When guidelines fail

She was a 78 year old widow who lived in sheltered accommodation and, despite being partially sighted because of advancing glaucoma, was still able to get about with her white cane. She rarely visited our surgery, and when she did it was for a flu jab or regarding moderate generalised osteoarthritis. This morning, however, she limped into my consulting room apologetically and said, “The heel of my right foot is hurting, doctor. I'm finding it difficult to walk to the shops. My eyesight doesn't help either.”

I set out to examine her foot. There was nothing grossly abnormal. It was well perfused, no swellings, and no evidence of any trauma. Deep palpation over the calcaneum produced tenderness. “Bingo,” I thought, “plantar fasciitis, with or without calcaneal spur.” I reached for an x ray form when I suddenly remembered the fate of the previous x …