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Atypical symptoms in young patient only when standing

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Paze, Nov 17, 2014.

  1. Paze

    Paze Member


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    Patient:
    24 years old, white male, normal weight, non-smoker, moderate/heavy drinker (10-15 a week), no illnesses, no significant family history.

    Sxs:
    BILATERAL plantar pain ongoing for 6+ years, claims pain originates AROUND aponeurosis attachment, traveling to the rest of the sole the longer subject stands still. When standing still, pain appears wherever patient places weight. Sxs subside when patient starts walking. No pain in the morning and pain is LEAST after resting.

    Plantar Fasciitis (PF) diagnosed various times by various physicians but subject has not responded to ANY PF treatments and remedies. MR from previous podiatrist reportedly normal.

    No pain reported while palpating. Aponeurosis quite stiff. Calves a bit stiff, but patient reports having tried stretching them for 6 months a year before, with no improvement. ROM normal.
    Patient reports SLIGHT relief (longer time before sxs appear) using insoles built for flat arches. He also reports that Nike Free 5.0 (shoes) procures sxs faster than other shoes.

    The abnormal sxs of subject is what puzzles me and it would be dubious to diagnose PF with such conflicting sxs. Anyone treated a patient like this?

    Negative for Tarsal Tinel's. Pain seems structural in nature.
     
  2. Craig Payne

    Craig Payne Moderator

    Articles:
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  3. Paze

    Paze Member

    Re: Atypical sxs in young patient only when standing

    No sign of Baxter's upon palpation and pain does not subside after a while. Patient claims pain gets progressively worse no matter how long he stands, until he sits down. Sxs seem to indicate something structural. Pain is reportedly not tingling or numbing in nature. No pain at night unless patient has been sitting the entire night at the computer (vascular?).
     
  4. Re: Atypical sxs in young patient only when standing

    What does "sxs" mean? Remember, not everyone uses the same acronyms or abbreviations.

    Also, where exactly is the pain? The plantar aponeurosis "attaches" to the plantar plates, fifth metatarsal base, plantar skin of the metatarsophalangeal joints, and medial calcaneal tubercle. So, which one of these attachments is it?:confused:

    If the pain is at the medial calcaneal tubercle, what is it about this patient's symptoms that is not consistent with proximal plantar fasciitis?
     
  5. Paze

    Paze Member

    Re: Atypical sxs in young patient only when standing

    Sxs = symptoms. Sorry.

    I thought I had written that it was the calcaneal fastening, but I see that I did not. I will edit the post (Edit: I can't seem to do that. I think there is a time-frame on that.)

    Would you say that it isn't extremely abnormal for the patient to have Plantar Fasciitis when the patient experiences no pain in the morning or after resting, no pain when walking, only when standing still and remedies such as orthotics, taping, stretching and NSAIDS do not alleviate the patients symptoms?

    Also the pain isn't isolated to the calcaneal fastening, it seems to start there acutely when standing on hard surface and placing weight on the heel but within 5 minutes, the pain appears wherever the patient places weight, be it laterally, medially, distally from the calcaneus or on the calcaneus. I think the symptoms are a lot like what we'd call "tired feet", but a patient should not experience this after 5 minutes.
     
  6. Paze

    Paze Member

  7. Re: Atypical sxs in young patient only when standing

    Paze, it would be nice to know your real name and where you practice. You will find that you will get many more responses from more experienced podiatrists here on Podiatry Arena if you give a little more information about yourself.

    In my 30 years of seeing patients with plantar heel pain, I have found that plantar heel pain is often due to a "calcaneal contusion" where the plantar calcaneus bone/periosteum is sensitive to the pressure from ground reaction force. Generally, I would treat this type of heel pain with activity modification, cortisone injections and a well-molded, tight and deep heel cupped, well-cushioned custom foot orthosis to reduce the ground reaction force acting on the plantar calcaneus in addition to boot-brace walker therapy if more severe.

    Not all types of plantar heel pain are due to "over-stretching" of the plantar aponeurosis. I estimate that at least one half of the plantar heel pain (i.e. what we call "proximal plantar fasciitis") patients that I see in my practice have symptoms that are largely due to the compression forces from ground reaction force acting on their plantar calcaneus, and are not solely due due to the tension force from the plantar aponeurosis acting on the plantar calcaneus.

    You must examine your patient more thoroughly for points of heel tenderness with firm manual pressure and then, when he is in your office, have him stand for long enough to detect exactly where the plantar calcaneus is tender. I can almost guarantee you the point of maximum tenderness will be directly plantar to the medial calcaneal tubercle if he is standing in a plantigrade position.

    Sometimes, the only diagnostic test that will show an abnormality with these patients is a technetium bone scan which will often detect increased radio-isotope activity in the plantar calcaneus of these patients. If an MRI is performed, make sure it is a 3.0 Tesla coil MRI that will allow one to better detect the plantar calcaneal bone edema that may accompany this condition. Also when these "plantar heel contusions" are more serious, firm manual side to side (i.e. medial to lateral) compression on the body of the calcaneus will elicit symptoms.

    In addition, ask if the patient walks barefoot at home (or anywhere for that matter) and what type of flooring he has in his home (i.e. tile, marble, padded carpet, hardwood floor) since many patients walk around barefoot or in sock feet in their homes. Does he do any sports? What type of work does he do? These are all parts of the proper history that must be taken to determine what factor may be causing his plantar heel pain.

    Please keep us informed with your progress with this patient since this will be very instructional for the others following along.

    Hope this helps.:drinks
     
  8. Paze

    Paze Member

    Re: Atypical sxs in young patient only when standing

    Thank you for your insight. I will provide further information after our next session.

    As I'm not used to using the internet for consult and am just trying it now, are there laws against sharing MR/CT photos with other physicians on the internet, if the patient consents to it?
     
  9. Re: Atypical sxs in young patient only when standing

    As long as you do not provide the patient's face or name (the condition can't be associated with a specific person), then you are free to share this information publicly on the internet.
     
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