HEEL PAIN

Commonest of all causes

Achilles enthesitis Achilles tendinitis Achilles bursitis Plantar fascitis Calcanel spur Heel pad fat atrophy

Achilles bursitis

Plantar fascitis

Less commoner causes

Achilles tendon rupture Bone bruise Bone cyst Fracture Gout Neuroma Peripheral neuropathy Tarsel tunnel syndrome

Approach towards case

HISTORYCLINICAL EXAMINATION

INVESTIGATIONTREATMENT

HISTORY

PRESENITNG COMPLAINT1.ONSET-acute subacute insidious2.SITE OF MAX. INTENSITY AND

RADIATION OF PAIN3.REST PAIN-inflammatory pain

improves with activity

4.NIGHT PAIN-destructive Avascular necrosis Mutilating arthritis Malignancy5.MOVEMENT PAIN-use increases pain and rest decreases pain

6.PERSISTENT PAIN-bone pain

07.STIFFNESS;SENSATION OF TIGHTNESS-fluid distension of capsule,tenosynovium or bursa.In the morning ,stiffness increase and activity decrease due to clearing of fluid.

08.DURATION OF MORNING STIFFNESS

09.SWELLING-soft tissue,bony & fluid10.DEFORMITY-malalignment,subluxation or dislocation

11.DISABILITY-inadequate function12.PRECIPITATING FACTORS FOR JOINT

INVOLVEMENT –i)TRAUMA ii)INFECTION-

sorethroat, urethritis,

dysentry iii)STD iv)CONTACT WITH INFECTIOUS

DISEASE13.AGGRAVATING AND RELIEVING FACTORS-

rest,exercise,activity,imobility and drugs.

PAST HISTORY 1.TRAUMA 2.INFECTION-urethritis,dysentry 3.SIMILAR EPISODES-rheumatic fever, gout,palindromic rheumatism 4.h/o STD-secondary syphilis 5.CHARCOT JOINT TREATMENT HISTORY 1.Aspirin,NSAID,steroid,DMARD 2.SURGERY FAMILY HISTORY 1.Rheumatoid arthritis 2.osteoarthrosis,gout 3.Seronegetive spondyloarthropathies

GENERAL CLINICAL EXAMINATIONSKIN ERYTHEMA-JOINT:Septic arthritis, crystal

arthropathy,palindromic rheumatism. RASH-SLE,vasculitis,drugs PSORIASIS KERATODERMA BLENORRHAGICA-Reiters

syndrome MUCOSAL ULCERS-Behcet syndrome,SLE PYODERMA GANGRENOSUM-IBD PALMAR ERYTHEMA-Rheumatoid arthritis

PHOTOSENSITIVITY-development of rash on exposure to sunlight of less than 30 min.

SLE

SUB CUTANEOUS NODULES Rheumatoid arthritis,rheumatic fever Gout,sarcoidosis,SLE,hyperlipidemia

NAIL CHANGES CLUBBING-fibrosing alveolitis,hypertrophic

osteoarthropathy PITTING & ONYCHOLYSIS-Psoriasis SPLINTER HAEMORRHAGE-Small vessel

vasculitis,infective endocarditis.

MUCOUS MEMBRANE LESIONS Reactive arthropathy, Reiter’s syndrome,

Behcet’s syndrome,SLE DRYNESS-Sjogren’s syndrome

EYE CHANGES EPISCLERITIS & SCLERITIS-Rheumatoid arthritis IRITIS-Ankylosing spondylitis IRIDOCYCLITIS-Juvenile chronic arthritis CONJUCTIVITIS-Reiter’s syndrome SCLEROSING TENOSYNOVITIS OF SUPERIOR

OBLIQUE TENDON=BROWN’S SYNDROME-In Rheumatoid arthritis

LYMPHADENOPATHY Still’s disease, SLE

LOCAL CLINICAL EXAMINATIONMOVEMENTS ANKLE JOINT – 40 degree

dorsiflexion 50 degree plantar flexion

SUB TALAR JOINT-5 degree inversion 5 degree eversion

MID TARSL JOINT-30 degree inversion 30 degree eversion

LOOK FOR:1. SWELLING2. DEFORMITY

Hallux valgus and varusClawing of foot-Fixed flexion deformity due to small muscle wasting.Crowding of toesSausage deformity of toes -Psoriatic arthritis -Ankylosing spondylitis -Reiter’s disease

3. CALLOSITIES-On points of abnormal pressures

4. DAY LIGHT SIGN-Abnormal spreads of 2 adjacent toes

5. TENDOACHILLE’S PALPATION-Tendinitis, Rheumatoid nodules,Xanthoma

6. HEEL TENDERNESS-Plantar fascitis7. TENDINITIS-Tendo achille’s, Peroneal

tendon & Tibialis posterior tendon8. BURSITIS:Pre-Achilles and retro-

achilles

Calcaneal spur

TREATMENT

Rest or reduced activity avoid any barefoot walking

Foot and leg exercises Ice and Anti-inflammatories

Support your arches with orthotics

ORTHOTICS

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