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Orthotic shoe inserts
Plain radiograph of the foot
Resting of the foot
Ultrasound of the foot
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This patient presents after intensive ballet practice with heel pain notable on dorsiflexion, which is most consistent with plantar fasciitis. The best next step in management is resting of the foot.Plantar fasciitis is inflammation of the plantar fascia aponeurosis and typically presents as heel pain with walking. Athletes such as runners and ballerinas are the most common group to be affected. Patients often note that the pain is worse in the morning after a period of inactivity at night, improved with gradual movement, then worse throughout the day with additional use. Examination should include dorsiflexion of the foot to pull the plantar fascia taut, and there will be tenderness to palpation at the plantar heel where the fascia inserts. There is almost never any visible inflammation, and there should be no bony tenderness. Of note, when attempting to distinguish plantar fasciitis from Achilles tendionopathy, the latter tends to present with posterior heel pain and swelling. When clinical suspicion for plantar fasciitis is high, rest and ice with NSAIDs as needed are the recommended course of action. Imaging and more invasive or elaborate measures are unnecessary before first attempting conservative treatment. Incorrect Answers:Answer 1: Orthotic shoe inserts are commonly marketed for plantar fasciitis but have not been proven to be of benefit. Footware choices in general are, however, important for plantar fasciitis, as flat shoes or barefoot walking are known to exacerbate symptoms. Answer 2: A glucocorticoid injection may be used in plantar fasciitis that is refractory to conservative therapy. It has been proven efficacious for short-term relief but should be used sparingly due to the risk of heel pad atrophy. Answer 3: Plain radiograph of the foot would be useful for identifying overt fractures or stress fractures, which many athletes may encounter from overuse. Although a calcaneal stress fracture is possible as a cause of heel pain in this patient, her presentation is more consistent with plantar fasciitis, which is much more common. Answer 5: Ultrasound of the foot may reveal plantar fascial thickening or other signs of inflammation, but it is largely unnecessary as clinical suspicion of plantar fasciitis is high. If the patient’s pain is refractory to rest and conservative measures, this mode of imaging may be pursued for confirmation of the diagnosis. Bullet Summary:Plantar fasciitis is common in runners and ballerinas and presents with pain on the plantar surface of the heel that is worse with the first few steps of the day and overuse; treatment is rest and symptom management.
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