Sonographic Evaluation of Plantar Hindfoot Pain in Athletes

To provide an anatomy-based review of musculoskeletal ultrasound (US) in the evaluation of plantar hindfoot pain in athletes. This review summarizes normal sonographic anatomy, characteristic findings, diagnostic utility, and limitations for plantar fascia, heel fat pad, calcaneal, peripheral nerve, vascular, and foreign-body pathology. It also examines how US findings should be integrated with the history and physical examination in athletes.

Recent studies support high-resolution, dynamic US as a useful imaging modality for plantar hindfoot pain. US enables real-time assessment, contralateral comparison, sonopalpation, and evaluation during dynamic maneuvers. Emerging literature has further characterized the layered structure and loading behavior of the heel fat pad, dynamic sonographic findings of fat pad fracture and subluxation, and assessment of peripheral nerve entrapment. Recent studies also demonstrate that plantar fascia, heel fat pad, and other hindfoot abnormalities are prevalent in asymptomatic athletes. Although sonographic abnormalities may be associated with future time-loss injury, their low positive predictive value limits their role as a screening tool. MRI remains important when evaluating suspected calcaneal stress injury, marrow pathology, or complex soft-tissue disease. US is an accessible and valuable modality for the assessment of plantar heel pain in athletes. A structured, symptom-driven examination may improve diagnostic precision and identify alternative or coexisting pathology. Sonographic findings should be correlated with symptom location, physical examination, and sonopalpatory pain, particularly because structural abnormalities are common in asymptomatic athletes.