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 49 yr old man with heel pain  

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A 49-year-old factory foreman comes to your office with a 2-month history of increasing left heel pain. He notes the gradual onset of left heel pain over that last 2 months and cannot remember a specific injury to the heel. He states that the pain is in the middle of the heel, sharp, and most severe when he first arises from bed and stands, often requiring that he tiptoe to the bathroom. The pain gradually lessens as he walks in the house and on the factory floor during his workday. He has tried acetaminophen, without relief. His medical history is significant only for diet-controlled hypertension. He has no ocular complaints.

Physical examination reveals a mildly obese man in no distress. Temperature is 37.2 °C (98.9 °F), pulse rate is 76/min, and blood pressure is 138/88 mm Hg. The left ankle is nontender to palpation and has full range of motion without pain. The Achilles tendon is nontender but has slightly decreased range of motion in dorsiflexion. The plantar surface of the left foot shows no swelling or erythema. The heel is tender to palpation 4 cm from the posterior margin on the plantar surface. Mediolateral compression of the heel does not elicit tenderness, and the arch exhibits mild pes planus. Examination of the right foot is unremarkable.

The most appropriate next step in diagnosis and management of this patient’s condition is:

A) Radiograph of the foot to rule out compression fracture
B) Injection of long-acting corticosteroid at the site of heel pain
C) Use of heel cups and Achilles tendon–stretching exercises
D) Podiatric referral for plantar fascia release
E) Podiatric referral for neurectomy


it is A, :roll:


I think planter fascitis. Ans is B


i think its c


Doctor Zaki what's the answer :?: :oops:


sorry for answering late, c is the answer filiz and the explanation is

Plantar fasciitis is the most common cause of heel pain. It usually presents with a subacute onset over several weeks, with the initial pain being diffuse and migratory before localizing to the plantar aponeurosis. It is most often unilateral but is bilateral in about 15% of patients; when bilateral, it is sometimes a finding in Reiter’s syndrome. Classic symptoms of plantar fasciitis include pain with walking or standing, which is worse on first standing in the morning but improves as walking is continued. Risk factors for this condition include pes planus, excessive ankle pronation, tightness of the Achilles tendon, obesity or sudden weight gain, excessive walking or standing on hard surfaces, increases in running distance or intensity, and shoes with poor cushioning. Differential diagnoses for heel pain include heel pad syndrome, which usually exhibits acute onset following trauma to the heel, and calcaneal stress fracture, which symptomatically worsens with continued walking or running. Patients with nocturnal heel pain should be evaluated for neuropathic pain, infection, or malignancy.
The physical examination in plantar fasciitis reveals tenderness to palpation at the calcaneal origin of the plantar fascia, a dime-sized area approximately 4 cm from the posterior margin of the heel. Tightness of the Achilles tendon, manifested by decreased dorsiflexion of the ankle by more than 5 degrees (normal, 25 to 30 degrees), is seen in 78% of patients. Other findings can include pes planus and evidence of excessive ankle pronation on walking. Pain on palpation of the entire plantar surface of the heel suggests heel pad syndrome. Pain on calcaneal compression (squeeze test) should raise suspicion of calcaneal stress fracture, especially in runners; a radiograph of the heel should be obtained in patients with this finding. Radiographs of the foot in plantar fasciitis will often show a heel spur, but this is present in patients without the condition and thus has no diagnostic value.
Although plantar fasciitis is usually a self-limiting condition, symptoms can persist over several months in spite of conservative treatment. Treatment of plantar fasciitis is aimed at protecting the inflamed fascia and increasing Achilles tendon flexibility. Padded heel cups (three-quarters to full length) are recommended, as are well-padded shoes. Avoidance of prolonged walking or standing is recommended, and 10 to 15 minutes of icing after activities such as these are helpful. Exercises that stretch the Achilles tendon through separate gastrocnemius (passive foot dorsiflexion with knee extended) and soleus (knee flexion while foot is dorsiflexed) muscle stretching are helpful and should be performed daily. Nonsteroidal anti-inflammatory medications are helpful for acute inflammation. Night splints, which hold the Achilles tendon in 5-degree dorsiflexion, have been used with good results. For persistent cases, local injection of a long-acting steroid preparation is indicated. Referral to a podiatrist or orthopedist is appropriate for refractory cases (usually after 12 months of conservative treatment). Surgical options include plantar fascia release with or without calcaneal spur excision. There is currently no role for neurectomy.

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