First Aid for the USMLE Step 2 CS

Section 4. Practice Cases

Case 24. 31-Year-Old Man with Heel Pain

DOORWAY INFORMATION

Opening Scenario

Will Foreman, a 31-year-old male, comes to his primary care physician complaining of heel pain.

Vital Signs

BP: 125/80 mm Hg Temp: 99.0°F (37.2°C)

RR: 14/minute HR: 69/minute, regular

Examinee Tasks

1. Take a focused history.

2. Perform a focused physical exam (do not perform rectal, genitourinary, or female breast exam).

3. Explain your clinical impression and workup plan to the patient.

4. Write the patient note after leaving the room.

Checklist/SP Sheet

Patient Description

Patient is a 31 yo M.

Notes for the SP

 Pretend to have pain on the bottom of your right heel and into the arch of your right foot when the examinee extends your toes (moves them up).

 Exhibit pain when the examinee palpates the arch of your right foot and the bottom of your right heel.

 Give the appearance of pain with the first few steps you take after sitting.

Challenging Questions to Ask

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

Sample Examinee Response

“First we need to do a complete evaluation to determine the cause of your pain. Then we can discuss the nature of your treatment.”

Examinee Checklist

Building the Doctor-Patient Relationship Entrance

 Examinee knocked on the door before entering.

 Examinee introduced self by name.

 Examinee identified his/her role or position.

 Examinee correctly used patient’s name.

 Examinee made eye contact with the SP.

Reflective Listening

 Examinee asked an open-ended question and actively listened to the response.

 Examinee asked the SP to list his/her concerns and listened to the response without interrupting.

 Examinee summarized the SP’s concerns, often using the SP’s own words.

Information Gathering

 Examinee elicited data efficiently and accurately.

Connecting with the Patient

 Examinee recognized the SP’s emotions and responded with PEARLS.

Physical Examination

 Examinee washed his/her hands.

 Examinee asked permission to start the exam.

 Examinee used respectful draping.

 Examinee did not repeat painful maneuvers.

Closure

 Examinee discussed initial diagnostic impressions.

 Examinee discussed initial management plans:

□ Follow-up tests: X-ray of right ankle.

 Examinee asked if the SP had any other questions or concerns.

Sample Closure

Mr. Foreman, the most likely cause of your heel pain is plantar fasciitis, which is the most common cause of pain on the bottom of the heel. It typically resolves over a few months, with conservative treatment consisting of stretching, massage, NSAIDs, and avoidance of painful activities. I would highly suggest that you decrease the amount of running you do and avoid walking barefoot on hard surfaces until this improves. We will get an x-ray today to help confirm that there is no obvious fracture or foreign body and to look for possible bone spurs. If you would like, I can send you to physical therapy to help you get started on these exercises. If your symptoms are not responsive to this treatment over the next 2 months, we may consider a bone scan to rule out a stress fracture. Do you have any questions for me?

History

HPI: 31 yo M c/o pain on the plantar surface of his right heel. The pain started gradually about 2 weeks ago and has not progressed. The patient denies trauma or a specific inciting event but admits to training for a marathon. He describes the pain as intermittent and states that it is worse after getting out of bed in the morning and after prolonged sitting. He reports that the pain has a tearing/stretching quality and that it can get as high as 7/10. He has used ice, massage, and occasional ibuprofen for the pain, with limited relief. The patient denies any tingling, burning, or numbness. He denies proximally radiating symptoms but does report occasional pain radiating into his arch.

ROS: Denies nausea/vomiting, weight/appetite changes, fever/chills, diarrhea/constipation, or fatigue.

Allergies: NKDA.

Medications: Occasional ibuprofen.

PMH: None. Denies cancer, rheumatologic disorders, or diabetes.

PSH: None.

SH: No smoking, 1-2 beers/week, no illicit drugs. Works as an accountant; sexually active with wife of 10 years. Marathon runner.

FH: Father with arthritis. Denies FH of cancer, rheumatologic disorders, or diabetes.

Physical Examination

Patient is pleasant and in no acute distress.

VS: WNL.

Chest: Clear to auscultation bilaterally.

Heart: RRR; normal S1/S2; no murmurs, rubs, or gallops.

Abdomen: Soft, nontender, nondistended,BS.

Extremities: Posterior tibialis and dorsalis pedis pulses 2+ bilaterally; mild bilateral rear/midfoot pronation; range of motion 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.

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

Differential Diagnosis

CASE DISCUSSION

Patient Note Differential Diagnoses

Heel pain in adults can be caused by several distinct entities. For this reason, it is essential that the examiner ascertain the precise location of the symptoms, as this is the first step in determining the most likely diagnosis.

 Plantar fasciitis: The most common cause of plantar heel pain in adults, plantar fasciitis typically results from repetitive use or excessive loading (eg, training for a marathon). Pes planus, pes cavus, decreased subtalar joint mobility, and a tight Achilles tendon can all predispose to plantar fasciitis. The pain is typically gradual in onset and worse with the first few steps in the morning and after prolonged sitting. Examination reveals marked tenderness over the medial calcaneal tuberosity and increased pain with passive dorsiflexion of the toes. Conservative management includes analgesics, stretching, exercise, orthotics, and night splinting.

 Calcaneal stress fracture: The calcaneus is second only to the metatarsals in terms of stress fractures of the foot. Stress fractures are common in athletes who are involved in running or jumping sports as well as in patients who have risk factors for osteopenia. Patients typically have diffuse heel pain that is made worse by medial and lateral compression. A calcaneal stress fracture may be considered in this patient if his symptoms prove refractory to conservative management. Follow-up diagnostic testing (eg, x-ray, bone scan) may then be warranted.

 Achilles tendinitis: Patients with Achilles tendinitis typically complain of posterior heel pain either on the Achilles tendon insertion site or on the tendon itself during running, jumping, and harsh activities. Tenderness to palpation, swelling, and nodules along the Achilles tendon are common. Pain may also increase with passive dorsiflexion of the ankle. Again, this condition is commonly due to overuse or to poor biomechanics. Conservative management includes rest, analgesics, and stretching/strengthening exercises.

Additional Differential Diagnoses

 Retrocalcaneal bursitis: Patients with this condition usually complain of posterior heel pain secondary to chronic irritation of the underlying bursae. The bursae are located between the posterior calcaneus and the Achilles tendon and between the Achilles tendon and the skin. The condition is commonly caused by ill-fitting footwear that has a poorly fitting, rigid heel cup. It can also be associated with Haglund’s deformity (a bony spur on the posterosuperior aspect of the calcaneus), which may exacerbate the condition. Conservative management includes analgesics, proper shoe wear, and heel padding.

 Tarsal tunnel syndrome: The tarsal tunnel is on the medial aspect of the heel and is formed by the flexor retinaculum traversing over the talus and calcaneus. Compression of the tibial nerve in the tunnel can lead to pain, burning, tingling, or numbness that can radiate to the plantar heel and even to the distal sole and toes. Symptoms may be exacerbated by percussion of the tarsal tunnel or with dorsiflexion and eversion of the foot. Conservative management includes analgesics and correction of foot mechanics with orthotics.

 Foreign body: If a foreign body is suspected, the foot should be inspected for signs of an entrance wound. The patient may or may not describe a mechanism of injury. Signs of local infection such as warmth, erythema, pain, induration, or a fluctuant mass should also be sought. Conservative management includes foreign body removal, topical antimicrobials, and appropriate dressing.

 Ankle sprain: Ankle ligament injuries are the most common musculoskeletal injury, with the lateral collateral ligament complex most commonly involved. Patients typically describe an injury pattern consistent with “rolling” the ankle, often in the plantarflexed and inverted position. Examination reveals tenderness to palpation over the involved ligaments and increased laxity on stress testing. Significant edema and ecchymosis are often present in the acute/subacute stages. Conservative treatment involves rest, ice, compression, elevation, NSAIDs, and bracing.

Diagnostic Workup

 XR—right ankle/foot: X-rays in this region may demonstrate calcaneal spur formation (calcification) at the proximal plantar fascia (as in this patient) or at the Achilles tendon insertion. Care must be taken to correlate these findings with symptoms and with the physical examination, as such calcification can also be seen in asymptomatic patients. Increased prominence of the posterosuperior calcaneus (Haglund’s deformity) may also be demonstrated.

 Bone scan: If conservative treatment fails in this patient, follow-up with a bone scan is recommended in two months to rule out calcaneal stress fracture, as would be demonstrated by an increased area of uptake.

 MRI—right ankle/foot: Reserved for suspected soft tissue involvement, which could include the degree of Achilles tendon degeneration, rupture of the Achilles tendon, or articular cartilage defects.



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