,PRESENTING COMPLAINT:
Patient reports ongoing pain in the plantar aspect of the left foot, especially in the morning and after prolonged standing. The pain has been present for approximately 6 weeks and is gradually worsening.
,Footwear and orthotics:
Patient wears Asics Gel-Kayano trainers, model year 2023, primarily for running and daily activities. The upper is made of breathable mesh and synthetic materials. Fastening is via laces.
Practitioner noted mild wear on the lateral aspect of the left shoe, suggesting possible overpronation.
Patient currently uses off-the-shelf arch supports in their trainers.
,Patient goals:
Patient aims to reduce foot pain, improve mobility, and return to running without discomfort.
,ASSESSMENT OF CONDITION:
POP: Tenderness on palpation of the plantar fascia insertion point and medial calcaneal tubercle.
Assessment revealed reduced dorsiflexion in the left ankle.
Observations: Mild pes planus noted bilaterally.
,Gait:
Patient demonstrates a mild overpronated gait pattern on the left side.
,TREATMENT OF CONDITION:
Treatment included massage to the plantar fascia and calf muscles.
Strapping applied to support the medial arch using rigid sports tape.
Advice given to patient included rest, ice application, and activity modification.
,Prescribed exercises:
Prescribed calf stretches, holding for 30 seconds, repeated 3 times, twice daily.
Patient should feel a stretch in the calf muscle.
,PLAN:
Patient to return in 2 weeks for review.
Review plantar fascia pain and gait pattern.
Patient to be provided with a handout on plantar fasciitis management.
Date: 1 November 2024