A 54-year-old man comes to the office due to left foot pain. The patient has had progressively worsening pain for the last month since starting a walking program to help lose weight. He has been walking 2-3 miles each morning and has pain and a stabbing sensation in the sole of his left foot at the end of the walks. The pain usually improves with rest and typically does not recur during normal activity. The patient has used ibuprofen and ice for pain relief. He has type 2 diabetes mellitus; his most recent hemoglobin A1c was 7.9%. Medical history is also notable for appendectomy, cholecystectomy, and bilateral carpal tunnel release. Vital signs are normal. BMI is 36 kg/m². The left foot has a normal arch. When the toes are dorsiflexed, there is tenderness to palpation between the heel and forefoot. There is no pain with firm palpation along the back or sides of the heel. Sensation and range of motion are normal. Which of the following is the most likely cause of this patient's pain?

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11ec25c8_d2c4_4dfc_bc81_83daf0fa54ab_MD0003_00 This patient with heel pain that is worse with weight bearing has plantar fasciitis. The plantar aponeurosis (deep plantar fascia) is a fibrous band that extends from the calcaneus to the toes and supports the longitudinal arch of the foot. Plantar fasciitis is characterized by inflammation and degeneration of the aponeurosis due to overuse and repetitive stress. It is common in middle-aged adults, especially those who are obese. The pain is typically worst during the first steps of the day but gets better during the day (eg, does not recur with normal activity); the pain also worsens after long periods of standing or walking. plantar aponeurosis Examination in plantar fasciitis shows tenderness at the insertion of the plantar fascia on the calcaneus, which is worse during passive dorsiflexion of the toes. Initial management includes activity modification (eg, avoiding walking barefoot), stretching, and padded heel inserts. Symptoms may take months to completely resolve. (Choice A) Calcaneal stress fractures can occur after initiation of a high-impact exercise program. They cause heel pain with weight bearing, but the pain is elicited by pressure at the sides of the heel (calcaneal squeeze test) rather than at the insertion of the plantar fascia. (Choice B) Charcot joint (neurogenic arthropathy) presents with deformity and sensory deficits of the foot. Because it relates to recurrent trauma due to impaired proprioception and pain sensation, the pain is typically mild. (Choice C) X-ray in patients with plantar fasciitis may show calcifications in the proximal fascia (heel spurs), but this is neither sensitive nor specific. Heel spurs are a late sign of inflammation and degeneration in the proximal plantar fascia but are not the cause of pain. calcifications in the proximal fascia (Choice D) Morton (interdigital) neuroma is mechanically induced neuropathic degeneration of the interdigital nerves. It presents with numbness or pain at the distal forefoot between the third and fourth toes. The pain is often reproduced by squeezing the forefoot across the metatarsals but is not aggravated by palpation between the heel and forefoot. (Choice F) Tarsal tunnel syndrome is caused by compression of the tibial nerve under the flexor retinaculum at the medial ankle. It presents with numbness and paresthesia at the toes and distal sole. The pain is provoked by percussion at the tarsal tunnel, not stretching of the plantar fascia. Educational objective: Plantar fasciitis presents with pain at the sole of the foot that is worse with prolonged weight bearing or with the first steps of the day. The pain may be reproduced by palpation of the insertion of the aponeurosis on the calcaneus with dorsiflexion of the toes. X-ray may show calcifications in the proximal fascia (heel spurs), but this is neither sensitive nor specific. References: Diagnosis and management of plantar fasciitis. (http://www.ncbi.nlm.nih.gov/pubmed/25429080)

A 54-Year-Old Man Comes to the Office Due to Left