Case BBR 549

[NousDefionsDoc]

S - 50 y/o WM, WDWN c/o "left heel hurts"X9 months after running on rocky road in jungle boots.

O - VS WNL, PERRLA, gait normal when walking-PT unable to run, no overt signs of trauma to (L) foot.

[shadowflyer]

I am thinking calcaneus spur or chip that only presents when shock of running occurs. Poss stress FX to area?

Any edema noted on exam? PMS intact? Full range of motion?


Fire away gentleman.

[NousDefionsDoc]

Any edema noted on exam? PMS intact? Full range of motion? No, Yes, Yes

[shadowflyer]

Ok, No edema and PMS and Range of Motion intact.

SAMPLE/OPQSRT

Focused Physical Exam based on CC and HX.

Normal Gait , is there pain to palpation? Does it hurt when he walks but the pain is manageable to maintain a normal gait?


I am just trying to narrow this down.

Does the pain radiate at all? Does anything make it better or worse?

[Sacamuelas]

Discomfort upon palpation of area?

When standing on affected side is there pain in the back of the ankle when pushing off the ball of the foot ?

[NousDefionsDoc]

Minimal pain on palpation, but he is as tough as woodpecker lips - Old SAS, so hard to tell. Same when standing on affected side.

No edema. No radiation. Nothing makes it better - running makes it worse.

[shadowflyer]

Well damn. I am going to drop back and research some more.

[Doc T]

Originally posted by NousDefionsDoc
Minimal pain on palpation, but he is as tough as woodpecker lips - Old SAS, so hard to tell. Same when standing on affected side.

No edema. No radiation. Nothing makes it better - running makes it worse.

has he tried anything on his own to make it better? nonsterioidals like the motrin you all hand out like candy? where is the pain.... at the bottom of the heel? posteriorly along the tendon?

doc t.

[NousDefionsDoc]

has he tried anything on his own to make it better? nonsterioidals like the motrin you all hand out like candy? where is the pain.... at the bottom of the heel? posteriorly along the tendon?

He is not running, and that is what worries me. When a man that hard stops an activity on his own due to pain....

I have him on SF Candy - 800mg TID for unrelated Old Dude Syndrome in his knees. I'm hoping to get some collateral benefit for the foot problem.

Pain is on the bottom, about center of the heel. Seems to be a point almost. He didn't have any trouble showing me with one finger - went right to it. I was thinking tendon as well, but the geography doesn't fit. I tend to think he has a deep bruise from stepping down on a rock. The thing that bothers me is the time without improvement. Of course he hasn't been inactive all that time either, he's been walking and standing alot.

I've ordered him to change his footware as well.

[Kyobanim]

Not to butt in here since I'm a medically challenged person but I do have the Old Dude Syndrome.

I get something that sounds similar. Localized pain, no color, swelling, but an intense pain in one spot. I've gotten it from stepping on a rock or something similar though it can happen from a sharp blow also. I get them on my arms and hands when sparring. Candy and not using the offended item usually makes the pain go away within 5 to 7 days. If I keep using it the pain stays the same.

Maybe it's age related? Lots of weird things start happening at this age.

[NousDefionsDoc]

All opinions welcome.

[shadowflyer]

NDD,

You might suggest to him some Oregon Aerosoles. I have read about them and our Surgicalcric friend swears by them.


Just a suggestion.

Jason

here is the link

Oregon Aerosoles (http://www.oregonaero.com/p109_04.html#ShockBlockers)

[Surgicalcric]

Bone spur that has just now reared its head?

I would think if its pinpoint and in the center of the heel it would be either a chipped bone or a spur.

I would not think it would be a stone bruise, kyobanim, not with the elapsed time, but good guess.

Call for a portable X-ray...lol.

[Sacamuelas]

NDD-
If you have ruled out any posterior heel/achilles tendon etiologies.. then I, too, am thinking along the same lines as Cric. especially with your deescription of its exact location being on the plantar surface verses posterior heel along the tendon insertion.

My WAG:
O- plantar calcaneal spur (having that Xray Cric wants might be helpful:D )

[Sacamuelas]

another view...

[NousDefionsDoc]

That looks like the spot. Thanks

[shadowflyer]

Plantar Fasciitis due to Posterior Calcaneus Spur



???

[Sacamuelas]

Shadow-
From my understanding from the literature, it is more likely the opposite. Hx of chronic plantar fasciitis leading to calcanous spur formation or just a ideopathic heel spur. Although, the radiographic evidence of spurs can be a nonpathologic consequence of aging in some individuals. Just seeing observation of their presence on X-ray does not indicate need for treatment.

Another pic..

[shadowflyer]

And that folks is why he is a Doctor and I am not. I was just going on the fact that the spur is superior to the plantar fascia and that the spur was rubbing on the fascia causing the fasciitis.


Edit....

Man this place is awesome, some serious learning and training going on in here. Thanks Dr Saca

[Sacamuelas]

Shadow-

I only offer suggestion/advice based on symptoms, likelyhood of occurence, and knowledge of the anatomy of the area. NDD knows that, I just don't want you to put to much stock in internet forum advice.

***edit- Joke pickin on myself removed due to the likelyhood of hijacking NDD's thread with follow-up cracks. LOL