Case Study: Foot pain

TEMPLATE

Patient Identifiers

Age: 42 years old

Sex: Male

Occupation: Builder - Business owner. Works on the tools in addition to desk work for book-keeping duties.

Physical activity: Pretty physical job so doesn’t do any extra physical activity apart from walking the dog for 20 minutes daily.

Onest:

2 months ago was playing with the kids in the park, kicking the footy. Noticed soreness in the right foot the morning after, which then progressively got better during the day. This pain pattern continued for a couple of weeks until eventually the patient noticed the pain was starting to become present during the work day, and also in the afternoon after taking his work boots off.

Site of pain - Along the length of the sole of the foot (right side) however tends to be most intense at the front of the heel

Quality of pain - Sharp when aggravated otherwise, achey

Radiation of pain - Tends to stay local to the foot however can get tightness into the calf

Timing of pain - Worse in the morning and evenings

Aggravating factors:

• Wearing shoes (particularly rigid ones)

• Long periods of immobility

• After a long day at work

• Sleep - taking the first few steps in the morning

Relieving factors:

• Icing

• Anti inflammatories

No effect:

Other Musculo-skeletal complaints:

• The patient reports a similar episode of this pain however on the left foot. This was during his early 20s when playing footy. It resolved on its own after 4-6 weeks.

• Generalised lower back pain related to desk work. Moving around tends to help this.

OSTEOPATHIC IMPRESSION

Physical assessment:

• Decreased mobility: right foot, left foot, left hip, left sacro-iliac joint, lumbar spine

• Tight muscles: right calf & hamstring, left glutes and lower back

• Familiar pain reported with weight bearing calf raise, active and passive toe extension

• Slight swelling noticed on the sole of the foot

Diagnosis:

Right-sided plantar fasciitis with a potential heel spur present (xray imaging will be required in order to determine the presence of a heel spur). There seems to be inefficient loading through the lower extremities (ie. increased weight bearing through the right leg), due to restrictions in the entire left side.

The patient’s tendency to wear rigid footwear will be significantly restricting the mobility in both feet. For whatever reason, there are further restrictions in the left lower extremity meaning there will be altered force transmission through that leg. To compensate, more weight is placed in the right lower extremity. This puts strain through the vulnerable area which in this case, is the right foot / plantar fascia.

6-8 week TREATMENT PLAN:

• Address restrictions in both feet - mobility techniques to the joints in the forefoot, midfoot and hindfoot. This includes the ankle joints.

• Myofascial release techniques targeting the right sided plantar fascia directly AND indirectly. Indirect techniques will focus on the structures of the superficial and deep back lines including the calves, hamstrings, pelvic ligaments and thoraco-lumbar fascia.

• Mobility techniques will focus on restoring movement through the left lower extremity, pelvis and lower back to address load transmission (this will assist in offloading the right side/foot so the patient can weight bear more evenly between both legs).

6-8 week MANAGEMENT PLAN:

• Home exercises to include:

  • Muscle release techniques direct to the plantar fascia, calves, hamstrings & lower back

  • Mobility exercises for the feet and lumbo-pelvic region

  • Gentle strength exercises targeting the muscles of the feet (to be introduced when pain levels are reduced)

After 4-6 weeks if there is minimal change to the pain presentation...

• Referral to podiatrist who will:

  • Assess feet biomechanics

  • Potentially administer shockwave therapy if deemed appropriate

  • Assess footwear and discuss better suited alternatives