There is real value in defining the underlying pathology in patients with plantar heel pain—not only to guide treatment, but also to avoid interventions that may be ineffective or even harmful.
While both MRI and ultrasound can demonstrate findings of proximal plantar fasciopathy, ultrasound offers several important advantages, including accessibility, superior resolution of superficial structures involved in plantar hindfoot pain, dynamic assessment, and the ability to correlate imaging findings directly with sonopalpatory pain. These principles are emphasized throughout my Plantar Hindfoot Module, where I walk through a systematic scanning protocol, detailed anatomy and live scan, and a comprehensive pathology review.
While treatment recommendations are beyond the scope of this Post, please leave a comment on how you would treat this patient?
Cases with coexisting plantar fasciopathy and a fractured plantar fat pad can be particularly challenging, and often under-recognized. Treatment needs to reflect both pain generators. A number of options exist for the plantar fasciitis (e.g. shockwave therapy, image-guided interventions including PRP, Tenex tenotomy), but there are limited options for the fat pad pathology. Adipose tissue grafting (e.g. Lipogems MFAT) has emerged as an option for plantar forefoot atrophy, and has been successfully used in our clinic for hindfoot atrophy similar to what is seen in this case.