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ABSTRACT: Plantar fasciitis, a self-limiting condition, is a common cause of heel pain in adults. It affects more than 1 million persons per year, and two-thirds of patients with plantar fasciitis will seek care from their family physician. Plantar fasciitis affects sedentary and athletic populations. Obesity, excessive foot pronation, excessive running, and prolonged standing are risk factors for developing plantar fasciitis. Diagnosis is primarily based on history and physical examination. Patients may present with heel pain with their first steps in the morning or after prolonged sitting, and sharp pain with palpation of the medial plantar calcaneal region. Discomfort in the proximal plantar fascia can be elicited by passive ankle/first toe dorsiflexion. Diagnostic imaging is rarely needed for the initial diagnosis of plantar fasciitis. Use of ultrasonography and magnetic resonance imaging is reserved for recalcitrant cases or to rule out other heel pathology; findings of increased plantar fascia thickness and abnormal tissue signal the diagnosis of plantar fasciitis. Conservative treatments help with the disabling pain. Initially, patient-directed treatments consisting of rest, activity modification, ice massage, oral analgesics, and stretching techniques can be tried for several weeks. If heel pain persists, then physician-prescribed treatments such as physical therapy modalities, foot orthotics, night splinting, and corticosteroid injections should be considered. Ninety percent of patients will improve with these conservative techniques. Patients with chronic recalcitrant plantar fasciitis lasting six months or longer can consider extracorporeal shock wave therapy or plantar fasciotomy.
Analgesics for Osteoarthritis - Implementing AHRQ Effective Health Care Reviews
Evaluation of Scrotal Masses - Article
ABSTRACT: Scrotal masses are caused by a variety of disorders, ranging from benign conditions to those requiring emergent surgical intervention. Painful scrotal masses require urgent evaluation. Characteristics that suggest testicular torsion include rapid symptom onset, nausea and vomiting, high position of the testicle, and abnormal cremasteric reflex. Doppler ultrasonography or surgical exploration is required to confirm the diagnosis. Surgical repair must occur within six hours of symptom onset to reliably salvage the testicle. Epididymitis/orchitis have a slower onset and are associated with a C-reactive protein level greater than 24 mg per L (228.6 nmol per L) and increased blood flow on ultrasonography. Acute onset of pain with near normal physical examination and ultrasound findings is consistent with torsion of the testicular appendage. Testicular malignancies cause pain in 15% of cases. If ultrasonography shows an intratesticular mass, timely urology referral is indicated. Inguinal hernias are palpated separate to the testicle and can cause pain. Emergent surgery is indicated for a strangulated hernia. Hydrocele, varicocele, and scrotal skin lesions may be managed in nonurgent settings. A biopsy should be performed to rule out cancer in patients with scrotal skin lesions that are erosive, vascular, hyperkeratotic, or nonhealing, or that change color or have irregular borders.
Evaluation of Elbow Pain in Adults - Article
ABSTRACT: The elbow is a complex joint designed to withstand a wide range of dynamic exertional forces. The location and quality of elbow pain can generally localize the injury to one of the four anatomic regions: anterior, medial, lateral, or posterior. The history should include questions about the onset of pain, what the patient was doing when the pain started, and the type and frequency of athletic and occupational activities. Lateral and medial epicondylitis are two of the more common diagnoses and often occur as a result of occupational activities. Patients have pain and tenderness over the affected tendinous insertion that are accentuated with specific movements. If lateral and medial epicondylitis treatments are unsuccessful, ulnar neuropathy and radial tunnel syndrome should be considered. Ulnar collateral ligament injuries occur in athletes participating in sports that involve overhead throwing. Biceps tendinopathy is a relatively common source of pain in the anterior elbow; history often includes repeated elbow flexion with forearm supination and pronation. Olecranon bursitis is a common cause of posterior elbow pain and swelling. It can be septic or aseptic, and is diagnosed based on history, physical examination, and bursal fluid analysis if necessary. Plain radiography is the initial choice for the evaluation of acute injuries and is best for showing bony injuries, soft tissue swelling, and joint effusions. Magnetic resonance imaging is the preferred imaging modality for chronic elbow pain. Musculoskeletal ultrasonography allows for an inexpensive dynamic evaluation of commonly injured structures.