From the Guidelines
The next step for an adult who fell from a height and complains of severe heel pain, despite being conscious, oriented, and having stable vitals, should be pulse palpation (option C). This is critical to assess for potential vascular compromise that might accompany calcaneal or other foot injuries, as compromised blood flow represents a time-sensitive emergency that could lead to tissue necrosis or compartment syndrome 1. The clinician should check the dorsalis pedis and posterior tibial pulses to evaluate distal circulation.
While pain control and imaging are important, vascular assessment takes precedence. After confirming adequate circulation, pain management should be provided using appropriate analgesics such as NSAIDs, as suggested by the american college of foot and ankle surgeons 1. Following stabilization and pain control, lower limb X-rays would be indicated to evaluate for calcaneal fractures or other bony injuries, which are common in falls from height due to axial loading forces transmitted through the heel.
Key considerations in this case include:
- Assessing for potential vascular compromise
- Providing pain management using appropriate analgesics
- Evaluating for calcaneal fractures or other bony injuries using lower limb X-rays
- Considering the patient's overall condition and potential for occult injuries, particularly in the geriatric population, as falls can lead to significant morbidity and mortality 1.
From the Research
Initial Assessment
The patient is an adult who has fallen from a height and is complaining of severe heel pain, but is conscious, oriented, and has stable vitals. The next step in management would involve:
- Assessing the patient's airway, breathing, and circulation (ABCs) to ensure stability, although it's mentioned that the patient has stable vitals
- Considering the mechanism of injury and the symptoms presented, a thorough physical examination is necessary to identify any potential injuries or conditions that could be causing the heel pain
Diagnostic Considerations
Given the patient's symptoms and the mechanism of injury, potential causes of heel pain include:
- Fractures or bone bruises, as mentioned in the study by 2
- Plantar fascial lesions, tendinous lesions, or osseous lesions, as discussed in the study by 2
- Calcaneal stress fractures, which can cause progressively worsening pain after an increase in activity or change to a harder walking surface, as noted in the study by 3
Imaging and Further Evaluation
The study by 4 emphasizes the importance of a thorough evaluation and treatment of foot and ankle injuries in the Emergency Department, including a focused history, physical examination, and imaging to determine the stability of the injury.
- Imaging studies, such as X-rays, may be necessary to rule out fractures or other bony abnormalities, as suggested by the study by 3
- The study by 2 highlights the usefulness of magnetic resonance (MR) imaging in determining the cause of heel pain and assessing the extent and severity of the disease in ambiguous or clinically equivocal cases
Management
The management of heel pain would depend on the underlying cause, but may include:
- Pain control, as mentioned in the options
- Immobilization or stabilization of the affected area, if necessary
- Further evaluation and management by a specialist, such as an orthopedic surgeon, if the condition is severe or does not respond to initial treatment, as suggested by the study by 5