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Review Question - QID 212989

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QID 212989 (Type "212989" in App Search)
A 48-year-old female presents with acute-on-chronic heel pain. She had been training for a marathon for 3 months when she felt an acute pop near her heel and has been unable to bear much weight since. Prior to this event, pain only occurred during the beginning of her runs and slowly subsided. Her family physician had placed her on a regimen of daily stretching and night-time splinting for 2 months prior to this incident, but also administered a pain shot in this area 3 weeks ago. She denies recurrent ankle sprains. What finding do you expect on physical exam and what is her diagnosis?

Pain with resisted toe flexion, symptomatic os trigonum

3%

83/2552

Pes planus, rupture of the plantar fascia

85%

2175/2552

Pes cavus, peroneal tendon subluxation

3%

66/2552

Pes planus, posterior tibial tendon insufficiency

7%

190/2552

Lateral ankle swelling, lateral talar process fracture

1%

13/2552

Select Answer to see Preferred Response

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This presentation is classic for an acute plantar fascia rupture after receiving a corticosteroid injection for fasciitis. A complete rupture may lead to loss of the medial longitudinal arch and a pes planus deformity.

Plantar fasciitis is a common condition among recreational athletes, often seen following a steep increase in workload and volume. This can be treated successfully with non-operative modalities, beginning with stretching programs and splinting. Corticosteroids have been a part of standard practice but are associated with plantar fascia ruptures and heel pad atrophy. Help pad atrophy is amenable to shoe wear modifications with extra padding. In cases of plantar fascia rupture, immobilization with a CAM boot is sufficient, with repair very rarely being indicated.

Kim et al. retrospectively reviewed a cohort of patients receiving plantar fascia corticosteroid injections. They noted a rupture rate of 2.4%, with those ruptures having at least 2 injections prior and mean BMI over 38. This demonstrates corticosteroids as relatively safe modality but practitioners must be aware of this potential complication.

Suzue et al. reported a case of a 29-year-old professional soccer player with plantar fasciitis who received 2 corticosteroid injections and had partial plantar fascia rupture 49 days after last injection. He was treated conservatively with a PRP injection and therapy, returning to sport 5 months post-rupture. This highlights the perils of steroid use in the healthy high-demand individual and again reinforces the judicious use of steroid injections.

Illustration A is a normal T2 sagittal MR of the ankle showing the plantar fascia in continuity. Illustration B shows a rupture of the medial band of the plantar fascia.

Incorrect Answers:
Answer 1- Posterior ankle pain is usually seen with os trigonum
Answer 3- Though pes cavus would certainly predispose one to peroneal tendon injury and ankle instability, distinct heel pain not usually seen
Answer 4- PTTI can cause pes planus but it doesn't involve heel pain
Answer 5- The injuries are usually seen with snowboarding not running

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