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Review Question - QID 108969

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QID 108969 (Type "108969" in App Search)
A 24-year-old woman presents to her primary care physician’s office complaining of right foot pain for the last week. She first noticed this pain when she awoke from bed one morning and describes it as deep at the bottom of her heel. The pain improved as she walked around her apartment but worsened as she attended ballet practice. The patient is a professional ballerina and frequently rehearses for up to 10 hours a day, and she is worried that this heel pain will prevent her from appearing in a new ballet next week. She has no past medical history and has a family history of sarcoidosis in her mother and type II diabetes in her father. She drinks two glasses of wine a week and smokes several cigarettes a day but denies illicit drug use. At this visit, the patient’s temperature is 98.6°F (37.0°C), blood pressure is 117/68 mmHg, pulse is 80/min, and respirations are 13/min. Examination of the right foot shows no overlying skin changes or swelling, but when the foot is dorsiflexed, there is marked tenderness to palpation of the bottom of the heel. The remainder of her exam is unremarkable. Which of the following is the best next step in management?

Orthotic shoe inserts



Glucocorticoid injection



Plain radiograph of the foot



Resting of the foot



Ultrasound of the foot



Select Answer to see Preferred Response

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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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