The following objective information was obtained : ● FPI : Scored 0. ● Windlass test : Negative. ● Tarsal tunnel test : Negative. ● Heel tap test : Positive. ● Palpation : Very tender to palpation over the plantar surface of the heel. There were no palpable lumps of any sort. There was some soreness over the plantar fascia, but not as severe as over the heel. The Achilles tendon was also moderately tender to palpation. ● Range of motion : Within normal limits in the hip, knee and ankle. There was pain with dorsiflexion and plantarflexion in the end ranges. ● Strength : This was within normal limits for the hip, knee, and ankle. The patient was able to demonstrate standing, unilat- eral heel raises with minimal pain in the heel. ● Achilles tendon reflex : Measured 1+ with sensation to light touch within normal limits throughout the foot. Assessment This patient most likely has a calcaneal stress fracture, not plantar fasciitis. The heel tap test was positive indicating a possible fracture, and the windlass test was negative, making plantar fasciitis less likely. The patient also does not have significant pain first thing in the morning, which is a classic sign of plantar fasciitis. Pain that diminishes with rest is more likely a stress fracture or a tendon injury. The pain was most significant on the plantar Case study #3 A 47-year-old man presents to the outpatient physical therapy clinic with the diagnosis of plantar fasciitis. He states this has been going on for 8 months with no real relief of symptoms. He went to three visits of physical therapy 4 months ago, and it did not help at all. The patient goes on to lament, “I don’t know why the doctor sent me back to therapy.” The patient states that first thing in the morning the pain is the worst. He rates the pain as 9/10. He does stretch some in the morning before continuing his day. Of note, the patient also states that he is a runner, and has continued running despite increased pain after running, though his distance has been limited. This patient is now dealing with a chronic issue. It is critical to find out what has already been tried for treatment and to complete another thorough examination to make sure that plantar fasciitis is an appropriate diagnosis. The patient states that previous physical therapy treatments consisted of iontophoresis, stretching exercises, and ice. The doctor has given him one corticosteroid shot, and that did help for 2 to 3 months, but now the pain is back. The patient stated that the iontophoresis helped for a couple of days but did not provide any lasting relief. The stretching does seem to help some if he does it regularly. The patient has purchased some new running shoes that were supposed to provide more support. He states that these have helped a little bit but not significantly. The patient denies numbness and tingling, and other joint pain; however, he does complain of some pain in his calf as well. The following objective information was obtained : ● FPI: Scored a 5+. ● Windlass test : Positive. ● Tarsal tunnel test : Negative. ● Palpation : The patient was very tender in the calf muscula - ture, the Achilles tendon insertion, and the insertion of the plantar fascia. There was also some tenderness in the arch of the foot. There are no abnormal lumps present. ● Range of motion : Hip and knee were within normal limits. Ankle dorsiflexion measures 2°, ankle plantarflexion measures 50°, ankle inversion and eversion are within normal limits. ● Strength : Hip flexion and extension are within normal limits, hip adduction is 5/5, hip abduction is 4+/5, hip internal rota- tion 4+/5, hip external rotation 4/5. Knee extension 5/5, knee flexion 4+/5, ankle inversion and eversion are within normal limits, ankle dorsiflexion is 5/5, ankle plantarflexion is 4+/5.
surface of the heel; an Achilles tendon injury will more likely have pain over the insertion of the tendon. This patient also did not present with a decrease in strength of the gastrocnemius or soleus that might be expected with an Achilles tendon injury. Heel pad atrophy is more likely as a person ages and is also more likely to present with bilateral symptoms versus unilateral symptoms. Plan With the likely cause of symptoms being a stress fracture, the recommendations will be significantly different than recommendations for treatment of plantar fasciitis. This patient will need to be referred back to the physician with a copy of the findings from the physical therapy examination. In the meantime, the patient needs to be counseled to avoid running and other high-impact activities that might aggravate the current injury. As this patient wants to continue with exercise for weight loss, the best option would be swimming, as it does not require continued weight bearing on the heel. This illustrates why a full examination of each patient is indicated. A physician may only be able to spend a limited time with each patient, and the patient may present the physician with multiple issues, further limiting the thoroughness of the physician’s exam. In this case, if the patient went through traditional treatment for plantar fasciitis, the symptoms would likely not improve, as the recommendations for stress fractures differ significantly. ● Neurological testing : Normal reflexes in the Achilles tendon, and normal sensation to light touch. Assessment This patient does have many signs pointing to plantar fasciitis, but he also has many of the symptoms of Achilles tendonitis. His FPI was 5, so he has mildly flat feet. The positive windlass test indicates that he likely has plantar fasciitis. The tenderness in the calf musculature and at the insertion of the Achilles tendon make Achilles tendinitis likely. The tenderness at the insertion of the plantar fascia points to plantar fasciitis being likely. The limited ankle dorsiflexion is very common with both plantar fasciitis and with Achilles tendinitis. The decreased hip strength can occur with plantar fasciitis, and the decreased function of the gastrocnemius and soleus musculature are common with Achilles tendinitis. Neurological testing is normal, so nerve injuries can be ruled out. There are no complaints of joint pain, ruling out rheumatoid arthritis. The pain is unilateral, ruling out heel pad atrophy. As there are no abnormal lumps present, Haglund’s deformity is ruled out, and cancer is less likely with the intensity of the pain being intermittent. This patient has been running for some time, so stress fractures are not likely. Plan With this patient likely having both plantar fasciitis and Achilles tendinitis, as well as previously failed physical therapy treatment, a significant amount of patient education will be indicated. In his case, the continued running is likely aggravating the Achilles tendinitis and therapists should suggest an alternate exercise, such as cycling or swimming. 1. Low-dye taping : This can be initiated in the clinic to provide arch support and decrease the tension on the plantar fascia. Heel pads are often recommended for Achilles tendinitis, so it may be helpful for this patient to have an orthotic that ad- dresses the need for both support of the arch and a heel pad. 2. Stretching : This patient has already found stretching to be helpful, so he should continue. The home exercise program should include stretching for both the plantar fascia, and the gastrocnemius/soleus muscle group. The patient also needs to understand the importance of regaining full ankle dorsiflex- ion range to the treatment of his condition. The patient has reported that he stretches in the morning, but he likely needs to incorporate stretching into his routine multiple times a day.
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Book Code: PTCA2624
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