Introduction to the clinical observation
Detailed treatment rationale from the clinician
Analyse and synthesis of literature
Comparison between literature and observed clinician practice
Conclusion and recommendation
The objective of the assignment is to elaborate clinical reflection on Plantar Fasciitis (PF). The case study revolves around Susie Smith, the patient and John Jones, the therapist. Susie was 40 years old, overweight, and waitress that required her to stand on feet for 32 hrs/week. In the case study, Susie was diagnosed with PF, after clinical monitoring of John. John noticed pronated foot posture, tight soleus and gastrocnemius calf musculature, and tight ankle joint movement, tenderness in the insertion area of the plantar fascia. She could not stand on one leg for more than 5 seconds. John took her consent to treat her with joint mobilisation and ultrasound. The main advice given to Susie was to roll frozen water bottle several times a day, calf stretch, wear mid height heel, and avoid exasperating tasks. He holds her to visit podiatrist after a couple of months after observing improvements. The clinical observation consulted by John has been evaluated in the assignment with assistance to evidence based literature and comparing the clinical practice.
The main approach of John was to reduce pain due to inflammation in plantar fasciitis. In the beginning, John advised Susie iced bottle rolling exercise after observing the insertion of plantar fascia and tightening of calf musculature. This advice is beneficial as it is an easy home remedy for PF and bottom foot pain. It helps to lengthen and stretching of plantar fascia ligament as well as relieves tension in the feet and also decreases inflammation. Susie was late for her appointment and due to shortage of time, John recommended her this home treatment.
The basic clinical examination for PF includes equine position walking while walking barefoot to avoid pressure pain on the heel. The reason for the pain might be due to palpation in medial plantar calcaneal that will elicit stabbing and sharp pain. Discomfort in proximal plantar fascia could be due to passive toe dorsiflexion (Kanumalla et al., 2018). For this purpose, john observed her standing foot posture and barefoot walking and assessed her ankle to join the accessory movement. In order to evaluate the condition of her proximal plantar fascia, he asked her to stand on her one leg. In PF cases, the pain often reappears with fatigue or throbbing dull ache like sensation in the medial arch of the foot after prolonged weight bearing. Observing the insertion of the plantar fascia was vital to analyse the condition of calcaneal insertion.
Magnetic resonance imaging and ultrasonography are useful to diagnose PF as it highlights abnormal tissue signals and increased thickness in the plantar fascia (Henriksen, Jørgensen & Aaboe, 2012). For this reason, John observed ultrasound of Susie’s foot and mobilised her sub-talar joint.
In her treatment process, John advised her to continue to roll the foot over the iced bottle and avoid aggravating tasks and exercises like foot stretches and a sheet of the calf. These exercises are vital to correct dysfunction of muscles, which contributes to pain (Goff & Crawford, 2011). The stretches concentrate on gastrocnemius muscles that affected in case of Susie.
A podiatrist is not advised by John as these exercises might diminish the pain of Susie in a couple of months. Moreover, he suggested her to wear mid height heel shoes to help her offload plantar fascia. It was suggested as proper shoe fitting is essential for PF patients (Boakye et al., 2018). The structure of the shoe needs to be medially and laterally flare at the sole and heel to enhance body stability. So, half inch foam in the heel is recommended to take the pressure on the Achilles tendon.
According to Lim, How & Tan, (2016), orthotics is applied to decrease the load on the plantar fascia while bearing weight. The treatment is used to hold medial arch of the foot by not placing direct pressure upon plantar fascia. Moreover, it also helps in decreasing direct pressure on the plantar fascia while placing the foot on the ground and avoid pain due to swelling. It is done by incorporating aperture in the orthotic so that swelling is shaped in the aperture. The application of orthotics involves insole support and heel cups in plantar fascia that are found to reduce pain in PF.
Kanumalla et al., (2018) focused on maintaining proper nutrition which is essential to obtain a healthy weight. It is vital for obese individuals who are suffering from PF. The problem increases in obese individuals due to increased weight holding activity done by the foot arches. Excess body weight is considered overload in a mechanical truss. For this purpose, anti-inflammatory foods involve the consumption of omega 3 fatty acids to manage body weight or Body Mass Index. Dark leafy green vegetables are also recommended for the patients. High rich foods in Trans – fats and red meats should be avoided by the patients.
Yoga is also considered as a good treatment for PF. Functional movements and postures in yoga support to strengthen and build plantar arches and restore alignment, and biomechanics in the feet and other lower extremities. Taping techniques is a therapeutic taping which is popularly used in conservative treatment of PF to decrease pain in supporting joints. It reduces the load on the plantar fascia and to avoid prolongation of the foot. This practice is effective in decreasing calcaneal eversion, lateral plantar pressure transfer in the mid-foot, and preservation of arch height. Kocaman, Yildiz & Bek, (2017), highlighted that taping in gastro soleus muscles along with plantar fascia for about one week through flexible tape is effective in decreasing pan as well as the thickness of plantar fascia as compared to other physiotherapy treatments.
Another treatment of PF involves focal extracorporeal shockwave therapy. (Karami, Daryabor, Vahab Kashani & Ahmadi Bani, (2019), marked that patients suffering from plantar fascia pain are often provided with ultrasonography guided with focal extracorporeal shockwave therapy. This treatment is active in efficacious patients with severe pain of PF when they do not respond to conservative treatment.
The observation, diagnosis, and treatment of John are effective to some extent for Susie. However, John has not noticed risk factors that trigger pain in case of Susie like prolonged standing and walking as she is a waitress in the profession and mainly her obesity. Obesity is an intrinsic factor that leads to tightening of calf muscles and causes pain in the plantar fascia. As discussed by Henriksen, Jørgensen & Aaboe, (2012), excess weight increases mechanical pressure on the longitudinal arch and plantar fascia for the patients working on their feet. Obese patients could also face the onset of pain while initiating stretching exercise. Dietary modifications must be advised to patients to reduce weight before doing weight bearing exercise like walking. Therefore, in comparison to the advice of John, Susie should have been suggested to reduce weight through dietary modification or doing low impact exercise on plantar fascia like swimming or cycling.
In the case study, John has completely ignored the profession of Susie that includes prolonging standing for hours and crossed the suggestion of orthotics. However, Owens, (2017), marked that foot orthotics are recommended for patients suffering from PF to avoid over pronation of the foot and relax tensile pressure on the plantar fascia. There are many orthotics like custom made full length shoe insoles, prefabricated longitudinal arch, or viscoelastic heel cups. These foot orthotics are effective in PF patients to reduce pain in rear foot and enhance foot function. Thus, as Susie is a waitress by profession, orthotics might have relaxed tightening of calf muscles and also enabled her to carry on her profession effectively.
Lim, How & Tan, (2016), suggested night splints overcome contracture in plantar fascia by keeping ankle and foot in 90 degree position. Night dorsiflexion splints might support PF in case of Susie mainly for the pain that is severe during the first few footsteps in the morning. It is effective with positive outcome and resolution within 12 weeks.
The case study analysis of shows that clinical diagnosis and treatment provided by John is not as per the lifestyle pattern of Susie. Though prior exercises like iced bottle rolling was effective but the first priority must have been given to reduce the body weight of Susie. The profession of Susie should also have been noted while providing treatment and exercises. Susie was advised with stretch calf exercise that is not enough for Susie as she was a waitress in the profession and requires prolonged standing for hours.
Moreover, it is recommended to John to follow treatment procedure for PF patients as per their profession and physical examination that involves obesity of the patients. Thus, at first, Susie must be given a proper dietary plan to reduce body weight before starting stretching exercise, where swimming and cycling are the best options (Kanumalla et al., 2018). Apart from iced bottle rolling exercise, night splints are suggested along with orthotics. As Susie requires standing prolong in her profession, she must be consulted by a podiatrist to suggest her custom foot orthotics or prefabricated foot orthotics as per her condition of calf muscles.
Boakye, L., Chambers, M., Carney, D., Yan, A., Hogan, M., & Ewalefo, S. (2018). Management of Symptomatic Plantar Fasciitis. Operative Techniques In Orthopaedics, 28(2), 73-78. doi: 10.1053/j.oto.2018.02.001
Goff, J., & Crawford, R. (2011). Diagnosis and Treatment of Plantar Fasciitis. American Family Physician, 84(6). doi: https://dolor.org.co/biblioteca/articulos/Fascitis%20plantar.pdf
Henriksen, M., Jørgensen, L., & Aaboe, J. (2012). Obesity and Walking: Implications for Knee Osteoarthritis and Plantar Heel Pain. Current Obesity Reports, 1(3), 160-165. doi: 10.1007/s13679-012-0017-8
Kanumalla, R., Keane, J., Matsushita, S., Shoup, D., Mauro, A., & Goldstein, L. (2018). Plantar Fasciitis: Diagnosis and Management. A.T. Still University School Of Osteopathic Medicine In Arizona, 9(3), 154-165. doi: https://www.ecronicon.com/ecor/pdf/ECOR-09-00271.pdf
Karami, E., Daryabor, A., Vahab Kashani, R., & Ahmadi Bani, M. (2019). The Effect of Different Types of Foot Orthoses on Foot Plantar Pressure in Subjects with Plantar Fasciitis: A Literature Review. Journal Of Rehabilitation, 202-209. doi: 10.32598/rj.20.3.202
Kocaman, A., Yildiz, S., & Bek, N. (2017). Plantar Fasciitis and Current Treatment Approaches. Clinics In Surgery, 2. doi: http://www.clinicsinsurgery.com/pdfs_folder/cis-v2-id1752.pdf
Lim, A., How, C., & Tan, B. (2016). Management of plantar fasciitis in the outpatient setting. Singapore Medical Journal, 57(04), 168-171. doi: 10.11622/smedj.2016069
Owens, J. (2017). Diagnosis and Management of Plantar Fasciitis in Primary Care. The Journal For Nurse Practitioners, 13(5), 354-359. doi: 10.1016/j.nurpra.2016.12.016
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