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Clinical History

A 40-year-old female patient presented to the radiology department with increasing, a-traumatic, lateral foot pain since three weeks.

Imaging Findings

X-ray of the foot was normal. On ultrasound, the lateral cord of the plantar fascia showed thickening, hypoechogenicity and loss of its fibrillar echotexture at the insertion on the base of the fifth metatarsal bone (Fig. 1). No hypervascularity was noted. The peroneus brevis tendon appeared normal (Fig. 2). No aberrant soft-tissue structure was found. Furthermore, the origin of the plantar fascia near the calcaneum was also hypoechoic and thickened in comparison to the contralateral side. The diagnosis of lateral cord plantar fasciopathy (LCPF) in addition to central cord plantar fasciopathy (CCPF) was made.

Discussion

Plantar fasciopathy typically causes heel pain or plantar foot pain. However, it can also cause lateral foot pain. Anatomically, the plantar fascia is comprised of a central cord and a lesser known yet clinically relevant lateral cord [1]. The central cord runs from the medial tubercle of the calcaneum and divides into 5 diverging bands, inserting onto the plantar plates of the metatarsophalangeal joints. Plantar fasciopathy most commonly involves the proximal third of this central cord. The lateral cord originates on the lateral calcaneal tubercle in close relation to the abductor digiti minimi muscle and inserts onto the plantar and lateral aspect of the base of the fifth metatarsal bone (Fig. 3). It can also be subject to fasciopathy, typically distally [2]. Moreover, CCPF can provoke LCPF by changing the gait of the patient, as was seen in this case. The sonographic features of LCPF are similar to other enthesopathies or tendinopathies. Generalised or focal hypoechoic thickening and loss of the normal fibrillar echo texture are the most frequent findings. Accepted standards for the normal thickness do currently not exist, obliging comparison to the contralateral side [3]. Cortical irregularity of the fifth metatarsal base and hypervascularity are possible, additional findings. The lateral cord of the plantar fascia inserts to the plantar and lateral aspect of the fifth metatarsal bone and the distal fibers widen into a broad attachment. On the other hand, the peroneus brevis tendon inserts to the dorsal and more distal aspect of the fifth metatarsal base with a small footprint [3]. Therefore, ultrasound can readily differentiate between LCPF and tendinopathy of the distal peroneus brevis tendon, the former being the more common cause of a-traumatic lateral foot pain. Written informed patient consent for publication has been obtained.

Differential Diagnosis List

Lateral cord plantar fasciopathy

Peroneus brevis tendinopathy

Fifth metatarsal stress fracture

Os vesalianum syndrome

Baxter neuropathy

Final Diagnosis

Lateral cord plantar fasciopathy

Liscense

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Figures

Ultrasound shows thickening of the LCPF insertion on the symptomatic side (between calipers in a), compared to the contralate

The peroneus brevis tendon (white arrows) had a normal echographic appearance. It inserts more superiorly and distally on the

Anatomy of the lateral cord of the plantar fascia (white arrows), peroneus brevis tendon (yellow arrowheads) and abductor dig

Medical Analysis Report

Imaging Findings

Based on ultrasound imaging, the lateral band of the plantar fascia (located at the lateral-plantar aspect of the base of the fifth metatarsal) shows localized thickening and disorganized echotexture, appearing as hypoechoic or mixed echoes, indicating possible inflammatory or degenerative changes in the fascia. Some images reveal areas where demarcation with surrounding soft tissue is unclear, potentially accompanied by mild cortical irregularity. Comparison of thickness and morphology with the contralateral plantar fascia shows significant abnormal thickening and altered echogenicity on the affected side. No significant tendon rupture signal is noted, which would be atypical for a primary tendinopathy.

Potential Diagnoses

Plantar Fasciitis (Lateral Band Type): Given the imaging findings and clinical presentation (lateral foot pain, abnormal plantar fascia thickness and echogenic changes), lateral band plantar fasciitis is the primary consideration, especially after excluding other soft tissue injuries.
Peroneal Tendon Lesion (Fibularis Brevis Attachment Inflammation): The fibularis brevis tendon attaches at the dorsal aspect of the base of the fifth metatarsal. If inflammation or microtears occur at this attachment point, it can also cause lateral foot pain; however, imaging abnormalities are typically more dorsal with a smaller area involved.
Bone Stress Reaction or Minor Fracture of the Metatarsal Base: Although there is no obvious history of trauma, a stress reaction or minor fracture should be ruled out. If cortical irregularity or periosteal reaction is observed, further evaluation is warranted.

Final Diagnosis

Considering a 40-year-old female patient with no obvious history of trauma, whose symptoms are localized to the lateral plantar aspect and whose ultrasound shows abnormal thickening and disorganized echotexture of the lateral band of the plantar fascia, the most likely diagnosis is Lateral Band Plantar Fasciitis (LCPF). The current ultrasound images and clinical findings do not suggest significant involvement of the fibularis tendons or distinct bone abnormalities, thus LCPF is the most probable diagnosis.

Treatment Plan and Rehabilitation

Conservative Treatment:
- Rest and Activity Reduction: Avoid prolonged standing or weight-bearing activities, especially during the acute pain phase.
- Foot Support and Orthotic Insoles: Reduce tension on the plantar fascia and alleviate inflammation.
- Medication: Non-steroidal anti-inflammatory drugs (NSAIDs) or topical treatments to alleviate pain and inflammation. If severe pain persists, a local injection near the plantar fascia attachment can be considered.
- Physical Therapy: Ultrasound therapy or extracorporeal shockwave therapy (ESWT) can help reduce inflammation and promote tissue repair.
Rehabilitation Exercises and Exercise Prescription (FITT-VP Principle):
- Frequency: 3-4 times per week initially. As symptoms improve, gradually increase to 5 times per week.
- Intensity: Start with low-intensity stretching and plantar muscle strengthening exercises; gradually increase range of motion and load as pain allows.
- Time: 15-20 minutes per session initially, gradually extending to 30 minutes based on recovery.
- Type: Wall-assisted calf stretches, plantar fascia massage (e.g., rolling a tennis ball or chilled water bottle under the foot), toe-towel curl exercises (to strengthen plantar and toe muscles), and balance exercises (e.g., single-leg stance).
- Progression: As pain subsides, introduce core and lower extremity strength training, eventually progressing to moderate running or jumping exercises with higher impact.
- Volume: Begin with low-volume training; shorten the session if pain occurs, and gradually increase volume as tolerated without significant discomfort.
Emphasize that if the patient has relatively weak bone density or additional foot conditions, rehabilitation should be conducted under professional supervision to ensure safety.
Surgical Indications:
Generally, lateral band plantar fasciitis is managed conservatively. Surgery is only considered if there is no significant improvement after prolonged, standardized conservative treatment (approximately 6 months or more).

Disclaimer: This report is a preliminary analysis based on available information and does not replace an in-person consultation or professional medical diagnosis and treatment. If you have any concerns or if symptoms worsen, please seek medical attention promptly.

Human Doctor Final Diagnosis

Lateral cord plantar fasciopathy

AI Doctor