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A 34-year-old female complained of insidious onset of pain in the posterior aspect of the right ankle, which began about 3 months ago when she began a jogging program, but which had not worsened significantly until last week. The pain is worse in the morning and after prolonged positions. The patient denies numbness or tingling in the foot or ankle area. The increase in pain this past week had prompted the patient to visit her MD, who prescribed physical therapy, and gave her a heel lift to wear in each of her shoes.

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List the structure(s) and differential diagnoses that may be involved with complaints of unilateral heel pain related to running.

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Given the presentation, the structures involved and the differential diagnosis for this individual should include the following: a fat pad disorder, plantar fasciitis, flexor tendonitis, superficial Achilles bursitis, retrocalcaneal bursitis, Haglund’s syndrome, Achilles tendonitis, tibialis posterior tendonitis, and flexor hallucis longus tendonitis. There is no indication in the history that this is a vascular or neurologic condition, but rather an inflammatory condition.

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What does the history of no significant worsening of the pain tell the clinician?

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This type of history is typical with chronic inflammatory conditions.

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Why do you think the patient’s symptoms are worse after rest?

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Chronic inflammatory conditions tend to produce soreness and stiffness following rest or immobilization.

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What additional questions would you ask?

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Questions should be directed as to whether the physician gave a diagnosis to the patient when prescribing the heel lifts, whether the pain is worse when jogging is initiated but improves with exercise, and whether the patient changed something (intensity, duration, etc.) in their training regimen in the past week.

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What is your working hypothesis at this stage? If you have a number of hypotheses, which tests would you use to rule out each one?

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Of the conditions listed in the differential diagnosis, it would be difficult to rule out any on the history alone. Further examination is warranted to isolate the various structures.

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Does this presentation/history warrant a lower quarter scanning examination? Why or why not?

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This presentation does not warrant a lower quarter scanning examination as there is nothing in the history to suggest a systemic, vascular, or neurologic cause for the symptoms. On the contrary, the symptoms appear to have a mechanical basis.

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  • Gait analysis revealed:
    • Evidence of antalgic gait on right during stance phase.
    • Premature heel-off.
    • Excessive pronation during stance phase on right.
    • Right lower extremity held in external rotation during gait.
  • Crepitation felt with palpation during ...

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