Comment to: Spontaneous plantar vein thrombosis: state of the art by Karam L, Tabet G, Nakad J, Gerard JL. Phlebology 2013;28:432.

In the last 20 years, less than 20 cases of plantar vein thrombosis were reported in the literature. Current ultrasound investigation protocols for deep venous thrombosis neglect this entity which is also not specifically mentioned in therapeutic guidelines. Case 1: An 82-year-old man presented for a left foot plantar pain. Foot X-rays and duplex sonography of the deep venous system were unremarkable; plantar fasciitis was diagnosed and non-steroidal anti-inflammatory drugs were given. One week later, physical examination revealed swelling and tenderness of the plantar side of the foot with retromalleolar tenderness and slight redness extending below and above the medial malleolus. A new Duplex sonography showed enlarged non-compressible left lateral plantar veins with a 10 cm extension of the thrombus to the posterior tibial veins. The patient was put under low molecular weight heparin and switched later to anti vitamin K for a three-month period. Investigations did not reveal any malignancy however, one year later, colonoscopy was performed in the setting of a rectal bleeding and an adenocarcinomatous lesion was discovered. Case 2: A 57-year-old female who presented with one-week history of spontaneous left foot plantar pain. She had no history of foot trauma, recent surgery and was not under any hormonal treatment. Physical examination revealed tenderness along the lateral course of the plantar side of the left foot with a discrete swelling. A contrast-enhanced magnetic resonance imaging revealed filling defects in one of the left lateral plantar veins, confirmed by a color Doppler ultrasound showing the non-compressible vein. The patient was put under low molecular weight heparin followed by anti-vitamin K therapy for a three-month period. Duplex control showed complete re-permeabilization of the vein. A complete hypercoagulation investigation revealed slightly positive anticardiolipine antibodies and heterozygote mutations of the MTHFR gene and the G20210A mutation of the prothrombin gene. In front of a unilateral plantar pain plantar fasciitis, described as first-step pain, is the most common cause, followed by plantar fibromatosis, Morton’s neuroma, stress fractures of the metatarsal bones, tendon abnormalities and ganglion cysts, while retromalleolar redness and tenderness may suggest erysipelas, arthritis, hyperuricemia and neuroalgodystrophia. In plantar veins thrombosis cases usually predisposing factors are present, as recent surgery, trauma, infection, malignancy, airplane travel, use of contraceptive pills. Thrombophilia should be highly suspected in the absence of other predisposing factors, specially the G20210A prothrombin mutation. In over 50-year-old patients with no evident predisposing factors, undiagnosed malignancy should be ruled out. For treatment, the use on anticoagulation for a three-month period is recommended.