POD SOAP + OUTCOME / GOALS

PODIATRIST Referral Source: Patient was referred by their General Practitioner due to persistent foot pain affecting daily activities. Subjective: * Chief complaint: Bilateral heel pain, worse in the mornings and after periods of rest. Symptoms have been present for approximately 3 months. Patient describes the pain as a sharp, stabbing sensation in both heels, particularly concentrated on the medial aspect. Severity is rated as 7/10 at its worst, decreasing to 3/10 with activity. Pain does not radiate significantly but is occasionally felt extending into the arch of the foot. Bilateral symptoms are present, with the right heel being marginally more painful than the left. Pain is aggravated by prolonged standing, first steps in the morning, and wearing flat shoes. Eased by rest and wearing supportive footwear with arch support. Associated symptoms include mild stiffness in the ankles upon waking, but no swelling, numbness, tingling, or skin changes observed by the patient. Pain intensity rating: 7/10 upon waking, 3/10 with moderate activity. * Relevant medical history: No significant past medical history. No surgeries. Currently takes paracetamol occasionally for pain relief. No known allergies. MOTIVATION TO SEEK HELP: Patient reports motivation to seek podiatry treatment due to the impact of heel pain on their ability to exercise, perform daily chores, and enjoy walks with their family. They are keen to return to their regular running routine. Objective: Gait observations: Antalgic gait noted, particularly on initial weight-bearing. Foot posture reveals pes planus (flat feet) bilaterally, with mild pronation during stance phase. No obvious limping observed after a few minutes of walking. Visible swelling, lesions, skin or nail abnormalities: No visible swelling or lesions. Mild callus formation noted under the metatarsal heads, but otherwise healthy skin. Nails appear healthy. Range of motion findings: * Ankle dorsiflexion: Right 10 degrees, Left 12 degrees (with knee extended) * Ankle plantarflexion: Right 45 degrees, Left 48 degrees * Subtalar joint inversion/eversion: Within normal limits bilaterally, but restricted end-range eversion due to perceived tightness. * First MTP joint dorsiflexion: Right 60 degrees, Left 65 degrees Joint-specific observations: Palpation reveals tenderness over the plantar fascia insertion at the medial calcaneal tubercle bilaterally, more pronounced on the right. No crepitus noted in any foot joints. Skeletal abnormalities: Mild hallux abducto valgus noted bilaterally. No other significant structural deformities observed. Observations of other joints: Right knee active ROM appears unrestricted and pain-free. Lumbar spine flexion and extension are within normal limits without pain. Assessment: Primary podiatric diagnosis: Bilateral Plantar Fasciitis, more severe on the right. Secondary podiatric diagnoses or contributing conditions: * Pes Planus (contributing factor) * Reduced ankle dorsiflexion (contributing factor) Outcome Measures/Baseline: Patient needs, goals and desired outcomes: * Reduce heel pain to a manageable level (3/10 or less) to allow for comfortable daily activities. * Return to running 5km without pain. * Improve overall foot function and stability. Pain scale results and baseline measures: Visual Analogue Scale (VAS) 7/10 for heel pain. Foot Function Index (FFI) baseline score 65/100. Functional Goals: Short-term (2-4 weeks): * Achieve 50% reduction in morning heel pain. * Be able to stand for 30 minutes comfortably without significant pain increase. * Perform home stretching exercises daily. Long-term (8-12 weeks): * Return to pain-free walking for over an hour. * Gradually reintroduce light jogging (1-2km) without post-activity pain. * Independently manage foot health through appropriate footwear and exercise. Sterile Pack Number: No sterile pack used. Plan: Immediate interventions performed or initiated during today's consultation: * Provided education on Plantar Fasciitis, causes, and management strategies. * Strapping applied to both feet for immediate arch support and pain reduction. * Prescribed specific calf and plantar fascia stretching exercises. Patient education provided including advice, activity modifications and self-management strategies: Patient advised on activity modification, including reducing prolonged standing and avoiding flat footwear. Recommended ice application for acute pain relief. Emphasised consistency with home exercise programme. Discussed the importance of supportive footwear and potential benefits of orthotics. Follow-up timeline and next appointment details: Follow-up appointment scheduled for 1 November 2024 (2 weeks) to review progress and adjust treatment plan. Future interventions to consider based on patient progress: * Custom orthotics if conservative measures are insufficient. * Referral for imaging (ultrasound) if no improvement. * Consider shockwave therapy if persistent symptoms. Plan for formal reassessment of outcomes and goals: FFI and VAS to be reassessed at the 4-week and 12-week marks to track progress against established goals.