Heel pain

HEEL PAIN
Plantar fascitis is an enthesitis at the insertion of the tendon into the calcaneum .It produces localized pain when standing and walking ,and tenderness in the mid line.It occurs alone or in seronegative spondarthritis.

Plantar spurs are traction lesions at the insertion of the plantar fascia in older people and are usually asymptomatic.They become painful after trauma.

Calcaneal bursitis is a pressure - induced ( adventitious ) bursa that produces diffuse pain and tenderness under the heel.Compression of the heel pad from the sides is painful ,which distinguishes it from plantar fascia pain.

Whatever the cause ,the pain is always worse in the morning as soon as weight is placed on the foot.

All of these lesions are treated with heel pads ,and reduce walking  ,these are often self-limiting .A splint at night to hold the foot dorsiflexed and to stretch the plantar fascia is preferable to a local corticosteroid injection in plantar fasciitis . When an injection is necessary , a medial approach is used ,rather than through the heel pad ,under a posterior tibial nerve block.

Heel pain causes
-Plantar fascitis   ___ below heel.
-Plantar spur  ___ below
-Achilles tendonitis / bursitis  ___behind heel.
-Sever's disease.
Arthritis of ankle / subtaloid joints.


PAIN BEHIND THE HEEL AND LEG

Sever's disease is a traction apophysitis of the Achilles tendon in young people  ( cf.Osgood -Schlatter's disease) .
Achilles tendonitis is an enthesitis at the insertion of the tendon into the calcaneum.This is traumatic or it can complicate seronegative spondarthritis .Raising the shoe heel reduces pain.Occasionally a low-pressure corticosteroid injection near the enthesis is necessary.

Partial tear of the Achilles tendon causes a painful ,tender swelling a few centimetres above its insertion.Advise against walking barefoot and jumping .Therapeutic ultrasound is helpful.( Caution - a local injection may cause the tendon to rupture .)

Achilles bursitis lies clearly anterior to the tendon and can be safely injected with corticosteroid.

COMPARTMENT SYNDROMES

The muscles of the lower leg are enclosed in facial compartments ,with little room for expension to occur.Compartment syndromes can be acute and severe ,such as following exercise.

In the anterior tibial syndrome there is severe pain in the front of the shin ,occasionally with foot drop. Immediate surgical decompression to prevent muscle necrosis is sometimes required.

Chronic compartment syndrome produces pain in the lower leg that is aggravated by exercise and may therefore be mistaken for a vascular or neurological disorder.  

Pain in the foot

PAIN  IN THE FOOT

The feet are subjected to extreme pressures by weight bearing and inappropriate shoes .They are commonly painful.Broad ,deep .thick -soled shoes are essential for sporting activities ,prolonged walking or standing ,and in people with congenitally flat or arthritic feet.

There are two common types of foot deformity :

• Flat feet stress the ankle and throw the hind foot into a valgus ( everted ) position - a flat foot is rigid and inflexible.
• High -arched feet place pressure on the lateral border and ball of the foot .

The foot is affected by a variety of inflammatory arthritic conditions.After the hand ,the foot joints are the most commonly affected by rheumatoid arthritis ,The diagnosis depends upon careful assessment of the distribution of the joints affected ,the pattern of other joint problems , or by finding the associated condition ( e.g psoriasis  ).

PAIN IN THE FOOT CAUSES

Structural ( flat ( pronated ) or high arched ( supinated ).

Hallux valgus /rigidus ( +/- Osteoarthritis ).

Metatarsalgia.

Morton's neuroma.

Stress fracture.

Inflammatory arthritis.

-Acute ,monarticular -gout.

-chronic ,polyarticular -rhematoid arthritis.

-Chronic ,pauciarticular -seronegative spondarthritis.

Tarsal tunnel syndrome.

HALLUX VALGUS 

The great toe migrates laterally .In the congenital form the first metatarsal is displaced medially ( metatarsus primus varus ) .The shape of modern shoes causes later onset of hallux valgus .It is a common complication of rheumatoid arthritis .

HALLUX RIGIDUS 

Osteoarthritis of the first MTP joint in a normally aligned or valgus joint causes hallux rigidus - a stiff ,dorsiflexed and painful great toe .Careful choice of footwear and the help of a podiatrist suffice for most cases ,but some require surgery .

METATARSALGIA

This is common  ,especially in women who wear high heels ,after trauma and in those with hammer toes.The balll of the foot is painful to walk and stand on .Callosities and pressure -inuced bursae develop under the metetarsal  heads . Rheumatoid arthritis causes misalignment of the metatarsal bones and severe metatarsalgia.

TREATMENT is with podiatry and the wearing of appropriate shoes.Surgery is occasionally needed ,particularly in the rheumatoid forefoot.

Morton's metatarsalgia is due to a neuroma , usually between the third and fourth toes .It causes pain , burning and numbness in the adjacent surfaces of the affected toes when walking .It is helped by wearing wider , cushioned -soled shoes.

STRESS ( MARCH ) FRACTURES 

 These cause sudden ,severe weight -bearing pain in the distal shat of the fractured metatarsal bone .They occur after unaccustomed walking or with new shoes.There is local tenderness and swelling ,but initially X-rays are normal and diagnosis delayed.A radioisotope bone scan reveals the fracture earlier than X-rays .Reduced weight -bearing for a few weeks usually suffices.

TARSAL TUNNEL SYNDROME 

This is an entrapment neuropathy of the posterior tibial nerves as it rounds the medial maleolus.It produces burning ,tingling and numbness of the toes ,sole and medial arch.The nerve is tender below the maleolus and ,when tapped ,produces a shock -like pain  ( Tineli's sign ).A local steroid injection under the retinaculum ,between the medial maleolus and calcaneum ,is helpful.

Chest pains

Chest pain can be a symptom of a number of severe conditions and is generally considered a medical emergency. Although it is clear that pain is non-cardiac origin, which is often a diagnosis of exclusion after excluding the most serious causes of pain.

SYMPTOMS AND SIGNS ACCORDING TO LIKELY ETIOLOGY

COSTOCHONDRAL OR CHEST WALL PAIN
Localized sharp/stabbing or persistent/dull pain ,reproduced by pressure over the painful area.

CERVICAL OR THORACIC SPINE DISEASE WITH NERVE ROOT COMPRESSION
Sharp pain,may be in radicular distribution ,exacerbated by movement of neck,back.

ESOPHAGEAL OR GASTRIC PAIN
Associated with dysphagia or gastric regurgitation,may be worsened by aspirin/alcohol ingestion/certain foods/supine position: often relieved by antacids.

BILIARY PAIN
Intolerance of fatty foods, right upper quadrant tenderness also present.

MYOCARDIAL ISCHEMIA
Precipitated by exertion or emotional arousal .ECG ( or holter monitor ) during pain shows ST segment shifts ,pain relieved quickly ( < 5 minutes ) by sublingual TNG

DIFFERENTIAL DIAGNOSIS OF ACUTE CHEST PAIN

1.

*DESCRIPTION OF PAIN
Oppressive,constrictive ,or squeezing ,may radiate to arms ,neck and back.

*BACKGROUND HISTORY
Less severe ,similar pain on exertion plus coronary risk factors.

*KEY PHYSICAL FINDINGS
Diaphoresis ,pallor S4 common .S3 less common.

*CONSIDER
Acute Myocardial Infarction.

*CONFIRMATORY TESTS
Serial ECGs ,Serial cardiac markers ( especially troponin ,CK )

2.
*DESCRIPTION OF PAIN
tearing or ripping may travel from anterior chest to mid back.

*BACKGROUND HISTORY
Hypertension or Marfan syndrome.

*KEY PHYSICAL FINDINGS
Weak,asymptomatic peripheral pulses ,possible diastoic murmur or aortic insufficiency.

*CONSIDER
Aortic Dissection

*CONFIRMATORY TESTS
CXR -Widened mediastinal silhoutte ,MRI .CT ,or transesophageal echogram ,intimal flap visualized.Aortic angiogram ,definitive diagnosis.

3.
*DESCRIPTION OF PAIN
Crushing ,sharp ,pleuritic ,relieved by sitting forward.

*BACKGROUND HISTORY
recent upper respiratory tract infection ,or other conditions which predispose to pericarditis.

*KEY PHYSICAL FINDINGS
Pericardial friction rub ( usually 3 component best heard by sitting patient forward )

*CONSIDER
Acute pericarditis

*CONFIRMATORY TESTS
ECG ,diffuse ST elevation and PR segment depression. Echogram ,pericardial effusion often visualized.

4.
*DESCRIPTION OF PAIN
Pleuritic ,sharp possibly accompanied by cough /hemoptysis

*BACKGROUND HISTORY
Recent surgery or other immobilization

*KEY PHYSICAL FINDINGS
Tachypnea ,possible pleural friction rub.

*CONSIDER
Pulmonary Embolism

*CONFIRMATORY TESTS
Arterial blood gas ,hypoxemia and respiratoy alkalosis ,Lung scan ,V/Q mismatch ,pulmonary angiogram ,arterial luminal filling defects.

5.
*DESCRIPTION OF PAIN
Very sharp, pleuritic

*BACKGROUND HISTORY
recent chest ,or history of chronic obstructive lung disease.

*KEY PHYSICAL FINDINGS
tachypnea ,breath sounds and hyperesonance over affected lung field

*CONSIDER
Acute Pneumothorax

*CONFIRMATORY TESTS
CXR ,radioluency within pleural space poss ,collapse of adjacent lung segment , If tension pneumothorax mediastinum is shifted to opposite side.

6.
*DESCRIPTION OF PAIN
Intense substernal and epigastric accompanied by vomiting and/or hemoptysis.

*BACKGROUND HISTORY
Recent recurrent vomiting /retching

*KEY PHYSICAL FINDINGS
Subcutaneous emphysema ,audible crepitus adjacent to the sternum.

*CONSIDER
Rupture of esophagus

*CONFIRMATORY TESTS
CXR pneumomediastinum .Esophageal endoscopy is diagnostic

DIFFERENTIAL DIAGNOSIS OF PATIENTS ADMITTED TO HOSPITAL WITH ACUTE CHEST PAIN RULED NOT MYOCARDIAL  INFARCTION

Gastroesophageal Disease    42%
*Gastroesophageal reflux
*esophageal motility disorders
*Peptic ulcer
*Gallstones

Ischemic Heart Disease  31%
Chest Wall Syndrome  28%
Pericarditis  4%
Pleuritic/pneumonia  2%
Pulmonary embolism  2%
Lung cancer   1.5%
Aortic aneurysm  1%
Aortic stenosis  1%
Herpes zoster   1%

Chest pain

CHEST PAIN

Pain in the chest is sometimes cause of Musculoskeletal conditions.An example is Tietze's disease.In this condition ,pain arises from the costochondral junctions.It is usually unilateral and affects one,two or three ribs. There is local tenderness ,which helps to make diagnosis.The condition is benign and self-limitin.It often responds well to anti-inflammatory drugs.Other causes of chst wall pain include rib fractures due to trauma or osteoporosis or a malignant deposit.

Chest pain may appear suddenly at any time. Try to ignore at first, but your chest pain has you scared and worried. Chest pain is one of the most common causes of application for emergency medical assistance. All medical emergency room doctors Every year evaluate and treat millions of people with chest pain.

There is little correlation between the severity of chest pain and the seriousness of its cause.

POSSIBLE SERIOUS CAUSES

The differential diagnosis of chest pain as (1).new ,acute ,and ongoing .(2).Recurrent,episodic and (3).persistent,sometimes for days.

MYOCARDIAL ISCHEMIA

*ANGINA PECTORIS

Substernal pressure,squeezing ,constriction ,with radiation typically to left arm; usually on exertion,especially after meals or with emotional arousal,

Characteristically relieved by rest and nitroglycerine.

*ACUTE MYOCARDIAL INFARCTION

Similar to angina but usually more severe ,of longer duration ( > or equal 30 min ) and not immediately relieved ,and hypoxemia.

PULMONARY EMBOLISM

May be substenal or lateral ,pleuritic in nature ,and associated with hemoptysis ,tachycardia , and hypoxemia.

AORTIC DISSECTION

Very severe in center of chest ,a "ripping " quality ,radiates to back ,not affected by changes in position.May be associated with weak or absent peripheral pulses.

MEDIASTINAL EMPHYSEMA

Sharp,intense,localized to substernal region ,often associated with audible crepitus.

ACUTE PERICARDITIS

Usually steady ,crushing ,substernal,often has pleuritic comonent aggravated by cough,deep inspiration, supine positio,and relieved by sittingg upright ,one,two ,or three-component pericardial friction rub often audible.

PLEURISY

Due to nflammation,less commonly tumor and pneumothorax.Usually unilateral ,knifelike ,superficial,aggravated by cough and respiration.

LESS SERIOUS CAUSES

*COSTOCHONDRAL PAIN

In anterior chest ,usually sharply localized.may be brief and darting or a persistent dull ache.Can be reproduced by pressure on costochondral and /or chondrosternal junctions.In Tietze's syndrome ( costochondritis ) ,joints are swollen ,red , and tender.

*CHEST WALL PAIN

Due to strain of muscles or ligaments from excessive exercise or rib fracture from trauma,accompanied by local tenderness.

* ESOPHAGEAL PAIN

Deep thoraci discomfort; may be accompanied by dysphagia and regurgitation.

EMOTIONAL DISORDERS

Prolonged ache or dart like,grief,flashing pain.associated with fatigue,emotional strain.

OTHER CAUSES

(1) Cervical disk.(2) Osteoarthritis of cervical or thoracic spine.  (3) Abdominal disorders ,peptic ulcer, hiatus hernia ,pancreatitis ,biliary colic .  (4) Tracheobronchitis,pneumonia.  (5) Disese of the breast ( inflammation ,tumor ).  (6) Intercostal neuritis ( herpes zoster ). 

Hips pain and treatment

Hip pain , that occurs in and around the hips ,due to some causative problems in joint. This type of pain usually shows up within the hip or in part of groin. Hip pain can be caused by problems with muscles, ligaments, tendons and other structures that support the hip joint. problems with hip pain usually occur outside of the hip or thigh.Sometimes  it can be caused by the disease in the body than others. This type of pain is called referred pain.This type of pain rarely an emergency, and the pain can be managed by self-care at home with some home remedies ,with restricted movements and by taking some analgesic cream massage.

HIP PAIN TREATMENT

SELF - CARE AT HOME

In the older age, the body usually covered less easy to tolerate. Falls can often cause bruising (or bruising) and inflammation of tissue that is damaged. That does not feel pain immediately, and within a few hours of the injured area may stiffen and begin to get angry. If the patient can stand and walk quite easily with some limp, so it is sensible to rest and ice, injured areas and initiating activities tolerated. Over-the-counter pain killers can be used. Usually pain and stiffness should be resolved within a few days. If pain persists or begins to worsen rather than improve, a medical assessment may be useful. Hip pain and tenderness, which are developed as excessive, but without a specific injury can be treated at home for rest and a gradual return to full activity. Although rest is important, it is also important to maintain range of motion, or should try to stretch your legs, hips and back and keep your body moving.

Care for pain in the hip that exists due to an underlying disease should be coordinated with the health care practitioner. Often, pain in the hip sporadically, depending on the control of the state of health.

MEDICAL CARE AND MEDICATION FOR HIP PAIN

The cause of hip pain guide treatment. Outside of medicine, treatment should be to maintain strength and range of motion of the hip. As with any illness or injury, the goal is to bring the patient to their normal level of functioning. A team approach involving the health care practitioner, physiotherapist or chiropractor treats can be considered.We can use  ( analgesics) pain killers for hip pain.

The discomfort can often be treated with drugs against pain. Acetaminophen, ibuprofen and naproxen can all be used. Although these drugs do not require a prescription, each with its own potential side effects and whether there are underlying medical conditions present, it is useful to ask for help from a pharmacist or to inform your healthcare professional health that you take a new medication without a prescription.

Use of medication will depend on the prescription for the pain in the hip. Very often, the drugs are intended for the treatment of the underlying disease or damage that causes pain. Depending on the situation, small courses of drugs, or narcotic analgesics, with or without muscle relaxants may be used until the underlying problem is resolved.

Hip pain

HIP PAIN 

" Hip " refers to a wide area between the upper buttock ,trochanter and groin.It is useful to ask the patient to point to the site of pain and its field of radiation.Pain arising from the hip joint itself is felt in the groin ,lower buttock and anterior thigh and may radiate to the knee .Occasionally and inexplicably ,hip arthritis causes pain only in the knee .

Pain in the hip is not always felt directly on the hip. Instead, you can feel it in the mid-thigh or groin. Similarly, you feel pain in the hip may actually reflect a problem in the back, rather than pain in the hip.

The hip pain is a most common problem and it can be confusing because there are many reason .It is more important to accurately diagnose the cause of your symptoms so that appropriate treatment can be directed to the underlying problem.

 If you have pain in the hip, some Common causes include:

PAIN IN THE HIP  __ CAUSES .

HIP REGION PROBLEMS          _________________      MAIN SITES OF PAIN 

Osteoarthritis of hip .            ____________________     Groin ,buttock ,front of thigh to knee.

Trochanteric bursitis.            ____________________     Lateral thigh to knee.

Meralgia paraesthetica.          ___________________      Anterolateral thigh to knee .

Referred from back.               ____________________      Buttock.

Facial joint pain .                 _____________________     Buttock and posterior thigh .

Inflammatory arthritis .          ____________________       Groin ,buttock ,front of thigh to knee.

Sacoillitis (AS ).                   ____________________       Buttock.

Avascular necrosis .              ____________________       Groin ,buttock .

Polymyalgia rheumatica .        ____________________       Buttocks ,lumbar spine .         

OSTEOARTHRITIS ( OA ) 

Osteo-arthritis is the most common cause of hip joint in a person over the age of 50 years .It causes pain in the buttock and groin on standing and walking .Stiff hip movements cause difficulty in putting on a sock and may produce a limp.

TROCHANTERIC BURSITIS 

This may be due to trauma or unaccustomed exercise ,but sometimes has an unknown cause.It occurs in inflammatory arthrithis.the pain over the trochanter is worse going up stairs and when abducting the hip ,and the trochanter is tender to lie on .A local corticosteroid injection onto the surface of the trochanter is helpful.

MERALGIA PARAESTHETICA 

This cause numbness and burning dysaesthesia ( increased sensitivity to light touch ) over the anterolateral thigh and may be precipitated by a sudden increase in weight.

FRACTURE OF THE FEMORAL NECK

This usually occurs after a fall ,occasionally spontaneously .There is pain in the groin and thigh ,weight bearing is painful or impossible ,and the leg is shortened and externally rotated .Occasionally a fracture is not displaced and remain undetected .X-rays are diagnostic.Anyone with a hip fracture ,especially after minimal trauma ,should be reviewed for osteoporosis .

AVASCULAR NECROSIS ( OSTEONECROSIS ) OF THE FEMORAL HEAD 

This is uncommon but occurs at any agr.There  is severe hip pain .X-rays are diagnostic after a few weeks ,when a well -demarcated area of increased bone density is visible .In the femur this lies at the upper pole of the femoral head.The affected bone may collapse.Early ,the X-ray is normal but bone scintigraphy or MRI demonstrate the lesions.Risk factors include treatment with corticosteroids or heparin ,exposure to high barometric pressures ( diverse and tunnellers ) ,excessive alcohol consumption ,and sickle cell disease.

INFLAMMATORY ARTHRITIS OF THE HIP 

This produce pain in the groin and stiffness ,which are worse in the morning .Rheumatoid arthritis ( RA)   rarely presents with hip pain ,although the hip is involved eventually in severe RA .Ankylosing spondylitis and other seronegative spondarthritides cause inflammatory hip arthritis in younger people.

POLYMYALGIA RHEUMATICA 

 Bilateral hip ,buttock and thigh pain and stiffness that are worse in the morning in an elderly patient may be attributable to polymyalgia rheumatica .

Neurosurgery could be a part of pain management

Pain is part of the body's defense system, producing a reflexive retraction from the agonized stimulus, and tendencies to protect the affected body part while it heals, and avoid that bruising situation in the future. It is an important part of animal life, vital to healthy survival. 


People with congenital insensitivity to pain have reduced life expectancy. Idiopathic pain (pain that persists after the trauma or pathology has healed, or that arises without whatever manifest cause), may be an omission to the intent that pain is helpful to survival, although, such pain is psychogenic, enlisted as a protective amusement to keep dangerous emotions unconscious. It is not clear what the activity benefit of whatever extremity forms of pain (e.g. toothache) strength be, and the intensity of whatever forms of pain (for example as a result of injury to fingernails or toenails) seems to be out of all proportion to whatever activity benefits.

MANAGEMENT OF CHRONIC PAIN
Chronic discompose is gravely disabling and distressing and taxing to trait .Multidisciplinary discompose relief clinics are helpful in providing limited and supportive therapy.Pain control should ,however ,be part of all doctors skills.
A management organisation for intractable discompose ,when it is often difficult to find the fine cause has heptad components.

DIAGNOSTIC
Rigorous attention must be paid to the question of identification ,reviewing the history ( first assistance ), the investigations and radiology.A limited surgical approach may then become apparent ( e.g discompose in undiagnosed spinal stenosis trigeminus hurting ,glossopharyngeal hurting ,or discovery of syringomyelgia in intractable upper branch discompose ).

PSYCHOLOGICAL
Chronic discompose influences quality of life and lifestyle.Clinical depression is almost universally associated with chronic discompose event when the underlying pathology is benign .Perhaps paradoxically a relative minority of patients suffering discompose from secondary cancer are clinically depressed despite the gravity of their disease.Antidepressant drugs and modification of style are of help in improving the quality of life.Preservance and compliance with therapy is an invariable issue.

ANALGESICS

CO-ANALGESICS
Co-analgesics are drugs that have a primary use in conditions another than discompose but are also effective ,either lonely or when additional to customary analgesics.
Examples are non-steroidal anti-inflammatory drugs uesd in bone discompose or antidepressant antidepressants and anticonvulsants utilised in deafferentation pain.
Calcium-channel blockers ( nifedipine ) improve sympathetically mediated discompose ,as occurs in ,for example Raynaud's disease.Muscle relaxants , antibiotics and steroids by injection each relieve discompose when utilised in pertinent situations ( e.g nonindulgent spastically , infection and inflammatory arthropathy ,respectively ).

STIMULATION
Acupuncture,ice,heat ultrasound,massage ,transcutaneous electrical cheek stimulation ( TENS ) and spinal cord stimulation all achieve analgesia by a gating gist on large fat cheek fibres.

NERVE BLOCKS
Pain pathways can be closed either temporarily by local anaesthetic or permanently with phenol or with radiofrequency lesions.Examples are .

SOMATIC BLOCKS
(a) Peripheral cheek and plexus injections.
(b) Epidural and spinal analgesia.

SYMPATHETIC BLOCKS
(a) Sympathetic ganglia and cheek endings injections.
(b) Central epidural and spinal likable blockade.

NEUROSURGERY
Highly specialized and sometimes disputable techniques have a locate alongside pharmacalogical remedies.Examples are dorsal rhizotomy ,sympathectomy,cordotomy and neurostimulation.