P A I G E F A B R E1 3 6 5 4 5 8 4

CASE STUDY – FIBROMATOSIS

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 IMAGESX- RAY I M AG E S W E R E P E R F O R M E D B E F O R E T H E U LT RA S O U N D

T H E A B O V E I M A G E W A S P E R F O R M E D O N A C R S Y S T E M W I T H T H E A N K L E A N D F O O T I N E X T E R N A L R O T A T I O N .

IMAGE 1: LATERAL IMAGE OF THE RIGHT HEEL IMAGE

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.

I M A G E S O F T H E R O O M P R E PA R AT I O N A S D E S C R I B E D P R E V I O U S LY

IMAGE 2: ROOM PREPARATION

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

C A L L I P E R S A R E P L A C E D O N T H E I M A G E T O I N D I C A T E T H E T H I C K N E S S O F T H E P L A N T A R F A S C I A . N O T E T H E T H I C K N E S S O F T H E H E E L I N T H I S R E G I O N .

IMAGE 3: LONGITUDINAL IMAGE OF THE PROXIMAL INSERTION OF THE PLANTAR FASCIA

D E M O N S T R A T I O N O F T H E P L A N T A R FA S C I A A S I T C O N T I N U E S T O T H E D I S T A L P O R T I O N O F T H E F O O T.

IMAGE 4: LONGITUDINAL IMAGE OF THE PLANTAR FASCIA DISTAL TO IMAGE 3

N O T E T H E M O R E S U P E R F I C I A L N A T U R E O F T H E P L A N T A R F A S C I A A S I T T R A V E L S M O R E D I S T A L LY.

IMAGE 5: LONGITUDINAL IMAGE OF THE PLANTAR FASCIA DISTAL TO IMAGE 4

T H I S P O R T I O N I S A G A I N M O R E S U P E R F I C I A L I N N A T U R E T O T H E P R O X I M A L P O R T I O N . N O T E T H E F L E X O R D I G I T O R U M B R E V I S M U S C L E D E E P T O T H E P L A N T A R F A S C I A .

IMAGE 6: LONGITUDINAL IMAGE OF THE PLANTAR FASCIA MORE DISTALLY TO IMAGE 5

T H E T H I C K N E SS O F T H E H E E L I S AG A I N N O T E D .

IMAGE 7: TRANSVERSE IMAGE OF THE PROXIMAL INSERTION OF THE PLANTAR FASCIA

T H E T H I C K N E S S O F T H E P L A N T A R FA S C I A I S A G A I N D E M O N S T R A T E D W I T H C A L L I P E R S .

IMAGE 8: LONGITUDINAL IMAGE OF THE PLANTAR FASCIA MORE DISTAL TO IMAGE 7.

T H E T H I C K N E S S O F T H E H E E L I S S T I L L S E E N P R O M I N E N T LY I N T H I S A R E A .

IMAGE 9: A MORE DISTAL IMAGE OF THE PLANTAR FASCIA IN TRANSVERSE AFTER THE REGION OF INCREASED THICKNESS

T H E S U P E R F I C I A L N AT U R E O F T H I S P O RT I O N I S A G A I N N O T E D .

IMAGE 10: TRANSVERSE IMAGE OF THE PLANTAR FASCIA, AGAIN MORE DISTALLY

T H E T H I N N I N G O F T H E P L A N TA R FA S C I A I S AG A I N SE E N

IMAGE 11: A TRANSVERSE IMAGE OF THE PLANTAR FASCIA MORE DISTALLY THAN IMAGE 10

C A L L I P E R S A R E U S E D T O M E A S U R E T H E T H I C K N E S S O F T H I S R E G I O N O F I N C R E A S E D T H I C K N E S S A N D D E C R E A S E E C H O G E N I C I T Y

IMAGE 12: LONGITUDINAL IMAGE OF THE LATERAL PORTION OF THE PLANTAR FASCIA 10CM DISTAL TO THE INSERTION

C A L L I P E R S I N D I C AT E A L E N GT H O F 4 4 M M

IMAGE 13: TRAPEZOID VIEW IS UTILISED TO DEMONSTRATE THE LENGTH OF THE AREA SEEN IN IMAGE 12

N O I N C R E A SE D F LO W I S N O T E D I N T H I S I M AG E

IMAGE 14: COLOUR DOPPLER IMAGING IS USED LOOK FOR AN INCREASE IN FLOW IN THE ROI IN TRANSVERSE

T H E S T R U C T U R E I S S E E N H Y P O E C H O I C T O T H E S U R R O U N D I N G T I S S U E .

IMAGE 15: IMAGE IN TRANSVERSE OF THE ROI

T H E H Y P O E C H O I C N A T U R E O F T H E S T R U C T U R E I S A G A I N N O T E D W I T H T H E P O S S I B I L I T Y O F T R A C E F L U I D S E E N A D J A C E N T T O T H E S T R U C T U R E .

IMAGE 16: FURTHER TRANSVERSE IMAGES OF THE ROI

SO N O G RA P H I C F E AT U R E S A R E S E E N S I M I L A R T O I M AG E 1 6

IMAGE 17: MORE DISTAL IMAGE IN TRANS OF THE ROI

S I D E B E S I D E C O M P A R I S O N O F R I G H T A N D L E F T H E E L S / C A L L I P E R S A R E U S E D T O D I S P L A Y T H E I N C R E A S E D T H I C K N E S S O F T H E R I G H T P L A N T A R F A S C I A J U S T D I S T A L T O T H E I N S E R T I O N . T H E R I G H T

P L A N T A R F A S C I A A P P E A R S M O R E T H A N D O U B L E T H A T O F T H E L E F T .

IMAGE 18: COMPARATIVE IMAGING OF THE PLANTAR FASCIA

T H O U G H T H E R E I S S L I G H T LY B E T T E R R E S O L U T I O N O F F I B R E S , T H E P R O B E A P P E A R S T O B E A T I T ’ S L I M I T A T I O N O F P E N E T R A T I O N

IMAGE 19: AN ATTEMPT IS MADE TO BETTER VISUALISE THE PLANTAR FASCIA FIBRES USING A HIGHER FREQUENCY TRANSDUCER

S I M I L A R I M AG E F I N D I N G S A R E N O T E D

IMAGE 19: A TRANSVERSE IMAGE WAS ALSO ATTEMPTED

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 FINDINGST H E R A D I O L O G I S T W A S S AT I S F I E D W I T H T H E I M A G E S A N D I N F O R M AT I O N

P R O V I D E D A N D D I D N O T F E E L T H E N E E D T O P E R S O N A L LY S C A N T H E P AT I E N 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)

REFLECTIONWHAT COULD HAVE BEEN DONE BETTER

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.