1. HEEL PAIN

2. Commonest of all causes
 Achilles enthesitis
 Achilles tendinitis
 Achilles bursitis
 Plantar fascitis
 Calcanel spur
 Heel pad fat atrophy

3. Achilles bursitis

4. Plantar fascitis

5. Less commoner causes
 Achilles tendon rupture
 Bone bruise
 Bone cyst
 Fracture
 Gout
 Neuroma
 Peripheral neuropathy
 Tarsel tunnel syndrome

6. Approach towards case
HISTORY
CLINICAL EXAMINATION
INVESTIGATION
TREATMENT

7. HISTORY
 PRESENITNG COMPLAINT
1.ONSET-acute
subacute
insidious
2.SITE OF MAX. INTENSITY AND RADIATION
OF PAIN
3.REST PAIN-inflammatory pain improves with
activity

8. 4.NIGHT PAIN-destructive
 Avascular necrosis
 Mutilating arthritis
Malignancy
5.MOVEMENT PAIN-use
increases pain and rest
decreases pain
6.PERSISTENT PAIN-bone
pain

9. 07.STIFFNESS;SENSATIONOFTIGHTNESS-
fluid distension of capsule,tenosynovium
or bursa.In the morning ,stiffness increase
and activity decrease due to clearing of
fluid.
08.DURATION OF MORNING STIFFNESS
09.SWELLING-soft tissue,bony &
fluid
10.DEFORMITY-malalignment,subluxation
or dislocation

10. 11.DISABILITY-inadequate function
12.PRECIPITATING FACTORS FOR JOINT
INVOLVEMENT –i)TRAUMA
ii)INFECTION-sorethroat,
urethritis, dysentry
iii)STD
iv)CONTACTWITH
INFECTIOUS DISEASE
13.AGGRAVATINGAND RELIEVING
FACTORS-rest,exercise,activity,imobility
and drugs.

11.  PAST HISTORY
1.TRAUMA
2.INFECTION-urethritis,dysentry
3.SIMILAR EPISODES-rheumatic fever,
gout,palindromic rheumatism
4.h/o STD-secondary syphilis
5.CHARCOT JOINT
 TREATMENT HISTORY
1.Aspirin,NSAID,steroid,DMARD
2.SURGERY
 FAMILY HISTORY
1.Rheumatoid arthritis
2.osteoarthrosis,gout
3.Seronegetive spondyloarthropathies

12. GENERAL CLINICAL EXAMINATION
SKIN
 ERYTHEMA-JOINT:Septic arthritis, crystal
arthropathy,palindromic rheumatism.
 RASH-SLE,vasculitis,drugs
 PSORIASIS
 KERATODERMA BLENORRHAGICA-Reiters
syndrome
 MUCOSAL ULCERS-Behcet syndrome,SLE
 PYODERMA GANGRENOSUM-IBD
 PALMAR ERYTHEMA-Rheumatoid arthritis

13.  PHOTOSENSITIVITY-development of rash on
exposure to sunlight of less than 30 min.
SLE
SUB CUTANEOUS NODULES
 Rheumatoid arthritis,rheumatic fever
 Gout,sarcoidosis,SLE,hyperlipidemia
NAIL CHANGES
 CLUBBING-fibrosing alveolitis,hypertrophic
osteoarthropathy
 PITTING & ONYCHOLYSIS-Psoriasis
 SPLINTER HAEMORRHAGE-Small vessel
vasculitis,infective endocarditis.

14. MUCOUS MEMBRANE LESIONS
 Reactive arthropathy, Reiter’s syndrome, Behcet’s
syndrome,SLE
 DRYNESS-Sjogren’s syndrome
EYE CHANGES
 EPISCLERITIS & SCLERITIS-Rheumatoid arthritis
 IRITIS-Ankylosing spondylitis
 IRIDOCYCLITIS-Juvenile chronic arthritis
 CONJUCTIVITIS-Reiter’s syndrome
 SCLEROSING TENOSYNOVITIS OF SUPERIOR
OBLIQUETENDON=BROWN’S SYNDROME-In
Rheumatoid arthritis
LYMPHADENOPATHY
 Still’s disease, SLE

15. LOCAL CLINICAL EXAMINATION
MOVEMENTS
 ANKLE JOINT – 40 degree dorsiflexion
50 degree plantar flexion
 SUBTALAR JOINT-5 degree inversion
5 degree eversion
 MIDTARSL JOINT-30 degree inversion
30 degree eversion

16. LOOK FOR:
1. SWELLING
2. DEFORMITY
Hallux valgus and varus
Clawing of foot-Fixed flexion deformity due
to small muscle wasting.
Crowding of toes
Sausage deformity of toes
-Psoriatic arthritis
-Ankylosing spondylitis
-Reiter’s disease
3. CALLOSITIES-On points of abnormal
pressures

17. 4. DAY LIGHT SIGN-Abnormal spreads of 2
adjacent toes
5. TENDOACHILLE’S PALPATION-Tendinitis,
Rheumatoid nodules,Xanthoma
6. HEELTENDERNESS-Plantar fascitis
7. TENDINITIS-Tendo achille’s, Peroneal tendon
&Tibialis posterior tendon
8. BURSITIS:Pre-Achilles and retro-achilles

18. Calcaneal spur

19. TREATMENT
 Rest or reduced activity
avoid any barefoot walking
 Foot and leg exercises
 Ice and Anti-inflammatories
 Support your arches with
orthotics

20. ORTHOTICS

21. THANK YOU