CASE 24 - Heel Pain

Question 1

Doctor, can you just give me some powerful pain meds so that I can keep running? I am training for a marathon.

Answer 1

First, we need to do a complete evaluation to determine the cause of your pain. Then we can discuss the nature of your tx.

Question 2

When does it hurt in the morning?

Answer 2

It hurts the most with the first few steps I take after I get out of bed.

Question 3

PEx:

Answer 3

1. CV ==> A + distal pulses + cap refill of the toes.
2. Chest ==> A.
3. Abdo ==> A + P.
4. Extr ==>

—Inspection of both feet and ankles—non-weight bearing, weight bearing, and with ambulation.
—Palpation of medical calcaneal tuberosity—Achilles tendon—Plantar fascia—Retrocalcaneal bursae.
—Passive ROM 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.

5. Neuro ==> Checked sensation to light touch for dermatomes of foot and ankle — assessed ankle reflex.

Question 4

DDx:

3+3 + 2

Answer 4

1. Plantar fasciitis.
2. Calcaneal stress fracture.
3. Achilles tendinitis.
4. Heel frax.
5. Splinter/foreign body.
6. Foot sprain.
7. Retrocalcaneal bursitis.
8. Tarsal tunnel syndrome.

Question 5

Workup:

Answer 5

1. XR-R ankle/foot.
2. Bone scan.
3. MRI-R ankle/foot.

Question 6

Q1:

Answer 6

When does it hurt in the morning ==> It hurts the most with the first few steps I take after I get out of bed.

Question 7

Q2:

Answer 7

Burning — Tingling — Numbness.

Question 8

Extr — What to write?

Answer 8

Posterior tibialis and dorsalis pedis pulses 2+ bilaterally.
Mild bilateral rear/midfoot pronation.
ROM of hip/knee/ankle and foot WNL.
Tender to palpation over medial calcaneal tuberosity and plantar fascia.
Plantar heel and arch pain with dorsiflexion of toes.

Question 9

Neuro — what to write:

Answer 9

Motor: Strength 5/5 in hip/knee/ankle and foot.
Sensation: Intact to light touch in saphenous, sural, and deep/superficial peroneal nerve distribution (dermatomes L4-S1).
DTRs: 1+ in Achilles tendon.
Gait: Non-antalgic gait pattern.

Question 10

Calcaneal stress fracture:

Answer 10

1. Calcaneus is 2nd only to the metatarsals in terms of stress fractures of the foot.
2. Diffuse heel pain that is made worse by medial and lateral compression.

Question 11

Retrocalcaneal bursitis:

Answer 11

1. Posterior heel pain.
2. Commonly caused by ill-fitting footwear that has a poorly fitting, rigid heel cup.
3. Conservative management ==> analgesics + proper show wear + heel padding.