Foot Case Study 1: Plantar Fascitis

Case Study 1 – Ankle & Foot

Danny Watson is a 32-year-old postman who sustained a sharp pain in the right heel
3-4 months ago. He was running 60 miles per week and noticed a gradual ache in the
heel on the medial aspect that has been gradually worsening. It has been diagnosed as
Plantar Fascitis and he has been advised by his GP to rest from running for 2 weeks.
There is no bony injury on x-ray but he complains of stiffness am and is unable to run
more than 1 mile without pain. He also has some slight limitation in ROM of
dorsiflexion and extension of the toes due to mild pain. He lives with his wife and 2
young children in a 3 bedroom house.

Anatomy & Pathology

Plantar Fascistic is a bowstring – connects ball of foot to heel and helps propulsion –
as toes extend in stance phase – elevates arch and externally rotates leg and inverts
hind foot.

P.F. is a painful inflammatory condition of foot cause by excessive wear and tear to
the plantar fascia that supports the arch of the foot – some times its build can be
traumatic – other times it can be caused by the gradual effects of an inhibited gait
pattern.

Build up – gait complication. There is a dynamic relationship between dorsiflexion

and plantarflexion – they create a rolling motion. If plantarflexion is impaired so is
rolling and the foot tends to hit the ground with extra pressure on heel strike. This
repeated motion can cause injury – and in this case plantar fascitis might be associated
with a tight gastrocnemius.

Trauma – tear from calcaneus followed by inflammation – oseophytes – 50% of

sufferers have these – against 20 % in the overall population. Patients over 30 are
prone to this – as are overweight individuals or athletes.

Passive dorsiflexion stretches the plantar fascia.

Subjective Examination
Where\What: right heel – expect pain at front and bottom of heel

When: 3-4 months ago – expect pain to come over days/weeks/months

How: possible overuse with poor gait – ask was there an injury around the time of
onset and has he recently changed his running style or footwear

0-10 rating: ask

24-hour cycle: can be worst with first few steps in the morning (feet are generally
plantar flexed during sleep)

Better for: ask

Worse for: expect for long periods of weight bearing?

Type of pain: expect a “stone like bruise” and a throbbing pain

Past Medical History/ General History: nil

Red Flags and general concerns: is there an oseophyte – has he had an x-ray

SH: lives in 3-bedroom house – ask how old are his children

DH: nil

Patient’s main outcome: exercise freely?

Objective Examination

Working Hypothesis: plantar fascitis caused by gait issues

Advice & Consent: give and obtain

General Observations: watch walking – flatfooted

Acute Observations:
Skin colour – N.A.
Swelling – N.A.
Posture – associated with excessive pronation
Muscle bulk – claves (over/under)
Deformity – heel spur / x-ray only

Active Tests , Passive Tests , Resisted Tests

Have the patient sitting up for these:

Dorsiflexion
Plantarflexion
Inversion
Eversion
Pronation
Supination
Flexion extension of toes

In active tests expect some pain in dorsiflexion as the fascia stretches – also possibly
some reduced range in plantarflexion caused by a tight gastrocnemius (if gait build
up)

In passive tests expect the same In Restricted tests – expect some reduction in
dorsiflexion if underused.

Special Tests: windlass test – pain in passive dorsiflexion – this has already
been performed

Functional Tests: get patient to walk – are they flatfooted? Look for excessive
heel strike.

Palpation: expect tenderness over medial calcaneal tuberosity – often-

considerable pressure – from whole body weight

Measurements: measure movement into pain in passive dorsiflexion – check

calf range – plantarflexion – measure actively

Advice & Possible Treatment: expect pain after treatment. 95% of

patients can be managed without surgery – 6-> 12 months recovery – avid walkers
and joggers – could be advised to take up recumbent cycling. Heel pads may help –
contrast baths, ice, NSAIDS – reduce inflammation.