COHF 005: 55 year old female presents chronic pain to left posterior heel for the past 5 years
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We are gonna be talking about a 55-year-old female, presents with chronic pain to the left posterior heel for the past five years. The patient has seen several orthopaedists, podiatrists and physical therapists, but the pain persists, causing a limitation in daily activities and exercise. Patient states that the pain is greatest in the morning, decreases slightly during the day and then increases again at the end of the day. There’s a sharp pain and it’s rated a six out of 10, no associated tingling or numbness. The patient does not recall an acute injury and it’s been a gradual increase over the past five years.
PMH: Breast CA, Htn
PSH: Right breast mastectomy (2008) with TRAM flap
SH: Social EToH, Non-smoker
Derm: grossly normal
Vascular: Lymphedema right upper extremity, pedal pulses wnl, cft < 3 seconds
Neuro: protective sensation in tact, vbt wnl
Ortho: Limited ankle mobility B/L, pop posterior calcaneus with hypertrophic changes noted to left Achilles mid-tendon, muscle strength 5/5 lower extremity, on stance pes plano valgus on stance with increased knee valgus on single leg squat, step up and step down.
Xray negative for osseous changes, no posterior or plantar calc spur noted
MRI increased thickening with degenerative changes mid-tendon, no tear noted
Let’s Hear From The Council!
With this particular case, in a chronic pain case, I always try to, as I said in previous episodes, trying to establish the pathways, projections and the systems involved in the pain experience. And also, I would appreciate with something that has gone on this long, is there a limbic component to it? Is there a limbic emotional brain correlate to the person’s condition? The emotional mode system can modulate sensory afferentation and it can mess the whole thing up. We need to know if there’s anything involved on that level with the patient. It may not be a primary driver, but it should be considered.
Obviously with the information presented here, it almost appears to be like a classic case of possible plantar fasciitis, just based on the initial information gathered from the patient. Classic pain in the back of the heel, hurts most first thing in the morning, decreases a little bit through the day as the plantar fascia tissue loosens up, and then gets worse throughout the day as that person continues to walk on it. As we know, as humans, we can’t quit walking, that’s how we get from one place to the other. So if we never give that tissue a chance to heal or relax, it’s gonna consistently get irritated, and hence it goes on for a long period of time. And if not corrected, in this case, this person’s been dealing with it for five years.
You’d wanna confirm from a case study, the exact sort of location of the pain. So whether it is more inferior aspect to the calcaneus or whether it is more that posterosuperior aspect, given on the MRI findings there’s some degenerative changes in the Achilles tendon as well. But tentatively, this lady is 55 so that often makes you think more of those load, and more degenerative tendon-type issues tend to be more common in that age group in females sort of four to one. Whereas before 40, it tends to be more in your males. Often maybe that’s because the estrogen has got a bit of protective effect, they suggest. Given it’s been going on for five years, we’ve also gotta consider potentially there’s some central pain changes there as well that maybe continue to drive this, irrespective of the tissue and the nociception in the area.
Dr. Brandon Brock
Well, again, anytime somebody has what looks like muscle imbalance, this has been from what I can tell, a chronic situation, we kinda have pain for really no reason, there’s been no trauma, there’s been no, anything apparent. You go back and you check out the history again and I’ve had very similar injuries to this, being a gymnast, I got a lot of stone bruises, but this doesn’t sound quite like a stone bruise. So of course, you go back, you do your history and then if you find out, man, maybe there’s some sort of aberrant patho, bio mechanical, repetitive movement that’s been going on, the question always has to be, why?
Dr. Emily Splichal
One thing that I do wanna mention, though, particularly in this patient who’s complaining of mid-tendon Achilles tendon pain. When I look at Achilles tendonitis or Achilles tendinosis in my patients, is insertional tendonitis is treated or is associated with stressors different than mid-tendon Achilles tendonitis. Typically when I see insertional Achilles tendonitis, it’s usually on impact and those patients will present with pain when they’re contacting the ground. I typically look at the patients as far as how their body is anticipating the ground and are they preactivating their stabilizers and their decelerators before their foot contacts the ground. If they have a delay in that preactivation sequencing, then they typically present with that insertional Achilles tendonitis.
Want to slowly activate the tissue before we go too strong. I also want to look at her activities such as is she standing, or sitting all day, does she work out, what type of shoes is she wearing, is it heels, or stable boots. I would then look specifically at the tight tissue in the calf, allowing to free up some movement in the foot and ankle.
Dr. Mark Wade
With this presentation I would definitely be checking the pelvic alignment as we’ve mentioned several times and as a Dr. Brandon said, I would go even further up and I’d go into the lumbar spine. Any type of hyperkyphosis of that lumbar or pelvic superiority is gonna alter those gait patterns, causing an increased wear and tear on the joints. So not always but often the affected or symptomatic joint is the compensation. So I would expect to find some dysfunction, in this case presentation of the right pelvis and ilium as well as the sacrum. Most likely we’d be seeing some decreased or weak glutes that are causing part of that gait dysfunction. I’d like to see the patient’s gait, as we’ve all already mentioned, it’s important to obtain as much objective data as possible
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Dr. Mark Wade: Council President, Posture Expert, & Global Health Leader, bringing insight together with the council on health, wellness, physical rehabilitation, neurology and exercise fitness strategies for health care professionals.
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