I am having difficulty figuring what to do with this patient. Let me know if you have some thoughts. Sorry it’s long but there is a lot.
Patient Case Study:
Subjective: Patient, Pt, is a 17 year old female diagnosed with bilateral plantar fasciitis for the past couple of years. Pt states that her discomfort ranges from 5/10 to 7/10 predominately at the plantar aspects of both of her feet and describes her pain as sharp to dull aching. Pt mentions that when her symptoms worsen her feet swell and the symptoms will be present from the bottom of the feet to the posterior lower legs and thighs and occasionally to the sacrum. She states that the pain can increase quickly and take a bit to subside depending on how severe the symptoms become. Pt reports a history of posterior sacral and tailbone pain that started from a fall during a novelty race (such as a tough mudder or wipe out type race) when she was eleven. Pt states that she was running up a ramp and fell back onto her butt hard. She mentions that her pain occurred later that day. She states that her symptoms have worsened at her coccyx and sacrum since then. Pt states that when her pelvic pain increases so do the symptoms at the bottoms of her feet and back of her legs. She is on the track team and runs the 100-m and 200-m races. Her symptoms prevent her ability to fully participate in practice. She mentions that she has to take breaks during practice due to increases in pain and swelling at her feet. During the breaks, she completes calf stretches that return her pain to more manageable levels but the swelling does not subside for a day or two. She was referred by her podiatrist. Pt mentions that she was treated by the podiatrist for the last couple of years with massage creams, injections at the feet, and three different types of orthotics; none of which changed her symptoms. Pt denies changes in her bowel and bladder function or numbness at her saddle region. She has not had imaging completed of her lower back as of yet but will be getting imaging next week (May 20).
- DF: R = 15 degrees with knee bent and 5 degrees with knee straight; L = 15 degrees with knee bent and 10 degrees with knee straight
- PF: R = 55 degrees; L = 60 degrees
- Inversion: R = 15 degrees; L = 15 degrees
- Eversion: R = 28 degrees; L = 15 degrees
- Extension: R = -5 degrees; L = 0 degrees
- External rotation: R = 22 degrees; L = 14 degrees
- Internal rotation: R = 35 degrees; L = 25 degrees
- 3+ at patellar tendons and Achilles tendons; bilaterally
- Tenderness at bilateral tibial nerves and sciatic nerves and lumbar paraspinals.
- Slight hypomobility of L2-5 with central PA’s with increases of pain in lumbar region to 5/10 (PA’s at L5 and sacrum reproduced symptoms to posterior thigh and popliteal fossa)
- (+) SLR with reproduction on pain in the back and posterior thigh at 25 degrees hip flexion bilaterally
- (+) Sacral thrust test bilaterally
- (+) Thigh thrust with symptoms into posterior thighs bilaterally
- (-) Heel Drop test bilaterally
- Pt ambulates with a stiff-legged gait (limited hip flexion and extension)
- Completed at IE and given as HEP
- Focus on improving neurodynamics and core/pelvic stability
- Supine hamstring stretch with a belt
- Supine hamstring stretch with a belt and completing ankle pumps
- Supine TA contractions while marching
- Pelvic Tilts
- Completed at second visit
- Grade 2 joint mobilizations at L2-5 with central PA’s
- Single leg stance on a Bosu ball
- Balancing on knees on a Swiss ball
- Balancing while sitting on a Swiss ball
- Neutral planks and lateral planks
Other Plan of Action: Pt was recommended to see an orthopedic physician with a specialty in sports related injuries while she is being seen at physical therapy. Pt is awaiting x-rays and potential MRI next week.
Penny for your thoughts: Was the referral to see an orthopedic physician necessary or should I have completed a trial period of PT first? Should I still be seeing the patient or wait for results from the imaging and the physician? What other tests and measures would you do? What treatments would you recommend to do and what would you recommend not to do? What else do you want to know?