DOCSLIB.ORG

When Heel Pain Is Not Plantar Fasciitis

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
When Heel Pain Is Not Plantar Fasciitis ORTHOTICS & BIOMECHANICS When Heel Pain Is Not Plantar Fasciitis Consider the wide variety of differential diagnoses. BY PAUL SCHERER, DPM linicians can consider the fails. None of these diagnoses is com- differential diagnoses be- patible with mechanical control. fore making a pair of or- thotics for plantar fasciitis Alternative Etiologies to Heel Pain or after the orthotic fails • Spondyloarthropathy (SpA) 89 Cto relieve the symptoms. Before is • Rheumatoid arthritis (RA) always better and more efficient, but • Rheumatoid arthritis (JRA) everyone must accept the premise • Systemic lupus erythematosus that there are zebras when treating (SLE) this condition. • Neuropathy For several years, I attended at a • Vascular impairment special problems clinic that allowed • Trauma podiatrists to send their patients for • Gout Figure 1: Enthesis in a young patient with anky- losing spondylitis (Scherer) consultation when their orthotics did • Tumors not work for pathologies that usu- • Calcaneal cyst lower back, along with enthesis of ally responded to custom orthotics. the medial tubercule of the calcaneus The majority of these patients were Spondyloarthropathy (Figure 1). A 1995 paper presented treated for heel pain and plantar fas- This is a group of so-called sero- three cases of young males with heel ciitis but did not improve. Some of these patients had clearly received inappropriate or poorly casted and manufactured orthotic devices but Few podiatrists do a proper differential diagnosis surprisingly, many of the patients when encountering heel pain because it is had good orthotics but did not in fact have plantar fasciitis. such a common disorder. Few podiatrists do a proper dif- ferential diagnosis when encounter- ing heel pain because it is such a negative arthropathies, all of which pain who were treated with injec- common disorder. It is an accepted present with heel pain in various tions and orthoses for approximately concept in medicine, “If you hear forms and ages. The following is a one year before the HLA-B27 test was hoof beats, think horses, not zebras.” brief discussion of each and what the performed and the patients properly But that doesn’t mean there are no literature tells us about this disorder diagnosed and treated.1 zebras in our world and maybe you and heel pain. should know what they look like and Reactive Arthritis where they come from. Ankylosing Spondylitis This disorder was called Reiter’s In the world of heel pain, here This is a strongly genetic disorder syndrome until Dr. Reiter was rec- is the zebra list that every student that the literature suggests occurs ognized as an individual who per- in the special problems clinic was when the HLA-B27 gene is turned on formed human experimentation on required to learn. You can either re- by klebsiella or another GI infection. prisoners at the Buchenwald concen- view it before making the diagno- The pathology is joint fusion and tration camp. sis and orthotic, or after the orthotic bone production, particularly in the Continued on page 90 www.podiatrym.com SEPTEMBER 2016 | PODIATRY MANAGEMENT ORTHOTICS & BIOMECHANICS Heel Pain (from page 89) en pox or herpes simplex. The liter- gins between the ages of 7–12. The ature shows that often the patient same joint pathology as RA exists The disorder is an autoimmune will seek medical care for heel pain, and more often than not it involves reaction, possibly also related to the causing an antalgic gait, before seek- muscle spasm, which affects the HLA-B27 gene’s reaction to chlamyd- ing eye care for their uveitis.6 Heel lower extremity, producing a wide ia, gonorrhea, and more commonly pain, in children, is rarely mechani- variety of symptoms and deformity. HIV infection. Symptoms appear as cal; when associated with what ap- The most common is digital dorsal conjunctivitis, urethritis and arthri- tis. A 1983 review in Rheumatology International listed asymmetrical heel pain as the second most common Systemic lupus erythematosus affects nine times (44%) presenting symptom.2 A later more women than men and presents as a non-erosive 1993 paper of 143 patients demon- strated that 36% presented with uni- arthritis, a photo sensitivity cheek rash, lateral heel pain.3 This disorder is and a 35% chance of heel pain. why non-mechanical heel pain is list- ed as a presenting symptom of HIV infection. pears to be conjunctivitis, it must be subluxation in the toes and spindle Enteropathic Spondylitis investigated for this disorder. Treat- fingers in the hand. This disorder is recognized as ing the heel pain is of no value to the A 2010 Canadian cohort study an arthropathy that is often concur- patient. of 319 patients with JRA demon- rent with inflammatory bowel dis- strated two important findings. First, 90 ease, ulcerative colitis, and Crohn’s Rheumatoid Arthropathies 95% of the patients had a presenting disease. The pathology is not fully (SeroPositive) symptom of a limp and 95% of the understood, but GI infection may ex- The American College of Rheu- patients had heel pain. Second, if a haust the largest immune system in matology in 2011 documented that patient presented with a symptom of the body, leading to bowel symptoms presently 7,416,000 individuals in the a limp, there was a short duration to and possibly arthritic symptoms. A United States are treated for one of confirming a diagnosis, while if they 2011 paper revealed that even before the five major presentations of these had heel pain, it took twice as long to diseases. This leaves 500 make the diagnosis of RA.8 Someone patients for each podiatrist had been dropping the ball. Children in the United States. Many between 7 and 12 do not get plantar present before diagnosis fasciitis. This is a huge clue to appro- with symptoms of heel priate diagnosis and treatment. pain, or heel pain becomes a significant part of their Systemic Lupus Erythematosus presentation after diagno- (SLE) sis. The following describe This “autoimmune” disease af- Figure 2: 50-year old patient with a 20-year history of psoriatic the diseases and the inci- fects nine times more women than arthritis (Scherer) dence of heel pain. men and presents as a non-erosive arthritis, a photo sensitivity cheek the GI infection is evident, or diag- Rheumatoid Arthritis (RA) rash, and a 35% chance of heel pain. nosed, patients present with knee This “autoimmune” arthritis pro- One study group suspected the heel pain (65%) upon their first step in duces synovitis, pannus formation pain was the result of calcaneal stress the morning (62%).4 and nodules (Figure 3) as a pathol- Figure 3: Rheumatoid nodules in the calcaneus ogy, causing joint destruction and causing heel pain (Source unknown) Psoriatic Arthritis severe foot disability and deformity. This is another seronegative au- A 1979 survey demonstrated that al- fractures similar to those that occur toimmune reaction that researchers though the pathology occurs within in the vertebrae of patients with this suspect happens when there is a pep- the foot joints, 21% of the population disease.9 Many of these women are tide defect of the 6th chromosome. experience daily heel pain.7 immediately post-pubescent and Only 25% of the patients that have should not first be suspected of hav- the skin lesions develop arthritic Childhood Rheumatoid Arthritis ing plantar fasciitis, which is ex- symptoms, but of this group fully (JRA) tremely rare in this age and gender 54% report heel pain (Figure 2).5 The etiology of this disease in population. children continues to be a genetic Anterior Uveitis mystery. The term “autoimmune” is Neuropathy This is a rare arthropathy that is also applied to this predominantly This etiologic category contains associated with an eruption of chick- Caucasian female disease which be- Continued on page 91 SEPTEMBER 2016 | PODIATRY MANAGEMENT www.podiatrym.com ORTHOTICS & BIOMECHANICS Heel Pain (from page 90) in 2002 identified heel pain as a con- Trauma sistent hallmark of TTS.10 This is The three traumatic events pro- one etiological factor that might be ducing heel pain are also familiar helped with orthotics, although it is to most podiatrists, but not always masquerading as plantar fasciitis. before first thinking plantar fasci- itis. Stress fractures (Figure 4), en- Neurilemmona thesopathy fractures (Figure 5), and This enlargement of Schwann apophysitis (Figure 6) all have a hall- cells in the myelin sheath of the tibial mark of progressive pain on walking, nerve has been suspected of causing where plantar fasciitis is quite the heel pain. It is suspected of that ir- opposite. ritation from repetitive motion and certain sporting activity causing the Gout Figure 4: Stress fracture of the calcaneus pseudo-tumor; the pressure on the Rarely do practitioners think of (Source unknown) axion causes the heel pain.11 gout when considering heel pain, but Rarely do practitioners think of gout when considering heel pain, but this systemic disease is one of the most common camouflaged diagnoses. 91 Figure 5: Enthesopathy fracture following a ver- Infracalcaneal Nerve Neuropathy this systemic disease is one of the tical fall (Scherer) In a study of twenty-two subjects most common camouflaged diagno- with acute and first-step heel pain, ses. The use of hydrochlorothiazide, EMG demonstrated obstructive sig- alcohol abuse, and renal failure often nals to the first branch of the lateral produce atypical gout pain in the plantar nerve.12 Often this is errone- heel with the hallmark that the pain ously referred to the medial calcaneal is the same intensity weight-bearing nerve, which has little to do with or not. heel pain. Heaslet, in a very inter- esting and important paper on heel Tumors pain, identified the entrapment of the Only 3% of osseous tumors occur lateral calcaneal nerve as producing in the foot, and benign lesions out- heel pain.13 number malignant lesions by 5:1.
Load more

Recommended publications
  • Juvenile Spondyloarthropathies: Inflammation in Disguise
    PP.qxd:06/15-2 Ped Perspectives 7/25/08 10:49 AM Page 2 APEDIATRIC Volume 17, Number 2 2008 Juvenile Spondyloarthropathieserspective Inflammation in DisguiseP by Evren Akin, M.D. The spondyloarthropathies are a group of inflammatory conditions that involve the spine (sacroiliitis and spondylitis), joints (asymmetric peripheral Case Study arthropathy) and tendons (enthesopathy). The clinical subsets of spondyloarthropathies constitute a wide spectrum, including: • Ankylosing spondylitis What does spondyloarthropathy • Psoriatic arthritis look like in a child? • Reactive arthritis • Inflammatory bowel disease associated with arthritis A 12-year-old boy is actively involved in sports. • Undifferentiated sacroiliitis When his right toe starts to hurt, overuse injury is Depending on the subtype, extra-articular manifestations might involve the eyes, thought to be the cause. The right toe eventually skin, lungs, gastrointestinal tract and heart. The most commonly accepted swells up, and he is referred to a rheumatologist to classification criteria for spondyloarthropathies are from the European evaluate for possible gout. Over the next few Spondyloarthropathy Study Group (ESSG). See Table 1. weeks, his right knee begins hurting as well. At the rheumatologist’s office, arthritis of the right second The juvenile spondyloarthropathies — which are the focus of this article — toe and the right knee is noted. Family history is might be defined as any spondyloarthropathy subtype that is diagnosed before remarkable for back stiffness in the father, which is age 17. It should be noted, however, that adult and juvenile spondyloar- reported as “due to sports participation.” thropathies exist on a continuum. In other words, many children diagnosed with a type of juvenile spondyloarthropathy will eventually fulfill criteria for Antinuclear antibody (ANA) and rheumatoid factor adult spondyloarthropathy.
    [Show full text]
  • Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions
    Name of Blue Advantage Policy: Extracorporeal Shock Wave Treatment for Plantar Fasciitis and Other Musculoskeletal Conditions Policy #: 076 Latest Review Date: November 2020 Category: Medical Policy Grade: A BACKGROUND: Blue Advantage medical policy does not conflict with Local Coverage Determinations (LCDs), Local Medical Review Policies (LMRPs) or National Coverage Determinations (NCDs) or with coverage provisions in Medicare manuals, instructions or operational policy letters. In order to be covered by Blue Advantage the service shall be reasonable and necessary under Title XVIII of the Social Security Act, Section 1862(a)(1)(A). The service is considered reasonable and necessary if it is determined that the service is: 1. Safe and effective; 2. Not experimental or investigational*; 3. Appropriate, including duration and frequency that is considered appropriate for the service, in terms of whether it is: • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member; • Furnished in a setting appropriate to the patient’s medical needs and condition; • Ordered and furnished by qualified personnel; • One that meets, but does not exceed, the patient’s medical need; and • At least as beneficial as an existing and available medically appropriate alternative. *Routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000 which meet the requirements of the Clinical Trials NCD are considered reasonable and necessary by Medicare. Providers should bill Original Medicare for covered services that are related to clinical trials that meet Medicare requirements (Refer to Medicare National Coverage Determinations Manual, Chapter 1, Section 310 and Medicare Claims Processing Manual Chapter 32, Sections 69.0-69.11).
    [Show full text]
  • The Painful Heel Comparative Study in Rheumatoid Arthritis, Ankylosing Spondylitis, Reiter's Syndrome, and Generalized Osteoarthrosis
    Ann Rheum Dis: first published as 10.1136/ard.36.4.343 on 1 August 1977. Downloaded from Annals of the Rheumatic Diseases, 1977, 36, 343-348 The painful heel Comparative study in rheumatoid arthritis, ankylosing spondylitis, Reiter's syndrome, and generalized osteoarthrosis J. C. GERSTER, T. L. VISCHER, A. BENNANI, AND G. H. FALLET From the Department of Medicine, Division of Rheumatology, University Hospital, Geneva, Switzerland SUMMARY This study presents the frequency of severe and mild talalgias in unselected, consecutive patients with rheumatoid arthritis, ankylosing spondylitis, Reiter's syndrome, and generalized osteoarthosis. Achilles tendinitis and plantar fasciitis caused a severe talalgia and they were observed mainly in males with Reiter's syndrome or ankylosing spondylitis. On the other hand, sub-Achilles bursitis more frequently affected women with rheumatoid arthritis and rarely gave rise to severe talalgias. The simple calcaneal spur was associated with generalized osteoarthrosis and its frequency increased with age. This condition was not related to talalgias. Finally, clinical and radiological involvement of the subtalar and midtarsal joints were observed mainly in rheumatoid arthritis and occasionally caused apes valgoplanus. copyright. A 'painful heel' syndrome occurs at times in patients psoriasis, urethritis, conjunctivitis, or enterocolitis. with inflammatory rheumatic disease or osteo- The antigen HLA B27 was present in 29 patients arthrosis, causing significant clinical problems. Very (80%O). few studies have investigated the frequency and characteristics of this syndrome. Therefore we have RS 16 PATIENTS studied unselected groups of patients with rheuma- All of our patients had the complete triad (non- toid arthritis (RA), ankylosing spondylitis (AS), gonococcal urethritis, arthritis, and conjunctivitis).
    [Show full text]
  • The Pathomechanics of Plantar Fasciitis
    Sports Med 2006; 36 (7): 585-611 REVIEW ARTICLE 0112-1642/06/0007-0585/$39.95/0 2006 Adis Data Information BV. All rights reserved. The Pathomechanics of Plantar Fasciitis Scott C. Wearing,1 James E. Smeathers,1 Stephen R. Urry,1 Ewald M. Hennig2 and Andrew P. Hills1 1 Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Queensland, Australia 2 Biomechanik Labor, University Duisburg-Essen, Essen, Germany Contents Abstract ....................................................................................585 1. Anatomy of the Plantar Fascia ............................................................586 1.1 Gross Anatomy of the Plantar Fascia...................................................586 1.2 Histological Anatomy of the Plantar Fascia .............................................589 1.2.1 Neuroanatomy ................................................................590 1.2.2 Microcirculation ...............................................................590 1.2.3 The Enthesis ...................................................................590 2. Mechanical Properties of the Plantar Fascia ................................................592 2.1 Structural Properties ..................................................................593 2.2 Material Properties ...................................................................593 3. Mechanical Function of the Plantar Fascia .................................................594 3.1 Quasistatic Models of Plantar Fascial Function ..........................................594
    [Show full text]
  • Extracorporeal Shock Wave Therapy (ESWT) for Plantar Fasciitis and Other Musculoskeletal Conditions
    Extracorporeal Shock Wave Therapy (ESWT) for Plantar Fasciitis Page 1 of 62 and Other Musculoskeletal Conditions Medical Policy An Independent licensee of the Blue Cross Blue Shield Association Title: Extracorporeal Shock Wave Therapy (ESWT) for Plantar Fasciitis and Other Musculoskeletal Conditions Professional Institutional Original Effective Date: July 11, 2001 Original Effective Date: July 1, 2005 Revision Date(s): November 5, 2001; Revision Date(s): December 15, 2005; June 14, 2002; June 13, 2003; October 26, 2012; May 7, 2013; January 28, 2004; June 10, 2004; April 15, 2014; April 14, 2015; April 21, 2005; December 15, 2005; August 4, 2016; January 1, 2017; October 26, 2012; May 7, 2013; August 10, 2017; August 1, 2018; April 15, 2014; April 14, 2015; July 17, 2019, March 11, 2021 August 4, 2016; January 1, 2017; August 10, 2017; August 1, 2018; July 17, 2019, March 11, 2021 Current Effective Date: August 10, 2017 Current Effective Date: August 10, 2017 State and Federal mandates and health plan member contract language, including specific provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. To verify a member's benefits, contact Blue Cross and Blue Shield of Kansas Customer Service. The BCBSKS Medical Policies contained herein are for informational purposes and apply only to members who have health insurance through BCBSKS or who are covered by a self-insured group plan administered by BCBSKS. Medical Policy for FEP members is subject to FEP medical policy which may differ from BCBSKS Medical Policy. The medical policies do not constitute medical advice or medical care.
    [Show full text]
  • Conditions Related to Inflammatory Arthritis
    Conditions Related to Inflammatory Arthritis There are many conditions related to inflammatory arthritis. Some exhibit symptoms similar to those of inflammatory arthritis, some are autoimmune disorders that result from inflammatory arthritis, and some occur in conjunction with inflammatory arthritis. Related conditions are listed for information purposes only. • Adhesive capsulitis – also known as “frozen shoulder,” the connective tissue surrounding the joint becomes stiff and inflamed causing extreme pain and greatly restricting movement. • Adult onset Still’s disease – a form of arthritis characterized by high spiking fevers and a salmon- colored rash. Still’s disease is more common in children. • Caplan’s syndrome – an inflammation and scarring of the lungs in people with rheumatoid arthritis who have exposure to coal dust, as in a mine. • Celiac disease – an autoimmune disorder of the small intestine that causes malabsorption of nutrients and can eventually cause osteopenia or osteoporosis. • Dermatomyositis – a connective tissue disease characterized by inflammation of the muscles and the skin. The condition is believed to be caused either by viral infection or an autoimmune reaction. • Diabetic finger sclerosis – a complication of diabetes, causing a hardening of the skin and connective tissue in the fingers, thus causing stiffness. • Duchenne muscular dystrophy – one of the most prevalent types of muscular dystrophy, characterized by rapid muscle degeneration. • Dupuytren’s contracture – an abnormal thickening of tissues in the palm and fingers that can cause the fingers to curl. • Eosinophilic fasciitis (Shulman’s syndrome) – a condition in which the muscle tissue underneath the skin becomes swollen and thick. People with eosinophilic fasciitis have a buildup of eosinophils—a type of white blood cell—in the affected tissue.
    [Show full text]
  • Advice and Exercises for Patients with Plantar Fasciitis
    Advice and exercises for patients with plantar fasciitis This leaflet provides management advice and exercises for people diagnosed with plantar fasciitis, a condition causing pain in the heel, sole and /or arch of the foot. Structures of the foot The plantar fascia is a sheet or broad band of fibrous tissue that runs along the bottom of the foot. This tissue connects the heel to the base of the toes. Under normal circumstances, the plantar fascia supports the arch of the foot and acts as a shock absorbing “bow string” within the arch of the foot. With weight bearing, the foot flattens and the plantar fascia stretches, then springing you forward ready for the next step. While walking, the stresses placed on the foot can be one and a quarter times your body weight (this increases to two and three quarter times your body weight when running). Unsurprisingly then, that heel pain is common. If tension on this “bowstring” becomes too great, irritation or inflammation can occur causing pain. What is plantar fasciitis? Plantar fasciitis is a relatively common foot problem affecting up to 10-15% of the population. It can occur at any age. It is sometimes known as “policeman’s heel”. When placed under too much stress due to abnormal loading, the plantar fascia stretches causing micro tearing and degeneration of the tissue. It can lead to pain in the heel, across the sole of the foot and sometimes into the arch area of the foot too. These micro tears repair with scar tissue, which is less flexible than the fascia and can cause the problem to persist for many months.
    [Show full text]
  • Plantar Fasciitis
    Recent Advances in Orthotic Therapy for Plantar Fasciitis An Evidence Based Approach Lawrence Z. Huppin, D.P.M. Assistant Clinical Professor, Western University of Health Sciences, College of Podiatric Medicine Disclosures I disclose the following financial relationships with commercial entities that produce health care related products and services relevant to the content of this lecture: ◦ Employee (Medical Director) of ProLab Orthotics, manufacturer of foot orthoses Our Goals . Review Three Studies that Help Optimize Clinical Outcome of Custom Foot Orthoses Used to Treat Plantar Fasciitis • Cause of Plantar Fascial Tension • Forefoot Wedging Effect on Plantar Fascial Tension • Arch Contour Effect on Plantar Fascial Tension . Develop a “pathology specific” orthosis prescription to most effectively treat plantar fasciitis . Offloading Excessive Fascia Tension is Goal of Orthotic Therapy . What Causes Tension? Tissue Stress Theory McPoil, Hunt. Evaluation and Management of Foot and Ankle Disorders: Present Problems and Future Directions. Journal of Orthopaedic & Sports Physical Therapy, 1995 Effect of STJ Pronation on PF Strain . Cannot by itself cause strain of plantar fascia . Can only increase plantar fascia strain via the MTJ • (inversion of the forefoot on the rearfoot) Scherer. “Heel Pain Syndrome: Pathomechanics and Non-surgical Treatment. JAPMA 1991 Effect of Forefoot Inversion on Plantar Fascial Strain 73 patients with 118 painful heels 91% had foot deformity compensated by supination of long axis of MTJ Out of 118 painful heels 63 had forefoot valgus 33 had everted rearfoot 20 had plantarflexed first ray Scherer 1991 What foot types supinate the MTJ? . 47% forefoot valgus . 24% everted heel . 20% plantarflexed first ray Scherer 1991 What foot types supinate the MTJ? .
    [Show full text]
  • Mcl Injuries
    MCL INJURIES Definition Medial Collateral Ligament (MCL) injury is an injury to the ligament on the inner part of the knee. This ligament keeps the shin bone (tibia) in place. It can be a stretch, partial tear or complete tear of the ligament. Causes The MCL is usually injured by pressure or stress on the outside part of the knee. A block to the outside part of the knee during football is a common way for this ligament to be injured. It is often injured at the same time as an anterior cruciate ligament (ACL) injury occurs. Symptoms Symptoms of a tear in the medial collateral ligament are: Knee Swelling Locking or catching of the knee with movement Pain and tenderness along the inside of the joint The knee gives way or feels like it is going to give way when it is active or stressed in a certain way First Aid A health care provider should examine your knee. A MCL test will be done to detect looseness of the ligament. This test involves bending the knee to 25 degrees and putting pressure on the outside surface of the knee. Other tests may include: Knee joint x-rays Knee MRI Treatment Includes: Applying ice to the area Nonsteroidal anti-inflammatory drugs (NSAIDS) Raising the knee above heart level You should limit physical activity until the pain and swelling go away. The health care provider may put you on crutches and in a brace to protect the ligament. You may also be told not to put any weight on your knee when you walk.
    [Show full text]
  • Chronic Foot Pain
    Revised 2020 American College of Radiology ACR Appropriateness Criteria® Chronic Foot Pain Variant 1: Chronic foot pain. Unknown etiology. Initial imaging. Procedure Appropriateness Category Relative Radiation Level Radiography foot Usually Appropriate ☢ US foot Usually Not Appropriate O MRI foot without and with IV contrast Usually Not Appropriate O MRI foot without IV contrast Usually Not Appropriate O CT foot with IV contrast Usually Not Appropriate ☢ CT foot without and with IV contrast Usually Not Appropriate ☢ CT foot without IV contrast Usually Not Appropriate ☢ Bone scan foot Usually Not Appropriate ☢☢☢ Variant 2: Persistent posttraumatic foot pain. Radiographs negative or equivocal. Clinical concern includes complex regional pain syndrome type I. Next imaging study. Procedure Appropriateness Category Relative Radiation Level MRI foot without IV contrast Usually Appropriate O 3-phase bone scan foot Usually Appropriate ☢☢☢ MRI foot without and with IV contrast May Be Appropriate O US foot Usually Not Appropriate O CT foot with IV contrast Usually Not Appropriate ☢ CT foot without and with IV contrast Usually Not Appropriate ☢ CT foot without IV contrast Usually Not Appropriate ☢ Variant 3: Chronic metatarsalgia including plantar great toe pain. Radiographs negative or equivocal. Clinical concern includes sesamoiditis, Morton’s neuroma, intermetatarsal bursitis, chronic plantar plate injury, or Freiberg’s infraction. Next imaging study. Procedure Appropriateness Category Relative Radiation Level MRI foot without IV contrast Usually Appropriate O US foot May Be Appropriate O MRI foot without and with IV contrast May Be Appropriate O CT foot without IV contrast May Be Appropriate ☢ Bone scan foot May Be Appropriate ☢☢☢ CT foot with IV contrast Usually Not Appropriate ☢ CT foot without and with IV contrast Usually Not Appropriate ☢ ACR Appropriateness Criteria® 1 Chronic Foot Pain Variant 4: Chronic plantar heel pain.
    [Show full text]
  • Eosinophilic Fasciitis (Shulman Syndrome)
    CONTINUING MEDICAL EDUCATION Eosinophilic Fasciitis (Shulman Syndrome) Sueli Carneiro, MD, PhD; Arles Brotas, MD; Fabrício Lamy, MD; Flávia Lisboa, MD; Eduardo Lago, MD; David Azulay, MD; Tulia Cuzzi, MD, PhD; Marcia Ramos-e-Silva, MD, PhD GOAL To understand eosinophilic fasciitis to better manage patients with the condition OBJECTIVES Upon completion of this activity, dermatologists and general practitioners should be able to: 1. Recognize the clinical presentation of eosinophilic fasciitis. 2. Discuss the histologic findings in patients with eosinophilic fasciitis. 3. Differentiate eosinophilic fasciitis from similarly presenting conditions. CME Test on page 215. This article has been peer reviewed and is accredited by the ACCME to provide continuing approved by Michael Fisher, MD, Professor of medical education for physicians. Medicine, Albert Einstein College of Medicine. Albert Einstein College of Medicine designates Review date: March 2005. this educational activity for a maximum of 1 This activity has been planned and implemented category 1 credit toward the AMA Physician’s in accordance with the Essential Areas and Policies Recognition Award. Each physician should of the Accreditation Council for Continuing Medical claim only that credit that he/she actually spent Education through the joint sponsorship of Albert in the activity. Einstein College of Medicine and Quadrant This activity has been planned and produced in HealthCom, Inc. Albert Einstein College of Medicine accordance with ACCME Essentials. Drs. Carneiro, Brotas, Lamy, Lisboa, Lago, Azulay, Cuzzi, and Ramos-e-Silva report no conflict of interest. The authors report no discussion of off-label use. Dr. Fisher reports no conflict of interest. We present a case of eosinophilic fasciitis, or Shulman syndrome apart from all other sclero- Shulman syndrome, in a 35-year-old man and dermiform states.
    [Show full text]
  • Ruptured Popliteal Cyst Diagnosed by Ultrasound Before Evaluation for Deep Vein Thrombosis Joon Sung Kim, MD, Seong Hoon Lim, MD, Bo Young Hong, MD, So Young Park, MD
    Case Report Ann Rehabil Med 2014;38(6):843-846 pISSN: 2234-0645 • eISSN: 2234-0653 http://dx.doi.org/10.5535/arm.2014.38.6.843 Annals of Rehabilitation Medicine Ruptured Popliteal Cyst Diagnosed by Ultrasound Before Evaluation for Deep Vein Thrombosis Joon Sung Kim, MD, Seong Hoon Lim, MD, Bo Young Hong, MD, So Young Park, MD Department of Rehabilitation Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea Most popliteal cysts are asymptomatic. However, cysts may rupture, resulting in pain and swelling of the leg that could also arise from other diseases, including deep vein thrombosis, lymphedema, cellulitis, and tear of a muscle or tendon. Therefore, it is difficult to diagnose a ruptured popliteal cyst based on only a patient’s history and physical examination. Musculoskeletal ultrasound has been regarded as a diagnostic tool for ruptured popliteal cyst. Here, we describe a patient who was rapidly diagnosed as ruptured popliteal cyst by ultrasonography. Therefore, ultrasound could be used to distinguish a ruptured popliteal cyst from other diseases in patients with painful swollen legs before evaluation for deep vein thrombosis. Keywords Calf pain, Complicated popliteal cyst, Ultrasonography INTRODUCTION or tendon (e.g., the medial head of the gastrocnemius [MHG] or Achilles tendon), neoplasm, and hemorrhage Popliteal cyst is a benign disease filled with fluid in the can cause similar symptoms. Some studies evaluated popliteal fossa. It occurs by distention of the semimem- nonspecific leg symptoms, such as swelling or pain, by branosus-gastrocnemius bursa communicating with the ultrasonography and ruptured popliteal cyst was easily knee joint [1].
    [Show full text]