Case 24 - 31 yo M with heel pain

Question 1

Gathering information

Answer 1

Constitutional symptoms (fevers, chills, sweats, N/V/D/C, appetite or weight changes, fatigue)

Question 2

Physical examination

Answer 2

CV exam (auscultation, distal pulses, including posterior tibialis and dorsalis pedis, capillary refill of toes)
Pulmonary exam
Abdominal exam
Extremities (inspection of both feet and ankles, palpation of medial calcaneal tuberosity, Achilles tendon, plantar fascia and retrocalcaneal bursae, passive range of motion and general strength of ipsilateral knee and hip, ankle dorsiflexion and great toe extension and passive range of motion, strength testing of ankle dorsiflexion and plantar flexion
Neurologic exam (sensation to light touch in feet and ankle, Achilles tendon reflex)

Question 3

Closure

Answer 3

Obtain an XR to confirm there are no fractures or bone spurs
Refer to physical therapy
If not improved over the next two months, consider a bone scan to R/O stress fracture
Do you have any questions for me?

Question 4

Differential diagnosis

Answer 4

Plantar fasciitis (marathon training, pain worse with first few steps, tenderness over medial calcaneal tuberosity, pain with toe dorsiflexion)
Calcaneal stress fracture (refractory to conservative management, diffuse pain over heel, tenderness over plantar heel and arch)
Achilles tendinitis (marathon training, pain with toe dorsiflexion)

Question 5

Diagnostic work-up

Answer 5

XR - right ankle/foot
Bone scan
MRI - right ankle/foot

Question 6

Dorsiflexion

Answer 6

Pivoting foot at ankle UP

Question 7

Plantar flexion

Answer 7

Pivoting foot at ankle DOWN

Question 8

Plantar fasciitis

Answer 8

Tenderness to palpation at medial calcaneal tuberosity
Pain during passive dorsiflexion
Pain worst during first few steps when walking