48-year-old patient with left plantar heel pain. The right heel is asymptomatic. Ultrasound examination was performed to assess the calcaneus, Achilles tendon, plantar fascia, bursae, and heel fat pad.
Ultrasound of the left heel demonstrates clear thickening of the origin of the plantar fascia at the calcaneal insertion. The affected segment shows a hypoechoic appearance compared with the contralateral, asymptomatic right side. These findings are consistent with plantar fasciopathy/fasciitis.
A calcaneal heel spur is also visible on the left side. However, a similar heel spur is present on the asymptomatic right side. Therefore, the heel spur is interpreted as an aspecific degenerative finding rather than the primary explanation for the patient’s symptoms.
The remaining examined structures, including the Achilles tendon, bursae, calcaneal region, and heel fat pad, show normal anatomical appearances without evidence of structural damage.
1. Final diagnosis
Ultrasound findings are consistent with left plantar fasciopathy/fasciitis at the calcaneal origin of the plantar fascia, most likely representing the main cause of the plantar heel pain.
2. Differential diagnosis
In patients with plantar heel pain, irritation or entrapment of the tibial nerve, including Baxter neuropathy, may be considered. In this case, this is less likely because of the clear structural abnormalities of the plantar fascia, but it remains relevant if symptoms persist.
3. Teaching points
Plantar fasciopathy is characterized on ultrasound by thickening and reduced echogenicity of the plantar fascia near its calcaneal origin. Comparison with the asymptomatic contralateral side is useful to support the diagnosis and to avoid overvaluing incidental findings.
4. Injury/disease information
Calcaneal heel spurs are common degenerative findings and may be asymptomatic. Their presence alone does not prove that they are the cause of heel pain. In this case, the bilateral spurs with symptoms only on the left side support the plantar fascia abnormality as the clinically relevant finding.
To complete the case, the useful missing details are: patient age, duration of symptoms, exact pain location, provoking activities such as walking/running/standing, and whether there is typical start-up pain in the morning.
Marc is founder of, and trainer at, SonoSkills. SonoSkills is an organization dedicated to MSK ultrasound education. He's also an MSK Sonographer at EchoConsult in Roermond, the Netherlands.
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