musculo scenario 3

Case study 1 – ankle and foot

Subjective assessment
History of present complaint:

The patient is a 32 year old male who has sustained a sharp pain in his right heel 3-4 months ago. He was running on average 60 miles per week and he is also a postman by trade so he is constantly on his feet. He noticed a gradual ache on the medial aspect of his right heel which has gradually increased over time due to his work and running. The patient complains of most pain in the morning and has slight limitation in ROM of dorsiflexion and extension of the toes due to mild pain. X-ray showed no bony injury. The patient has been diagnosed with plantar fasciitis and has been advised to rest from running for 2 weeks.

Past medical history: nil
Drug history: nil
Social history: lives with wife and 2 young children in 3 bedroom house.

Plantar fasciitis is a painful inflammatory condition of the foot caused by excessive wear to the plantar fascia that supports the arch of the foot. It can also be caused by biomechanical faults that cause abnormal pronation of the foot.
Typical symptoms :
· Pain is usually felt on front and bottom of heel.
· Most intense pain with first steps of day.
· Brought on by long periods of weight bearing.
· Patients are often over the age of 30.
· Pain may be sharp, like a stone bruise or throbbing.
· Condition usually develops over a period of days/weeks/months.
Causes:
· A change or increase in activities.
· Lack of flexibility in calf muscles.
· Long periods of standing/walking in poor shoes.
· Arthritis
· More commonly affects overweight people and athletes.
· Loss of natural tissue for cushioning under the heel.

Plantar fascia supports the arch of the foot by acting as a “bowstring” to connect the ball of the foot to the heel. Its function is to invert the heel (turn inwards) for propulsion.

After speaking about the pathology go on to talk about the anatomy of the the foot. Give a brief description of the bone structure of the foot i.e the tibia and fibula articulate with the talus and medially and laterally form the malleoli (its up to you how much detail you want to go into but keep in mind the problem is on the medial side of the heel ). The calcaneus should be mentioned here along with its medial and lateral tubercles....... basically show them that you know the structures involved etc

the most important part of the anatomy to be familiar with for this pathology is the ankle dorsi flexors and plantar flexors. Talk about these muscles and their functions in realtion to the foot.

dorsiflexors: tibialis anterior, extensor digitorum longus, extensor hallucis longus, peroneus tertius.
plantarflexors: gastrocnemius, soleus, tibialis posterior, flexor hallucis longus.

these work as agonists and antagonists against each other. if either of them are tight then it will have an affect on the way our foot hits the ground. If the foot is not landing correctly then it will not use its shock obsorbers correctly and the foot ends up slapping off the ground which puts extra pressure on the heel.

The calf muscles are very important as tendons deep to gastrocnemius insert into the quadratus plantae muscle at the base of the foot. If gastrocnemius is tight then this could be the source of the problem.

Objective assessment


Ask the patient to lie on the plinth in the supine position. Observe the area around the heel and check for contraindications such as swelling, skin colour and muscle bulk. Palpate the area and feel for tenderness etc. Ask the patient to walk and observe their gait pattern. Watch out for heel-toe strike and the pronantion and supination of their foot. If the patient is landing relatively flat on his/her foot then their gait pattern could be affecting their condition (watch a clip on youtube). Possibly ask the patient to walk up a few steps of stairs to examine functional ability.

From there ask the patient to lie on the plinth in supine position to begin observing active and passive movements.
Make sure the bed is at a correct level as to not cause any discomfort in your lower back. Explain to the patient exactly what you want them to do and also tell me why they are doing this. Before each passive movement and resisted test make sure you are in the correct position and handle the patients foot in an appropriate way giving adequate support throughout the movement. Talk through every movement and continually ask patient about levels of discomfort or pain.
The active physiological movements the patient needs to undertake are:
1. Dorsiflexion
2. Plantar flexion
3. Inversion
4. Eversion
5. Extension of the toes
Observe these movements on both feet so as to compare and contrast the range of movements.

The passive physiological movements the patient needs to undertake are:
1. Dorsiflexion
2. Plantar flexion
3. Inversion
4. Eversion
5. Extension of the toes
Again observe these movements on both feet to compare any differences.

The resisted tests the patient needs to undertake are:
1. Dorsiflexion
2. Plantar flexion
3. Inversion
4. EversionThese tests also need to be completed on both feet for same reasons as above.