Sunday, April 29, 2012

IN R.A. PATIENTS CORRECTLY POSITION UPPER JOINTSJOINTS, MINIMISE CONTRACTURES AND DEFORMITIES AND INCREASE JOINT STABILITY


Static orthoses aim to support structures within the
wrist and hand that are vulnerable. The radio-carpal,
carpometacarpal joint (CMJ), metacarpophalangeal
(MCPJ) and proximal interphalangeal (PIPJ) joints
and the thumb web space are key anatomical areas
for consideration when splinting. Where inflammation
causes the potential for muscle imbalance, for
example in swan neck and boutonnière deformities,
orthotics apply a counterbalance force to prevent
or correct extensor tendons slipping across normal
joint fulcrums.


IMPROVE HAND FUNCTION



By adding support to proximal joints, applying
counterbalanced force to deforming joints and
improving biomechanical advantage splints have
the potential to improve hand function (Prosser &
Conolly 2003). In particular improving support to
the wrist can improve grip strength and gross hand
function (Nordenskiöld 1990).
Hand orthotics have some biological and biomechanical
rationale for their use and action, however,
evidence to support and clarify the clinical effectiveness
of orthotics in rheumatology is still emerging
(Adams et al 2005). This evidence is considered
below in regard to five types of orthotics.


THE WRIST EXTENSION ORTHOSIS



Wrist extension orthoses may be custom-made
using either thermoplastic or neoprene material
or commercially manufactured from a soft or reinforced
fabric with a possible addition of a volar
metal support (Fig. 12.1). They may be prescribed
to limit wrist circumduction and decrease torque
during heavy tasks involving the wrist (Cordery &
Rocchi 1998). They may also be used to increase
the mobility of the arthritic hand. Wrist extension
orthoses can stabilise the wrist in a functionally
effective position (10-15 degrees of extension), and
facilitate the action of the extrinsic finger flexors
to improve handgrip strength (Stern et al 1996).
Wrist orthoses provide support to the carpals and
wrist joint and several designs of commercial wrist
splints have been shown to significantly reduce
the electrical activity of the wrist extensors during

lifting tasks in people without RA (Stegink- Jansen
et al 1997). This may serve to reduce potentially
deforming forces on the wrist and carpals.
When worn these orthosis can provide immediate
pain relief and significantly reduce pain on
functional use of the hand (Haskett et al 2004,
Kjeken et al 1995, Nordenskiöld, 1990, Pagnotta et al
2005). Kjeken et al’s (1995) randomised controlled
trial analysed splint wear versus non-splint wear
over 6 months (n  69). There was no difference by
group on pain, joint swelling, grip or hand motion.
However, the control group (n  33) without splints
showed statistically significant improvement in
wrist range of motion that was not evident in the
splinted group. Both Kjeken et al (1995) and Sharma
et al (1991) comment that these wrist orthoses can
reduce wrist movement when worn over a number
of months and the effects of this should be considered
on provision.
In small-scale studies, elastic wrist orthoses have
been shown to improve power grip strength for
individuals with moderate to severe RA (Backman &
Deitz 1988, Haskett et al 2004, Nordenskiöld 1990).
However, they have been reported in a small sample
(n  36) to transiently reduce grip strength
when first worn and to offer no improvement in
grip strength (Stern et al 1996). Although both commercially
available and custom made splints have
contributed towards improvements in pain and
grip strength after four weeks wear in the most able
male patients elastic orthoses can hinder maximum
grip strength (Sharma et al 1991).
Studies examining hand function have shown
that these orthoses are particularly task specific, i.e.



Figure 1 Wrist extension orthosis.



they may be able to assist one particular hand skill
but reduce another (Pagnotta et al 1998, Stern et al
1996). Functional grip strength has been seen to
increase significantly by up to 29% in a woman with
RA when these orthoses were worn (Nordenskiöld
1990) yet dexterity, fine finger movement and speed
of hand activity have not (Backman & Deitz 1988,
Stern et al 1994, 1996).
In summary, wrist extension orthosis have been
seen to increase handgrip strength, hand function
and provided immediate hand pain relief in some
patients. However, they may also contribute to a
less dextrous and less mobile hand. There is little
evidence to demonstrate the long-term effectiveness
of these splints and the quality of evidence available
to indicate the clinical effectiveness of these splints
is weak (Egan et al 2003).


METACARPAL ULNAR DEVIATION ORTHOSIS



These may be small palm-based orthoses or have
the additional support of a wrist and forearm component.
They may be used early in the rheumatoid
disease process to limit the physical factors predisposing
the MCPJs to ulnar deviation. By providing
a medial force to the proximal phalanges, these
orthotics can realign the metacarpals and phalanges
during use to improve functional ability of the hand
and to prevent further MCPJ ulnar drift and volar
subluxation (Adams et al 2005). Therapeutic exercise
MCP splints have also been designed to provide
exercise options for extrinsic hand extensors
and flexors and combat intrinsic plus deformities in
the rheumatoid hand (Wijdenes et al 2003).
There is limited evidence for the clinical effectiveness
of metacarpal ulnar deviation (MUD)
orthoses. In a small repeated measures six months
study patients (n  26) rated them as highly acceptable
and satisfactory (Rennie 1996). When worn
they realigned the MCPJs and maintained that
alignment during functional use of the hand and
significantly improved ulnar drift in middle, ring
and little finger. They also significantly improved
three-point pinch grip strength but did not significantly
improve scores on the Sollerman test of hand
function (Sollerman 1984), reduce visual analogue
pain levels nor improve gross power grip strength.
There was no evidence to suggest that they had any
long-term effect on correcting MCP joint alignment
nor delayed the progression of ulnar deviation.


STATIC RESTING ORTHOSIS



This orthosis aims to decrease localised pain and
inflammation by resting the joint in a correct anatomical
position, provide volar support for the
carpus and proximal phalangeals to prevent subluxation
realigning drifting MCP joints by providing
an ulnar border to the orthosis and restricting
carpal movement (Biese 2002). The rationale that
correct joint positioning at rest can influence joint
integrity has been challenged. Adams et al (2005)
argue that the forces contributing towards joint
deformity are present when the hand is used functionally
thus correct positioning at rest is unlikely
to address or correct these (Fig. 12.2).
It is the most commonly used orthosis for treating
people with RA and the most frequently used
to relieve wrist and hand pain (Henderson &
McMillan 2002). These splints do not permit wrist
or hand joint movement and are recommended to
be worn whilst resting and/or during the night.
There have been a few controlled studies examining
clinical effectiveness.
Malcus Johnson et al’s (1992) small, 18-month
follow-up study of seven people with RA identified
that the orthoses reduced nocturnal but not day
time pain and MCPJ ulnar deviation continued unabated
with splint use. Callinan and Mathiowetz’s
(1996) investigation (n  39) demonstrated that for
two types of resting orthosis (soft fabric and hard
thermoplastic), there were significant reductions in
overall pain levels when these orthoses were worn
at night for a month. Hand function and morning
stiffness were no different over time when wearing

Figure 2 Static resting orthosis.



the splint. The majority of the study sample preferred
the soft splints.
Janssen et al’s (1990), 12-month, randomized,
controlled trial of 29 patients reported a statistically
significant reduction in hand joint swelling and a
decrease in pain and tenderness scores when these
splints were worn. There were improvements in
grip strength but not hand function. These findings
are difficult to interpret when changes in disease
activity nor baseline values of outcomes were considered
in the analysis.
Adams et al (2008) randomised controlled trial
recruited (n  116) controlled for baseline outcome
value as well as disease activity at baseline
in analysis. There were no significant differences in
handgrip strength, self-report hand function using
the Michigan Hand Outcomes questionnaire and
MCPJ ulnar deviation by groups over 12 months
follow-up. There was some evidence to indicate that
early morning stiffness increased with splint wear
(Adams et al 2006).
There is little evidence from longitudinal fully
powered studies to indicate that these splints can
impact on hand function and deformity, there is
some evidence to suggest that hand pain may be
improved.


FINGER SWAN NECK ORTHOSIS



These small finger based splints apply a three-point
force around the PIPJ to prevent PIPJ hyperextension
and subsequent distal interphalangeal joint
(DIPJ) flexion present in swan necking of the fingers.
They are small functional orthoses that permit
full PIP joint flexion but prevent hyperextension.
They aim to decrease digital pain, correct or prevent
swan necking in the digits and improve hand function
(Zijlstra et al 2002).
These splints can be custom made using thermoplastic
material or silver. Silver custom made
options (Fig. 12.3) are more costly but have been
reported as more durable than the thermoplastic
alternatives, they are also more popular gaining
higher adherence levels than thermoplastic alternatives
(Macleod & Adams 2002, Macleod et al 2003).
There have only been three reported studies of
clinical effectiveness. Ter Schegget and Knipping
(2000) demonstrated in a crossover study of 18 individuals
there was pain relief when worn but this
did not reach statistically significant levels. There
were significant improvements in digital stability


Figure 3 Silver ring swan neck orthoses.



and DIPJ extension. Zijlstra et al’s (2002) small longitudinal
study of 15 people with RA (using 48 ring
orthoses) over a 12 month period demonstrated that
these orthoses improved functional dexterity levels
to statistically significant levels. These results were
confirmed by their later study (Zijlstra et al 2004).
Conversely, they were seen to have no effect on selfreported
hand function, grip strength or hand pain
(Zijlstra et al 2002, 2004).


THUMB SPLINTS




In CMCJ basal joint osteoarthrtis thumb splints are
used for relief of thumb pain, weakness, contracture
and improvement of function (Wajon & Ada 2005).
Thumb splints may immobilise just the CMCJ: short
opponens type (Fig. 12.4) or combine CMCJ with
distal radio carpal joint immobilisation: long type
(Fig. 12.5).
There have been no published studies that
have compared splinting to no splint intervention.
Studies that have examined both short and long
type of splints in one study have reported no difference
between the outcome of the splints. Weiss
et al’s, (2000) short, 2-week cross-over study, examined
26 hands using short and long splints. They
reported that both types of splint appear to reduce
subluxation of the first CMCJ. Pinch strength was
not improved over 2 weeks of splinting, however
patients reported anecdotally that they gained some
pain relief on wear. Short splints were preferred to
long. Soft neoprene splints are preferred to rigid

Figure 4 CMCJ short opponens type splint.




Figure 5 CMCJ and distal radio carpal immobilisation
(long type) splint.



thermoplastic splints and patients prefer the soft
splints for daily and long-term use. The beneficial
effects have been seen to be amplified with the soft
type of thumb splint (Weiss et al 2004).
Patients report preference for soft splints (Buurke
et al 1999). In their cross-over study ten female
patients were recruited and wore three types of
manufactured splints (supple elastic, elastic and
semi rigid material), over a period of 12 weeks.
There was no difference in pain and pinch scores
between the orthoses.
Wajon and Ada’s (2005) randomised trial (n  40)
compared a short opponens type splint and a pinch
exercise regime with a thumb strap splint and an
abduction exercise regime over a 6 week period.
Comparison of change scores over the 6 week
follow-up assessments by a blinded assessor demonstrated
no difference in outcome by groups for
reported pain at rest, pinch grip strength and levels
of hand function.
Swigart et al’s retrospective study (1999) examined
the effects of thumb splinting on 130 thumbs
with varying stages of CMCJ osteoarthritis (OA).
Some patients received surgical intervention but
patients were excluded if they had been treated
with exercise or steroid injections. Long thumb
splints were reviewed after a maximum of 4 weeks
wear. In milder forms of OA, 76% of patients benefited
from some symptomatic improvement and in
more severe cases of OA, 54% benefited. These benefits
were maintained over 6 months.
Evidence that static thumb splinting may delay
or prevent the need for surgical intervention has

also been supported by Berggren et al’s seven year
follow-up study (Berggren et al 2001). The provision
of occupational therapy including aids and equipment,
joint protection advice and thumb splinting
reduced the number of individuals requiring thumb
joint surgery by 65% over a 7 year period (Berggren
et al 2001).
Static thumb orthoses have been reported as
being effective in long-term relief of OA symptoms
when used alongside a single corticosteroid
injection (Day et al 2004). A single corticosteroid
injection combined with 3 weeks static splinting
produced long-term relief from the symptoms of
OA in stage I OA (n  30 thumbs). Although individuals
with later stage OA (stage IV) reported less
benefit, 40% of participants received symptomatic
improvement that was considered sufficient and
sustained irrespective of their stage.


CONCLUSION



Static orthoses continue to be enthusiastically
endorsed by therapists (Henderson & McMillan
2002). During an era when drug developments continue
to assist with more effective control of disease
activity and synovitis, continued research is needed
into the most appropriate types of orthosis to recommend.
The challenge is to provide objective evidence
as to whether the continued use of orthoses
is indicated for people with arthritis and if so which
designs are the most effective and at which stage of
the disease process.




Rheumatology Evidence-Based Practice for Physiotherapists and Occupational Therapists 

Edited by Krysia Dziedzic PhD, MCSP and Alison Hammond PhD, MSc, BSc(Hons), DipCOT, FCOT
2010, © Elsevier Ltd. ISBN 978-0-443-06934-5
























































Friday, February 10, 2012

Disorders of the Plantar Aponeurosis A Spectrum of MR Imaging Findings




1.       Daphne J. Theodorou1, 
2.       Stavroula J. Theodorou, 
3.       Shella Farooki,
4.       Y. Kakitsubata and 
5.       Donald Resnick
+Author Affiliations
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1.       1All authors: Department of Radiology, School of Medicine, University of California San Diego and Veterans Administration Medical Center, 3350 La Jolla Village Dr., San Diego, CA 92161.

The plantar aponeurosis, or plantar fascia, has received considerable attention in the scientific literature and has been shown to be the most important structure for dynamic longitudinal arch support in the foot [1]. The plantar aponeurosis comprises histologically both collagen and elastic fibers arranged in a particular network of bundles and is a tough tendinous (rather than a fascial) layer of the plantar aspect of the foot. This sophisticated combination of fibers, having different biomechanical properties during stress application to the plantar aponeurosis, affords an increased modulus of elasticity during weight bearing [2].
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Abnormalities affecting the plantar aponeurosis are well recognized. Patients with suspected abnormality involving the aponeurosis traditionally have been examined with conventional radiography and bone scintigraphy and occasionally with sonography. Although conventional radiography remains essential in the initial diagnostic approach, MR imaging is particularly well suited for depicting the plantar aponeurosis (Fig. 1A,1B) and for detecting the presence of a wide range of disorders. MR imaging also may be useful in limiting the broad differential diagnosis of subcalcaneal heel pain.
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  Fig. 1A.
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Fig. 1A. —MR imaging configuration of normal plantar aponeurosis with anatomic correlation. In cadaveric specimen, sagittal T1-weighted spin-echo MR image (TR/TE, 600/20) outlines plantar aponeurosis as uniform bandlike structure of low signal intensity (arrows).
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  Fig. 1B.
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Fig. 1B. —MR imaging configuration of normal plantar aponeurosis with anatomic correlation. Anatomic section, approximately 8 mm more laterally to mid-sagittal level than MR image, delineates central component of plantar aponeurosis (arrows).
This pictorial review summarizes the most common abnormalities that affect the plantar aponeurosis and addresses their characteristic MR imaging features. Although in clinical practice plantar fasciitis is the most common diagnosis in patients with heel pain, a spectrum of disorders may also affect the plantar aponeurosis, including enthesopathy, traumatic and corticosteroid-induced rupture, rheumatologic and infectious processes, and plantar fibromatosis.
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Plantar Fasciitis
Plantar fasciitis, the most common cause of heel pain in the athlete, is a low-grade inflammation involving the plantar aponeurosis and the perifascial structures. Affecting a wide range of age groups, it is a relatively common disorder that is characterized by chronic deep pain in the subcalcaneal area and along the medial aspect of the plantar surface of the foot. In general, the factors associated with plantar fasciitis fall into three major categories [3]: mechanical, degenerative, and systemic. Mechanical causes of plantar fasciitis include overuse syndromes (participation in competitive sports involving repetitive application of tension force to the aponeurosis), various foot deformities, tight Achilles tendon or limited dorsiflexion, increased body weight, leg length inequality, and externally rotated lower extremity. Degenerative factors associated with plantar fasciitis include age-related increases in foot pronation and atrophy of the heel fat pad. Predisposing systemic factors include various rheumatoid disorders, especially rheumatoid arthritis, seronegative spondyloarthropathies, and gout [3].
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Repetitive trauma produces microtears of some fibers of the plantar aponeurosis, mostly close to the site of its attachment, that are accompanied by a local inflammatory reaction. Acute plantar fasciitis may be displayed conspicuously with MR imaging. The inflamed plantar aponeurosis may show abnormal high intrasubstance signal intensity on T2-weighted and short tau inversion-recovery (STIR) MR images, with or without associated fascial thickening (Fig. 2A,2B,2C). The signal-intensity changes of perifascial soft-tissue edema either deep, superficial, or both deep and superficial in relation to the plantar aponeurosis are revealed. Marrow edema of the calcaneus also may be observed. After administration of gadolinium-containing contrast material, ample enhancement of the inflamed perifascial soft tissues may be seen (Fig. 3A,3B,3C).
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  Fig. 2A.
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Fig. 2A. —Acute plantar fasciitis in 42-year-old man with subcalcaneal pain. (Courtesy of Skaf A, Sao Paolo, Brazil) Unenhanced T1-weighted spin-echo MR image (TR/TE, 620/25) (A) and short tau inversion-recovery (STIR) MR image (3760/16; inversion time, 150 msec) (B) show thickening of central component of plantar aponeurosis (large arrows). Extensive edema infiltrates perifascial soft tissue (curved arrows). Note abnormal foci of intrafascial high signal intensity corresponding to intrasubstance edema because of acute inflammation evident on STIR image (small arrows).
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  Fig. 2B.
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Fig. 2B. —Acute plantar fasciitis in 42-year-old man with subcalcaneal pain. (Courtesy of Skaf A, Sao Paolo, Brazil) Unenhanced T1-weighted spin-echo MR image (TR/TE, 620/25) (A) and short tau inversion-recovery (STIR) MR image (3760/16; inversion time, 150 msec) (B) show thickening of central component of plantar aponeurosis (large arrows). Extensive edema infiltrates perifascial soft tissue (curved arrows). Note abnormal foci of intrafascial high signal intensity corresponding to intrasubstance edema because of acute inflammation evident on STIR image (small arrows).
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  Fig. 2C.
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Fig. 2C. —Acute plantar fasciitis in 42-year-old man with subcalcaneal pain. (Courtesy of Skaf A, Sao Paolo, Brazil) T2-weighted fast spin-echo MR image (4367/86) with fat saturation shows thickening of plantar fascia (straight arrows), extensive high signal intensity infiltrating perifascial soft tissues (curved arrows), and abnormal intermediate intrafascial signal intensity.
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  Fig. 3A.
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Fig. 3A. —MR imaging findings of acute plantar fasciitis in 23-year-old male athlete. (Courtesy of Skaf A, Sao Paolo, Brazil) Unenhanced T1-weighted spin-echo MR image (TR/TE, 400/10) (A) and enhanced T2-weighted fat-suppressed fast spin-echo MR image (4000/105) (B) show the signal-intensity changes of edema in perifascial soft tissues (straight arrows). Note foci of abnormal marrow high signal intensity at calcaneal insertion of plantar fascia (curved arrows), evident on fast spin-echo T2-weighted MR image (B).
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  Fig. 3B.
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Fig. 3B. —MR imaging findings of acute plantar fasciitis in 23-year-old male athlete. (Courtesy of Skaf A, Sao Paolo, Brazil) Unenhanced T1-weighted spin-echo MR image (TR/TE, 400/10) (A) and enhanced T2-weighted fat-suppressed fast spin-echo MR image (4000/105) (B) show the signal-intensity changes of edema in perifascial soft tissues (straight arrows). Note foci of abnormal marrow high signal intensity at calcaneal insertion of plantar fascia (curved arrows), evident on fast spin-echo T2-weighted MR image (B).
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  Fig. 3C.
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Fig. 3C. —MR imaging findings of acute plantar fasciitis in 23-year-old male athlete. (Courtesy of Skaf A, Sao Paolo, Brazil) Short tau inversion-recovery MR image (TR/TE, 3000/48; inversion time, 150 msec) again reveals prominent abnormal high signal intensity in perifascial soft tissues consistent with edema (arrows).
With chronicity, the plantar aponeurosis may show significant fusiform thickening extending to its calcaneal origin. Erosive changes of the calcaneus also may occur as a result of chronic inflammation at the osseotendinous junction. Chronic inflammation of the aponeurosis and the perifascial structures is characterized by collagen degeneration and necrosis, angiofibroblastic hyperplasia, chondroid metaplasia, and matrix calcification. On MR imaging, these histopathologic changes may correspond to abnormal intrafascial intermediate signal intensity on T1-weighted MR images and high signal intensity on T2-weighted and STIR MR images. On T2-weighted and STIR images, however, areas of high signal intensity reflecting edema also may be shown in the marrow of the calcaneus and in the adjacent subcutaneous tissues. After administration of gadolinium-containing contrast material, enhancement of the aponeurosis and the surrounding soft tissues may be evident (Fig. 4A,4B). In almost all patients, however, fluid-sensitive sequences are sufficient, and the use of IV gadolinium rarely is required. Because the imaging findings of acute and chronic plantar fasciitis may be similar, accurate diagnosis requires adequate clinical information. In the correct clinical circumstances, MR imaging may be of particular value in differentiating plantar fasciitis from other causes of plantar heel pain, including fascial strain or rupture, infections, tumors, tendinosis and tenosynovitis, subcalcaneal bursitis, nerve entrapment syndromes, and calcaneal stress fractures [3].
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  Fig. 4A.
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Fig. 4A. —Chronic plantar fasciitis in 42-year-old woman. (Courtesy of Kerr R, Los Angeles, CA) Unenhanced T1-weighted spin-echo MR image (TR/TE, 720/12) (A) and enhanced T1-weighted fat-suppressed spin-echo MR image (610/12) (B) display abnormal intermediate and high signal intensity, respectively, in soft tissues superficial to plantar aponeurosis (solid arrows). Contrast enhancement of soft tissues deep in relation to plantar aponeurosis (open arrows) because of edema also can be appreciated.
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Fig. 4B. —Chronic plantar fasciitis in 42-year-old woman. (Courtesy of Kerr R, Los Angeles, CA) Unenhanced T1-weighted spin-echo MR image (TR/TE, 720/12) (A) and enhanced T1-weighted fat-suppressed spin-echo MR image (610/12) (B) display abnormal intermediate and high signal intensity, respectively, in soft tissues superficial to plantar aponeurosis (solid arrows). Contrast enhancement of soft tissues deep in relation to plantar aponeurosis (open arrows) because of edema also can be appreciated.
Calcaneal Enthesophyte
Plantar calcaneal enthesophytes originate from the medial calcaneal tuberosity at the attachment of the flexor digitorum brevis and abductor hallucis muscles. As with enthesophytes at other sites, calcaneal enthesophytes may occur as a result of excessive repetitive traction by these intrinsic muscles, causing chronic microtrauma, which in turn, leads to periostitis and calcification. Systemic arthritis with reactive bone proliferation and the aging process may also be associated with the formation of calcaneal enthesophytes, which may become symptomatic in the setting of plantar heel pad atrophy. Although calcaneal enthesophytes have been described in association with plantar fasciitis, most publications conclude that they rarely cause this condition as also indicated by Berkowitz et al. [4], who found calcaneal enthesophytes in patients with plantar fasciitis, as well as in asymptomatic controls. MR imaging can display conspicuously calcaneal enthesophytes and may show abnormalities at the enthesis of the plantar aponeurosis in some patients in whom the outgrowths are associated with enthesitis [3] (Figs. 5A,5B and 6).
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  Fig. 5A.
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Fig. 5A. —Calcaneal enthesophyte in asymptomatic 53-year-old man. Lateral radiograph of heel shows calcaneal enthesophyte (arrow) with smooth margins and normal adjacent soft tissues.
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Fig. 5B. —Calcaneal enthesophyte in asymptomatic 53-year-old man. Unenhanced T1-weighted spin-echo MR image (TR/TE, 516/20) again shows calcaneal enthesophyte (curved arrow). Plantar aponeurosis (straight arrow) and adjacent soft tissues appear unremarkable.
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  Fig. 6.
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Fig. 6. —Calcaneal enthesophyte in 51-year-old man with chronic heel pain. Gradient-echo MR image (TR/TE, 620/25; flip angle, 25°) shows enthesophyte (curved arrow) and abnormal high signal intensity in soft tissues superficial to plantar aponeurosis consistent with edema (open arrow). (Courtesy of Roger B, Paris, France)
Fascial Rupture
Although plantar fasciitis is common, rupture of the plantar aponeurosis, either complete or partial, is not a commonly encountered diagnosis because it occurs infrequently or is not recognized. Most commonly seen in competitive athletes at the time of injury by an acceleration type of motion that leads to forcible plantar flexion, rupture of the plantar aponeurosis also may occur as a result of repetitive stress or repetitive minor trauma to the aponeurosis in recreational running and jumping. Spontaneous rupture of the plantar aponeurosis, however, may occur in patients with prior plantar fasciitis and most commonly in those patients treated with local steroid injections (Fig. 7A,7B,7C). Research by Acevedo and Beskin [5] indicates a 10% plantar aponeurosis rupture rate after corticosteroid injection for plantar fasciitis.
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  Fig. 7A.
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Fig. 7A. —32-year-old man with complete rupture of plantar aponeurosis after local corticosteroid injections for chronic plantar fasciitis. Lateral radiograph of foot shows calcaneal enthesophyte (curved arrow) with erosion of undersurface of calcaneus (straight arrows) and small bone fragment (open arrow).
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  Fig. 7B.
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Fig. 7B. —32-year-old man with complete rupture of plantar aponeurosis after local corticosteroid injections for chronic plantar fasciitis. Unenhanced T1-weighted fast spin-echo MR image (TR/TE, 466/12.6) of foot shows prominent pointed calcaneal enthesophyte (arrow).
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  Fig. 7C.
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Fig. 7C. —32-year-old man with complete rupture of plantar aponeurosis after local corticosteroid injections for chronic plantar fasciitis. Enhanced T1-weighted fat-suppressed fast spin-echo MR image (716/13.8) shows large osseous defect at plantar aspect of calcaneus (long arrow) and absence of plantar aponeurosis. Note remarkable enhancement of bone caused by marrow edema (short arrows). Soft-tissue edema also is evident (open arrow).
Regardless of the mechanism of rupture, MR imaging clearly reveals and localizes the lesion and aids in distinguishing recent and longstanding ruptures of the plantar aponeurosis. In many patients, MR imaging also may provide additional diagnostic information with regard to inflammatory changes of the heel fat pad, accompanying rupture. Recent rupture may be diagnosed when the aponeurosis shows disruption of its continuity with abnormal loss of its low signal intensity on T1-weighted MR images at the site of the complete rupture (Fig. 8A,8B,8C) or when it shows partial loss of its low signal intensity with partial rupture (Fig.9A,9B). Typically, the aponeurosis appears thickened at the site of partial disruption of its continuity. Soft tissues show abnormal high signal intensity on T2-weighted MR images because of edema or hemorrhage, or both, and show considerable enhancement after administration of gadolinium-containing contrast material.
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  Fig. 8A.
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Fig. 8A. —Posttraumatic acute complete rupture of plantar aponeurosis in 48-year-old sheriff who was running after suspect. (Courtesy of Edwards J, Savannah, GA) Unenhanced T1-weighted spin-echo (TR/TE, 760/20) (A) and short tau inversion-recovery (STIR) (B) MR images (5830/30; inversion time, 150 msec) display complete disruption of plantar aponeurosis with abnormal intermediate and high signal intensity, respectively, at proximal part of plantar aponeurosis (straight arrows). On STIR images, edema infiltrating perifascial soft tissues (open arrows) mostly deep in relation to plantar aponeurosis is evident. Signal-intensity changes of minimal bone marrow edema involving calcaneal enthesophyte also are present (curved arrows).
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  Fig. 8B.
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Fig. 8B. —Posttraumatic acute complete rupture of plantar aponeurosis in 48-year-old sheriff who was running after suspect. (Courtesy of Edwards J, Savannah, GA) Unenhanced T1-weighted spin-echo (TR/TE, 760/20) (A) and short tau inversion-recovery (STIR) (B) MR images (5830/30; inversion time, 150 msec) display complete disruption of plantar aponeurosis with abnormal intermediate and high signal intensity, respectively, at proximal part of plantar aponeurosis (straight arrows). On STIR images, edema infiltrating perifascial soft tissues (open arrows) mostly deep in relation to plantar aponeurosis is evident. Signal-intensity changes of minimal bone marrow edema involving calcaneal enthesophyte also are present (curved arrows).
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  Fig. 8C.
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Fig. 8C. —Posttraumatic acute complete rupture of plantar aponeurosis in 48-year-old sheriff who was running after suspect. (Courtesy of Edwards J, Savannah, GA) T2-weighted fat-suppressed fast spin-echo MR image (3901/98) shows area of abnormal high signal intensity in central component of plantar aponeurosis (arrows), corresponding to complete disruption of aponeurosis.
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  Fig. 9A.
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Fig. 9A. —MR imaging findings of acute incomplete rupture of plantar aponeurosis in 38-year-old man. (Courtesy of Edwards J, Savannah, GA) Short tau inversion-recovery MR image (TR/TE, 5800/30; inversion time, 150 msec) (A) and T2-weighted fast spin-echo MR image (3901/98) (B) show incomplete rupture of central component of plantar aponeurosis with abnormal intrafascial signal intensity (curved arrows) at junction of proximal and middle portion of plantar aponeurosis. Note fusiform thickening of plantar aponeurosis (straight arrows) and perifascial soft-tissue edema (open arrows).
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  Fig. 9B.
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Fig. 9B. —MR imaging findings of acute incomplete rupture of plantar aponeurosis in 38-year-old man. (Courtesy of Edwards J, Savannah, GA) Short tau inversion-recovery MR image (TR/TE, 5800/30; inversion time, 150 msec) (A) and T2-weighted fast spin-echo MR image (3901/98) (B) show incomplete rupture of central component of plantar aponeurosis with abnormal intrafascial signal intensity (curved arrows) at junction of proximal and middle portion of plantar aponeurosis. Note fusiform thickening of plantar aponeurosis (straight arrows) and perifascial soft-tissue edema (open arrows).
Chronic rupture, however, is displayed as a scar of intermediate-to-low signal intensity on both T1- and T2-weighted MR images. This scar shows no enhancement after contrast administration. The plantar aponeurosis appears focally thickened, and chronic hematoma formation also may be seen (Fig.10A,10B,10C). On some occasions, secondary formation of a cyst is revealed as a welldefined collection of abnormal intermediate signal intensity on T1-weighted MR images and high signal intensity on T2-weighted images, located between the superficial and the deep layers of the aponeurosis.
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  Fig. 10A.
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Fig. 10A. —Chronic partial rupture of plantar aponeurosis in 42-year-old male jogger. (Courtesy of Roger B, Paris, France) Unenhanced T1-weighted spin-echo (TR/TE, 400/13) (A) and gradient-echo MR images (340/20; flip angle, 25°) (B) show fusiform thickening of plantar fascia (straight arrows) with abnormal intermediate (A) and high (B) intrafascial signal intensity (open arrows). Extensive edema infiltrating subcutaneous soft tissues can be seen (curved arrows).
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  Fig. 10B.
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Fig. 10B. —Chronic partial rupture of plantar aponeurosis in 42-year-old male jogger. (Courtesy of Roger B, Paris, France) Unenhanced T1-weighted spin-echo (TR/TE, 400/13) (A) and gradient-echo MR images (340/20; flip angle, 25°) (B) show fusiform thickening of plantar fascia (straight arrows) with abnormal intermediate (A) and high (B) intrafascial signal intensity (open arrows). Extensive edema infiltrating subcutaneous soft tissues can be seen (curved arrows).
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  Fig. 10C.
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Fig. 10C. —Chronic partial rupture of plantar aponeurosis in 42-year-old male jogger. (Courtesy of Roger B, Paris, France) Unenhanced T1-weighted MR image (400/13) reveals thickening of central component of plantar aponeurosis (thin arrows) and linear regions of intrafascial abnormal high signal intensity consistent with intrasubstance tear (arrowheads). Normal contralateral central component of plantar aponeurosis (thick arrow) is shown for comparison.
Rheumatoid Nodules
Among pedal manifestations of rheumatoid arthritis, rheumatoid nodules are considered one of the most common soft-tissue lesions, occurring in 20-30% of instances of rheumatoid arthritis [6]. Although rheumatoid nodules have traditionally been associated with advanced rheumatoid arthritis and treatment with methotrexate, they also may occur in patients with rheumatic fever, ankylosing spondylitis, systemic lupus erythematosus, and agammaglobulinemia. These subcutaneous lesions are commonly found in areas that are subject to repetitive minor trauma and, specifically, in those areas overlying osseous prominences. Typically, rheumatoid nodules are revealed as subcutaneous focal demarcated nodular areas of fibroinflammatory reaction.
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With MR imaging, rheumatoid nodules usually appear nearly isointense to muscle in T1-weighted images and display slightly heterogeneous intermediate-to-high signal intensity in T2-weighted images. On enhanced MR images, rheumatoid nodules may reveal a spectrum of appearances, including areas of heterogeneous increased signal intensity, faint peripheral enhancement, or homogeneous enhancement in solid lesions with no central necrosis (Fig. 11A,11B).
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  Fig. 11A.
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Fig. 11A. —Rheumatoid nodule in 45-year-old woman with rheumatoid arthritis and swelling over plantar aspect of calcaneus. (Courtesy of Eilenberg S, San Diego, CA) Unenhanced T1-weighted fast spin-echo MR image (TR/TE, 433/16) (A) and enhanced T1-weighted fat-suppressed fast spin-echo MR image (466/17) (B) show large lobulated soft-tissue mass of intermediate signal intensity located between skin and calcaneal tubercle (arrow). Note that underlying bone appears unremarkable.
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  Fig. 11B.
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Fig. 11B. —Rheumatoid nodule in 45-year-old woman with rheumatoid arthritis and swelling over plantar aspect of calcaneus. (Courtesy of Eilenberg S, San Diego, CA) Unenhanced T1-weighted fast spin-echo MR image (TR/TE, 433/16) (A) and enhanced T1-weighted fat-suppressed fast spin-echo MR image (466/17) (B) show large lobulated soft-tissue mass of intermediate signal intensity located between skin and calcaneal tubercle (arrow). Note that underlying bone appears unremarkable.
Plantar Infection
As with infections at the plantar aspect of the foot in general, the plantar aponeurosis may be contaminated by direct implantation of foreign bodies, puncture wounds, surgical procedures, spread from a contiguous source of infection, and, in diabetic foot disease, via plantar skin ulceration and inoculation of infectious agents. A variety of bacteria can cause infectious fasciitis, withStreptococci being most commonly reported. Because fascial inflammation can cause destruction of mechanical barriers, spread of infection along the intermuscular fascial tissue planes to adjacent soft tissues, underlying bone, or both, may require amputation. Necrotizing fasciitis, however, is a rare type of pedal softtissue infection limited to the fascia only, and it is associated with generalized sepsis, endotoxic shock, and high mortality rates.
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MR imaging may be helpful in the early detection, localization, and determination of the depth of inflammation. Infectious fasciitis may be diagnosed when the plantar fascia and perifascial soft tissues show abnormal high signal intensity on T2-weighted MR images. It has been suggested [7] that high T2-weighted signal intensity in the deep fascial planes and muscles, along with rim enhancement after gadolinium administration, are specific findings for necrotizing fasciitis, whereas high signal intensity on T2-weighted MR images limited to the subcutaneous fat, with or without contrast enhancement, are findings consistent with nonnecrotizing soft-tissue infections (Fig. 12A,12B). However, it remains to be further investigated whether these MR imaging findings may allow differentiation between the two entities.
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  Fig. 12A.
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Fig. 12A. —Local infection of plantar soft tissues in 43-year-old man with no known history of diabetes. (Courtesy of Roger B, Paris, France) Unenhanced T1-weighted spin-echo MR image (TR/TE, 380/12) shows abnormal intermediate signal intensity in plantar aponeurosis and adjacent plantar soft tissues (arrows).
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  Fig. 12B.
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Fig. 12B. —Local infection of plantar soft tissues in 43-year-old man with no known history of diabetes. (Courtesy of Roger B, Paris, France) Enhanced T1-weighted spin-echo MR image (390/12) at same level as (A) shows diffuse enhancement of signal intensity in plantar aponeurosis and perifascial soft tissues (arrows).
Plantar Fibromatosis
Superficial plantar fibromatosis is a benign fibroblastic proliferative disorder associated with replacement of elements of the plantar aponeurosis with abnormal fibrous tissue. Although several etiologic factors have been proposed [8], including trauma, infection, neuropathy, biochemical and metabolic imbalance, faulty development, and the patient's occupation, the precise etiology of plantar fibromatosis remains unclear. Typically, plantar fibromatosis is multinodular and occurs along the medial aspect of the central part of the plantar aponeurosis. Single or multiple plantar fibromas, usually measuring less than 3 cm in diameter, are located in the plantar aponeurosis and the subcutaneous tissues.
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With MR imaging, plantar fibromas appear as well-defined nodules with abnormal low signal intensity on T1-weighted and low-to-intermediate signal intensity on T2-weighted MR images. In some instances associated with a more aggressive disorder, areas of abnormal high and low signal intensity on T2-weighted and STIR images reflect the relative proportions of cellular elements within the mass [8] (Fig. 13A,13B,13C). With administration of gadolinium-containing contrast material, however, a spectrum of enhancement patterns corresponding to the cellular portions of the lesion may be seen, varying from heterogeneously moderate or marked contrast enhancement to absolutely no enhancement. Local infiltrative growth associated with poor margination of the lesion and involvement of the subcutaneous tissue, muscles, or bones may be observed in aggressive or deep fibromatosis [8]. In deep fibromatosis, lesions are most commonly solitary and are characterized by a high recurrence rate.
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  Fig. 13A.
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Fig. 13A. —Solitary plantar fibroma in 64-year-old woman with palpable soft-tissue mass in sole of foot. (Courtesy of Taketa R, Long Beach, CA) Unenhanced T1-weighted spin-echo MR image (TR/TE, 600/11) reveals large fusiform mass of intermediate signal intensity in plantar soft tissues (arrows).
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  Fig. 13B.
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Fig. 13B. —Solitary plantar fibroma in 64-year-old woman with palpable soft-tissue mass in sole of foot. (Courtesy of Taketa R, Long Beach, CA) T2-weighted fat-suppressed fast spin-echo MR image (4900/46) (B) and enhanced T1-weighted spin-echo MR image (800/17) (C) show lobulated mass of high signal intensity with internal septation (open arrows) in continuity with plantar fascia (long arrows). Note distortion of contour in plantar aspect of foot.
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  Fig. 13C.
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Fig. 13C. —Solitary plantar fibroma in 64-year-old woman with palpable soft-tissue mass in sole of foot. (Courtesy of Taketa R, Long Beach, CA) T2-weighted fat-suppressed fast spin-echo MR image (4900/46) (B) and enhanced T1-weighted spin-echo MR image (800/17) (C) show lobulated mass of high signal intensity with internal septation (open arrows) in continuity with plantar fascia (long arrows). Note distortion of contour in plantar aspect of foot.
In summary, subcalcaneal heel pain is a common presenting complaint associated with a multitude of etiologic factors. The most common abnormalities are plantar fasciitis, calcaneal enthesopathy, fascial rupture, rheumatoid nodules, plantar infection, and plantar fibromatosis. MR imaging is particularly helpful for the diagnosis of these entities.
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Footnotes
  • Supported by Veterans Administration grant SA-360 and the A. S. Onassis Public Benefit Foundation Educational Stipend U-033.
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  • Address correspondence to D. Resnick.
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·  Received March 13, 2000.
·  Accepted June 20, 2000.
·  © American Roentgen Ray Society

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