All right, so we'll go ahead and get started here. So I have the pleasure of introducing Dr. Doug Hoffman today, who's going to be our speaker. He is a founder and continues to work at the MSK Ultrasound Department at Essentia Health, which is a very large multi-specialty group in Minnesota. He continues to practice 100% MSK ultrasound, both diagnostically as well as interventionally. And most importantly, he's kind of been the founder for this AMSSM Sports Ultrasound Case Series, which I know everybody that is listening today is just really appreciative of. And obviously, we continue to really value Dr. Hoffman's insight into all these ultrasound cases because he continues to basically show up every single week. And he's going to be giving us a case today on plantar foot pain. All right, so let me share my laptop here. Stephen, thank you for that introduction. Of course. And how does that look to you? Yeah, we're starting to see the... Are we good? Yeah, I think we're seeing slide 21 right now. So I don't know if you have to go back to the start. And it might be... I was just going to shorten the talk a little bit. Yeah. Okay. All right, yeah. And then there, I don't know if you can go into... Because I think we're seeing the presenter view. Okay. I don't know if you can just go into the slideshow view. There we go. Perfect. All right. All right, thanks. Yep. Good morning from Northern Minnesota. I'm presenting today on plantar foot pain. And before I get started, there are a couple of thank yous in order. So first of all, I'd like to thank AMSSM and Andy Meyer. Andy, you're doing an awesome job keeping this going, and all the stuff on the back end. I would also like to thank Ryan, Brennan, and Stephen for their successive hosting of this. It takes a ton of work to do that, and organization line up speakers every two weeks. People cancel. So thank you for keeping this going. I've learned a ton from these presentations. I think it's a valuable addition to the ultrasound teaching. So thank you guys. My work with Sonex really has no bearing on this presentation. So the goals of this presentation are the review of the ultrasound protocol for plantar hindfoot pain, discuss the diagnosis of mid-substance plantar fasciopathy and its differential diagnosis, mainly that of a plantar fibroma, and then review the ultrasound report for this case. So the clinical history is pretty straightforward. So this 42-year-old female recreational walker had about six months of non-traumatic plantar foot pain. Symptoms increased with her first steps in the morning. They would increase after activity. She would sit down and get up from a sitting position and have pain with those first few steps. Pain was to the point where she had to curtail her walking routine. Treatment included shoewear modification. She's tried various over-the-counter arch supports and modifications of the arch supports. She's been referred to physical therapy. She has an ongoing home exercise program without improvement. So she had a clinically guided corticosteroid injection into the proximal central cord of the plantar fascia with incomplete and temporary improvement. Her physical exam showed a neutral arch hindfoot alignment. She had moderate gastroxilius tightness. And then her pain was more over the proximal third of the central cord and less so over the medial tubercle, the calcaneus. So this is a pretty typical presentation. We've talked a lot about radiographs before starting the sonographic evaluation. So here's a standing lateral radiograph of the foot. And we've seen in thesis at the insertion of the Achilles tendon as well as that of the plantar fascia, which would be expected with a tight gastroxilius complex. So this patient was referred with a diagnosis of plantar fasciitis to our ultrasound department and referred for a diagnostic ultrasound and a possible ultrasound guided procedure. Just a couple of comments to get started on the sonographic approach to the plantar hindfoot region. And so you can scan the patient either supine or prone. I prefer supine, and I have a tau on their Achilles, but certainly scanning prone is perfectly okay. Advantages and disadvantages to both. I like to use a transducer with a fairly wide range of frequencies because structures in the plantar hindfoot area can be deep, and then you add the thick skin to that, and you need lower frequencies to get resolution. And then some of the structures in this protocol are fairly superficial, and therefore it's more optimal to have higher frequencies. If my sonographers are doing the exam before me, I ask them to keep on the ultrasound gel until I get in. Just to let it soak in. If I'm doing the exam from start to finish, I will often apply gel first, do my history, maybe do other structures in the protocol, and then go back to the plantar hindfoot area as it soaks in. Again, it can be challenging, and I've even had people soak their feet in warm water that had thick calluses. So let's go to our plantar hindfoot protocol, and this is one of the simpler protocols in my armamentarium of protocols. And it's fairly quick. I mean, really, it's about a 5-10 minute scan for most of these individuals. And I break the protocol down into two parts. The first part really looks at the central cord of the plantar fascia, both the long and short axis, looks at the mid-substance of the central cord as well, and on a short axis image of the plantar fascia, I'm also looking at the fat pad. And then the second part of the protocol looks at related structures. So that of the lateral cord of the plantar fascia, I look at the abductor digiti minimi muscle, and I look at structures within the medial tarsal tunnel. Probably my two most common add-ons, depending on the clinical situation, would be looking at the distal achilles and looking at the plantar veins in the acute setting. All right. So let's just start with a quick review of anatomy of the plantar fascia. So as we all know, the central cord is the largest of the three cords of the plantar fascia. It has an origin on the medial tubercle, as does the lateral cord of the plantar fascia, where the majority of its fibers insert onto the base of the fifth metatarsal with other fibers traversing more distally. The medial cord of the plantar fascia does not have an enthesis on the medial tubercle, has a fairly complex distal insertion, and is thought to be the least clinically relevant, which I would agree with, although I would point out that it's the second most common location for the occurrence of fibroblasts to that of the central cord. So let's just look a little closely at the central cord here. So it does take its origin from the medial tubercle, the calcaneus. Now the medial tubercle is a fairly broad tubercle, taking up the majority of the cortex of the calcaneus at this location. And it shares an enthesis with that of the lateral cord. So those fibers blend together, and there are no fibers from the plantar fascia that insert on the lateral cord. Now, if we look at the mid substance of the central cord, kind of down the pike here, we see that the plantar orientation is that of medial, and it's often described as a triangular medial orientation of the mid substance of the central cord. Although I would say it has more of a semicircular rather than a triangular morphology, although that's probably not clinically important. But what is clinically important is this medial orientation, because that influences our optimal probe position. So the optimal probe position would not be then a sagittal anatomic position, but have a medial tilt to it. And so you can see going back to my picture, my position, I do have a medial tilt to the probe when scanning the proximal central cord of the plantar fascia on the medial tubercle. Now, sonographically, we would expect a compact fibular structure, which it is because of the tight parallel collagen fibers of the central cord. And I also want to point out that the thickness of the central cord in the normal state is relatively uniform in the proximal and middle third, and of course thins out more distally. And so for an abnormal proximal central cord, oftentimes we measure and we say over four millimeters is abnormal, which I would agree with that upper limit to normal is about four millimeters. But for me, I mostly look at the echo texture and that fibular echo texture to decide if something is abnormal or normal. Now on the short axis, the plantar fascia appears as homogenous hyper-echoic dots. And so I look at almost a three layer approach when looking at the short axis. I first look at the cortex of the medial tubercle. I look for irregularities and I also look for small bony fragments. Some of these small bony fragments can actually be pain generators. I look at the central cord itself, and then I look at the plantar fat pad. Now, one of the detail that I've learned over time may have clinical relevance is the insertional fibers on the medial wall of the calcaneus. So in this case, these fibers go a fair amount proximal on the medial wall. And the reason why this is clinically relevant is I've seen a number of patients that have more medial calcaneal pain than they have plantar calcaneal pain. And when I look sonographically, what I'm seeing is fibers that insert, you know, again, fairly proximal on the medial wall. All right. So let's go to our case here. And this is the first image in our protocol. This is a long axis image of the proximal central cord at its enthesis. And so again, I'm scrutinizing the surface of the calcaneus. Here we see the enthesiophyte. And in our patient, she has a relatively normal proximal central cord of the plantar fascia. So we see normal fibular echo texture here. And obviously there's an abnormality in the junction of the proximal and middle third here. Now also part of my protocol is a dynamic exam where I passively dorsi and plantar flex the ankle. And so this is what we did with this patient where I passively dorsi flex and plantar flex. And as you would expect, it was fairly normal, but it's not uncommon to see undersurface tears corresponding to the enthesiophyte. And again, I just sort of point out that even our abnormal area tensions nicely as we're doing our dynamic exam. So why do I do a dynamic exam? So it's very common for patients with proximal plantar fasciopathy to have partial undersurface tears. I would say probably the majority of patients have this or some form of this. And sometimes these can be underestimated with static images. And so I like to perform a dynamic exam and you can see here, it does separate a little bit, but the plantar fascia tensions nicely with these dynamic exams. But there are times when I've seen these partial tears track all the way through to the proximal insertional fibers here that I would not have seen on the static exam. I do want to point out that stretching the heel cords is an important part of our rehab protocol with patients with proximal plantar fasciopathy. But think about it is we're actually pulling this partial thickness tears as we're stretching. So I question whether we should be aggressively stretching the gastro soleus complex in our rehab of plantar fasciopathy. The second reason I like to perform a dynamic exam is to look for what I call signs of insufficiency when I do see a tear. So this is a companion case where we see a proximal central core plantar fascia tear. And then with the dynamic exam, we see that the central core does not tension. And so I call this insufficiency. So anytime I see any type of tearing partial thickness or not, I like to comment whether the plantar fascia tensions normally or there are signs of insufficiency as like in this case. All right. So this is our short axis image of our patient. And again, sort of a three-step approach here. The cortex looks good. The central cord fibers look good. And then the plantar fat pad. And I look for two things really in the plantar fat pad. I look for heterogeneity or, or if it's homogeneous, we want to look for homogeneity as being normal. So I'm going to look for fractures or I'm going to look for focal areas of hypoecogenicity. And then I'm also going to compress the fat pad. And I like to see approximately it compressed less than 50%. And so in this case, we can see here, clearly it compresses less than 50%. Once I do a short axis, I go back to long axis and I slide the probe towards the middle third of the central cord of the plantar fascia. So obviously here's where we see our pathology. And we see hypoecolic thickening of the central cord in the middle third. And I call it segmental hypoecolic thickening because distal and proximal to the thickening, we see normal fibular echo texture. And of course we want to look at this in short axis. And in short axis, we see that the full width and thickness of the central cord are affected in this case. I also did Doppler imaging, which was normal. Now, this is the same patient in the same, in a sense, the same image as before, but there's quite a difference between the two here. So here you can see that the resolution is not so great. And here you can see a marked improvement in the resolution. So this first image was taken at the beginning of the examination, and this image was taken at the end. And again, is just an illustration that soaking in ultrasound gel can make a big difference. And not only was the resolution better, but I was able to use a higher frequency probe. I wasn't able to start with to see better detail, the central cord. So let's just hone on this a little bit. And so what we're seeing is a increase in hypoecogenicity. We lose our normal fibular echo textures. And now we start to see some partial thickness tearing in here. And so I would say that this is a mid substance central cord fasciopathy. I'm just going to pause for a second here and just say that I'm, you know, most of us who scan a lot of these see this quite a bit. We see these thickenings in the central cord and is this a fasciopathy or is this a fibroma? Because fibromas are quite common. But what I find interesting is that there's very little written about the details of mid substance plantar fasciopathy. There's plenty written about fibromas, but nothing written about trying to distinguish a fibroma from a fasciopathy. So my goal here is to get the conversation started. I'm not sure I have all the answers here, but I'll certainly give you my two cents on how I use to distinguish these. And so, again, we see in a sense a change in the fibular echo texture and tearing of the echo texture. So let's look at a couple of companion cases of mid-substance thatchiopathy. So in this patient, we see a hypoechoic thickening at the, again, the junction of the proximal and middle third. We get a sense that the fibular echo texture here is not completely disrupted, but also there's an important detail here. And that important detail is that there is hypoechoic thickening that extends into the enthesis. Can you guys see my arrow here? Let me just double-check and make sure. There we go. So we see that not only do we see thickening of the mid-substance, but we see thickening that extends into the enthesis. Now, it is really rare to see a fibroma at this area or this proximal central chord of the plantar fascia. And so when I see thickening that goes into the enthesis, I'm thinking plantar fasciopathy. And interestingly, when we did a comparison view, we see the typical findings of a proximal central chord fasciopathy. In this older case of mine, but very similar, we see the exact same thing. So we see that there is some maintenance of fibular echo texture, but there's a thickening of the plantar fascia. And if we look carefully, some of these changes in the plantar fascia move towards the enthesis, something we would not see with the fibroma. And interestingly, in this patient on the contralateral side, we have a moderately severe proximal plantar fasciopathy. Now let's contract that with a patient with a fibroma. So this is a rather large fibroma within the middle third of the central chord. And I think of fibromas as expansile, and so, or at least larger ones. So this to me has a very expansile look, a growth that is expanding within the central chord. And we see increase through transmission here, and we also see vascularity of this. Now I'm gonna go into this view here. And so as we scan distally from this mass here, we see a small fibroma. And this is a very typical appearance of a small fibroma. And this small fibroma has an expansile look just to the superficial fibers with preservation of the deeper fibers. So this is characteristic of a fibroma, but it would be very atypical for a fasciopathy. So one of the criteria that I use to help me distinguish is are there other fibromas? And it's pretty unusual in my experience to see a large fibroma within the central chord without other small fibromas or fibromas on the contralateral side. So if we do go to the contralateral side, and I were to see this just in isolation, I would have a hard time distinguishing between a fasciopathy and a fibroma. But on the contralateral side, as I scan distally, there are other small fibromas. So putting this in the context of multiple fibromas or fibromatosis of the central chord, then I'm more confident in saying what I'm seeing here is an actual fibroma. Again, this was the asymptomatic side. Let's go to a different case of a plantar fibroma. And again, we're in the central chord, to the left is distal. And this has a very expansile look to it. It did not have any vascularity. And I'm gonna just insert here the image from our case. And you can, in first pass, it looks very similar. And it's like, oh, you know, how are we distinguish between the two? But there's some important details here. And one of the important details is that this has a very different look in that there is hyperechoic fibrous tissues overlaid on a hypoechoic cellular matrix background. So these almost have a paste on appearance versus kind of a disruption appearance of these fibers here. Now, it's a little soft and I understand, but we're gonna go to the short axis image here. And if we kind of take a bird's eye look at this image, we see, or at least we can convince ourselves that we see these alternating lines of hyperechoic tissue with hypoechoic tissue. So alternating lines of hyper and hypoechoic tissue. And in one series, looking at the ultrasound findings in details of fibromas, they call this the comb sign. And so again, as we enlarge this, we again can make out these hyperechoic and hypoechoic alternating structures within the short axis. And in some cases, you can even see this in long axis. So again, to me, this has almost a paste on appearance or a mosaic appearance of hyperechoic structures on top of a hypoechoic background. So that's an important sonographic feature that helps me distinguish. And again, it's always not so easy. Here's a obvious case of that where we see a large mid-substance fibroma. And again, we see this hyperechoic fibrous tissue that's overlaying the hypoechoic cellular matrix. We don't see any form of fibular echo texture here or even disruption of a fibular echo texture. So this is really an obvious case of a plantar fibroma. So in going back and looking at all of these, I have found that there are helpful findings and not helpful findings. So I look at these two and I go, wow, this is hard. And so is there any way they help distinguish these two? And I found for me, the most helpful things is one is, as are a couple of examples about the fasciopathy, a connection with the enthesis. So if I see even subtle abnormalities that go towards the enthesis, then I'm thinking plantar fasciopathy because fibromas just don't occur there. If I see other fibromas, and so in our case, for example, there were no other fibromas on the side we're scanning or the contralateral side. But if I'm seeing other fibromas, then I'm thinking the mass that I'm seeing is probably a fibroma. And then this, again, this echo texture of this hypoechoic fibrous tissue on a hypoechoic background. And I actually think that's what we're seeing here. That leads me towards thinking about that this is a fibroma. What I've not found helpful is vascularity. Vascularity can or cannot occur with either. I don't find that posterior acoustic enhancement has been helpful. And I actually don't think that sonopalpatory pain has been that helpful as well because both can be asymptomatic and both can be symptomatic. All right, so let's just finish up our protocol here. And the next structure in the protocol is the lateral cord of the plantar fascia. Again, this is important structure to image with plantar fasciopathy because people often don't want to walk on the inside or medial aspect of their foot or over the medial tubercle and they walk on the outside of their feet, now putting more stress on the lateral cord. And it's very common to see enthesiopathic changes of the lateral cord as it inserts onto the base of the fifth metatarsal in the setting of plantar fasciopathy. Not all of them are symptomatic. And so quickly, just anatomically, we see that, again, the enthesis shares its fibers with that of the central cord, and then it traverses distally along the superficial border of the adducted digiti minimi muscle, curves around that muscle and inserts onto the base of the fifth metatarsal with a separate footprint than that of the peroneus brevis. So sonographically, we see that hypercoic fibular echo texture. But what I would like to point out is the fairly broad insertion of the lateral cord. It has a large footprint. It is a very stout enthesis. And we even see that on the short axis. So to the right is lateral here, this is dorsal, and here is the enthesis of the brevis, and the enthesis of the lateral cord is larger. And so when we read in a textbook, for example, that the avulsion fractures of the base of the fifth metatarsal due to the peroneus brevis, that's wrong. It's really due to the lateral cord. And I have some nice, actually, ultrasound images of acute fractures confirming that. Contrast that to the footprint of the peroneus brevis, and it's a much smaller footprint. We see both in long and short axis. Now, another important anatomic detail is the probe position is really a straight transverse anatomic probe position. You would think you would have a plantar tilt to it since it comes from the plantar aspect, but really to optimize the image of the enthesis, it's a straight transverse orientation. And so on our patient, we see a markedly abnormal central cord of the plantar fascia. It is diffusely hypoechoic and thickened. We don't see any of the normal fibular echotexturing. We see partial thickness tearing, and importantly, this person had quite a bit of pain with sonopalpation at this site. All right, so again, finishing up the protocol, I always get a short axis of the abductor digiti minimi muscle, looking for denervation changes because that muscle is innervated by the inferior calcaneal nerve or the so-called Baxter's nerve. So if we have a compressive neuropathy of the inferior calcaneal nerve, we're gonna see denervation changes of the ADM. And I like to couple this short axis image with that of the flexor digitorum brevis so I can compare echotexture and look for changes. So here we see in our companion case, denervation changes of the ADM. Here's a flexor digitorum brevis, and here it is on long axis. And then my last image is that of the medial tarsal tunnel. And I include this in the protocol for a number of reasons. First of all, then there's no question I'm doing a complete exam because it fulfills the criteria. I also can get a look at the lateral plantar nerve. So here's the tibial nerve is divided into the medial and lateral plantar nerve. And if clinically relevant, I'm gonna follow this and follow the inferior calcaneal nerve distally to look for signs of compression or abnormalities. And abnormalities of the medial tarsal tunnel can present as heel pain. So it's an easy image to get, and I always include it in my protocol. All right, so before I go to my report, I'm just gonna show you this. And this is a 70-year-old who developed acute onset of plantar foot pain, avid hiker. This was after a long hike, no improvement after three weeks of rest, physical therapy or corticosteroid injection and was referred for an ultrasound guided procedure. And so here we see the flexor digitorum brevis, lateral is to the right, lateral plantar vein. We're gonna follow that from distal to proximal. And as we do, we see a thrombus in there. So this is a lateral plantar vein thrombosis. And I add this to the protocol with any acute onset of symptoms. And I see this about once, maybe every year to two years, but I've seen two in the last six months. And both of these patients were physicians. So obviously that's a risk factor. All right, so let's go to our report. And actually for this, I decided I'm not gonna alter the report. I did retype it, but there were really no changes in this report from my original report. So this is a diagnostic ultrasound of the left foot, attention to the plantar hind foot region. I actually just put in the indication that comes in with the order for the diagnostic ultrasound. So plantar foot pain, evaluate for PRP or ultrasound guided procedure. And I correlate with the radiographs. And I just have a structure that I do. I start with the medial tubercle. So then there is an enthesiophyte at the medial tubercle, the calcaneus. The insertion of the proximal central cord is basically normal onto the medial tubercle. And then I state there is segmental hypocoic thickening, loss of fibular echo texture and partial thickness tearing of the central cord of the plantar fascia, the junction between the proximal and middle third. The adnormal segment measures, and I give a measurement and I'll also say involves a full width and depth of the central cord. There was no associated vascularity, but I did state that there was corresponding pain with sonopalpation. Now, there was a reason why I put this last sentences and the remainder of the central cord looked normal because there was no other fibromas or there was no fibromas that I saw. So my thinking was, this was an important piece of information, at least for me it was. And then I also say something similar for the lateral cord that we have loss of fibular echo texture, partial thickness tearing, and again, corresponding sonopalpatory pain was present. And then in this case, I did look at the brevis since the lateral cord was abnormal and that was normal. And then I finish up by just saying the abductor digiti minimi muscle was normal and size and echogenicity in the medial tarsal tunnel was unremarkable. So my conclusion that this is a mid substance plantar fasciopathy with a low to moderate grade partial thickness tear and corresponding sonopalpatory pain similar for the lateral cord as well with corresponding sonopalpatory pain. So thank you, comments. I'd be interested to hear what others have to say about distinguishing the two. All right, well, thank you so much, Doug. I think we already got some hand raised here for questions. Got a clap from Ryan here already. So thanks again. I think we have Dr. Cianca, do you have a question? Yes, sir. So Doug, you talked about insufficiency. I'm presuming you mean in a functional capacity or is there some structural finding there that you're referring to? Yeah, it's very qualitative. I mean, I'm looking to see if the central cord tensions normally. And so with a lot of these partial tears, they look fairly big, but their central tears in the plantar fascia tensions normally. And again, very qualitative. Whereas in that example I gave, it just didn't tension. You know, the tear almost separated. And I've occasionally seen that with, you know, the tears of the proximal central cord of the plantar fascia so that's what I meant. Does the central cord tension normally as you apply a stress to it? So, and then are you saying that with that type of finding, you suspect there is a tear? Well, in the second example, in the first example where we had that larger partial undersurface tear, it did tension normally. So the tear was really fairly large, but there really wasn't any sign of insufficiency where in the second case I give, there was a larger tear and the central cord did not tension normally. Okay, so it should be, if there's a failure to develop tension, then there should be a tear someplace. Yeah, and the tear is probably has clinical relevance in terms of now there's insufficiency of the plantar fascia. I get it, right. And does anybody else use that term or is that a Doug Hoffman? I'm sorry, yeah, probably. All right, well, I'll wait to see if we have any more questions, but yeah, just Doug, thanks again for going through, I think a very complicated area that can be kind of daunting to go through at first. And I think just in general, I just appreciate you kind of describing a complete protocol for this area, which I think has not been too well described before. So I think this is the kind of whole reason for this case series is describing complete protocols for these different areas, especially into the plantar foot, which can be helpful to make sure that we don't miss a diagnosis and we're coming to kind of the appropriate conclusion here. Just kind of a couple of points to reiterate is I definitely agree that this is one area that you got to be comfortable adjusting the frequency or changing transducers in this area, especially as the scan goes on, just because it can definitely help to provide better resolution of these structures, which can be extremely helpful in differentiating some of the changes that you had mentioned. Is this just a fasciopathy, or are you starting to get kind of partial tears within that area as well? As you had mentioned, another thing constantly doing would be dynamic exam, especially trying to differentiate between just kind of these fasciopathy changes versus truly a partial tear, which as you had mentioned, may not then result in kind of that tension of the plantar fascia. And so I think that that is always extremely helpful. In the cases where I had seen the plantar fibromatosis, I definitely agree with you that very rarely am I just seeing a single nodule. And so I think the comments you had made, what is helpful and what's not helpful, I mean, those are always things that I include as well too, but I completely agree with you that I think obviously if you start to see multiple right away, you can start to be a little bit more concerned about fibromatosis. And one other thing I would say is in these cases, I don't know how frequently you do this, but potentially doing serial examinations as well too, just because I know sometimes obviously with those nodules, if it is more fibromatosis, they can start to increase in size, especially if you're starting to see those early on, or they may develop more multiple nodules. And obviously at that time period, you'd start to be more concerned about a plantar fibromatosis rather than just an underlying fasciopathy, but these definitely can be extremely difficult, I think, to differentiate early on in the process. Yeah, good point, yeah. All right, well, I think we got, Ryan, did you have a question or comment? Yeah, let Jake raise his hand first. Let Jake go ahead. Okay, yeah, Jake, sorry. Yeah, Doug, thanks so much. Fantastic. I guess just to echo, I think, like you said, when you move away from the heel into the arch, you know, that's where I think you have to think more about the fibroma, and then I really love the idea of the stuck-on appearance. I think that's a fantastic way to distinguish. With that said, a couple of things that you said that were really thought-provoking. So the far-medial origin of the central cord when patients have pain or tenderness in that area, I think that's an area that is easily missed in treatment. Say, if you're doing an intervention, it's an area that you may not even really visualize that well, and so just, I guess I'm curious if that's something that, have you focused treatments in that area for a first question, and then secondly, with regard to if you do have a fibroma, you know, distinguishing the fibroma from the plantar fasciosis, how does that change your treatment approach? Yeah, all good questions. So I do scrutinize that medial cord and the medial fibers. I can't say that, I mean, I've seen some fibromas there, and at the proximal aspect of those medial cord, I've seen fibromas of the central cord almost kind of worked their way into those proximal fibers of the medial cord. I know that a medial cord rupture has been reported. I personally haven't seen it. And so for me, from the clinical point of view, it's just that I've seen fibromas there. I can't say I've treated those on the medial cord. For me, I tend to want to stay away from fibromas. I know people have injected cortisone with these fibromas and with varying success, not a high rate of success. I have not personally done any kind of tenotomy on a fibroma. Have you, Jake? Have you actually performed a tenotomy on a fibroma before? I have, can't say that it's been uniformly successful. I've had a couple of cases that responded. You know, we're often asked about things like PRP, which doesn't really make sense to me to inject that into a benign growth that you don't want to grow anymore. But yeah, I mean, I would probably, I've tried cortisone. That's probably my go-to intervention. I know some people have had some success. One of our podiatrists uses verapamil, but I think you, I'm not sure, topical verapamil. But yeah, very tough problem. Surgeons don't want to operate on them because of recurrence. And I mean, theoretically, you would think that a fasciopathy, you know, would potentially respond better than obviously a fibroma. But again, that's in theory. And even, I've treated a couple, you know, mid-substance fibromas with varying success as well. I think if you have a smaller one, that may be more doable, but you know, a lot of these are fairly large. I just don't think it's realistic for, you know, ultrasonic debridement procedure. Right, right. No, I would agree with that. Thank you. Other thoughts or other- Brian, did you have a comment you want to make? Yeah, sure. Yeah, that was awesome, Doug, and as expected. And, you know, this is tough, you know, differentiating these, I think, is one of the more challenging things to do. And, you know, I struggle with this on a fair number of patients. And, you know, then I ask myself, does it matter clinically? You know, if we differentiate them, and I do think it does from a treatment perspective. You know, I just had one comment I was going to make, and then I have a question for you. You know, the medial band or the medial cord, for me, routinely has not been part of my standard protocol, for better or for worse. The times that I look at it, and you alluded to this previously, if I see somebody with, you know, a region of central cord fascial thickening that may or may not be a fibroma, you know, it's distal, it's calcaneous, that's when I'll swing over to the medial band and the medial cord to see if I can find additional fibromas there. And I often do, like you mentioned, and I will often see them a bit further distal, like we were talking about a patient yesterday, had multiple through the medial band, farther distal, but that's just something that we should always think about, you know, always evaluating the medial band when indicated, because I think a lot of times we kind of forget that that's part of the plantar fascia. The question that I had, and I just wanted you to clarify, so the presence or absence of multiple lesions, you know, historically, if I had seen multiple regions of, you know, fusiform fascial thickening, that to me seems fairly consistent with this being a fibromatosis problem, but it sounds like the presence of multiple lesions to you does not seal the deal that this is fibromatosis and it may be just multiple foci of fasciopathy. Did I understand that correct? No, no. So if I'm seeing multiple fibromas, then I'm thinking fibroma. Okay, okay. So that to me is one of the distinguishing factors is if I'm seeing other fibromas. And, you know, my experience is if there's a big fibroma, I'm almost always gonna see smaller ones. I rarely see a big fibroma in isolation. And, you know, I've seen a couple of small fibromas distally what I think is something plantar fasciopathy, but that's unusual. In this case, didn't have it, but no, if I do see other fibromas, that is gonna most likely seal the deal. Okay, perfect. That's what I thought, just wanted you to clarify. Thanks, Doug. All right, and then I think Brennan has two quick questions as well, too. Hey, Doug, thanks. Thanks, Steven. Doug, thanks for presenting this and kind of bringing this topic up. And I know, you know, Jake commented earlier and he and I have had some discussions about this, you know, over the last couple of years as well, just, you know, a little bit of internal debate on, you know, what is what. When you were presenting, one thing that really stuck out to me was it almost made me think a little bit like differentiating a schwannoma from a neurofibroma, right? So there's like, there's some demarcation at the edges of a schwannoma, whereas the neurofibroma, you know, is infiltrative into the nerve tissue and kind of expand style. And that, when you were showing your pictures, I was thinking like, oh, I can see how, you know, the fibroma is more of kind of that like, yeah, pasted on appearance, as you said, versus, you know, potentially expanding further through that tissue. And so I think that, that kind of stuck a little bit with me of like how to differentiate these two things. The other question I had was on the fat pad. And this is one that I've kind of got stuck on a little bit in the past, as far as, you know, you said 50% is kind of your cutoff. Are you measuring from the skin to the surface of the plantar fascia, or from the top side of the fat to the bottom side of the fat? Like, what is, where are your measurements? Or is it an eyeball? Yeah, I eyeball it. But if I were gonna measure it, I would not measure it from the skin. I would measure it from where that outer aponeurosis is of the fat. Again, it's rare for me, I know Ryan, you have probably more experience with this. I know Maderek did a study, but for me, it's rare to have an insufficient fat pad, again, sorry about the term, but you know, where it compresses 70, 80% without seeing some echogenic changes or some changes within the fat pad itself, whether there's a fracture, whether there's an increase in hypoechogenicity, which corresponds to fibrotic changes. I mean, there's usually some change in the fat pad that leads to an increase in compressibility. So for me, I'm just eyeballing it. You know, I don't know if measuring it is gonna change anything clinically for me. Yeah, certainly. I think that's, you know, an area that, as far as like, you know, response to treatment goes, you know, I've had some patients that have had really, and I do use the word insufficient when I'm looking at the fat pad, you know, harder time treating those patients, I think, just because they have a lot of pressure-related pain. And then one other comment I had, just a patient recently shared with me, I usually scan people, you know, right away when I'm seeing them clinically for this sort of problem. Sometimes just based on their schedule or mine, we'll bring them back another time. And I, you know, people have big, thick calluses and really dry skin. I'll tell them, you know, you should moisturize. And like our dermatologists have told patients, put like a lotion, like a moisturizing lotion, and then seal it in with something like an Aquaphor or Vaseline, you know, for several days straight, and you wear a sock to bed, that sort of stuff. And I told the patient that, and he's like, well, it was way easier just to go and get a pedicure and have them like clean my foot up, and it was like better in like one day. And so, you know, when I do interventions in this area, if people have really cracked skin, I'll wait to do anything until that is appearing better. And the pedicure for my one gentleman was very helpful for that. Was that covered under insurance? Not sure, it's a great question. Yeah, you know, good points. Yeah, good points. Yeah, I mean, I think we all, when we start scanning and we get to our short access image and we see a not so good looking fat pad that's insufficient, we all kind of sigh going, oh, now what are we gonna do, you know, because they can be tough. Yeah. And then Doug, I had one more question as well too. In your experience, is this an area where you ever see, I guess, in companion to like Palmer fibromatosis, do you ever see on the differential diagnosis like ganglion cysts or retinacular cysts ever arising from the plantar fascial cord? I have not personally seen that. I, yeah. The only really differential is I've seen one, you know, leiomyoma, it was benign, so a different tumor, but I have not seen ganglion cysts in the plantar hindfoot region, you know, truly the plantar hindfoot region until I get to the midfoot region where I've seen ganglion cysts, you know, from midfoot joints track plantarly, but I haven't seen it more in the hindfoot area. Yeah, I was just wondering, I mean, I've had a few referrals from, you know, podiatry and things like that. Hey, for their differential diagnosis, why they were sending them is, hey, is this a ganglion cyst or a fibromatosis? And it was just, you know, just thinking wise that, you know, we see those potentially, you know, within palmar fibromatosis in the hand, just know this is one area that I've not seen, you know, too many cases related to that, which obviously might just be related to the biomechanics of that area and kind of the pressure on the foot versus the hand. Right, and you know, fibromas can actually occur outside the plantar fascia itself. It's rare, but I've had a couple of cases where there was a tumor and it wasn't in the, you know, well, at least the plantar fascia tissue that we could see. And it was a plantar fibroma histologically. All right, well, I will wait to see, let me just check the chat to see if there's anything else. Great comments. Discussion guys, I, yeah, like I said, I like to get this discussion going and because it's something that we all see pretty commonly. Yeah, this was extremely, extremely helpful. Obviously really, really appreciate the discussion and obviously finishing off the attending presentations for the year. Doug, always really appreciate kind of setting the gold standard here as we had talked about. I don't know about that, but again, thank you for your efforts in doing this and keeping this going. So we'll look forward to the fellow presentations. Yeah, of course. Yeah, of course. And that is a good transition. So as Doug had mentioned, we'll be taking just a few weeks off here. I'm gonna be ending the attending presentations now for the year for the AMSSM Ultrasound Case Series, but excited that we're gonna be starting the fellow presenters at the beginning of the year. So we already have a really good lineup set for that. The first one is gonna be then on January 5th. It's gonna be Dr. Thea Swenson, who's actually a fellow here at Vanderbilt, and she's gonna be presenting a case on the anterior knee and sending Larson-Johansson syndrome. So a pediatric case for that, just a quick plug just in a few weeks to start off that case series. So hopefully we'll see everyone at the beginning of the new year and I hope everyone has a good holiday season. Yeah, happy holidays, everybody.

3rd Edition, CASE 17

3rd Edition

Foot

MSK ultrasound

plantar foot pain

plantar fasciopathy

plantar fibroma

ultrasound protocol

sonographic features

diagnosis

treatment strategies