Disclaimer: Please read the Disclaimer at the bottom of this page.
Copyright © Educom Pty Ltd: All content on the acemsk.com website, including text, graphics, videos, and downloadable files, is the property of Educom Continuing Education, a division of Educom Pty Ltd, and is protected by copyright and other intellectual property laws under international conventions. Unauthorized use or duplication of this material without express written permission from Educom Pty Ltd is strictly prohibited.
To enhance your diagnostic reasoning skills, follow these steps:
- Review the Information: Carefully read through the content in each section of the case scenario.
- Consider the Question: Reflect on the Diagnostic Reasoning Question presented. Take your time to think about your answer.
- Compare Your Answer: Attempt to answer the question before viewing our suggested answer. When ready, click “View Suggested Answer” to compare it with your own.
Repeat these steps for each section of the case scenario. Please note that the suggested answers are only indicative and not exhaustive. They serve as guidelines and should not be considered complete answers.
Patient’s History
In the sections below, you will find case history information designed to guide you through a systematic approach to performing a focused and relevant case history. This process will help you narrow down the potential causes of the patient’s complaint. As you go through the material, we encourage you to answer the questions provided to test and enhance your diagnostic reasoning skills.
Who is the patient and where is the pain?
When was the onset and what caused the onset?
Emily is a 32-year-old retail store manager who presents with a primary complaint of pain in her right heel and foot. She identifies the medial aspect of the heel and foot as the main sites of her pain. The pain developed gradually over a period of approximately four months. She regularly plays basketball, and the problem began shortly after her team competed in the regional titles, which involved numerous games in a short period of time.
Diagnostic Reasoning Question
What potential differential diagnoses would you consider for this patient?
ViewHide Suggested Answer
- Tarsal tunnel syndrome
- Plantar fasciitis
- Lumbar or sacral radiculopathy
- Ankle or foot joint dysfunction
- Myofascial pain syndrome (e.g., abductor hallucis)
- Deep plantar flexor muscle tendinopathy
- Tarsal (e.g., calcaneal), or metatarsal stress fracture
- Arthritis
What are the pain characteristics?
What are the aggravating and relieving factors?
What has been the course of the pain?
Emily describes her pain as a burning sensation, accompanied by tingling and numbness extending along her medial sole towards her toes. She rates the pain as a 6 out of 10 in intensity at its worst. The pain arises when she bears weight on her right foot and becomes more severe during the course of a basketball game. After the game, the pain gradually subsides with rest. The condition has been progressively worsening since its onset, making it increasingly difficult for her to play basketball. It also affects her work, as her job requires her to “walk the floor” to engage with customers and instruct staff.
Diagnostic Reasoning Question
What are the differential diagnoses you would consider for a patient presenting with a burning sensation in the medial heel and foot, accompanied by tingling and numbness extending toward the toes?
ViewHide Suggested Answer
The differential diagnoses include:
- Tarsal Tunnel Syndrome (compression or entrapment of the posterior tibial nerve or its branches as it travels through the tarsal tunnel)
- Radiculopathy (compression or irritation of the lumbar or sacral nerve roots)
- Peripheral Neuropathy (damage to the peripheral nerves, often due to conditions like diabetes)
- Complex Regional Pain Syndrome (a chronic pain condition often affecting a limb after injury or surgery)
Are there any associated symptoms?
On further questioning, Emily reports that she often gets cramps in the sole of her right foot.
Diagnostic Reasoning Question
How does the report of cramps in the sole of the foot inform the diagnostic process?
ViewHide Suggested Answer
Cramping can be associated with several systemic conditions, including electrolyte imbalance or dehydration. Cramps may also arise as a side effect of certain medications (e.g., antihyperlipidemics such as statins). However, since her cramps only involve her right foot, they suggest a local musculoskeletal etiology, such as pes planus (flat feet), high arches (pes cavus), tarsal tunnel syndrome, and plantar fasciitis.
Is there any past history that may be relevant to the current complaint?
Emily reports that she suffered a serious right foot injury in her late teens, which resulted in a fracture of the calcaneus. She also has a history of right medial heel pain that has been previously diagnosed as plantar fasciitis.
Diagnostic Reasoning Question
How would you interpret Emily’s past history in relation to her current symptoms?
ViewHide Suggested Answer
- Serious Foot Injury and Calcaneus Fracture – A significant foot injury, such as a calcaneus fracture, could lead to structural changes or bone spurs. These changes can compress the tibial nerve in the tarsal tunnel, increasing the risk of developing tarsal tunnel syndrome.
- History of Plantar Fasciitis – Chronic heel pain, particularly from plantar fasciitis, can alter gait and foot biomechanics. This alteration can increase stress on the structures around the tarsal tunnel, potentially leading to nerve compression.
Are there any red flags?
The following questions are asked to identify any “red flags” that could suggest serious pathology. Even if the patient has previously mentioned related information during the case history, it is recommended to revisit these questions to ensure a comprehensive evaluation.
- Do your symptoms disappear even for a short time? “The pain eases when I’m not on my feet, but it does take a while.”
- Does the pain wake you up at night? “No.”
- Do you feel weak in your legs? “No.”
- Have you recently had any fever, chills, or night sweats? “No.”
- Do you have a history of cancer, respiratory disease, or heart disease? “No.”
- Have you recently had an infection or other illness? “No.”
Diagnostic Reasoning Question
Do any of the patient’s answers raise a red flag?
ViewHide Suggested Answer
None of the patient’s responses has raised any red flags
Differential Diagnosis
Diagnostic Reasoning Question
Based on the available history, how would you prioritize the list of differential diagnoses?
ViewHide Suggested Answer
- Tarsal tunnel syndrome
- Lumbar or sacral radiculopathy
- Plantar fasciitis
- Ankle or foot joint dysfunction
- Deep plantar flexor muscle tendinopathy
- Myofascial pain syndrome (e.g., abductor hallucis)
- Secondary osteoarthritis (e.g., ankle, subtalar)
- Tarsal (e.g., calcaneal), or metatarsal stress fracture
Reflection Point
Pause and consider whether the key elements of a thorough and relevant patient history have been addressed. Are there any additional questions you would have asked? If so, what are they, and why would they be important?
Before reviewing the physical examination findings below, take a moment to reflect on which physical examination procedures you would perform to accurately assess this patient.
Physical Examination
In the sections below, you will find physical examination findings for this patient. The material outlines a systematic approach to conducting a focused and relevant physical examination aimed at narrowing down the potential causes of the patient’s complaint. As you review the material, we encourage you to answer the questions provided to test and enhance your clinical reasoning and diagnostic skills. Additionally, consider whether all essential elements of the physical examination have been thoroughly addressed.
Vital Signs
Emily’s vital signs are within normal limits.
Diagnostic Reasoning Question
What is the significance of normal vital signs?
ViewHide Suggested Answer
Normal vital signs typically indicate that there are no immediate life-threatening conditions. Particularly, normal temperature indicates the absence of acute infection.
Inspection
Upon inspection, Emily has significant bilateral pes planus. There is no evidence of local swelling, bruising, or bony deformity.
Diagnostic Reasoning Question
How does the presence of pes planus inform the diagnostic process?
ViewHide Suggested Answer
Emily’s pes planus could be an aggravating factor for biomechanical problems affecting her ankles and feet. In particular, pes planus is reported to be associated with tarsal tunnel syndrome and plantar fasciitis.
Range of Motion
The active and passive ankle range of motion assessments are within normal limits. However, the patient reports slight symptom aggravation during full passive dorsiflexion of the right ankle. Passive foot movement reveals a loss of inversion in both feet and slight symptom aggravation during full eversion on the right. The range of motion assessments for the lumbar spine, right hip, and right knee are normal.
Diagnostic Reasoning Question
How do the range of motion findings inform the diagnosis?
ViewHide Suggested Answer
The aggravation of symptoms with full passive ankle dorsiflexion and foot eversion suggests the involvement of the tendons, fascia, or nerves on the medial side of the ankle due to traction loading. The bilateral loss of foot inversion indicates the mechanical consequences of pes planus. The normal range of motion findings for the lumbar spine, right hip, and right knee help to rule out their involvement.
Palpation
Palpation of Emily’s right foot and ankle reveals significant tenderness posteroinferior to the medial malleolus, directly over the flexor retinaculum. Applying firm pressure to this area reproduces the patient’s symptoms, causing pain and paraesthesia extending into the sole of the foot. The medial aspect of the right calcaneus feels uneven, with a slight prominence beneath the flexor retinaculum. No tenderness exists when pressure is applied directly over the medial calcaneal tubercle. No pain or nodules are detected upon palpation of the muscles of the sole of the right foot or calf. Functional assessment of the right foot, ankle, and knee articulations is normal.
Diagnostic Reasoning Question 1
How does reproducing pain and paresthesia when pressure is applied over the flexor retinaculum inform the diagnostic process?
ViewHide Suggested Answer
This result is consistent with the involvement of the posterior tibial nerve as it passes through the tarsal tunnel.
Diagnostic Reasoning Question 2
What does the prominence of the calcaneus beneath the flexor retinaculum indicate?
ViewHide Suggested Answer
The prominence may have resulted from the previous calcaneal fracture. This is likely to compromise the anatomical space of the tarsal tunnel.
Video Playback Issues: If videos aren’t playing, it could be because you’ve remained on this web page for too long or you’ve lost your Internet connection. To fix this, simply refresh or reload this web page.
Video Sound Issues: If you’re playing a video and the sound isn’t working, the sound might be turned off. On a desktop computer, locate the volume icon at the bottom right corner of the video. To adjust the volume, hover your cursor over the icon and move the slider up or down as needed. On smaller devices like tablets or phones, simply adjust the device’s volume to hear the video.
Neurological Examination
A screening neurological examination of the L2 to S1 nerve roots is performed and is found to be normal.
Diagnostic Reasoning Question
How do the normal results inform the diagnostic process, and where is the “key” sensory area for the L5 nerve root?
ViewHide Suggested Answer
The normal results help to rule out radiculopathy of the L2 to S1 nerve roots.
L5 key sensory area: Third metatarsophalangeal joint on the dorsum of the foot
Please watch the video below if you wish to see how a screening neurological examination for L2 to S1 nerve roots is performed.
A more detailed neurological assessment reveals a loss of sensation on the medial side of the sole of her right foot.
Diagnostic Reasoning Question
How does this finding inform the diagnostic process?
ViewHide Suggested Answer
The area of sensory loss indicates potential involvement or compression of the medial plantar nerve. This finding suggests the involvement of the tarsal tunnel, where the posterior tibial nerve branches off into the medial and lateral plantar nerves.
Reflection Point
Considering the patient’s history and examination findings thus far, take a moment to reflect on which special tests would be most appropriate to further evaluate this patient.
Special Tests
The Dorsiflexion-Eversion test is performed on the right side and aggravates her symptoms.
Diagnostic Reasoning Question
What is the Dorsiflexion-Eversion test designed to detect?
ViewHide Suggested Answer
The Dorsiflexion-Eversion test is designed to detect the presence of tarsal tunnel syndrome. Exacerbation of her symptoms with this test suggests the presence of tarsal tunnel syndrome. Please watch the video below if you wish to see how the Dorsiflexion-Eversion test is performed.
The Triple Compression Stress test is performed on the right side, which causes exacerbation of her symptoms.
Diagnostic Reasoning Question
What is the Triple Compression Stress test designed to detect?
ViewHide Suggested Answer
The Triple Compression Stress test is designed to detect the presence of tarsal tunnel syndrome. Exacerbation of her symptoms with this test confirms the presence of tarsal tunnel syndrome. Please watch the video below if you wish to see how the Triple Compression Stress test is performed.
Percussion over her right tarsal tunnel elicits a sudden exacerbation of burning pain and paraesthesia extending into the foot.
Diagnostic Reasoning Question
How does this finding inform the diagnostic process?
ViewHide Suggested Answer
The symptomatic response from percussion is known as the Tinel’s Sign. In this case, it indicates involvement of the posterior tibial nerve or one of its branches at the tarsal tunnel. Watch the video below if you wish to see how the Tinel’s Sign for tarsal tunnel syndrome is elicited.
The Windlass test is performed and is found to be negative.
Diagnostic Reasoning Question
What is the Windlass test designed to detect?
ViewHide Suggested Answer
The Windlass test is designed to detect plantar fasciitis. The negative result in this patient helps to rule out this condition. Please watch the video below if you wish to see how the Windlass test is performed.
The Heel Tap test is performed and is found to be negative with no aggravation of pain on striking the heel.
Diagnostic Reasoning Question
How does this finding inform the diagnostic process?
ViewHide Suggested Answer
The Heel Tap test is designed to screen for the presence of fracture in the lower extremity. The negative result in this patient helps to rule out the presence of a tarsal fracture. Please watch the video below if you wish to see how the Heel Tap test is performed.
The Valsalva and Straight Leg Raise tests are performed, and both are found to be negative, with no provocation of the patient’s symptoms.
Diagnostic Reasoning Question
How do these findings inform the diagnostic process?
ViewHide Suggested Answer
The negative results for the Valsalva and Straight Leg Raise tests help to rule out the possibility of radiculopathy as the cause of the patient’s symptoms. Please watch the videos below if you wish to see how these tests are performed.
Reflection Point
Please pause and assess whether all the essential elements of a thorough and relevant physical examination have been completed for this patient. Are there any additional procedures you would have performed? If so, why?
Clinical Diagnosis
Diagnostic Reasoning Question
Based on the available information, what is the most likely diagnosis?
ViewHide Suggested Answer
Tarsal Tunnel Syndrome.
References and Suggested Further Readings
Priscilla Tu. Heel Pain: Diagnosis and Management. Am Fam Physician. 2018 Jan 15;97(2):86-93.
Gianni Persich. Tarsal Tunnel Syndrome. www.emedicine.medscape.com.
Tarsal Tunnel Syndrome. American College of Foot and Anke Surgeons. www.acfas.org.
Overview of lower extremity peripheral nerve syndromes. www.uptodate.com.
Review Quiz
1. What is 2+2?
ViewHide Suggested Answer
The answer is????
Disclaimer: The acemsk.com website (including text, graphics, downloadable resources, and videos) is intended to provide general health information for educational purposes only. This information is not a substitute for personal consultation with a qualified healthcare professional. Always seek the advice of a healthcare professional for any questions regarding your condition, symptoms, and appropriate treatments.
Copyright © Educom Pty Ltd: All content on the acemsk.com website, including text, graphics, videos, and downloadable files, is the property of Educom Continuing Education, a division of Educom Pty Ltd, and is protected by copyright and other intellectual property laws under international conventions. Unauthorized use or duplication of this material without express written permission from Educom Pty Ltd is strictly prohibited.
Access Free with Registration