Case Report
Copyright ©The Author(s) 2019.
World J Orthop. Sep 18, 2019; 10(9): 339-347
Published online Sep 18, 2019. doi: 10.5312/wjo.v10.i9.339
Table 1 Key considerations when approaching heel pain
LocationAsking the patient to point with a finger over the point of greatest discomfort allows for narrowing of diagnosis. Subsequent provocation tests or history enquiring of exacerbating factors will provide greater clarity regarding the underlying pathology[30].
AgeIn the middle aged (> 45 years old) and elder patients (> 65 years old), degenerative causes such as tendinopathies should be considered[32-34,49]. Whereas in the young, traumatic or overuse injuries such as stress fractures and acute tendinitis are more common[31,36-38].
Trauma and stress injuriesFundamental to most orthopaedic history-taking, a recent traumatic injury should be ascertained. Radiographic evaluation to rule out fractures should there be a positive history of trauma[4]. In addition, nature of activity as well as occupation will provide insight as to whether patients are at risk of repetitive stress. Athletes as well as manual laborers are predisposed to repetitive strain injuries or tendinitis.
Pain characteristicCharacterising pain allows assessment of whether the pain is mechanical or non-mechanical. Start-up pain coupled with progressive worsening with activities may suggest a degenerative or inflammatory cause[30], whilst pain at rest and in the night may suggest a more sinister pathology.
Red flagsWhilst rare, it is crucial to exclude sinister causes of plantar heel pain. Tumour: Constitutional symptoms like loss of appetite and loss of weight as well as pain disrupting sleep are red flags suggestive of more systemic pathology[50]. Prompt and advanced imaging modalities are warranted. Infection: Classic features of inflammation – calor, dolor, rubor and tumour coupled with systemic symptoms of fever and malaise are suggestive of an infective process. Both radiological and laboratory tests are crucial in establishing diagnosis as well as evaluating its severity.
OthersNeurologic: Patients with compressive neuropathy can present with foot discomfort. In the presence of paraesthesia or numbness, it would be prudent to screen the spine for potential nerve root compression. Rheumatologic: Patients with inflammatory arthritis can present with heel pain. In patients with polyarthropathy, laboratory investigations looking at inflammatory and autoimmune markers are advisable.