01Approach to the Critical Patient/attcp51

Triage priorities

›Stability screen

›Airway

›Breathing

›Circulation

›If syncope

›Alternative diagnosis pathway

›ECG

›Glucose

›If open wound

›Open injury pathway

›Antibiotics timing

›Tetanus logic

Limb threat screen

›Limb threat triggers

›Neurovascular compromise

›Dorsalis pedis pulse

›Posterior tibial pulse

›Capillary refill

›Plantar sensation

›Compartment syndrome concern

›Pain out of proportion

›Pain with passive toe extension

›Tense plantar compartments

›Skin compromise

›Blanching

›Threatened skin from swelling

02History/hx40

Mechanism and timeline

›Mechanism timeline

›Sudden push off sprint jump pivot

›Pop sensation

›Immediate plantar pain

›Direct trauma to plantar arch

›Crush mechanism

›Laceration risk

›Overuse background

›Recent increase in running volume

›Recent change in footwear

›Time since injury

›Minutes to hours onset

›Delayed bruising within 24 to 48 hours

Risk factors and context

›Risk factors

›Prior plantar fasciitis

›Morning start up pain history

›Prior steroid injection

›Fluoroquinolone exposure

›Tendinopathy history

›Concurrent corticosteroids

›Foot biomechanics

›Pes planus

›Pes cavus

›Systemic risks

›Diabetes

›Inflammatory arthritis

03Physical Exam/exam48

Inspection and palpation

›Local exam

›Plantar ecchymosis

›Medial arch bruising

›Heel pad bruising

›Swelling

›Plantar arch swelling

›Heel swelling

›Point tenderness

›Medial calcaneal tubercle region

›Mid arch plantar fascia band

›Palpable defect

›Gap in plantar fascia

›Tender nodularity at tear edge

Functional tests

›Function tests

›Windlass test

›Pain with passive great toe dorsiflexion

›Reduced arch tension compared with other side

›Toe walking

›Unable due to pain

›Marked limp

›Single leg heel raise

›Limited by pain

›Compare to contralateral side

Neurovascular and associated injury exam

›Neurovascular and adjacent structures

›Sensation

04Differential Diagnosis/ddx39

Traumatic and structural

›Traumatic and structural

›Calcaneal fracture

›Axial load fall history

›Heel squeeze pain

›Metatarsal stress fracture

›Focal dorsal tenderness

›Pain with forefoot loading

›Lisfranc injury

›Plantar midfoot ecchymosis

›Pain with midfoot stress

›Achilles tendon rupture

›Positive Thompson test

›Weak plantar flexion

›Plantar plate tear

›MTP joint plantar pain

›Drawer test at toe

Soft tissue and inflammatory

›Soft tissue and inflammatory

›Plantar fasciitis

›Chronic morning pain

›No acute bruising

›Heel fat pad contusion

›Central heel pain

›Pain with direct heel strike

›Tarsal tunnel syndrome

›Burning paresthesia

›Tinel sign at tarsal tunnel

05Laboratory Tests/lt21

Routine testing

›Routine labs

›No routine labs for isolated closed plantar fascia rupture

›Clinical diagnosis common

›Imaging driven when fracture concern

Targeted labs when indicated

›Targeted labs

›If open wound

›CBC for infection concern

›CRP for infection concern

›If systemic illness

›Electrolytes for dehydration or illness

›Creatinine for NSAID safety

›If surgery possible

›CBC for baseline

›INR if anticoagulants

›Type and screen for operative pathway

Interpretation and pitfalls

›Interpretation

›Normal labs do not exclude infection early

›Early cellulitis may have normal CBC

›Clinical progression more important

›CK not useful for isolated rupture

›Use only if crush injury or prolonged ischemia

06Diagnostic Tests/dt39

Scoring Systems

›Decision tools

›Ottawa ankle and foot rules

›Midfoot pain

›Navicular bone tenderness

›Base of 5th metatarsal tenderness

›Inability to bear weight

›Four steps in ED or clinic

›Four steps immediately after injury

›Ankle pain

›Posterior edge or tip lateral malleolus tenderness

›Posterior edge or tip medial malleolus tenderness

Radiographs

›X ray evaluation

›Indications

›Ottawa rule positive

›High energy mechanism

›Focal bony tenderness

›Views

›Foot three view series

›Ankle three view series if ankle pain

›Key findings to assess

›Calcaneal fracture lines

›Avulsion fragments at calcaneal insertion

›Midfoot alignment

MRI

›MRI evaluation

›Indications

07Disposition/dispo23

Discharge versus admission

›Disposition decision

›Discharge criteria

›Pain controlled with oral meds

›Neurovascularly intact foot

›No fracture or unstable injury on imaging

›Admission criteria

›Uncontrolled pain

›Neurovascular compromise

›Suspected compartment syndrome

›Open injury requiring OR or IV antibiotics

Follow up timing

›Follow up plan

›Podiatry or orthopedics

›Within 3 to 7 days for suspected complete rupture

›Within 1 to 2 weeks for partial rupture improving

›Physiotherapy

›After acute pain phase

›Guided return to loading

Transfer triggers

›Transfer criteria

›Compartment syndrome concern

›Immediate surgical evaluation

›No delay for imaging

›Open fracture or major midfoot instability

›Higher level center if local resources limited

08Treatment/t78

Immediate life-saving interventions

›Life threatening alternatives

›If compartment syndrome concern

›Emergent ortho consult

›NPO status

›If open injury

›Antibiotics within 1 hour when feasible

›Tetanus prophylaxis

Immobilization and Splinting

›Immobilization strategy

›Walking boot

›Neutral to slight plantar flexion

›Heel lift optional for comfort

›Posterior short leg splint

›If pain severe or swelling significant

›If non weight bearing planned

›Non circumferential casting avoidance

›Swelling phase risk

›Compartment syndrome masking risk

Reduction

›Reduction considerations

›Reduction not applicable for isolated plantar fascia rupture

›Focus on exclusion of fracture dislocation

›Midfoot injury reduction only if dislocation present

Open fracture medications and timing

›Open injury pathway

›Antibiotics by contamination

›Clean low contamination

09Special Populations/sp30

Pregnancy

›Pregnancy considerations

›Analgesic selection

›Acetaminophen preferred

›NSAID avoidance in later pregnancy per obstetric guidance

›Imaging selection

›X ray if fracture concern with shielding

›MRI without gadolinium if needed

›Thrombosis risk

›Immobilization increases VTE risk

›Obstetric consultation for prophylaxis decisions

Geriatric

›Geriatric considerations

›Fragility fracture overlap

›Low energy mechanism with heel pain triggers fracture evaluation

›Osteoporosis risk assessment

›Skin integrity

›Boot pressure injury risk

›More padding and frequent skin checks

›Medication safety

›NSAID renal GI risk higher

›Opioid delirium risk higher

Pediatrics

›Pediatric considerations

›Rarity of true plantar fascia rupture

›Apophyseal injuries and fractures more likely

›Calcaneal apophysitis differential

›Imaging threshold

10Background/b30

Epidemiology

›Epidemiology

›Uncommon injury

›Often in athletes

›Often with prior plantar fasciitis

›Steroid injection association

›Increased rupture risk after local corticosteroid injection

›Counsel about recurrence and rupture risk

Pathophysiology

›Pathophysiology

›Plantar fascia role

›Supports medial longitudinal arch

›Windlass mechanism during toe dorsiflexion

›Rupture mechanism

›Acute tensile overload during push off

›Degenerative changes predispose to tearing

›Common tear location

›Proximal medial band near calcaneal origin

›Mid substance tears less common

Therapeutic Considerations

›Therapeutic considerations

›Conservative care success common

›Immobilization then progressive loading

›Symptom guided return to activity

›Surgery uncommon

›Consider for complete rupture with significant retraction

›Consider for persistent disability after prolonged conservative care

›Injection considerations

11Patient Discharge Instructions/pdi26

copy discharge instructions

›Discharge instructions

›Boot use

›Wear boot for walking

›Remove for hygiene if allowed and safe

›Weight bearing

›Protected weight bearing as tolerated

›Crutches if pain with steps

›Elevation and ice

›Elevate foot above heart when resting

›Ice 15 to 20 minutes at a time

›Pain medicines

›Acetaminophen as directed

›NSAID only if safe for kidneys stomach and bleeding risk

›Activity

›No running jumping sports until cleared

›Gradual return once walking is pain free

›Return to ED now

›Increasing pain not controlled

›New numbness tingling or weakness

›Pale cold foot or color change

›Rapid swelling or severe tightness

›Fever or spreading redness

›Wound drainage or open wound

›Follow up

›Podiatry or orthopedics within 3 to 7 days

›Earlier if worsening symptoms

12References/r20

Clinical guidelines and evidence

›Sources

›Ottawa ankle and foot rules original derivation and validation literature

›Imaging decision support for ankle and midfoot injury

›High sensitivity for clinically significant fractures in studied populations

›Sports medicine reviews on plantar fascia rupture

›Conservative management typical pathway

›Imaging role for unclear cases

›Orthopedic and podiatry texts on plantar fascia disorders

›Anatomy and windlass mechanism

›Rehabilitation progression principles

›Steroid injection risk literature for plantar fascia rupture

›Association between corticosteroid injection and rupture risk

›Counseling importance before injection

Coding systems

›Coding references

›ICD 10 CM plantar fascia rupture

›Use injury site and laterality specific code per local coding guidance

›Use external cause codes when required

›SNOMED CT plantar fascia rupture concept

›Document laterality when available

›Document acute traumatic versus spontaneous context

Evidence & Review

Evidence & Review