I had just started to write about all the Pathology Based Orthoses offered by KevinRoot Medical, but there seems to be low interest. Therefore, I am going to switch gears today and talk about a typical patient who I will work with mechanically during our time together. As with many similar patients, this one presents with a sudden onset of plantar heel pain and a pre-heel lingering bout of recurrent achilles pain. My initial thought goes into tying these two together mechanically into an achilles tightness or weakness category. For me, mechanical treatment is based on finding and reversing causation of the injury, speeding rehabilitation, and preventing relapses.
Since the patient walked (not limped) into the office, my working diagnoses were acute plantar fasciitis and chronic achilles tendonitis. My 5 minutes in the room should then spark 2 protocols. These were:
- Acute Plantar Fasciitis: Soft OTC arch support, plantar fascial and achilles stretching 3 times daily, activity modification to obtain 0-2 pain levels, no barefoot walking, and icing 3 times daily
- Chronic Achilles tendonitis: Stretching also 3 times daily both gastrocnemius and soleus, and nonpainful evening 2-sided straight and bent knee heel lifts, icing twice daily, changing to a shoe with an elevated heel if presently in zero-drop, and staying in 0-2 pain levels.
These protocols can be in your exam rooms, given by your medical assistant, or placed in their online portal. A one month followup is requested to make sure that they are improving. But, could you have done better on this first visit and how? There is nothing wrong with this approach as you are starting some simple treatments and see how they progress. Let’s talk about 4 common improvements of the many you could possibly make. Please leave me your feedback on how you would like to improve on this scenario.
Improvement #1: Simply add a prescription 4-6 PT visits for their expertise at pain reduction, stretching safely, and gradual strengthening.
Improvement #2: Examination of the heel and achilles to confirm or fine-tune your working diagnoses.
Improvement #3: Watch them walk to check for signs of instability (medial or pronatory instability may require an orthotic evaluation visit).
Improvement #4:Proper assessment of achilles flexibility and strength.
These 4 improvements are easily entered in the assessment of your visit to review when the patient comes in for their follow up visit. They are listed under possible interventions: PT, heel and achilles exam, gait, and full achilles assessment for tightness and weakness. Let me know your thoughts.
