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Plantar Fasciitis Case Study & Assessment

This orthopedic assessment and case study documents the evaluation and treatment plan for a 41-year-old female patient presenting with severe right heel pain lasting 5 years. On examination, the patient exhibited tenderness in the heel, calf muscle spasm, and limited range of motion in plantar flexion and dorsiflexion. Tests were positive for plantar fasciitis. The treatment plan includes ice, electrical stimulation, laser therapy, shock wave therapy, stretching exercises, mobilization, and a home exercise program to reduce pain and inflammation, improve range of motion and muscle power, and fully resolve the plantar fasciitis over several weeks.

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dana shaheen
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51 views6 pages

Plantar Fasciitis Case Study & Assessment

This orthopedic assessment and case study documents the evaluation and treatment plan for a 41-year-old female patient presenting with severe right heel pain lasting 5 years. On examination, the patient exhibited tenderness in the heel, calf muscle spasm, and limited range of motion in plantar flexion and dorsiflexion. Tests were positive for plantar fasciitis. The treatment plan includes ice, electrical stimulation, laser therapy, shock wave therapy, stretching exercises, mobilization, and a home exercise program to reduce pain and inflammation, improve range of motion and muscle power, and fully resolve the plantar fasciitis over several weeks.

Uploaded by

dana shaheen
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as ODT, PDF, TXT or read online on Scribd

Orthopdic assessment and Case Study

(Plantar fasciitis right)

Done by : Inas dawoud

Supervisor : Tamara rizqallah

2021
PERSONAL DATA

• Name: Wijdan.H
• Age: 41y
• D.O.B: 29-3-1980
• Gender : F
• Occupation : housewife
• D.O.assessment :28-2-2021
• Chief complain : Severe pain in the heel.

➢ Subjective examination:

• Present history :
–Date of onset of symptoms: Five years ago.
– Mechanism of injury:
When she was hanging clothes on the rope, she was
standing on her tiptoes.
• Pain history:
-Pain in the right foot in the heel.
-when sleeping there is severe pain she can’t sleep
-the pain increases when she standing a lot and
walking.
-pain decreases when resting.
-Type of pain: burus
• Past history:
-Gallbladder operation
-Appendix surgary
• Social history:
-Unmrried
-she lives on the first floor and there are no stairs.

➢ On observation:
- General condition of patient : good
- no wasting
- no scare
- no oedema
- no deformities

➢ On palpation:
-Spasm of calf muscles.
-Tenderness on the heel and lateral ,medial.
-Type of skin :dry
-Swelling around of ankle
- bluish on medial aspect of the heel.

Pain assessment:
☑ Intensity:
8/10
☑ Location:
there is pain on right foot in the heel.
☑ Aggravating factors:
planter flexion
☑ Easing factors:
rest
➢ Objective examination:
JOINTS ROM MUCSLES POWER

Type of Muscle ROM End feel


motion power Active Passive
Plantar 3 30 45 Muscle
flexion stretch

Dorsiflexion 4 8 10 Muscle
stretch

Eversion 4 25 25 Muscle
stretch

Inversion 4 15 25 Muscle
stretch

• Sensory Assessment:

Deep sensations : normal


Superficial sensation : normal
Combined sensation : normal

• Functional assessment:
she is independent.
• Gait Assessment:
- Type of gait :Calcaneal Gait.
- in stance phase of the knee increase flexion
heel strike to foot flat to midstance more than 15 degree.
heel off to toe off more than 40 degree.
- in stance phase of the ankle increase dorsiflexion
foot flat to midstance to heel off to toe off more than 15
degree.

-shorter step length


-Shortend single – support time.

• ADL : physical activity is normal.

•Special Tests:
Windlass Test : Positive.

• Final Diagnosis: Plantar fasciitis.

➢ Short term goals (2-3 Weeks):


-Reduce pain and inflammation
-Improve ROM
-Increase muscle power

➢ Long term goals(3-7 Weeks):


-Inflammation disappears.
-Decrease pain to 0
-Increase ROM to normal range.
-Increase muscle power to 5.
➢ Treatment plan:
-Ice pack around calf muscles and heel reduce swelling ,
pain and inflammation.
-Electrical stimulation stmulating muscle contraction.
-laser therapy accelerate connective tissue repair and act
as an anti – inflammatory.
-shock wave therapy .
-Stretching exercises.
-Mobilization and manipulations .
-Using TheraBand for resisted strengthening plantar
flexion and dorsiflexion.
-Achilles stretch she stops at the edge of the stair.
- Frozen can roll.

➢ Home programme:
-Using TheraBand for resisted strengthening plantar
flexion and dorsiflexion.
- Frozen can roll.

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