15. Plantar Entheses
It represent a firm site of attachment of a tendon, ligament
or articular capsule to bone
In an enthesis :
The fibers of the tendon become more compact , then cartilaginous & finally calcifies as
they the bone
These fibrous connections are often referred to as Sharpey,s
( perforating ) fibers
17. Causes of Traumatic Plantar Enthesopathy
• Major Trauma
• Micro Trauma
• Occupational
• Life style
• Lack of protective mechanisms
( Aging )
Soft tissue avulsion
Bone avulsion
Contusion
Soft tissue avulsion
RA , SLE , HPT , & Renal Osteodystrophy , GCs
therapy
Bone avulsion
Diseased bone , osteomalacia or metastatic disease
Manifested as osseous fragment separated from the underlying bone
18. It is observed at sites of ligamentous attachments
( Plantar Fascia / Long plantar ligament / Spring ligament ) ,
especially with advancing age = degenerative enthesophytes
Degenerative Heel Enthesopathy
Calcaneal enthesophytes in 25% of normal persons
Increase with Age
Obesity
Associated diseases as DM joint disorders
Degenerative enthesophytes : : They are well defined in comparison to the fluffy poorly marginated calcaneal outgrowths
seen in the SpA
20. More medial section ,
reveal degenerative
enthesopathy at
osseous attachment of
the long plantar
ligament
Sagittal section ,
reveal degenerative
enthesopathy at the
sites of attachment
of the achilles
tendon & plantar
aponeurosis
21. Inflammation … Erosions … Proliferations
Inflammatory Enthesitis
Ill defined bone margins on radiographs are characteristic of early involvement
; subsequently the margins of the affected bone may become more distinct or
better defined
22. Anatomy
It represent a firm site of attachment
of a tendon, ligament or articular
capsule to bone
In an enthesis :
The fibers of the tendon become more compact , then
cartilaginous & finally calcifies as they the bone
These fibrous connections are often referred to as Sharpey,s
( perforating ) fibers
25. Anatomy and function of the PF
It is a CT structure that helps maintain the longitudinal arch of the foot
The Central component
is proximally thick and distally thin and is the thickest of the three.
It arises from the medial tubercle of the calcaneus and extends distally becoming broader and covering the plantar surface
Distally, it divides into 5 digitations that insert into the MTP Js.
Three bundles:
The lateral portion
is also proximally thick and distally thin. It arises from the lateral margin of the medial calcaneal tubercle, covers the plantar
surface of the abductor digiti minimi muscle and inserts into the fifth metatarsal joint capsule.
The medial portion
is thinner than the others. It arises from the midportion of the central bundle, covers the plantar surface of the abductor hallucis
muscle and inserts into the first metatarsal joint capsule
Overall, PF thickness is greater in men
than in women
26. General features of PF disorders
Plantar fasciitis : is the most common injury of the PF and is estimated to induce > 1 million patients to seek treatment
annually
Plantar fasciitis has a degenerative rather than inflammatory nature
It is related to overuse trauma leading to microtears
Thus, the term “ Plantar Fasciopathy ” is often preferred.
27. Foot Deformities,
Improper Footwear,
Increased body mass index and
Increased activities that involve Prolonged Walking,
Prolonged Running or
Prolonged Standing
Aetiology of Plantar Fasciitis
It is multifactorial.
Biomechanical Risk Factors include those causing
Repetitive Stress on the PF, such as
All Local Therapy well be failed – If Risk Factors have been neglected
28. Calcaneal Spuring : have been investigated in great detail as a possible cause of plantar fasciitis , but they are not specific and also occur in
asymptomatic individuals.
Amongst Causes of of Plantar Fasciitis
Seronegative Spondyloarthropathies
Rheumatoid Arthritis
Among the medical conditions associated with plantar fasciitis
Plantar Calcaneal Spurs, also known as calcaneal enthesophytes
29. Many, but not all, of people experiencing plantar fasciitis have the “unlocked” foot because of failure of the foot to adequately supinate prior to the
push off phase of walking.
The CAUSE may be anywhere in the body.
9 Causes
of Plantar Fasciitis You Never Thought Of
SAME SIDE LEG :
1.Lack of ankle joint bend
2.Tight calf group
3.Weak butt muscles
OPPOSITE SIDE LEG :
1- Lack of ankle bend or tight calf muscle group
2- Limited hip extension
3- Painful or limited big toe extension
TRUNK / CORE
1- Loss of upper back motion
2- Insufficient upper back motion can result
in ineffective loading of the core muscles
3- Neck Muscle fatigue/ tightness
30. The Proximal Third of the central bundle of the PF is classically involved; however, distal plantar fasciitis has recently been
recognised as a cause of recalcitrant heel pain
Uncooperative attitude toward discipline
31. Diagnosis :
The diagnosis of plantar fasciitis generally relies on clinical history and physical examination.
The main symptoms include pain and stiffness in the morning, or pain at the beginning of activity after rest.
Post
Static Dyskinesia
Physical examination
It reveals tenderness at the origin of the PF and impaired dorsiflexion of the ankle and extension
of the toes .
32. Imaging
can aid in the diagnosis, particularly in recalcitrant cases or may rule out other heel pathology
Diagnosis :
Generally self-limiting,
But : It may result in physical inactivity and impact quality of life
33. On MRI, the normal PF (arrows) is seen as a thin band of low signal intensity on both T1-
weighted (d)
and fluid-sensitive (e) images
Normal plantar fascia.
A schematic representation (a)
lateral plain radiograph (b) show the normal PF (arrows).
On sagittal ultrasound scan, the normal PF (arrows) appears as a fibrillar ligamentous structure (c).
34. Plantar fasciitis.
Lateral plain radiograph highlights an increase in the
distance between subcutaneous fat and intrinsic
muscles of the foot at the calcaneal insertion of the PF
as an indirect sign of plantar fasciitis (double-head
arrow); calcific enthesopathy of the Achilles tendon is
Achilles tendon is also seen (open arrow) (a).
On ultrasound, plantar fasciitis presents with PF
thickening (dashed line, 6.5 mm), a hypoechoic
appearance and loss of fibrillar pattern (b).
MRI confirms thickening of the PF at its calcaneal
origin (double-head arrow) with intrasubstance areas
of intermediate and high signal intensity on T1-
weighted (c)
and fluid-sensitive (d) images, respectively
35. MRI confirms the presence of a calcaneal spur
(arrow) and PF thickening at its calcaneal
attachment (double-head arrow) (b).
Bone marrow oedema in the calcaneal spur (arrow)
is demonstrated on the fluid-sensitive image (c)
Plantar fasciitis.
Lateral plain radiograph shows PF
thickening (double-head arrow) and
fine calcifications at the calcaneal
insertion of the PF (arrowhead); a
plantar calcaneal spur at the origin of
intrinsic muscles of the foot (arrow) and
calcific enthesopathy of the Achilles
tendon (open arrow) are also evident
(a).
36. It is a benign nodular formation due to fibroblastic proliferation in the PF.
It tends to involve the distal 2/3 of the PF, usually in its central bundle, although proximal nodules are not uncommon.
Nodular lesions may be multiple and bilateral and typically measure < 3 cm
Plantar fibromatosis or Ledderhose disease
Frequently : isolated disease, but may associate
Dupuytren’s disease
Clinically, plantar fibroma appears as a firm thickening or a
single nodule, generally localised in the medial portion of the
sole, which is occasionally painful
37.
38. MRI shows a fusiform
thickening (arrows) in
the distal portion of the
PF with low signal
intensity on both T1-
weighted (a) and fluid-
sensitive images (b).
On ultrasound, a well-
demarcated, hypoechoic
nodule is demonstrated
(c) with no increased
internal vascularity (d)
Ledderhose disease.
39. Tears of the PF
They are uncommon and can be Partial or Complete.
Traumatic Tears are often related to forcible plantar flexion of the foot in competitive athletes, mostly runners and jumpers; these are typically
distal to calcaneal insertion of the PF and chronic overuse is considered an aetiological factor
Spontaneous Ruptures may occur at the calcaneal attachment of the PF in patients with previous history of plantar fasciitis and local
treatment with
GCs injections
Clinical presentation includes :
Acute pain, usually accompanied by a “Snap”
noise, and Local Swelling
40. Plantar Fascia Rupture.
On ultrasound, a tear in the PF (arrow) is shown; the PF is hypoechoic and thickened as a result of previous
plantar fasciitis treated with local injections (a).
MRI confirms PF rupture (arrow) and highlights marked oedema of soft tissues (b)
41. Xanthomas
They are described in many hyperlipidaemia states;
They typically involve tendons and are occasionally located within the PF.
They are usually asymptomatic and tend to recur after surgical removal
42. Plantar xanthoma.
On both sagittal T1-weighted (a) and fluid-sensitive (b) images, xanthoma (arrows) appears as fusiform enlargement of the PF and shows
heterogeneous signal intensity
47. It is a Calcium deposit causing a bony protrusion
on the underside of the heel bone.
On an X-ray, a heel spur can extend forward by
as much as a half-inch.
Without visible X-ray evidence, the condition is
sometimes known as
Heel Spur Syndrome
Heel Spur
48. Although Heel Spurs are often Painless,
they can cause heel pain.
They are frequently associated with plantar fasciitis,
Causes of Heel Spurs
Heel spurs occur when calcium deposits build up on the underside of the heel bone, a process that usually occurs over a period
of many months.
Heel spurs are especially common among athletes whose activities include large amounts of running
and jumping.
Heel spurs are often caused by :
Strains on foot muscles and ligaments,
Stretching of the plantar fascia, and
Repeated tearing of the membrane that covers the heel bone.
50. Bursae around the ankle
Tendoachilles
Subachillial / Retrocalcaneal
Retroachillial
Subcalcaneal
51. Plantar Bursitis
What Causes Plantar Bursitis ?
Overuse injury
Some people may Walk and Run with excessive heel strike
Others may have a Heel Spur creating extra pressure to the fat pad
Other people may have a thin fat pad.
52. • Minimal to No pain with first steps
in the morning or after sitting
• Pain worsens prolonged Standing
• Bruised or Swollen Feeling on the bottom of the heel
• Redness to the bottom of the heel
• Pain is worse barefoot or with heeled shoes
What are the Symptoms of Plantar Bursitis?
53. •Rest
•Ice massage
•Anti-inflammatory medicines like ibuprofen, naproxen or aspirin
•Horsheshoe shaped heel pads
•Cortisone injections
•Accommodative shoe inserts
•Rarely surgery is needed to excise the bursa or remove an associated heel spur
How is Plantar Bursitis treated?
55. Anatomy:
Honeycombed pattern of fibroelastic septa
These spaces are enclosed and contain fat globules
The tissue septa form in a U-shape and attach to the calcaneus & skin
Elastic transverse and diagonal fibers help reinforce the chambers
internally
The fat pad provides cushion to the hindfoot while keeping
mechanical integrity for its shock absorption
The force and impact that our feet absorb when we walk is 2.5 times the weight
of our body.
When you run or jump, that impact increases even more!
56. What Is Heel Fat Pad Syndrome?
It develops when the entire fat pad, or smaller sections of the heel fat pad, become thin and damaged.
In HFPS : the HFA failed to absorb & redistribute force & impact : with resultant dysfunction
57. . Increased age due to fat pad deterioration
• Obesity and subsequent increased pressure
• Genetics
• Steroid injections
• Prolonged standing or walking on hard surfaces
with inappropriate footwear
• Excessive heel strike with poor footwear
Risk Factors:
58. Improper Gait
If : overpronate or underpronate while walk or run,
Plantar Fasciitis
As the arch of the foot breaks down and struggles to absorb and distribute impact, the fat pad of the heel can be strained, worn, and injured much
more quickly than usual.
Inflammation of the Fat Pad
After repeated, forceful, and prolonged activity, like jumping during basketball or gymnastics.
Fat Pad Displaced or Thinned
exposing the heel bone and causing a bruised feeling.
Force or Walking on Hard Surfaces
Walking or running on hard surfaces while barefoot can quickly lead to a thinning, strained heel fat pad or bruising to the heel bone.
Common Causes of Heel Fat Pad Syndrome
59. • Pain that is a little duller (more like a bruise), and felt closer to the middle of heel
• Pain by pressing finger into the middle of heel pad
• Pain that is made worse when walk on hard surfaces
Both plantar fasciitis and heel fat pad syndrome are made worse by weight gain and as we age.
Heel Fat Pad Syndrome
The hallmark symptoms of heel fat pad syndrome are a little different:
60. Tests
Palpation of the fat pad
•softened and flattened surface
Observation
•erythema and inflammation over plantar aspect of the heel
Diagnostic Imaging (Ultrasound or MRI)
•Decreased thickness and height of fat pad
Diagnosis/Classification:
Central pain of the heel
• Deep, non-radiating pain at the weight bearing portion of the calcaneus
• Symptoms worsen with walking barefoot or on hard surfaces
• Symptoms are relieved in the absence of heel pressure
• Tenderness over the calcaneal tuberosity
• Swelling can be present
• Pain does not occur with passive motion of the ankle or toes
• History of trauma to the plantar surface of the calcaneus
(hard fall or jump landing on the heel)
61. Calcaneal Fat Pad Atrophy
The overall thickness and height of the fat pad decrease
•Each heel strike generates force equal to 110% of the body weight
•During running, heel strike can generate force equal to 250% of the
body weight
Overview:
After approximately age 40,
the fat pad begins to deteriorate
- Loss of collagen
- Decreased elastic tissue
- Decreased water concentration
62. Long Term Effects of Fat Pad Deterioration
Foot Fat Pad of a 20 Year Old
Adult
Foot Fat Pad of a 60 Year Old
Adult
63. Bruised Heel (Fat Pad Contusion)
Because the calcaneus is the largest bone in the foot and the primary weight bearing bone, it is subject to injury.
• Excessive body weight
• Age
• Poorly cushioned or worn-out running shoes
• Increases in training
• Hard, uneven training surfaces
• Walking or training barefoot
What causes a bruised heel?
A heel bruise can be caused by a one-time incident of the athlete landing on his/her heel from a height (or in poor shoes) or from repetitive trauma over time (running on
the beach without shoes).
64. Sometimes heel fat pad syndrome can be mistaken for plantar fasciitis. And while it’s true that many people have plantar fasciitis and heel fat pad syndrome at the
same time, it’s helpful to understand the difference between the two conditions:
Plantar Fasciitis
Plantar fasciitis (or plantar fasciosis) is caused by damage or deterioration to the arch of the foot, the fibrous band of tissue that runs between your heel and the ball
of your foot.
Healthy arch acts as a spring, absorbing and distributing the impact of physical activity properly. However, a flat, damaged, or overused arch begins to break down–
which can lead to HFPS as the heel fat pad sustains more wear and impact. Heel spurs, which may develop as the body tries to prop up the damaged arch, can also
dig into the fat pad of the heel and cause pain.
The hallmark symptoms of plantar fasciitis include the following:
•Pain that’s most severe toward the front of the heel (closer to the toes) and instep
•Sharp pain or dull, aching pain that is usually worse in the morning
•Pain that improves with rest and stretching
Plantar Fasciitis Vs. Heel Fat Pad Syndrome
65. Plantar Fat Pads
Where do many everyday foot aches and pains come from?
Research shows that the fat pads on the bottom of our feet get thinner with time and activity, and gradually lose their protective properties. Research
further shows that by age 50, many people—especially if they’re active—have lost half the fatty padding under the balls and heels of their feet.
Thorlos clinically-tested padding provides dense cushioned support to help make up for this natural loss of fat pads. Padding is positioned in exactly the
right anatomical places to provide protection for the ball and heel so your feet feel well cushioned and comfortable. Many wearers report their feet feel
years younger when wearing Thorlos clinically-tested padded socks that have been fitted properly with their shoes.
66. We destroy our Fat Pads by walking and running on hard surfaces without adequate protection.
1) This loss of fat pads is due primarily to damage from shearing forces from waling and running on smooth
unyielding man-made surfaces such as concrete, asphalt, and even hardwood flooring.
2) The damage is compounded by poorly designed, poorly fitted socks and shoes.
3) Thorlos protect the fat pads of your feet from shear forces by transferring these forces from the inner
tissues of your feet to the cushion fabrics of your socks. And, where degredation of fatty tissue has already
occurred, Thorlos engineering will help replace the function of the natural fat pads.
4) Proper protection is the best source of your comfort.
69. It is a small, accessory bone that forms at the back of the foot behind the ankle joint.
The talus bone forms part of the ankle joint.
As the talus grows during childhood, a small piece of bone develops just behind it, known as the Os Trigonum.
This usually happens around the ages of seven to eleven.
Os Trigonum is a small, extra bone at the back of the heel
This small bone is initially joined to the talus by fibrous structures and within one to three years, usually fuses i.e. joins with the talus bone forming part of the lateral tubercle, a
small lump on the talus.
However, sometimes it fails to join the talus and remains a separate piece of bone.
It is usually small, less than one centimetre, and varies in shape from round to oval to triangular.
Usually, if the bone fails to fuse it doesn’t cause any problems, but if the ankle is injured, either through a specific incident or recurrent trauma, Os Trigonum Syndrome can
develop.
It is also known as posterior talar impingement.
What Is Os Trigonum?
70. When the presence of the unfused bone is combined with an ankle injury,
Os Trigonum Syndrome can develop.
It is usually caused by either:
Ballet dancers
Over-Use: from repeated plantarflexion (foot pointing downwards).
Os Trigonum Syndrome commonly affects ballet dancers, runners and football players
Trauma: an ankle injury where the foot is forced into excessive plantarflexion
Either of these can cause what is known as a “nutcracker injury”, where the unfused Os
There is no specific age or gender that is more susceptible to Os Trigonum Syndrome, it is purely related to activity.
What Causes Os Trigonum Syndrome?
77. Sever’s Disease
Sever’s disease occurs in children when the growth plate (which is the growing part of the heel) is injured.
The foot is one of the first body parts to grow to full size. This usually occurs in early puberty.
During this time, bones often grow faster than muscles and tendons. As a result, muscles and tendons become tight.
The heel area is less flexible. During weight-bearing activity (activity performed while standing), the tight heel tendons may put too much pressure
at the back of the heel (where the Achilles tendon attaches).
This can injure the heel and cause Sever’s disease.
78.
79. Young athletes typically sustain the injury due to repeated stress caused by
running and jumping. Partaking in any high speed sports can thus partly
provoke the condition, such as football, rugby, basketball, hockey or track
athletics.
84. It is a type of calcaneal fracture.
They are fractures of the calcaneal body and may be
intra- or extra-articular.
History and etymology
The name "lover's fracture" is derived from the fact that
a suitor may jump from great heights while trying to
escape from the lover's spouse 2.
Lover’s Fracture :
also known as Don Juan fracture,
There is an important association between lover's fractures and burst fractures of the lumbar
spine.
93. Lateral Heel Radiograph
showing the Spur Length.
(a) Oblique line demarcating the calcaneal
border.
(b) (b) Horizontal line from the tip of the
spur to the calcaneal..
94. (A) Weight-bearing lateral view of foot and
(B) (B) method of obtaining weight-bearing lateral view of foot
Both PA (dorsoplantar) and lateral views of the foot are required to assess alignment.
The importance of obtaining FULL weight-bearing views cannot be overly emphasized.
The non-weight bearing position may mask significant abnormalities that only manifest in the position of function, and measurements will therefore be totally invalid.
Full weight-bearing AP and lateral views in the natural base and angle of stance, have been shown to closely approximate the position of dynamic gait (1).
95. Effect of weight bearing.
Non–weight-bearing (A) and weight- bearing (B)
lateral views of the ankle show the value of functional loading.
97. The heel pad thickness was measured on the non-weight bearing foot lateral plain radiograph from the lowest point
of the calcaneal tuberosity to the plantar surface
Heel pad thickness was measured from medial calcaneal
tuberosity of calcaneus to the boundary between superficial
fat pad and dermis on sagittal T2-weighted MRI
Heel Pad Thickness
98. Non weight-bearing :
Normal alignment
Simulated weight-bearing :
Mild pes planus (flatfoot)
Full weight-bearing :
Severe pes planus
Pes Planus
Effect of weight Bearing on Foot Alignment
99. Full weight-bearing.
The tibia is perpendicular to the floor.
Partial weight-bearing.
Note that the tibia is angled relative to the floor.
Partial weight-bearing.
Note that the tibia is angled relative to the floor.
Lateral views of the same patient with different degrees of weight bearing.
The true extent of the alignment abnormality is revealed only on the FULL weight-bearing view.
Often when patients have a painful extremity almost 70-80% of their body weight is placed on the Less Painful Side.
Therefore, full weight should be placed only on the affected leg.
One radiographic clue that a lateral view is not fully weight-bearing is that the tibia is < vertical.
Foot Alignment with Painful Limb & full Weight Bearing
101. A. Kager's triangle with a normal appearance.
B. The triangular lucency with sharp, smoothly curving borders is indicated with the dotted line.
C. The arrowhead indicates the retrocalcaneal recess : the “bursal wedge” of Kager's fat pad, which normally forms a radiolucent corner posterosuperior to the calcaneus.
102. A patient with a chronic retrocalcaneal bursitis. The retrocalcaneal
recess has disappeared because of the less radiolucent fluid in the
distended retrocalcaneal bursa.
103. Lateral conventional radiograph of a normal ankle demonstrating a well-defined
anterior margin of the Achilles tendon (arrowheads), the pre-Achilles/Kager’s
fat pad (*), and the retrocalcaneal bursal recess (solid arrow).
105. Reiter's disease –
At the calcaneus, erosions, fluffy periostitis
Erosions, fluffy periostitis, and soft tissue swelling are visible in up to 50%
of patients at the Achilles and plantar insertions
106. Lateral radiograph of the right foot showing a prominent posterosuperior osseous calcaneal protuberance (arrow), loss of lucency in the retrocalcaneal recess
suggesting retrocalcaneal bursitis (*), convex superficial soft tissue swelling at the insertion of the Achilles tendon (curved arrow) and ossification in the thickened
Achilles tendon (arrow heads) .
107. If you exclude the previously mentioned causes of Heel Pain
Therefore ,there is great possibility of Heel Soreness
( One of the prodromes pf Gout )
