CASE STUDY –
FIBROMATOSIS
PAIGE FABRE
13654584
Paige Fabre
PATIENT PRESENTATION
• 51 year old male
• Current heel pain
• Request
• X-ray and Ultrasound of plantar fascia
• Clinical indication:
• ? Calcaneal Spur ?Plantar Fasciitis
X-RAY IMAGES
X-RAY IMAGES WERE PERFORMED BEFORE THE
ULTRASOUND
IMAGE 1: LATERAL IMAGE OF THE RIGHT HEEL IMAGE
THE ABOVE IMAGE WAS PERFORMED ON A CR SYSTEM WITH THE ANKLE
AND FOOT IN EXTERNAL ROTATION.
IMAGE FINDINGS
The following are the findings as prepared by the radiologist
regarding the previous X-ray study. The series consisted of 2
images including the previous lateral image and an axial
image of the calcaneus.
ULTRASOUND OF THE
PLANTAR FOOT
ROOM PREPARATION
The room was prepared before the patient entered with:
• The head of the table slightly lowered for comfort
• The pillow moved from the end of the bed to allow the
patient to option of lying with their head or their chest on
the pillow to ensure comfort during the examination
• The foot end of the bed was lifted slightly to allow the
patient to rest with the dorsal aspect of their foot on the
edge of the bed so that it may be manipulated
throughout the scan
• Protective blueys were placed on the carpet below the
patient’s feet and on the bed to catch any gel run-off
• The ultrasound machine was moved to the end of the
bed and a selection of high frequency transducer were
connected or in close proximity.
IMAGE 2: ROOM PREPARATION
IMAGES OF THE ROOM PREPARATION AS DESCRIBED PREVIOUSLY
PATIENT PREPARATION
• The patient was welcomed into the room.
• Their clothing was assess for accessibility.
• As the patient was wearing trousers that could be easily
lifted they were not required to change.
• The patient removed their shoes and socks from both feet
to allow for comparison imaging.
• The examination was explained to the patient
• The patient was aware that the scan was to be performed
by a trainee with a supervising sonographer assisting.
EQUIPMENT PREPARATION
• The scan was performed on a Phillips IU22
• Initially a 18mHz transducer was attempted,
however due to the thickness of the patient’s heel a
12mHz multiple frequency transducer was selected
to perform the scan.
IMAGING PROTOCOL
IMAGING PROTOCOL
• Imaging protocol of a plantar fascia examination is as
follows:
• Transverse images of the plantar aponeurosis from calcaneal
tuberosity to the distal division.
• Longitudinal images of the plantar aponeurosis from calcaneal
tuberosity to the distal division.
• Further imaging of surrounding structures is encouraged if
indicated by pathology seen, radiologist request or patient
information.
• Doppler may be used to assess for vascularity and imaging
performed as required
US EXAMINATION
IMAGE 3: LONGITUDINAL IMAGE OF THE PROXIMAL
INSERTION OF THE PLANTAR FASCIA
CALLIPERS ARE PLACED ON THE IMAGE TO INDICATE THE THICKNESS OF
THE PLANTAR FASCIA. NOTE THE THICKNESS OF THE HEEL IN THIS REGIO N.
IMAGE 4: LONGITUDINAL IMAGE OF THE PLANTAR FASCIA
DISTAL TO IMAGE 3
DEMONSTRATION OF THE PLANTAR FASCIA AS IT CONTINUES TO THE
DISTAL PORTION OF THE FOOT.
IMAGE 5: LONGITUDINAL IMAGE OF THE PLANTAR FASCIA
DISTAL TO IMAGE 4
NOTE THE MORE SUPERFICIAL NATURE OF THE PLANTAR FASCIA AS IT
TRAVELS MORE DISTALLY.
IMAGE 6: LONGITUDINAL IMAGE OF THE PLANTAR FASCIA
MORE DISTALLY TO IMAGE 5
THI S POR TI ON I S AG AI N MOR E SUPER FI CI AL I N NATUR E TO THE PR OXI MAL POR TI ON.
NOTE THE FLEXOR DI GI TOR UM BR EVI S MUSCLE DEEP TO THE PLANTAR FASCI A.
IMAGE 7: TRANSVERSE IMAGE OF THE PROXIMAL INSERTION
OF THE PLANTAR FASCIA
THE THICKNESS OF THE HEEL IS AGAIN NOTED.
IMAGE 8: LONGITUDINAL IMAGE OF THE PLANTAR FASCIA
MORE DISTAL TO IMAGE 7.
THE THICKNESS OF THE PLANTAR FASCIA IS AGAIN DEMONSTRATED
WITH CALLIPERS.
IMAGE 9: A MORE DISTAL IMAGE OF THE PLANTAR FASCIA IN
TRANSVERSE AFTER THE REGION OF INCREASED THICKNESS
THE THICKNESS OF THE HEEL IS STILL SEEN PROMINENTLY IN THIS AREA .
IMAGE 10: TRANSVERSE IMAGE OF THE PLANTAR FASCIA,
AGAIN MORE DISTALLY
THE SUPERFICIAL NATURE OF THIS PORTION IS AGAIN NOTED.
IMAGE 11: A TRANSVERSE IMAGE OF THE PLANTAR FASCIA
MORE DISTALLY THAN IMAGE 10
THE THINNING OF THE PLANTAR FASCIA IS AGAIN SEEN
IMAGE 12: LONGITUDINAL IMAGE OF THE LATERAL PORTION
OF THE PLANTAR FASCIA 10CM DISTAL TO THE INSERTION
CALLIPERS ARE USED TO MEASURE THE THICKNESS OF THIS REGION OF
INCREASED THICKNESS AND DECREASE ECHOGENICITY
IMAGE 13: TRAPEZOID VIEW IS UTILISED TO DEMONSTRATE
THE LENGTH OF THE AREA SEEN IN IMAGE 12
CALLIPERS INDICATE A LENGTH OF 44MM
IMAGE 14: COLOUR DOPPLER IMAGING IS USED LOOK FOR AN
INCREASE IN FLOW IN THE ROI IN TRANSVERSE
NO INCREASED FLOW IS NOTED IN THIS IMAGE
IMAGE 15: IMAGE IN TRANSVERSE OF THE ROI
THE STRUCTURE IS SEEN HYPOECHOIC TO THE SURROUNDING TISSUE.
IMAGE 16: FURTHER TRANSVERSE IMAGES OF THE ROI
THE HYPOECHOIC NATURE OF THE STRUCTURE IS AGAIN NOTED WITH
THE POSSIBILITY OF TRACE FLUID SEEN ADJACENT TO THE STRUCTURE.
IMAGE 17: MORE DISTAL IMAGE IN TRANS OF THE ROI
SONOGRAPHIC FEATURES ARE SEEN SIMILAR TO IMAGE 16
IMAGE 18: COMPARATIVE IMAGING OF THE PLANTAR FASCIA
SIDE BE SIDE COMPARISON OF RIGHT AND LEFT HEELS/ CALLIPERS ARE U SED TO DISPLAY THE
INCREASED THICKNESS OF THE RIGHT PLANTAR FASCIA JUST DISTAL TO T HE INSERTION. THE
RIGHT PLANTAR FASCIA APPEARS MORE THAN DOUBLE THAT OF THE LEFT.
IMAGE 19: AN ATTEMPT IS MADE TO BETTER VISUALISE THE PLANTAR
FASCIA FIBRES USING A HIGHER FREQUENCY TRANSDUCER
THOUGH THERE IS SLIGHTLY BETTER RESOLUTION OF FIBRES, THE PROBE
APPEARS TO BE AT IT’S LIMITATION OF PENETRATION
IMAGE 19: A TRANSVERSE IMAGE WAS ALSO ATTEMPTED
SIMILAR IMAGE FINDINGS ARE NOTED
US FINDINGS
ULTRASOUND FINDINGS
• When conducting the ultrasound we found
• Thickened plantar fascia with a maximum thickness of 8.5mm,
almost twice the size of the contralateral side. The patient was
focally tender in this region. Though difficult to visualise, the
plantar fascia appeared reduced in echogenicity.
• In addition an area decreased echogenicity was seen laterally
and distally. The patient was not tender in this area
• Ultrasound characteristics
•
•
•
•
44x8x18mm
Hypoechoic
Continuous with the plantar fascia
No increased vascularity on Colour Doppler
• The suggestion of symptomatic plantar fasciitis with an
incidental finding of plantar fibromatosis.
RADIOLOGIST FINDINGS
THE RADIOLOGIST WAS SATISFIED WITH THE IMAGES AND INFORMATION
PROVIDED AND DID NOT FEEL THE NEED TO PERSONALLY SCAN THE PATIEN T
RADIOLOGIST REPORT
PLANTAR FIBROMATOSIS
DEFINITION
• Plantar fibromatosis can be defined as a benign
nodular fibroblastic proliferation of the plantar
aponeurosis or fascia(Foo and Raby 2005, 309)(Asib
et.al. 2014, 10)(Martinoli 2009, S40).
AETIOLOGY
• The exact aetiology of plantar fibromatosis is as yet
unknown. Further research is needed in this area.
• It is thought to occur in 0.2 – 2% of the population
(Touraine et.al. 2013, 88) (Cho and Wansaicheong
2012, 296).
CLINICAL INDICATIONS
• Patients are most commonly between 30 and 50 years of
age (Asib et.al. 2014, 2)(Foo and Raby 2005, 309).
• Touraine et.al. suggests of a link between plantar
fibromatosis and people who suffer from:
•
•
•
•
Excess intake of alcohol
Epilepsy
Keloids
Diabetes mellitus
• Patients often present with small painless or large painful
nodules on the plantar surface of the foot, swelling and
pain.
ULTRASOUND APPEARANCE
• On ultrasound, plantar fibromatosis appears as:
• Thickened hypoechoic nodular region along the line of the
plantar fascia or aponeurosis (Asib et.al. 2014, 10)(Foo and
Raby 2005, 309).
• Doppler imaging may show an increase in vascularity(Asib
et.al. 2014, 10).
• They may be single or multiple and may occur bilaterally
(Jacobson 2007, 318).
DIFFERENTIAL DIAGNOSIS
• Ahuja (2007, 13:127) suggests that possible
differential diagnosis include:
• Subcutaneous fat necrosis
• Calcaneal stress or insufficiency fracture
• Plantar bursitis
TREATMENT
• May be either conservative or surgical
• Conservative
• Shoe inserts to change the areas of pressure
• Steroid injection into the nodule
• Surgical
• Reserved for extremely painful nodules
• Nodes are removed however recurrence is common
(Ahuja 2007, 13:128)
REFLECTION
WH A T C O U L D H A V E B E E N D O N E B E T T E R
REFLECTION
• Overall the examination was successful as the
clinical question was answered.
• The patient tolerated the examination well and
seemed happy with the procedure.
• After the examination I reviewed the images with
my supervising sonographer and we discussed what
could have been improved.
REFLECTION
• Looking back on the images I identified that
improvement could be made on:
• Depth control
• On several of the images including Images 5-6 and 9-11 the
depth could have been reduced to better visualise the plantar
fascia.
• Transducer selection
• Although the lower frequency was needed to penetrate the
proximal insertion, a higher frequency could have been utilised
for the more superficial areas and the secondary region of
interest.
• Scouting
• The secondary area of interest was only noted when scanning
more laterally after the transverse images obtained.
REFLECTION
• Keeping light pressure with the use of Doppler
• No colour flow was seen in the secondary area during
examination. Upon reflection this may have been due to too
much pressure. Alternatively, factors could have been adjusted
more and perhaps Power Doppler used. Another suggestion is
that due to the lack of pain, this fibroma may not have been in
the acute phase and therefore no increased flow was there to
be detected.
• In future examinations I aim to improve on these
areas.
REFERENCES
Asib, O., E. Noizet, A. Croue, and A. Aube. 2014. “Ledderhose's disease: Radiologic/pathologic
correlation of superficial plantar fibromatosis.” Diagnostic Imaging and Intervention (Online
only) DOI 10.1016/j.diii.2014.01.018.
Ahuja, Anil. 2007. Diagnostic Imaging Ultrasound. Salt Lake City: Amirsys.
Cho, Kil-Ho, and Gervais Khin-Lin Wansaicheong. 2012. “Ultrasound of the Foot and Ankle”.
Ultrasound Clinics 7(4): 487-503. DOI 10.1016/j.cult.2012.08.004.
Foo, L.F., and N. Raby. 2005. “Tumours and tumour-like lesions in the foot and ankle”. Clinical
Radiology 60(3):308-332. DOI 10.1016/j.crad.2004.05.010.
Jacobson, Jon A. 2007. Fundamentals of Musculoskeletal Ultrasound. Philadelphia: Saunders Elsevier.
Martinoli, C. 2009. “Foot Ultrasound. What do we need to know and do”. Ultrasound in Medicine and
Biology 35(8): S40. DOI 10.1016/j.ultrasmedbio.2009.06.154.
Touraine, Sébastien, Valérie Boussona, Rachid Kacib, Caroline Parlier-Cuaua, Samuel Haddada, Liess
Laouisseta, David Petrovera, and Jean-Denis Laredoa. 2013. “Plantar fibromatosis may adopt
the brain gyriform pattern of a low-grade fibromyxoid sarcoma.” The Foot 23(2-3): 88-92. DOI
10.1016/j.foot.2012.12.006.