bursae in each intermetatarsal space)
Sagittal plane of the intermetatarsal space. Demonstrating the anatomical relationship of the intermetatarsal bursa and plantar nerve.
Transverse view showing the location of the common plantar digital nerve (green arrow).
With a high frequency (>12MHz) transducer, the normal digital nerve involved in a Morton’s neuroma can be identified.
Role of Ultrasound
Ultrasound is used for the soft tissue structures of the foot.
Ultrasound is a valuable diagnostic tool in assessing the following indications:
- Muscular, tendinous and ligamentous damage (chronic and acute)
- Plantar plates
- Soft tissue masses such as ganglia, lipomas Morton’s neuromas
- Plantar fascia
- Joint effusions
- Vascular pathology
- Classification of a mass eg solid, cystic, mixed
- Post surgical complications eg abscess, oedema
- Guidance of injection, aspiration or biopsy
- Some bony pathology.
The thick skin on the sole of the foot will require higher gain and/or power settings. You my need to use a lower frequency probe, particularly at the hind foot.
- None required
Use of a high resolution probe (7-15MHZ) is essential when assessing the superficial structures of the foot. Careful scanning technique to avoid anisotropy (and possible misdiagnosis). Beam steering or compounding can help to overcome anisotropy in linear structures such as tendons. Good colour / power / Doppler capabilities when assessing vessels or vascularity of a structure. Be prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures.
- Plantar fasciitis
- Inter-metatarsal bursitis
- Morton’s neuroma
- Foreign bodies
- Plantar plate degeneration/injury
- Adventitial bursal effusion
- Stress fracture
For example images, click here to goto the Foot pathology page.
Patient prone on bed, foot flexed with toes on the bed for support. Place the probe over the midline of the heel on the plantar aspect. The toe of the probe towards the heel. The plantar fascia will be seen as a fibrillar structure inserting onto the calcaneum (See pic). It should be flat and homogenous.
The patient will generally present with on or more palpable thickenings in the arch of their foot. Follow the plantar fascia into the arch and look for fusiform, nodular thickenings. They may be subtle and more numerous than can be palpated.
Begin by scanning each metatarso-phalangeal joint for effusions, synovial thickenings or ganglia. Assess the extensor then flexor aspects.
Morton’s neuroma V’s Bursa:
Scan in transverse across the plantar aspect of the metatarsal heads.
Utilise the ‘Mulder’s technique’ to elicit a click and visualise any correlating pathology. This involves gripping across the anterior forefoot whilst scanning the plantar aspect. Use a knuckle of your gripping hand to simultaneously apply pressure between the metatarsal heads as you squeeze across the foot.
A Morton’s neuroma will be seen as a non compressible, hypoechoic rounded mass at the metatarsal head interspace. Similarly, a thickened intermetatarsal bursa will be a hypoechoic area between the metatarsal heads but will be compressible and avascular. It will be seen to bulge out the plantar aspect and correspond to the Mulder’s click.
Scan in longitudinal over the plantar aspect of the metatarso-phalageal joints. The plantar plate is readily seen as a homogeneous elongated wedge arising from the base of the proximal phalanx extending under the head of the metatarsal
View with the toes slightly extended
Check for tears, calcification and heterogeneity (suggesting degeneration)
Ensure you approach the proposed site of the foreign body from different angles. Some materials will be poorly reflective and almost invisible unless the beam is perpendicular to them. There will usually be a surrounding hypoechoic halo representing an inflammatory reaction
identify the plane of tissue it is in, how close it is to the entry wound and to any blood vessels. It may be helpful to mark the location and orientation of the foreign body on the skin to guide removal.
- Joint effusions:
- Gout: Abnormal uric acid metabolism resulting in joint inflammation. May see tophaceous gout as a complex echogenic mass (tophus) in the soft
- Osteoarthritis: Bony irregularity at the bone ends with joint effusion. When acute the joint will be hyperaemic
- Rheumatoid arthritis: Thickened synovium with a complex ‘thick’ joint effusion, pannus & associated boney iregularity.
- Check for tendon thickening (compare with other side)
- Fluid in the tendon sheath
- Integrity of the tendon- any tear?
- does the tendon slide freely when mobilised?
Basic Hardcopy Imaging
Hard copy imaging should reflect the anatomy investigated.
- Document the normal anatomy. Any pathology found in 2 planes, including measurements and any vascularity.