Ross Marquette: A 68-Year-Old Retired Executive With Severe Posterior Foot Pain

Learning Objectives

  • Learn the common causes of foot pain.

  • Learn the common causes of plantar fasciitis.

  • Develop an understanding of the anatomy of the plantar fascia.

  • Develop an understanding of the differential diagnosis of plantar fasciitis.

  • Learn the clinical presentation of plantar fasciitis.

  • Learn how to examine the foot.

  • Learn how to examine the plantar fascia.

  • Learn how to use physical examination to identify plantar fasciitis.

  • Develop an understanding of the treatment options for plantar fasciitis.

Ross Marquette

Ross Marquette is a 68-year-old retired executive with the chief complaint of, “I can’t exercise because my feet are killing me.” Ross stated that over the last 6 weeks, his right foot has become increasingly more painful in spite of Advil, topical analgesic balm, and ice packs. He stated that since he retired and moved to the beach, he was “falling apart.” He stated, “My friends told me not to retire, and I should have listened to them, but you know, I had done all there was to do and the buyout offer was just too good to turn down. I have a place on the beach in Hilton Head, and it seemed like the perfect place to get my life back. I wanted to get in shape and started walking on the beach every day, rain or shine. I get up and head down to the beach, no meetings, no employees, no aggravation. Now I feel like somebody is stabbing me in the bottom of my feet! Mostly on the right, but now the left heel is starting to play up. It’s worse when I first get up—those first few steps are murder.” Ross tried to “work through it” because he didn’t want to “mess with his routine.” He noted that the pain was made worse with prolonged standing, and it was getting to where walking on the beach was just too painful. “Doctor, I didn’t retire to sit on my butt and watch the Golf Channel. I really hope that you can help me here.”

I asked Ross if he ever had anything like this in the past, and he said, “Not really. I always tried to watch my weight, but I spent most of the last 35 years sitting at a desk.” I asked if he was experiencing any numbness, and he shook his head no. “But you know, Doc, the craziest thing is, when I wiggle my toes, I get a sharp pain in the soles of my feet. It’s really painful. I’ve started walking like an old man.” I asked Ross about any fever, chills, or other constitutional symptoms such as weight loss or night sweats, and he shook his head no, and said, “It’s just this foot pain. I just don’t understand how walking barefoot down a sandy beach could hurt so much!”

I then asked Ross to point with one finger to show me where it hurt the most. He pointed to his right foot and then gingerly rubbed the sole of his right foot up toward his toes and said that the pain seemed to shoot from the heel up toward his toes.

On physical examination, Ross was afebrile. His respirations were 16, his pulse was 66 and regular, and his blood pressure was 112/68. Ross’s head, eyes, ears, nose, throat (HEENT) exam was normal, as was his cardiopulmonary examination. His thyroid was normal and his neck was well muscled. His abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. His low back examination was unremarkable. I noticed that he was wearing flip-flops. Visual inspection of the right foot was unremarkable. There was no rubor and no obvious infection. There was no evidence of a plantar wart, fibromatosis, or obvious bony abnormality. There was no evidence of Achilles tendonitis or bursitis. Palpation of the sole of the foot along the plantar fascia from the heel to the toe reproduced Ross’s pain, as did active resisted dorsiflexion of the toes. Ross had positive calcaneal jump signs bilaterally, right greater than left ( Fig. 12.1 ). The windlass test was also positive bilaterally, again right greater than left ( Fig. 12.2 ). The calcaneal squeeze test for calcaneal stress fracture was negative bilaterally ( Fig. 12.3 ). The left foot examination was normal. A careful neurologic examination of the lower extremities was completely normal, with no evidence of entrapment or peripheral neuropathy. Deep tendon reflexes were normal.

Fig. 12.1

To elicit the calcaneal jump sign, the patient is placed in a supine position on the examination table. The examiner uses the index finger to firmly press on the skin overlying the plantar medial calcaneal tuberosity. The calcaneal jump sign is considered positive if this maneuver reproduces the patient’s pain and causes the patient to jump or withdraw from the sudden onset of pain.

From Waldman SD. Physical Diagnosis of Pain: An Atlas of Signs and Symptoms . Philadelphia: Saunders; 2006:379.

Fig. 12.2

The windlass test for plantar fasciitis. To perform the windlass test for plantar fasciitis, the patient is placed in the supine position with the knee flexed to 90 degrees and the affected foot in neutral position. The examiner then stabilizes the head of the first metatarsal and dorsiflexes the great toe. The test is positive if it reproduces or exacerbates the patient’s pain.

Fig. 12.3

The calcaneal squeeze test for calcaneal stress fracture. To perform the calcaneal squeeze test, the patient is placed in the sitting position in the middle of the examination table with the legs resting comfortably off the side of the table. The examiner holds the affected foot with one hand and grasps the painful calcaneus and gently squeezes, gradually applying greater pressure. The test is considered positive if the pressure reproduces the patient’s pain.

From Waldman S. Physical Diagnosis of Pain: An Atlas of Signs and Symptoms . ed. 4. Philadelphia: Elsevier; 2021 [Fig. 276-1].

Key Clinical Points—What’s Important and What’s Not

The History

  • History of onset of right heel pain associated with walking barefoot on the beach

  • No numbness

  • No weakness

  • No history of previous significant foot pain

  • No fever or chills

The Physical Examination

  • Patient is afebrile

  • Point tenderness over plantar aspect of the calcaneus

  • Pain on active resisted dorsiflexion of the toes

  • Pain on palpation of the plantar fascia

  • Positive calcaneal jump sign—right greater than left

  • Positive windlass sign—right greater than left

  • Negative calcaneal squeeze test

  • No plantar masses

Other Findings of Note

  • Normal HEENT examination

  • Normal cardiovascular examination

  • Normal pulmonary examination

  • Normal abdominal examination

  • No peripheral edema

  • Normal lower extremity neurologic examination, motor and sensory examination

What Tests Would You Like to Order?

The following tests were ordered:

  • Plain radiographs of the right foot

  • Ultrasound of the right foot

  • Magnetic resonance imaging (MRI) of the right foot

Test Results

The plain radiographs of the right foot revealed a plantar spur on the calcaneus ( Fig. 12.4 ).

Fig. 12.4

(A) Lateral radiograph of a plantar spur on the calcaneus. (B) The sagittal T1-weighted (T1W) magnetic resonance imaging (MRI) demonstrates thickening and increased signal intensity (SI) within the plantar fascia origin (black arrow) . There is high-SI fatty marrow within the bony spur. (C) High-SI fluid (white arrow) is seen within the plantar fascia origin on the sagittal fat-suppressed T2W MRI. The appearances are consistent with plantar fasciitis and partial tearing of the origin of the fascia.

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Nov 19, 2022 | Posted by in PAIN MEDICINE | Comments Off on Ross Marquette: A 68-Year-Old Retired Executive With Severe Posterior Foot Pain

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