Rheuma Case: 33-year-old Man with Posterior Heel Pain

00:00 Let's move on to the 3rd case. So this is a 33-year-old man presenting to your office with posterior heel pain. No significant past medical history. Initial vitals; we have a temperature of 36.7°C, heart rate of 58, and the blood pressure is 114/65. So, what further information would you like at this point? And what's your initial differential diagnoses? As you get presented with these kinds of just initial one-liners, it's good to start to think about illness scripts and as your compendium of illness scripts expands, you'll be able to come up with the differential diagnoses for a 33-year-old man with posterior heel pain. So, what do you come up with for this particular opener? I thought of these 4 possibilities. A calcaneal stress fracture, retrocalcaneal bursitis and fasciitis from reactive arthritis or perhaps Achilles tendinopathy. So with that in mind, let's get some more information. So now we know this is a 33-year-old man presenting to your office with unilateral posterior heel pain which has progressed over the past 1 or 2 weeks. No significant past medical history. Recently increased his usual running regimen from 30 minutes a few times per week to now 60 minutes 5 days per week, pretty aggressive. Review of systems is unrevealing.

01:23 Temperature is 36.7°C, heart rate is 58, blood pressure is 114/65, benign cardiopulmonary exam and our musculoskeletal exam reveals that he is tender to palpation just proximal to the left Achilles tendon insertion. There's no tenderness over the posterior calcaneus or with squeezing the calcaneus. There's full range of motion of the ankle which is painless. No other joints are involved. So, using our 4 steps, we know that the time course is subacute, it's been going on for 1 or 2 weeks. We know that the pattern of joint involvement is monoarticular, there's only 1 joint involved. Evidence of joint inflammation, is not looking like it, the range of motion of the ankle was normal and painless and in terms of systemic involvement, our review of systems is completely unrevealing. So with that information, let's go back and take a look at our differential diagnoses. Well, Achilles tendinopathy is certainly possible. He says that he is having pain and tenderness just proximal to its insertion into the calcaneus. Osteoarthritis should really be more chronic and indolent, wouldn’t really come on in this way and the ankle can certainly be a joint for osteoarthritis but not one of the more common joints. Reactive arthritis is one of our axial spondyloarthritides and one of the classic features of that condition is to have inflammation at the insertion of the Achilles tendon into the calcaneus. That insertion site and with inflammation in that insertion site is called enthesitis. Sort of depicted here with these small arrows showing the insertion going into the back of the calcaneus there. But this condition should be oligoarticular, it would be unusual to only have 1 site involved and there ought to be systemic symptoms as well as it is a spondyloarthritides with a host of other manifestations. And lastly, septic joint. Again, you'd expect a lot more joint inflammation which we're not getting much of on this physical exam and with some tenderness but no swelling in the area. So, again, just with our limited information and looking at those 4 variables, I think our final diagnosis is Achilles tendinopathy.