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Wearing high heels and plantar fasciitis; MRI evaluation
Poster No.: C-0809
Congress: ECR 2015
Type: Scientific Exhibit
Authors: S. A. Z. Khodair, R. L. Younes; Qwuesna/EG
Keywords: Extremities, Musculoskeletal soft tissue, MR, Diagnostic
procedure, Occupational / Environmental hazards, Patterns of
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Aims and objectives
To determine the type and frequency of characteristic MRI changes of the plantaris fascia
in patients with painful heel and wear high heel shoes.
Women are interested to wear high-heeled shoes to increase their attractiveness. High-
heeled shoes might create harmful effects to the musculoskeletal system.(1)
Furthermore earlier studies proved that the function of foot and lower extremity will
be changed due to wearing high heeled shoes. (2) Plantar fasciitis (also known as
plantar fasciopathy or jogger's heel) is a common painful disorder affecting the heel and
underside of the foot. It is a disorder of the insertion site of ligament on the calcaneous
bone and is characterized by scarring, inflammation, or structural breakdown of the foot's
plantar fascia. It is often caused by overuse injury of the plantar fascia.(3)
Plantar fasciitis is the most common injury of the plantar fascia and is the most common
cause of heel pain. It is commonly associated with excessive inward rolling of the foot
as in high heel. Individuals with plantar fasciitis often have difficulty with dorsiflexion of
Though plantar fasciitis was originally thought to be an inflammatory process, newer
studies have demonstrated structural changes more consistent with a degenerative
process or repetitive minor trauma. As a result of this new observation, many in
the academic community have stated that the condition should be renamed plantar
Understanding of the normal anatomy of the plantar aponeurosis (PA) and familiarity
with pathologic conditions are required for an accurate evaluation of the patient with heel
The output of this research is describing the effect of wearing high heel on plantar
fascia. In this study, we evaluated the diagnostic capabilities of magnetic resonance (MR)
imaging in the assessment of the PA in correlation with the use of high heel
Methods and materials
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MRI study was conducted on 40 patients with a mean age of 40 ±7.2 years. Twenty
control volunteers, age-matched and healthy also were underwent the same protocol of
MRI study. All our 40 patients were using high heels as the following criteria : length of
the heel not less that 2.5 inches, a duration mean of 4 hours /day, 5 days/ week, with
average body mass index 25-30%. The control group were not wearing high heel & had
no painful heel.
Patients with the following criteria were excluded from our study: over weight, abnormal
shape of the foot as high arched foot, and sportive runners. All the examined patients
were laboratory investigated for blood glucose level, rheumatoid factor, uric acid & ESR.
Also plain x-ray foot was done in different direction for exclusion of other causes of painful
heel. Four patients were suspected to have tarsal tunnel syndrome & nerve conduction
study was done to exclude this cause.
Clinical orthopedic examination revealed heel pain with the following criteria : the pain
starts with initial weight bearing after a period of time & increases upon rising in morning ,
on palpation , tenderness was at the inferior aspect of the heel ,
MR images were obtained with a 1.5-T superconducting MR imager (Signa; GE Medical
Systems, Milwaukee, Wis) with a 5-inch (13-cm) standard small flexible surface coil (Flex
Coil;Medical Advances, Milwaukee, Wis).
Routine ankle MR imaging was performed in the axial, coronal, and sagittal planes.
The foot is imaged in the oblique coronal plane, oblique axial plane, and oblique
sagittal plane .T1-weighted (repetition time msec/echo time msec = 600/20) and T2-
weighted (2,000/20,80) Fat suppression techniques , fat-suppressed proton-density-
weighted imaging & short-inversion-time inversion recovery (STIR) sequences (1,500/20;
inversion time msec = 100-150).
The patients were in supine position with the foot in about 20° of plantar flexion, this
is specially helpful for the following reasons: it accentuates the fat plane between the
tendons specially the peroneal tendons & decreases the effect of the magic angle.
The imaging data were reviewed by two radiologists (with more than five years of
experience) blinded of the patients clinical pictures; and then they nearly reached a
The regional ethics committee approved the study and written informed consent were
obtained from all participants.
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The MR imaging features of our 40 clinical cases are listed in the Table(1), 10 cases
were excluded due to presence of other bony lesions as enthesopathy, spurs & tarsal
tunnel syndrome, also of the 20 control cases one case showed mild edema denoting
mild form of plantar fascitis .
MR imaging criteria in 3 patients, one patient aged 30 years, the other two at age group
(46-55) aging 47 & 50 years respectively, these patients were having partial tear of the
PS, showed partial high T2-weighted signal intensity of the plantar fascia. In the three
patients, abnormal thickening of the PA at the site of partial disruption was evident.
Tears involved the proximal PA was present in one case and no tear at the middle PA
was observed. The three cases showed edema in perifascial soft tissue with high signal
intensity on T2-WI . Fascial thickening & scar tissue was depicted with low signal intensity
on T2-WI, and STIR images.
MR imaging studies in the 27 patients with plantar fasciitis , 10 patients at age group
(25-35), 11 at age group (36-45) & 6 at age group (46-55) revealed the signal intensity
changes of perifascial edema either superficial to (n = 11) or both superficial and deep to
(n = 16) the PA . In 13 patients, the PA exhibited abnormal intrafascial high signal intensity
on T2-weighted images, STIR images, or both. The PA was abnormally thickened (5-7
mm) in 20 patients.
20 healthy non complaining control group were examined, one person showed
superfascial edema of the plantar fascia denoting mild fasciitis, while the rest of the control
group showed no abnormality.
Accordingly, out of the 40 patients; 10 cases (25% ) were clinically complaining but
radiologically free. On the other hand, one of the control non complaining group turned
to have mild plantar fasciitis that accounts for 1/20 = 0.05%
MRI findings Pt. (no. 40 ) Control (no 20%)
Rupture of PA 3
Soft tissue edema
Facial thickening 3
Plantar faciaitis 27
Intra fascial edema
Fascial thickening 20
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Images for this section:
Fig. 1: MRI right ankle joint , Sagittal STIR, shows abnormal peri-plantaris high signals
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Fig. 2: MRI Right ankle, Sagittal STIR, shows abnormal high signals of peri-plantaris
edema deep to it ( arrow ) with mildly thickened plantaris facia ( arrow heads )
Fig. 3: MRI Left ankle, Sagittal STIR, shows abnormal high signals of peri-plantaris
edema superfecial deep to it as well as abnormal high signals disrupting it partially
( arrow ) with mildly thickened plantaris facia ( arrow head )
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Fig. 4: MRI Right ankle, Sagittal STIR, shows abnormal high signals of peri-plantaris
edema superfecial deep to it as well as abnormal high signals disrupting it partially
( arrow )
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The plantar fascia is a thick, ligamentous connective tissue that runs from the calcaneus
to the ball of the foot. This tight tissue helps to maintain the arch of the foot and transmits
weight across the foot as person walks or runs. That's why tremendous stress is placed
on the plantar fascia.(6)
Heel pain is a very common complaint in adults especially in females. It is estimated that
more than one million patients seek treatment annually for this condition. The Plantar
fasciitis is thought to be the most common cause & is mainly due to biomechanical
overuse , thus creating microtears at the calcaneal enthesis.(7)
Some experts have deemed this condition "plantar fasciosis," implying that its etiology is
a more chronic degenerative process versus acute inflammation.(8)
Far and away the most common cause of plantar fascia pain is faulty biomechanics of
the foot or leg. Faulty biomechanics causes the foot to sustain increased or prolonged
stresses over and above those of routine ground contacts.(9)
High-heeled shoes can limit proprioception where the heel hits the ground first followed
by the toe .It has been shown that high heeled stiff shoes restrict the inversion/eversion
of the foot, which can lead to an increase in rearfoot pronation , therefore showing that
the stiffer the shoe, the more the natural foot motion is restricted.(10)
Not only is the normal foot motion restricted by shoes, it has also been shown that wearing
high heeled shoes restricts other biomechanics aspects of the foot.(10)
Forefoot to rearfoot eversion/inversion and abduction/adduction were restricted by shoes,
as well as forefoot spreading, which is important for comfort as well as natural gait, and
forefoot pronation during push-off. (11)
Plantar fasciosis can be confused with a condition called tarsal tunnel syndrome. In tarsal
tunnel syndrome, the tibial nerve is trapped and pinched as it passes through the tarsal
tunnel. This may cause symptoms similar to the pain of a Plantar fasciosis/fasciitis , in
this study , the suspected cases to have tarsal tunnel syndrome were investigated with
nerve conduction study & were all free.(12)
In all our patients suspected of having plantar fasciitis,high signal intensity consistent
with edema in the perifascial soft tissue was appreciated on T2-weighted images & STIR
images as well . Our findings are in agreement with those of a previous studies, in which
the perifascial edema was considered the most common manifestation of plantar fasciitis.
(13) In our patients with plantar fasciitis, soft-tissue edema superficial and deep to the PA
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was the dominant abnormal imaging finding in 90% of cases , that frequency for edema
superficial to the PA was reported previously .
The second most common MR imaging finding of plantar fasciitis, seen in 66% of our
patient , was mild thickening of the PA, corresponding to the presence of granulation
tissue. This finding was more common in our study than was previously reported .(13)
Then, the following MR imaging finding of plantar fasciitis, observed in 23 % of our cases,
was increased signal intensity within the involved plantar fascia on T2-weighted and STIR
images; this finding was consistent with edema , this findings did not match with the other
studies , we believe that the difference may be contributed to the different number of
patient & the plenty of exclusion criteria .(13)
In patients with a clinical diagnosis of partial rupture of the PA, MR imaging allowed
diagnosis of the case ,exact localization, and determination of severity of the lesion with
regard to the thickness of the affected PA.
In the examined volunteers with age matching not wearing high heels , onecase for mild
edema & plantar fasciitis was seen only among the group , raising the consideration to
the effect of high heel on the PA.
As we preceded , the causes of plantaris fascia pain were lots & we tried to exclude some
causes both by clinical examination & laboratory investigations , so that we come to a
conclusion that a relation is present between the presence of plantar fascial pathology &
high heel in absence of other obvious causes of heel pain .
In conclusion , MRI was helpful in diagnosis of pathology of the plantar fascia In our
patients with a clinical diagnosis of rupture of the PA, MR imaging allowed demonstration,
exact localization, and determination of severity of the lesion with regard to the thickness
of the affected PA. Depicting the relation between the complain , physical examination &
the presence of high heel in absence of any other cause for the presence of either PA
rupture or fasciitis/fasciosis, & drawing a line correlating the high heel & plantar fascial
We recognize that although the patients show the similar symptoms & similar imaging
findings , yet the implication of this examination over a larger population may help support
SAMEH AHMED ZAKY KHODAIR, MD
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RASHA LOUTFY YOUNES, MD
1-Amir Ahmady , Ehsan Soodmand , Iman Soodmand , Thomas L Milani. The effect of
various heights of high-heeled shoes on foot arch deformation: Finite element analysis.
Journal of Foot and Ankle Research. 2014; 7(Suppl 1):A78
2-Yu J . Biomechanical simulation of high-heeled shoe donning and
walking. Journal of Biomechanics. 2013, 46(12):2067-2074.
3- James.D.Goff and Robert Crawford. Diagnosis and Treatment of Plantar Fasciitis.
American Family Physician. 2012 , 84(6)
4-Thomas JL, Christensen JC, and Kravitz SR. The diagnosis and treatment of heel pain:
a clinical practice guideline-revision. J Foot Ankle Surg. 2010; 49(3 suppl):S1-S19.
5-Eugene G. McNally, and Shilpa Shetty. Plantar Fascia: Imaging Diagnosis and Guided
Treatment .Semin Musculoskelet Radiol. 2010;14:334-343.
6-Hedrick MR. The plantar aponeurosis. Foot Ankle. 1996; 17:646-649.
7-Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for
patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle
8-Karr SD. Subcalcaneal heel pain. Orthop Clin North Am. 1994; 25:161-173.
9-Lemont H, Ammirati KM, and Usen N. Plantar fasciitis: a degenerative process
(fasciosis) without in#ammation. J Am Podiatr Med Assoc. 2003; 93(3):234-237.
10-Yu J, et al: Development of a finite element model of female foot for
high-heeled shoe design. Clinical Biomechanics. 2008, 23:S31-S38.
11-Esenyel M, et al: Kinetics of high-heeled gait. Journal of the American
Podiatric Medical Association. 2003, 93(1):27-32.
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12-Bailie DS, Kelikian AS. Tarsal tunnel syndrome: diagnosis, surgical technique, and
functional outcome. Foot Ankle. 1998; 19:65-72.
13-Grasel R, Schweitzer M, Kovalovich A, et al. MR imaging of plantar fasciitis:
edema, tears, and occult marrow abnormalities correlated with outcome. AJR. 1999;