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Watch your step: Painful conditions of the plantar region of
the foot
Poster No.:
C-640
Congress:
ECR 2009
Type:
Educational Exhibit
Topic:
Musculoskeletal
Authors:
F. C. Miranda, R. D. Carneiro, L. A. Rosemberg, C. H. Longo, H.
P. Guidorizzi, R. Y. Fernandes, D. C. B. Santos, N. J. T. Kim, M. B.
G. Funari; São Paulo/BR
Keywords:
MRI, foot, Plantar Pain
DOI:
10.1594/ecr2009/C-640
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Page 1 of 57
Learning objectives
• Review the anatomy of the plantar compartment of the foot.
• Describe the imaging findings of painful conditions arising from or extending
into the plantar region of the foot.
Background
Pain in the plantar region of the foot is a symptom with high prevalence,
specially in athletes and runners. It can be caused by numerous entities
(inflammatory, vascular, cancer, trauma, among others) that can be
evaluated by different imaging methods, from radiography to magnetic
resonance imaging (MRI), which has excellent contrast resolution and
multiplanar capacity.
Imaging findings OR Procedure details
Plantar Anatomy
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Fig.: 1: Distal Phalanges2: Middle Phalanges3: Proximal Phalanges4: Metatarsal
Bones5: Medial Cuneiform Bone6: Intermediate Cuneiform Bone7: Lateral Cuneiform
Bone8: Cuboid9: Navicular10: Talus11: Calcaneus
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Fig.: The plantar region is divided in four layers from superficial to deep:First
layer: abductor hallucis, flexor digitorum brevis, abductor digit minimiSecond layer:
quadratus plantae, lumbricals, flexor digitorum longus tendons, flexor hallucis longus
tendonsThird layer: flexor hallucis brevis, adductor hallucis, flexor digiti minimi
brevisFourth layer: interossei plantaris, the peroneus longus tendon, tibialis posterior
tendon1: Abductor hallucis muscle, 2: flexor hallucis brevis muscle, 3: flexor hallucis
longus tendon, 4: flexor digitorum longus tendon, 5: quadratus plantae muscle, 6: flexor
digitorum brevis muscle, 7: lumbrical muscles and the tendons of the flexor digitorum
longus and brevis, 8: flexor digiti minimi muscle, 9: abductor digiti minimi muscle, 10:
adductor hallucis muscle.
Fig.: The plantar fascia consists of a central aponeurosis, lateral and medial
components:C = CalcaneusDB = Digital BandsCC = Central ComponentLC = Lateral
ComponentMC = Medial Component
Sesamoiditis
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Painful inflammatory condition.
Caused by repetitive injury to the plantar aspect of the foot.
MR imaging findings include decreased or normal signal intensity on T1W and
increased signal intensity on STIR / T2W Fat Sat images.
The findings are similar to those caused by a stress response, existing some overlap
between these conditions.
Involvement of both sesamoid bones favors a diagnosis of sesamoiditis.
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Fig.: Medial sesamoid marrow is hypointense on coronal T1W image and
hyperintense on coronal T2W Fat Sat image. Note the adjacent soft-tissue edema.
Bone marrow and adjacent soft-tissue enhancement.
Morton's Neuroma
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More often in middle-aged woman.
Perineural fibrosis.
Pain at the base of the web space radiating to the toes. Worsened by wearing shoes
and walking.
Most common site is the third web space.
Low to intermediate signal on T1W and T2W.
Late enhancement.
Fig.: Drawing of a coronal view of the inferior and superior intermetatarsal spaces. 1: Deep
Transverse Metatarsal Ligament, 2: Neurovascular bundle, Metatarsal heads 1-5 (M1-M5)
Page 5 of 57
Fig.: Teardrop-shaped Morton's neuroma - iso-signal on T2W Fat Sat and hyposignal
on T1W - between the third and fourth metatarsal head, with enhancement.
Bursitis
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Inflammatory process of the intermetatarsal bursae between the metatarsal heads.
Caused by trauma, infection, inflammatory and rheumatogic diseases.
On MRI it is important to identify the liquid collection (hypersignal on T2W/STIR
and hyposignal on T1W) and peripheral enhancement.
Fig.: The intermetatarsal bursae is located on the dorsal compartment of the foot,
above the deep transverse metatarsal ligament, differentiating from the diagnosis of
Morton´s neuroma, which is located in the plantar compartment.
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Fig.: Hour-glass distended intermetatarsal bursae between the third and fourth
metatarsal heads - hypersignal on T2W Fat Sat, hyposignal on T1W and peripheral
enhancement.
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Fig.: Hour-glass distended intermetatarsal bursae between the third and fourth
metatarsal heads - hypersignal on T2W, hyposignal on T1W and peripheral
enhancement. Exceptionally this inflamed bursae extends below deep transverse
metatarsal ligament.
Plantar Vein Thrombophlebitis
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Uncommon condition of unknown origin.
Related to previous surgery, trauma, paraneoplasic conditions and hypercoagulative
states.
May mimic plantar fasciitis.
Symptoms include sudden pain in the plantar region with soft-tissue edema. Pain is
located on the course of the main plantar veins.
Imaging findings include: dilated vessel, peri-venular edema, post-gadolinium
intraluminal defect.
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Fig.: 1. Lateral plantar veins and artery2. Medial plantar veins and artery3. Plantar
metatarsal veins and artery4. Digital proper veins and artery5. Hallux Digital proper
veins and artery
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Fig.: Dilated medial plantar vein with intraluminal defect as showed on T1W Gd
in different planes. On T2W the perivenular edema (hypersignal) is well seen. No
significant signal on T1W.
Fat Pad Necrosis
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Follows fat signal intensity on all sequences similar to lipoma.
May contain fibrosis and septations suggesting an atypical lipoma or liposarcoma.
Predominantly located over presure points or bony protuberances in the body.
Page 12 of 57
Fig.: Focal obliteration of the medial plantar fat pad with heterogeneous hypersignal
on T2W, hyposignal on T1WI with anelar / heterogeneuous enhancement.
Plantar Fasciitis
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Most common cause of heel pain.
Low-grade inflammatory disorder of the fascia.
In most cases results from increased load.
May be a part of systemic disorders: rheumatoid arthritis, seronegative
spondyloarthropathies and gout.
Most frequently affects the origin of the plantar fascia from the calcaneal tuberosity.
Intermediate to high signal in the normally low signal plantar fascia.
Most commonly involves the medial band plantar fascia near the calcaneal
attachment.
May have reactive edema in the calcaneus and surrounding soft tissue edema.
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Fig.: Thickening and increased signal in the central component of the plantar fascia
with surrounding soft tissue edema and marrow edema in the calcaneal origin.
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Fig.: Medial view of the right foot (sagital) revealing inflammation of the plantar fascia.
Plantar Fibromatosis
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Most frequently between the ages of 30 and 50 years.
Bilateral involvement in 40%.
Concomitant palmar fibromatosis in 35%.
Affects most commonly the medial component of the plantar aponeurosis
Manifests as one or multiple firm, fixed, fascial nodules.
MRI findings include a poorly defined, infiltrative mass with heterogeneous signal
intensity equal to or less that of skeletal muscle on T1W and T2W.
Fig.: Nodule with intermediate signal on all sequences arising from the mid-third of the
plantar fascia. The mass shows little enhancement.
Page 17 of 57
Fig.: Nodule with intermediate signal on all sequences arising from the distal-third of
the plantar fascia.
Fascial Rupture
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Usually located at the posterior insertion of the fascia.
Most often observed in patientes who have sustained forceful plantar flexion.
Fig.: Retracted plantar fascia with discontinuity of its calcaneal insertion.
Avascular necrosis
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Bone death due to ischemia.
Can be classified as obstructive, compressive or physical disruption (trauma) of
vessels.
Most commonly occurs during the second decade of life.
Female predominance.
MRI findings include hypointense signal of subchondral sclerosis on T1W and
hyperintensity on T2W / STIR.
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Fig.: T1W hyposignal and T2W hypersignal geographic line delineating a fragment
of avascular necrosis in the head of the first metatarsal. There is linear enhancement
concordant with granulation tissue around necrosis.
Trauma: Stress Fracture
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In the metatarsal bones are common in runners, ballet dancers, gymnasts, millitary
recruts and in the occasional tourist.
The middle or distal portion of the second, third and fourth metatarsal shafts are
most often involved.
Radiographs, CT may be negative.
MR shows soft tissue and marrow edema +/- fracture line.
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Fig.: Mid-third medial cortical thickening of the second metatarsal associated with
marrow edema (T2W hypersignal) and periosteal reaction around the bone ( well seen
on post-contrast).
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Fig.: Incomplete fracture line (T1W linear hyposignal) in the base of the fifth metatarsal
with marrow edema ( T2W hypersignal and T1W hyposignal). Adjacent soft tissue
edema.
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Fig.: Transverse fracture line (T1W linear hyposignal) in the mid-third of cuboid with
marrow edema ( T2W hypersignal and T1W hyposignal) and adjacent soft tissue
edema.
Fig.: Transverse fracture line (T1W linear hyposignal) in the anterior process of
calcaneous with marrow edema (T2W hypersignal and T1W hyposignal).
Tenosynovitis
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Inflammation of the tendon and tendon sheath.
May be caused by inflammatory disease, infection or mechanical irritation.
MRI findings include fluid in the tendon sheath and synovial thickening. Contrast
enhancement of the synovia typically occurs.
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Fig.: Subtle hypersignal on T2W and hyposignal on T1W in the flexor tendon of the
halux. Liquid (T2W hypersignal) within the tendon sheath. On post-contrast images
there is significant enhancement of tendon sheath.
Ganglionic Cyst
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Cystic lesions filled with gelatinous fluid.
Can be multiloculated and may have a narrow communication or neck with an
adjacent joint or tendon sheath.
Appear well defined on MRI. Hypointense on T1W and hyperintense on T2W. No
internal enhancement is observed.
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Fig.
Acute Osteomyelitis
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Acute inflammatory process of the bone secondary to infection with pyogenic
organisms.
Staphylococcus aureus is the most common bacteria involved.
On MRI, evidence of marrow edema and, with the use of gadolinium, hyperemia, in
a infected bone can be shown within 24-48 hours of symptom onset.
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Fig.: Coronal T2W Fat Sat shows marrow edema in the base of the third metatarsal,
associated with a collection between the flexor tendons. The collection is well
demarcated on T1W Gd on the coronal and axial planes, as well as on the T2W sagital
images.
Tumors: Hemangioma
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Benign lesions classified as capillary, cavernous, or venous vascular proliferations.
May occur in patients from 20 to 60 years of age.
Lobulated mass with fatty septae.
Phleboliths and fluid-fluid levels.
Variable in MR appearance and may demonstrate low, intermediate, or high signal
intensity on T1W. There is usually some increase in signal intensity on T2W or
STIR sequences.
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Fig.: Expansive lesion with predominantly hypersignal on T2W and hyposignal on
T1W. Located in the deep plantar musculature.
Calcinosis Cutis
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Calcium deposits in the skin due to local and/or systemic factors.
Solitary or multiple painless, periarticular masses.
Classified into 4 major types according to etiology: dystrophic, metastatic,
iatrogenic and idiopathic.
MRI findings include heterogeneous hypersignal on T2W and heterogeneous
hyposignal on T1W.
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Fig.: T1W, T2W and T1W Gd in the axial plane demonstrate an expansive lobulated
lesion with marked hyposignal and mainly peripheral heterogeneous enhancement.
Fig.: T1W shows the lesion around the fifth metatarsal bone, which is intact.
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Fig.: On the X-ray: solid calcified matrix of the lesion.
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Images for this section:
Fig. 1: 1: Distal Phalanges2: Middle Phalanges3: Proximal Phalanges4: Metatarsal
Bones5: Medial Cuneiform Bone6: Intermediate Cuneiform Bone7: Lateral Cuneiform
Bone8: Cuboid9: Navicular10: Talus11: Calcaneus
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Fig. 2: The plantar region is divided in four layers from superficial to deep:First layer:
abductor hallucis, flexor digitorum brevis, abductor digit minimiSecond layer: quadratus
plantae, lumbricals, flexor digitorum longus tendons, flexor hallucis longus tendonsThird
layer: flexor hallucis brevis, adductor hallucis, flexor digiti minimi brevisFourth layer:
interossei plantaris, the peroneus longus tendon, tibialis posterior tendon1: Abductor
hallucis muscle, 2: flexor hallucis brevis muscle, 3: flexor hallucis longus tendon, 4: flexor
digitorum longus tendon, 5: quadratus plantae muscle, 6: flexor digitorum brevis muscle,
7: lumbrical muscles and the tendons of the flexor digitorum longus and brevis, 8: flexor
digiti minimi muscle, 9: abductor digiti minimi muscle, 10: adductor hallucis muscle.
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Fig. 3: The plantar fascia consists of a central aponeurosis, lateral and medial
components:C = CalcaneusDB = Digital BandsCC = Central ComponentLC = Lateral
ComponentMC = Medial Component
Fig. 4: Medial sesamoid marrow is hypointense on coronal T1W image and hyperintense
on coronal T2W Fat Sat image. Note the adjacent soft-tissue edema. Bone marrow and
adjacent soft-tissue enhancement.
Fig. 5: Drawing of a coronal view of the inferior and superior intermetatarsal spaces. 1:
Deep Transverse Metatarsal Ligament, 2: Neurovascular bundle, Metatarsal heads 1-5
(M1-M5)
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Fig. 6: Teardrop-shaped Morton's neuroma - iso-signal on T2W Fat Sat and hyposignal
on T1W - between the third and fourth metatarsal head, with enhancement.
Fig. 7: The intermetatarsal bursae is located on the dorsal compartment of the foot, above
the deep transverse metatarsal ligament, differentiating from the diagnosis of Morton´s
neuroma, which is located in the plantar compartment.
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Fig. 8: Hour-glass distended intermetatarsal bursae between the third and fourth
metatarsal heads - hypersignal on T2W Fat Sat, hyposignal on T1W and peripheral
enhancement.
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Fig. 9: Hour-glass distended intermetatarsal bursae between the third and fourth
metatarsal heads - hypersignal on T2W, hyposignal on T1W and peripheral
enhancement. Exceptionally this inflamed bursae extends below deep transverse
metatarsal ligament.
Fig. 10: 1. Lateral plantar veins and artery2. Medial plantar veins and artery3. Plantar
metatarsal veins and artery4. Digital proper veins and artery5. Hallux Digital proper veins
and artery
Page 37 of 57
Fig. 11: Dilated medial plantar vein with intraluminal defect as showed on T1W Gd in
different planes. On T2W the perivenular edema (hypersignal) is well seen. No significant
signal on T1W.
Page 38 of 57
Fig. 12: Focal obliteration of the medial plantar fat pad with heterogeneous hypersignal
on T2W, hyposignal on T1WI with anelar / heterogeneuous enhancement.
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Fig. 13: Thickening and increased signal in the central component of the plantar fascia
with surrounding soft tissue edema and marrow edema in the calcaneal origin.
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Fig. 14: Medial view of the right foot (sagital) revealing inflammation of the plantar fascia.
Fig. 15: Nodule with intermediate signal on all sequences arising from the mid-third of
the plantar fascia. The mass shows little enhancement.
Fig. 16: Nodule with intermediate signal on all sequences arising from the distal-third of
the plantar fascia.
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Fig. 17: Retracted plantar fascia with discontinuity of its calcaneal insertion.
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Fig. 18: T1W hyposignal and T2W hypersignal geographic line delineating a fragment
of avascular necrosis in the head of the first metatarsal. There is linear enhancement
concordant with granulation tissue around necrosis.
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Fig. 19: Mid-third medial cortical thickening of the second metatarsal associated with
marrow edema (T2W hypersignal) and periosteal reaction around the bone ( well seen
on post-contrast).
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Fig. 20: Incomplete fracture line (T1W linear hyposignal) in the base of the fifth metatarsal
with marrow edema ( T2W hypersignal and T1W hyposignal). Adjacent soft tissue edema.
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Fig. 21: Transverse fracture line (T1W linear hyposignal) in the mid-third of cuboid with
marrow edema ( T2W hypersignal and T1W hyposignal) and adjacent soft tissue edema.
Fig. 22: Transverse fracture line (T1W linear hyposignal) in the anterior process of
calcaneous with marrow edema (T2W hypersignal and T1W hyposignal).
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Fig. 23: Coronal T2W Fat Sat shows marrow edema in the base of the third metatarsal,
associated with a collection between the flexor tendons. The collection is well demarcated
on T1W Gd on the coronal and axial planes, as well as on the T2W sagital images.
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Fig. 24: Subtle hypersignal on T2W and hyposignal on T1W in the flexor tendon of the
halux. Liquid (T2W hypersignal) within the tendon sheath. On post-contrast images there
is significant enhancement of tendon sheath.
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Fig. 25: Axial T1W, T2W Fat Sat and T1W Fat Sat Gd demonstrate a cystic lesion in
the hallux tendon sheath.Sagital T1W Fat Sat Gd shows peripheral enhancement and its
lobulated aspect.Note the homogeneous hypersignal on coronal T2W Fat Sat.
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Fig. 26: Expansive lesion with predominantly hypersignal on T2W and hyposignal on
T1W. Located in the deep plantar musculature.
Fig. 27: T1W, T2W and T1W Gd in the axial plane demonstrate an expansive lobulated
lesion with marked hyposignal and mainly peripheral heterogeneous enhancement.
Page 53 of 57
Fig. 28: T1W shows the lesion around the fifth metatarsal bone, which is intact.
Page 54 of 57
Fig. 29: On the X-ray: solid calcified matrix of the lesion.
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Conclusion
Many disorders produce discomfort in the plantar region of the foot and the cause may be difficult
to establish based solely on clinical findings. MR imaging, with its excellent contrast resolution
and multiplanar imaging capacity, is useful in the detection of numerous soft-tissue, as well as
bone and joint processes that occur in this portion of the foot. Radiologists should be familiar with
the differential diagnosis and MR imaging features of these disorders.
Personal Information
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