Foot and Ankle cases 25

A healthy 43-year-old female developed insidious onset of plantar right heel pain 2 months ago. She describes an exacerbation of symptoms when initiating weight bearing after getting out of bed in the morning and when transitioning from a seated to standing position during the day. There is no swelling or discoloration around the heel and no complaints of right lower extremity radiculopathy. Pain resolves quickly when the heel is off-loaded. Physical examination demonstrates significant and focal tenderness to directed pressure over the medial tubercle of the calcaneus.

What is the most likely diagnosis?

1. Calcaneal stress fracture

2. Plantar fasciitis

3. Tarsal tunnel syndrome

4. Compression of the first branch of the lateral plantar nerve

5. Symptomatic plantar calcaneal spur

 

Discussion

The correct answer is (B). The patient presents with a typical history of plantar fasciitis. The onset of pain is often insidious without any prior traumatic or overuse event. Pain is often exacerbated when the heel is loaded after a period of offloading or rest. Pain is most pronounced to direct palpation at the origin of the plantar fascia on the medial tubercle of the calcaneus. Symptoms are relieved quickly when the foot is off-loaded. Calcaneal stress fractures typically present with heel swelling and pain to compression of the calcaneal tuber. Tarsal tunnel syndrome is an uncommon condition caused by compression of the posterior tibial nerve within the tarsal tunnel located immediately posterior to the medial malleolus. Symptoms include radiating pain into the plantar aspect of the foot and, less commonly, up the medial aspect of the leg. Compression of the first branch of the lateral plantar nerve (Baxter’s nerve) between the deep fascia of the abductor hallucis muscle and the medial edge of the quadratus plantae muscle can be associated with plantar fasciitis. Pain is aggravated by weight-bearing activity, may radiate to the lateral foot, and often lingers after rest (so-called after burn). Symptoms are reproduced by direct pressure over the nerve deep to the abductor hallucis muscle belly. Approximately

15% of the population has a plantar calcaneal spur with only 5% of this subgroup reporting a history of heel pain. About 50% of patients with plantar fasciitis have a heel spur. Although heel spurs may be present in patients with plantar heel pain, they are not considered the cause.

An appropriate diagnostic workup would include which of the following?

1. HLA-B27 testing

2. MRI

3. Technetium bone scan

4. No further workup is required

 

Discussion

The correct answer is (D). In the vast majority of cases, obtaining a complete history and performing an appropriate physical examination is all that is necessary in making the diagnosis of plantar fasciitis. MRI or bone scan can be helpful when the history and physical examination are not straightforward and obtaining an accurate diagnosis is challenging. Typical MRI findings in cases of plantar fasciitis include increased T2 signal intensity and thickening at the origin of the plantar fascia. Technetium bone scan demonstrates marked increased uptake at the origin of the plantar fascia. The clinician can consider HLA-B27 testing in patients with protracted symptoms, other joint complaints, and bilateral symptoms as part of a greater rheumatological workup.

 

Objectives: Did you learn...?

 

 

 

Identify typical symptoms of plantar fasciitis? Describe differential diagnosis of heel pain? Perform a workup for plantar fasciitis?