Orthotics Assessment

Subjective (S): - A 45-year-old patient reports to the clinic for persistent right foot pain and swelling, particularly around the arch and heel area. - Nature of the pain: Sharp and throbbing - Rates the pain now: 6/10, increases to 8/10 after prolonged standing - Location of the pain: Right arch and heel - Duration of the pain: 3 months - Onset of the symptoms: Gradual - Aggravating factors: Standing for long periods, walking on hard surfaces - Alleviating factors: Rest, ice application - Any Treatments before: Over-the-counter pain medication - Are first steps in the morning painful? Yes - Does the pain radiate to the toes, ankle, or leg? No Objective (O): - Dermatological Findings: - Right foot hyperkeratosis at the 1st PMPJ - Musculoskeletal Findings: - Right foot low arch - Right calf muscle examination shows functional ankle equinus - Right subtalar joint (STJ) findings: Limited range of motion, weight-bearing - Right 1st metatarsal joint (MPT) findings: Hallux limitus - Leg length discrepancy positive: R<L Assessment (A) (Diagnoses): - Pes planus - Differential Diagnoses: Plantar fasciitis Plan (P) / Treatment: - Footwear advice: Recommend supportive shoes with arch support - Biomechanics and gait analysis: Conducted, findings suggest overpronation - Orthotics, Scan: Custom orthotics recommended - Patient Education: Discussed importance of proper footwear and stretching exercises - Return to Clinic (RTC): Follow-up in 4 weeks