A 55-year-old woman comes to the clinic due to foot pain. For the past 4 weeks, the patient has had gradually increasing pain in her left heel. The symptoms are worse when she walks, and lately, it has become difficult to ambulate. The patient recently started an exercise program that includes running, swimming, and bicycling. Vital signs are normal. BMI is 34 kg/m². Pedal pulses are full and symmetric bilaterally. The ankle has normal range of motion in all directions. Squeezing the heel laterally and medially reproduces the pain. Examination of the forefoot is normal, with no pain on dorsiflexion or plantar flexion of the toes. Which of the following is the most appropriate next step in management of this patient?

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11ec25c8_d86e_a6fe_bc81_9b2aa37351c7_MD0003_00 This patient likely has a calcaneal stress fracture, which is caused by repetitive microtrauma in high-impact activities (eg, running, jumping). It typically follows an abrupt increase in exercise or a transition of activities to hard surfaces. Calcaneal stress fracture is more common in women, and the risk is increased by obesity. Most calcaneal stress fractures form in the posterior calcaneus. posterior calcaneus Calcaneal stress fracture presents with heel pain that is worse with ambulation, especially during the first steps of the morning or after rest; this can be misdiagnosed as plantar fasciitis. On examination, pain is elicited by medial-lateral squeezing of the calcaneus (ie, calcaneal squeeze test). The diagnosis can be confirmed on imaging; x-ray typically shows a zone of lucency or sclerosis in the posterior calcaneus. If x-ray is nondiagnostic, MRI has a higher sensitivity. Treatment includes analgesics and reduction of weight-bearing activities. Heel pads or walking boots that dissipate impact during ambulation are also recommended. Calcaneal stress fracture usually heals well with conservative management. (Choice A) Vitamin D deficiency is associated with osteoporosis and can increase the risk of stress fracture. However, vitamin D testing would not establish the diagnosis of calcaneal stress fracture. If imaging confirms a fracture, additional testing can be considered later. (Choice B) Corticosteroid injection can be used for tarsal tunnel syndrome (ie, compression neuropathy of the posterior tibial nerve), which causes burning heel pain that radiates to the plantar forefoot and is reproduced by tapping over the nerve inferior to the medial malleolus (Tinel sign). Corticosteroid injections should be used carefully with heel pain because they carry a risk for fat pad atrophy, which can worsen calcaneal stress fracture. (Choice C) Plantar fasciitis is a common cause of exercise-related heel pain, but the pain is reproduced by palpation of the insertion of the plantar fascia on the calcaneus, not lateral squeezing. Initial treatment of plantar fasciitis includes activity modification and soft heel inserts; surgery is reserved for refractory cases. insertion of the plantar fascia (Choice D) An air-stirrup brace is most commonly used to stabilize the ankle after lateral ligament sprain, which occurs with acute inversion injuries. The pain is usually centered in the inframalleolar lateral ankle. Educational objective: Calcaneal stress fracture is caused by repetitive microtrauma to the calcaneus (eg, abrupt increase in running). On examination, the pain is elicited by medial-lateral squeezing of the calcaneus, and the diagnosis is confirmed with imaging (x-ray or MRI). References: Heel pain: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/29365222) Stress fractures of the foot and ankle in athletes. (http://www.ncbi.nlm.nih.gov/pubmed/25364480)

A 55-Year-Old Woman Comes to the Clinic Due to Foot