A 46-year-old woman comes to the physician because of right heel pain that is particularly severe upon getting out of bed in the morning. The pain has been present on and off for 6 weeks, but has recently intensified. It sometimes persists most of the day and can make walking difficult. She denies pain at night, foot numbness, or any recent trauma to the area. She is not a runner/jogger and has not recently worn any new footwear. She denies any history of back pain or stiffness or pain in other joints. Her review of systems is otherwise negative. She has tried over-the-counter NSAIDS with limited relief. She was diagnosed with breast cancer 3 years ago and was treated with lumpectomy followed by chemoradiation. Her current medications include tamoxifen and a multivitamin.
Her vital signs are normal. BMI is 29 kg/m². There is good range of motion at both ankles. There is no warmth, swelling, or deformity of either foot or ankle. There is no pain/discomfort when tapping with a reflex hammer inferior to the medial malleolus on either foot. She has pain in the right central heel that is increased by dorsiflexion of the toes. The Achilles tendon is not tender throughout its length. Lateral compression of the calcaneus does not elicit pain.
Which of the following is the most likely cause of her heel pain?

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11ec193a_9923_5587_853d_977a573dec7a_MD0002_00 This patient's history and examination is characteristic for plantar fasciitis, which is one of the most common causes of foot pain. People at risk include overweight individuals, runners/joggers, ballet dancers, those who engage in prolonged standing, and those with pes planus (flat feet). The pain is usually worst when first stepping out of bed and may improve as the day progresses. Examination reveals local point tenderness with dorsiflexion of the toes. The condition is usually unilateral but can be bilateral. Most patients have complete resolution of the pain within one year with conservative measures such as plantar stretching exercises, short-term NSAIDs use, and silicone heel shoe inserts. If these measures fail, corticosteroid injections can provide temporary relief. Shock-wave therapy and surgery are reserved for those who have failed conservative measures for 6-12 months. (Choice A) Pain caused by a neoplasm is typically constant and persists at nighttime. (Choice B) Calcaneal fractures are associated with constant foot pain that worsens with activity. Stress fractures are most common in runners and often occur after increased activity. Palpation of the bone elicits tenderness, which is not present in this patient. (Choice C) Heel spurs are commonly associated with plantar fasciitis and are likely secondary to inflammation of the fascia (reactive bone formation). However, their causal role is unclear. Thus, the presence of a heel spur on lateral foot x-ray does not help in either confirming or ruling out plantar fasciitis. (Choice E) Spondyloarthropathies and reactive arthritis are sometimes associated with heel pain at the insertion of the Achilles tendon (enthesitis). However, there is usually associated back pain and stiffness (spondyloarthropathy) or urethral, ocular, and/or gastrointestinal symptoms (reactive arthritis). Educational objective: Plantar fasciitis usually presents with heel pain that is most intense on the first step upon arising. Examination shows local point tenderness with dorsiflexion of the toes. The condition usually resolves with conservative measures such as plantar stretching exercises and short-term NSAID use. __________ References: Plantar fascia-specific stretching exercise improves outcome in patients with chronic plantar fasciitis. (http://www.ncbi.nlm.nih.gov/pubmed/16882901) Plantar fasciitis: evidenced-based review of diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/16342847)

A 46-Year-Old Woman Comes to the Physician Because of Right