PT Initial Evaluation : Plantar Fasciitis

Pamantasan ng Lungsod ng Maynila

General Luna St., Intramuros Manila

PHYSICAL THERAPY INITIAL EVALUATION

General Information:

Pt.’s Name: S.V.

Age: 25 yrs. old

Sex: Female

Address: Sta. Ana, Manila

Civil Status: Single

Handedness: ®

Occupation: Elementary School Teacher

Religion: Roman Catholic

Referring Doctor: Dr. P.G.

Referring Unit: PGH

Date of Referral: February 10, 2007

Date of IE: February 13, 2007

Informant/Reliability: Pt./God

Dx: (L) Plantar Fascitis

HPI:

Present condition started 3 mos. PTC when pt. felt uneasiness on her (L) foot accompanied by pain P/S (2/10) in doing walking activities after taking off her shoes. She ignored the condition thinking that it was only due to prolonged standing. The pain was relieved by liniments and upon resting.

1 mo. PTC, pt. experienced pain P/S (5/10) even after resting. She has now moderate difficulty in doing walking activities aggravated when she’s barefooted. At work, she takes Ponstan 250 prn to control the pain decreasing the P/S by 2-3 grades. At home, she also soaks her foot into a basin of warm water since it eases the discomfort.

1 wk. PTC, pt. presents severe pain P/S (8/10) and has difficulty making her first step out of bed. She cannot tolerate any prolonged walking and even wt. bearing (standing) activities. The pain reliever she was taking cannot control the pain anymore so she decided take a leave from work for a few days. Her condition didn’t get any better. She immediately went to PGH for medical advice. The doctor gave her steroids for temporary relief. She was then referred to rehabilitation department.

At present, pt. will start PT tx.

Drug Hx:

Drug	Administration	Dosage	Frequency	Indication	Date
Tiger Balm	Topical	------------	prn	Mm pain	Nov-Dec 2007
Ponstan	Oral	250	prn	Pain relief	Dec-Feb 2007
Steroids	Subcutaneous		Once	Pain relief	Feb 2007

Ancillary Procedure:

Radiograph findings are negative of heel spurs and other anomalies that can lead to heel pain.

PMHx:

· (-) Burn

· (-) Scars

· (-) Achilles tendon tear

· (-) Ankle Sprain

PSEHx:

· Type B personality

· Works 8 hrs a day

· Walks 500 meters a day

· Wears 3 inches of heels

· Lives c her parents

· Good financial status

· Primary caregiver: parents

S:

C/c: “ I cannot tolerate the pain whenever I walk or even with merely standing. It’s hard for me to work.”

PT Translation: Pt. has difficulty in doing ADLs due to pain.

Pt.’s Goal: To return to work without any limitations and pain-free.

O:

VS:

	a	during	p
BP	120/80	120/80	120/80
PR	60 bpm	75bpm	80 bpm
RR	13 cpm	13cpm	15cpm
T	36	37	37

OI:

· Ectomorph

· Ambulates independently

· (+) Gait deviation – see Gait Analysis

· (+) Postural deviation – see Postural Analysis

· (+) erythema on (L) plantar and medial aspect of the foot

· (-) scars on all exposed body parts

Palpation:

· (+) tenderness on (L) medial tubercle

· (+) hyperthermia on (L) plantar aspect and medial tubercle

· (-) subluxation

· (-) crepitation

Significance: Presence of inflammation

Tone A:

Normoreflexia on (L) ankle

Superficial Sensation:

Pin – for pain

Brush- for light touch

Thumb- for pressure

Findings: Intact sensation on (L) ankle

Significance: Intact sensory pathway

MSR:

(R) (L)

Legend:

0 - areflexia

+ - hyporeflexia

++ - normoreflexia

+++ - hypereflexia

++++ - clonus

Findings: Normoreflexive at all tested areas

ROM:

All major jts. are grossly assessed passively and actively done and are WNL and pain free except for:

(L) Ankle

Motion	Active	Passive	(N) Range	Difference	End-feel
Dorsiflexion	0-5 deg	0-10deg	0-15 deg	10 deg	firm

Significance: Limitation of motion was due to pain. Patient only presents with protective LOM.

MMT:

All major mm of the body was grossly assessed and were graded 5/5 except for:

· Ankle dorsiflexion – 4/5

Note: MMT of the ankle dorsiflexors were taken with in pain free limits.

Significance: There is no true mm weakness.

Special Test:

(-) Thompson Test

Findings: Plantar flexion occurred upon calf squeezing.

Significance: to R/O presence of Achilles tendon rupture.

(-)Prone Anterior Drawer test of the Ankle

Findings: No excessive anterior motion of the ankle occurred during test.

Significance: to R/O possible ankle sprain or ligamentous instability.

(-) Talar tilt

Findings: No excessive medial and lateral motion of the ankle occurred during the test.

Significance: to R/O possible deltoid and calcaneofibular ligament instability.

Postural Analysis:

All parameters of posture are assessed and WNL.

Gait Analysis:

Phases	(L)	®
Stance Phase	· decrease initial contact and loading response · decrease midstance and terminal stance	· increase initial contact and loading response · increase midstance and terminal stance
Swing Phase	· increase swing phase	· decrease swing phase

Significance: Pt. presents c antalgic gait. Wt bearing is increase on the unaffected side, avoiding painful heel strike and wt. bearing on (L) extremity.

Standing Tolerance & Balance:

Grading:

Tolerance

Normal – 60 min.

Good – 45-60 min

Fair – 15-30 min

Poor – 0-15 min

Nil – none

Balance

Normal – can assume, maintain, wt shift and be challenge

Good – can assume, maintain and wt shift

Fair - can assume and maintain

Poor – can assume

Nil – none

Findings: Pt. has normal balance and poor standing tolerance.

Significance: Pt.’s poor tolerance was due to pain.

ADL Analysis:

All aspects of ADL are independently done except for:

– Walking – presents c moderate difficulty

Significance: Pt.’s moderate difficulty in walking was due to pain.

A:

Dx: Plantar Fascitis of (L) heel

PT impression: Plantar fascitis on (L) LE of pt makes WB as well as ambulation moderately difficult.

Rehab Potential: Good, because the condition can be resolve through conservative treatment within 3 mo. and there was absence of heel spurs.

Problem List:

1. Pain c a (P/S 8/10) of (L) plantar aspect of foot.
2. Limited (L) ankle dorsiflexion because of pain
3. Poor standing tolerance
4. Moderate difficulty on doing ADL’s especially walking
5. (+) Gait deviation
6. False weakness of ankle (L) Dorsiflexors

LTG:

1. To be able to achieve highest functional activity and pain free after 15 tx sessions.

STG:

1. To decrease pain from ( P/S 8/10-3/10) after 7 tx session

2. Improve ankle dorsiclexion of (L) foot from 5 to 15 degrees 15 after 5tx session

3. Increase standing/balance tolerance from fair to good after 5 tx session

4. Improve ADL esp. in walking for 7 tx session

5. Improve gait pattern after 5 tx session

P:

Intervention for the 1^st 4 tx session

1. Cryocuff on (L) heel for 15 min.

2. Conventional TENS for pain on (L) heel

3. Bandaging on (L) heel ADA (Ankle Dorsiflexion Assist) Technique

Continuing Program

1. Deep friction massage for 20 min.
2. Bent knee exercises 5 reps x 3 sets to stretch the plantar aponeurosis
3. Bottle Rolling using the feet for 10 reps to loosen up plantar fascia
4. Recommend using heel pads and plastic heel cups

HI

1. Encourage patient to exercise the foot using towel wrinkling, picking up objects c the use of toes.
2. Do ative ankle dorsiflexion at home for at least 10 reps
3. Encourage pt to wear flat foot wear.

Abelardo, Camille Eunice

Adolfo, Dominic

Bartolome, Karen

Britanico, Maria Socorro

Librando, Kristine Zarah