CASE STUDIES
Case study #1 A 44-year-old obese man presents to the outpatient clinic with a diagnosis of plantar fasciitis. The patient describes heel pain that is significant in the morning. The patient rates the pain at 8/10, but the pain subsides somewhat during the day and then increases by the evening. The patient states he is a computer technician, so is primarily sedentary, but had just started a regular walking program prior to having the heel pain. The patient states he has begun to take NSAIDs to relieve the pain, and the doctor recommended that he begin using ice and come to physical therapy. He has not tried anything else prior to coming to therapy, but his friend who had plantar fasciitis last year recommended he get some special plantar fasciitis socks. He has not purchased them yet but wanted to know the therapist’s opinion as to whether or not they would be helpful. As a trained clinician, the first priority is to determine an appropriate diagnosis for the patient. The doctor has already made the diagnosis of plantar fasciitis, but for proper treatment and billing, a physical therapy diagnosis should also be made. Analysis of risk factors will help to determine what will be included in the subjective and objective exams. This particular patient does have several risk factors for plantar fasciitis: he is over 40, and his pain is significantly worse in the morning, subsiding throughout the day, and then gradually increasing by the evening. He is sedentary with a recent change in training patterns. These all suggest that this patient does have plantar fasciitis. The pain level is intermittent throughout the day, ruling out heel spurs and cancer, but the subjective exam still needs to rule out rheumatoid arthritis and nerve injuries. Stress fractures and Haglund’s deformity can be ruled out during the objective portion. Further questioning should ask about the nature and location of the pain in the heel as well as if the patient is having any symptoms in other joints. For instance, is there any numbness or tingling? Is the pain on the back of the heel or on the bottom of the heel? Is pain present in any other joints? In this case, this patient denies any numbness and tingling. He states the pain is on the bottom of his heel into the arch. He states that he does have back pain related to a lifting injury several years ago. These answers continue to indicate that this patient does have plantar fasciitis by ruling out nerve injuries, Haglund’s deformity, and rheumatoid arthritis. The objective exam should include special tests, such as the FPI test; the windlass test; and the tarsal tunnel tests, palpation; range of motion; and strength testing of the hip, knee, ankle and foot. It would also be beneficial to include a quick screen of the Achilles tendon reflexes as well as the ability of the patient to discern light touch in the foot. The following objective information was obtained: ● FPI : The patient scored a +8 bilaterally. ● Windlass test : Positive. ● Tarsal tunnel test : Negative. Case study #2 A 30-year-old woman presents with a diagnosis from the physician of plantar fasciitis after a new onset of left heel pain. The patient states she recently started a running program for a weight loss program. She described the pain as dull and achy in the morning and gradually getting worse throughout the day. The patient states the doctor prescribed NSAIDs and ice, along with telling her to come to physical therapy. She states that she also went out and bought heel pads for her running shoes because she feels they will help her to continue running. She has already lost ten pounds and does not want to stop running and slow her progress, but the heel pain is making it difficult. This patient does not fit the standard pattern for plantar fasciitis, especially as her heel pain is worse in the evening as opposed to the first step of the day. However, she does have one risk factor
● Palpation : The patient had no unusual lumps in the foot, pain was localized to the plantar surface of the foot, most notably at the insertion of the plantar fascia. ● Range of motion : Was within functional limits in the hip and knee, plantarflexion of the foot was 55°, dorsiflexion of the foot was 5°, inversion and eversion at the ankle were within normal limits. ● Strength : Hip flexion, extension, abduction, and adduction were within normal limits. Hip external rotation measured 4/5. Hip internal rotation was 5/5. Knee flexion and extension were within normal limits. Ankle strength was 5/5 in dorsiflexion, 4/5 in plantarflexion limited by pain. Inversion and eversion were within normal limits. ● Achilles tendon reflex : Tested at 2+. The patient had normal sensation to light touch in the foot. Assessment This patient has every indication pointing to plantar fasciitis. All other likely possibilities have been ruled out by a thorough examination. Since that has now been established, this patient’s specific deficits need to be identified and then addressed in the treatment program. The FPI of a +8 indicates that this patient holds their feet in pronation in standing. In other words, this patient has flat feet. The patient also has decreased dorsiflexion, a mild decrease in plantarflexion, decreased plantarflexion and hip external rotation strength, and pain. Based on the research, the plan most likely to produce results for this patient will include the following elements: 1. Low-dye taping initially, followed by recommendations for arch supports to address the flat feet if the taping decreases pain. 2. Manual stretching of the Achilles tendon and plantar fascia in the clinic with patient instructed in a home exercise program to include these stretches. 3. Strengthening of the calf muscles, specifically including unilat- eral heel raises. 4. Strengthening of the hip external rotators to address the weakness here. 5. Strengthening of the intrinsic musculature of the foot (e.g., picking up marbles with the toes or picking up a towel with the toes). 6. Trigger point therapy to the calf musculature and use of ice to decrease pain. A frozen, water-filled water bottle could be used with concurrent stretching of the plantar fascia to reduce the pain during this activity. 7. Education about reduction of BMI to prevent recurrence of symptoms. 8. Discussion with patient about the possible need for night splints. 9. This patient was also asking about special socks for plantar fascia; he will need education including the lack of evidence for the reduction of symptoms for products like this. consistent with plantar fasciitis: a change in her training program, specifically beginning a new running program. Upon further questioning, the patient denies any numbness or tingling, any other joint issues, and any prior history of heel pain. She describes the pain as intermittent, as she sometimes has no pain in the morning. This patient’s symptoms so far are more indicative of heel pad atrophy, Achilles tendon injury, or stress fractures. The history of a recent increase in running seems to suggest a calcaneal stress fracture or Achilles tendon injury. Therefore, the objective exam needs to focus on a differential diagnosis between plantar fasciitis, heel pad atrophy, Achilles tendon injury, and calcaneal stress fracture.
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