Orthopdic assessment and Case Study

(Plantar fasciitis right)

Done by : Inas dawoud

Supervisor : Tamara rizqallah

2021
 PERSONAL DATA

• Name: Wijdan.H
• Age: 41y
• D.O.B: 29-3-1980
• Gender : F
• Occupation : housewife
• D.O.assessment :28-2-2021
• Chief complain : Severe pain in the heel.

➢ Subjective examination:

• Present history :
–Date of onset of symptoms: Five years ago.
– Mechanism of injury:
When she was hanging clothes on the rope, she was
standing on her tiptoes.
• Pain history:
-Pain in the right foot in the heel.
-when sleeping there is severe pain she can’t sleep
-the pain increases when she standing a lot and
walking.
-pain decreases when resting.
-Type of pain: burus
 • Past history:
-Gallbladder operation
-Appendix surgary
• Social history:
-Unmrried
-she lives on the first floor and there are no stairs.

➢ On observation:
- General condition of patient : good
- no wasting
- no scare
- no oedema
- no deformities

➢ On palpation:
-Spasm of calf muscles.
-Tenderness on the heel and lateral ,medial.
-Type of skin :dry
-Swelling around of ankle
- bluish on medial aspect of the heel.

Pain assessment:
☑ Intensity:
8/10
☑ Location:
there is pain on right foot in the heel.
☑ Aggravating factors:
planter flexion
☑ Easing factors:
rest
➢ Objective examination:
JOINTS ROM MUCSLES POWER

Type of Muscle ROM End feel

motion power Active Passive
Plantar 3 30 45 Muscle
flexion stretch

Dorsiflexion 4 8 10 Muscle
stretch

Eversion 4 25 25 Muscle
stretch

Inversion 4 15 25 Muscle
stretch

• Sensory Assessment:

Deep sensations : normal

Superficial sensation : normal
Combined sensation : normal

• Functional assessment:
she is independent.
• Gait Assessment:
- Type of gait :Calcaneal Gait.
- in stance phase of the knee increase flexion
heel strike to foot flat to midstance more than 15 degree.
heel off to toe off more than 40 degree.
- in stance phase of the ankle increase dorsiflexion
foot flat to midstance to heel off to toe off more than 15
degree.

-shorter step length

-Shortend single – support time.

• ADL : physical activity is normal.

•Special Tests:
Windlass Test : Positive.

• Final Diagnosis: Plantar fasciitis.

➢ Short term goals (2-3 Weeks):

-Reduce pain and inflammation
-Improve ROM
-Increase muscle power

➢ Long term goals(3-7 Weeks):

-Inflammation disappears.
-Decrease pain to 0
-Increase ROM to normal range.
-Increase muscle power to 5.
➢ Treatment plan:
-Ice pack around calf muscles and heel reduce swelling ,
pain and inflammation.
-Electrical stimulation stmulating muscle contraction.
-laser therapy accelerate connective tissue repair and act
as an anti – inflammatory.
-shock wave therapy .
-Stretching exercises.
-Mobilization and manipulations .
-Using TheraBand for resisted strengthening plantar
flexion and dorsiflexion.
-Achilles stretch she stops at the edge of the stair.
- Frozen can roll.

➢ Home programme:
-Using TheraBand for resisted strengthening plantar
flexion and dorsiflexion.
- Frozen can roll.