Plantar Vein Thrombosis Mimicking Tendinopathy

Abstract

Teaching point : Plantar vein thrombosis is a rare condition that should be considered in the differential diagnosis of ankle pain, particularly in patients with a high clinical index of suspicion for venous thrombosis.

Magnetic Resonance Imaging Features of Plantar Vein Thrombosis

“…Perforating veins play a crucial role in the venous drainage of the foot, serving as an ascending venous pump, making the connection between the deep veins and the superficial dorsal venous arch [ 28 , 29 , 30 ]. Among these, the first interspace metatarsal perforator is the primary connector between the deep veins and the superficial veins and could potentially serve as the origin of PVT [ 1 , 28 ].…”

Imaging Features of Plantar Vein Thrombosis: An Easily Overlooked Condition in the Differential Diagnosis of Foot Pain

“…On the other hand, medial plantar veins are smaller, and thrombosis could be more difficult to be appreciated for this reason. Also important are the perforating veins of the foot that make connections between the deep and superficial veins at the superficial dorsal venous arch, acting as an ascending venous pump [11][12][13]. In the foot, perforating veins show distinctive features from lower limb veins, with some of them being valveless and allowing bidirectional flow or presenting inverted valves and enabling flow from deep to superficial veins [11].…”

“…Findings with US are similar to that of a DVT in other segments, including loss of venous compressibility, venous dilatation, lack of flow on Doppler study, and intraluminal content leading to filling defects (Figures 2-4) [1,2,4,8]. Forefoot PVT is difficult to evaluate using ultrasound due to the proximity of osseous structures and thickness of plantar skin and subcutaneous layer, causing artifacts and attenuation of the US beam, especially in patients with obesity and thickened skin [8,13]. Even with targeted Doppler ultrasound examination of the forefoot veins, sensitivity can be low due to small size of the vessels and anatomic variations [23].…”

“…For this reason, in our experience, MRI has shown to be particularly helpful in evaluating thrombosis of the foot, thus radiologists should actively assess plantar veins on every forefoot and ankle MR reading. Forefoot PVT is difficult to evaluate using ultrasound due to the proximity of osseous structures and thickness of plantar skin and subcutaneous layer, causing artifacts and attenuation of the US beam, especially in patients with obesity and thickened skin [8,13]. Even with targeted Doppler ultrasound examination of the forefoot veins, sensitivity can be low due to small size of the vessels and anatomic variations [23].…”

“…As per the authors' experience, the increased use of MRI to assess foot pain in the clinical workflow has led to PVT being frequently diagnosed first on MRI, with the method also being helpful to exclude other causes of plantar pain [13]. One of the critical points to be emphasized, based on the literature reviewed and the authors' experience, is the use of US in the context of diagnosing PVT, where this diagnosis is missed in two common scenarios.…”