A 22-year-old woman comes to the office for evaluation of new-onset foot pain. The pain is located at the heel and is most pronounced when she gets up from sitting after a long period of time. The patient is a collegiate soccer player who plays both indoor and outdoor soccer. In addition, she enjoys trail running and occasionally runs barefoot along the beach. Physical examination of the foot shows a moderately high arch with no discoloration or deformity. Direct pressure to the bottom of the heel elicits sharp pain, but mediolateral squeezing of the heel causes no discomfort. Which of the following is the most likely etiology of the patient's foot pain?

Question

A 22-year-old woman comes to the office for evaluation of new-onset foot pain.  The pain is located at the heel and is most pronounced when she gets up from sitting after a long period of time.  The patient is a collegiate soccer player who plays both indoor and outdoor soccer.  In addition, she enjoys trail running and occasionally runs barefoot along the beach.  Physical examination of the foot shows a moderately high arch with no discoloration or deformity.  Direct pressure to the bottom of the heel elicits sharp pain, but mediolateral squeezing of the heel causes no discomfort.  Which of the following is the most likely etiology of the patient's foot pain?

Quizplus · Accepted Answer

11ec25c8_d972_aa0f_bc81_93c9fb66e701_MD0003_00 This patient with heel pain that is worse with weight bearing has plantar fasciitis. Plantar fasciitis is most common in obese, middle-aged adults, but it may also be seen in younger, well-conditioned individuals who participate in high-impact exercise or spend extended periods in bare feet. Plantar fasciitis is characterized by inflammation and degeneration of the plantar aponeurosis (deep plantar fascia), a thick, fibrous band that extends from the calcaneus to the toes and supports the longitudinal arch of the foot. It is thought to be due to chronic overuse and repetitive microtrauma to the aponeurosis and its insertion point at the calcaneus. The diagnosis of plantar fasciitis is based on clinical factors. The pain is often worst when first standing from rest; it may lessen with activity but may again worsen after long periods of standing or walking. Physical examination typically shows tenderness at the insertion of the plantar fascia at the calcaneus, especially with the toes passively dorsiflexed. Patients frequently have preexisting abnormalities of the arch (eg, pes planus, high arch). X-ray may show calcifications in the proximal plantar fascia ("heel spurs"), but this finding is neither sensitive nor specific, and imaging is done primarily to rule out other causes of pain. Initial management includes activity modification (eg, avoiding walking barefoot, reducing high-impact exercise), stretching exercises, and padded heel inserts. However, the plantar aponeurosis recovers slowly; the long-term outcome is generally good, but symptoms may require months or even years for complete resolution. (Choice A) Tarsal tunnel syndrome is caused by entrapment and compression of the tibial nerve where it passes under the flexor retinaculum at the medial aspect of the ankle. It presents with numbness and paresthesias at the toes and distal sole. The pain is provoked by percussion at the tarsal tunnel (not palpation of the heel, as in this patient). (Choice B) Chronic exertion compartment syndrome is related to transient relative ischemia due to muscle expansion within a fixed fascial compartment. It is typically seen in distance runners and presents with episodic muscle pain and paresthesias during strenuous exercise. However, it does not cause pain when standing up from rest or tenderness to palpation of the heel. (Choice C) Achilles tendinopathy is a common cause of exercise-induced heel pain. However, the pain and tenderness are most prominent at the posterior heel, often with palpable thickening of the tendon. Also, the pain is typically reproduced by passive dorsiflexion of the ankle rather than palpation of the heel. (Choice E) Calcaneal stress fractures are typically seen in inexperienced athletes after initiation of a high-impact exercise program. Like plantar fasciitis, they cause pain at the heel that is worse with weight bearing. However, the pain can often be elicited by firm palpation at the sides of the heel (squeeze test). Educational objective: Plantar fasciitis is characterized by inflammation and degeneration of the plantar aponeurosis (deep plantar fascia), a thick, fibrous band that extends from the calcaneus to the toes and supports the longitudinal arch of the foot. It presents with chronic pain at the sole of the foot that is worse with weight bearing. References: Diagnosis and treatment of plantar fasciitis. (http://www.ncbi.nlm.nih.gov/pubmed/21916393)

A 22-Year-Old Woman Comes to the Office for Evaluation of New-Onset