| | HEEL PAIN
Doorway information about patient
the patient is a 35-year-old man who comes to the clinic due to 1 week of left heel pain.
Vital signs
. Temperature : 37’C
. Blood pressure : 120/70 mmHg
. Pulse : 80 /min
. Respirations : 12 /min
Approach to the patient
Assessing patients with musculoskeletal symptoms requires understanding of the -underlying anatomy- and acute and chronic application of force interacts with patients factors(eg , age , bod y habits) to produce disease . Orthopedic disorders can be categorized by associating to injury-acute injury , chronic/ repetitive injury, or atraumatic disorders.
Physical examination in orthopedics benefits form having a broad selection of specific , well-validated -maneuvers -(eg, Lachman test for anterior cruciate ligaments injury , Thessaly test for meniscal tear)/ In most cases , it is worthwhile to examine the joints immediately - above and below- the symptomatic area to avoid missing additional injuries and rule out referred pain.
Different diagnosis
Differential diagnosis of heel pain
Plantar facilities
. pain maximum upon first stepping out of bed
. Local point tenderness with dorsiflexion of the toes
Ruptured plantar fascia
. Sudden -onset pain
. Loss of height of the arch
. Visible swelling or ecchymosis
Bone infection/ Metastasis
. Constant throbbing pain
. Nocturnal Worsening
Calcanea stress fracture
. Worse with activity
. Palpation of the bone elects tenderness
Tarsal tunnel syndrome
. Pain , paresthesia & numbness on the sole of the foot
. Percussion tenderness over the posterior tibial nerve in the tarsal tunnel
For heel pain , the differential diagnosis is driven primarily by location . Chronic pain at the plantar aspect is usually due to -plantar fasciitis-. Risk factor include obesity , running /jogging , dancing , prolonged standing , and yes plants (flat feet). The pain is usually worst when first stepping out of bed and may improve as the day progresses. Examination shows point tenderness at the insertion of the plantar fascia on the calcaneus and increased pain with dorsiflexion of the toes.
HISTORY AND PHYSICAL EXAMINATION
The following section include many of themes common items that should be included in the evaluation of heel pain.
History
History of present illness
. Please tell me about your pain.
. Where do you feel it ? Dose the pain seem to radiate from here ?\
. When did you first noticed the pain ? Did it start suddenly , or did it come on slowly?
. Have you had accidents / trauma involving your foot ?
. On a scale 1 to 10 , with 10 being the worst ,how would you rate the severity of your pain?
. What dose the pain feel like ( eg,sharp , dull, burning , aching)?
. Dose anything make the pain better or worse?
. Is the pain always there , or is it coming & going ?
. Do you think it is getting worse over time?
. How long dose an episode last & how often do episodes occur?
. Do you stand for long periods during the day?
. Do you walk a lot during the day?
. Do you have other joint or back pain?
. Do you have nay joint stiffness in the morning that improves as the days goes on?
. Have you been diagnosed with bone , muscle , or joint disorders?
. Do you have diabetes or problems with your circulation?
Past medical history
. Have you been diagnosed with other medical conditions(eg, diabetes , osteoarthritis)?
. Have you had any surgeries?
Physical examination
Musculoskeletal
. Inspect the foot for deformity.
. Palpate foot for tenderness (especially insertion of plantar fascia).
. Evaluate range of motion at ankle.
. Palpate tendons during flexion to evaluate for tendinitis.
. Examine spine of range of motion & tenderness in sacroiliac joints,
. Examine knee & metatarsophalangeal joints.
Cardiovascular
. Assess regional pulses.
. Inspect for varicosities & signs of venous stasis.
Neurologic
. Test light touch , vibration & joint position sense in the foot.
Skin
. Inspect for ulcerations , calluses & dermal atrophy.
Closing the encounter
Follow the history and physical examinations , the diagnosis of musculoskeletal conditions his often apparent ( especially if there are positive findings on specific maneuvers .) however , your discussion should address the need for any additional testing . As musculoskeletal disorders are frequently discussed in popular culture and the ay media , you should allow adequate time for patient to ask questions and to tactfully counsel them on any misconceptions they may have .
Diagnostic studies
Patient with acute trauma warrant an expedited evaluation including imaging , as do those with chronic symptoms the are not improving as expected. However , if patient are experiencing gradual improvement , it may be best to simply counsel hem on appropriate measures (eg, activity modification) and defer additional testing . For the USMLE step 2 CS , if no additional testing is needed , write , “No studies indicated” In the diagnostic studies section of the documentation.
Most evaluations in orthopedics begin with plain film x-rays , which can identify acute fractures and many chronic disorders (eg, osteoarthritis) . X-rays have low sensitivity for soft -tissue injuries , but may reveal bony deformity that predispose the patient to chronic complications .
For plantar fasciitis specially , x-rays are rarely helpful and the diagnosis is usually made based on clinical features . Imaging frequently identifies nonspecific abnormalities (eg, ligamentous calcification) that do not correlate with symptoms and are not useful for clinical decision making .
Other studies that can be considered for musculoskeletal disorders include:
. Inflammatory markers: Erythrocyte sedimentation rate , C-reactive protein (usually one or he other but not both)
. Serologic studies : Antinuclear antibody, rheumatoid factor(do not order unless there are signs of specific autoimmune disorder)
. Joint aspiration : Gram stain , culture , cell count, polarized microscopy(for crystals)
. MRI: Useful for soft -tissue and ligament injury , but not frequently ordered as a first -line test
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2018/05/24 09:55pm 
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