SUBJECTIVE: The patient presented to my office as a followup on plantar fasciitis of her right heel. The patient stated that, after receiving the orthotics, she took the Lodine as prescribed for approximately one more week. She then discontinued the Lodine and noticed significant improvement wearing the orthotics. The patient is on her feet quite a bit as part of her job. She now has no pain in the morning and only feels an ache by late in the day.
OBJECTIVE:
MUSCULOSKELETAL: On exam of her right heel, there is minimal swelling and some pain on palpation. Her description of her ache is a 3 on a pain scale of 1-10 with 10 being what she had when she presented to my office.
ASSESSMENT: Plantar fasciitis.
TREATMENT PLAN: The treatment provided for the patient today was review of her stretching program and home physical therapy. We taped her foot. She is to continue to ice it.
We modified a pair of dress shoes for her, for her son’s wedding, and she is to continue to wear the orthotics. We discussed with her resuming her walking program and discussed how she should do that. The patient is to call if she does not continue to improve, and at that time, we may start her on some physical therapy program.
Plantar Fasciitis Sample Report #2
SUBJECTIVE: The patient presented today stating that her heel pain feels significantly better than two weeks ago. Her right heel, which hurt the worst, is only minimally painful, and she is without pain while she is strapping her foot wearing her athletic shoes and using the arch support, which we recommended. She is able to do walking and gardening without significant pain.
OBJECTIVE:
MUSCULOSKELETAL: There is no swelling, only mild poststatic dyskinesia and mild pain on palpation of the plantar central aspect of the right heel. No pain on range of motion and negative Tinel’s sign.
ASSESSMENT: Resolving plantar fasciitis, right foot.
TREATMENT PLAN: The treatment provided for the patient today was discussion about shoe gear and specifically dressier shoes that she can wear the arch supports in.
The patient is to continue strapping for several more weeks and return to the office on a p.r.n. basis.
Plantar Fasciitis Sample Report #3
SUBJECTIVE: The patient is a (XX)-year-old who presented to the office complaining of right heel pain for approximately one year. The patient has treated herself with heel pads and arches, but they have not been successful. The patient states that her right heel pain is sore in the morning but worse since as the day goes on and with increased ambulation. The intensity has been increasing over the last year.
PAST MEDICAL HISTORY: Remarkable for a right foot fracture, which she was casted for and a fractured right knee.
PRESENT MEDICAL HISTORY: Significant for chronic pain syndrome, for which she goes to a pain clinic and has acupuncture as well.
PODIATRIC HISTORY: Significant for walking just for activities of daily living and she has back pain. Her regular shoe gear, Easy Spirit shoes with posterior heel wear.
OBJECTIVE:
VASCULAR:
DP: 3/4 DP of the right and 1/4 DP of the left.
PULSES: Capillary filing time is 2-3 seconds bilateral. The feet are warm.
VARICOSITIES: Mild.
EDEMA: None.
NEUROLOGIC: There was negative Tinel’s; vibratory sense was intact and deep tendon reflexes 1/5 bilateral.
DERMATOLOGIC: There was a mild callus on the plantar aspect of the first metatarsal bilateral, and there was also noted to be a soft tissue mass on the medial aspect of the fifth toe of the left foot. There was decreased fat pad of the forefoot.
MUSCULOSKELETAL: The feet appeared to have a metatarsus adductus foot structure with a mild C-shaped deformity. The muscle strength was 4/5 plantarflexion and 3/5 inversion. There was no pain on passive or active range of motion. The medial aspect of the right heel showed some swelling, and there was pain on palpation of the plantar medial aspect of the heel and no pain on compression of side-to-side motion. The patient was able to raise and invert her heels without pain. The first MPJ range of motion is 60 degrees. The first ray was plantarflexed and semi-rigid. On stance, the longitudinal arch did not compress and there was an increase arch structure off weightbearing, and on weightbearing, there was a 3 inch genu valgum. The subtalar range of motion was within normal limits. Neutral calcaneal stance was 3 degrees varus, resting 3 degrees varus, and the forefoot position was 5 degrees valgus bilateral. Ankle dorsiflexion was 0 degrees bilateral with the knee straight, 10 degrees of the right with the knee bent, and 5 degrees of the left with the knee bent. There was also pain on palpation of the medial aspect of the tibia, the right greater than the left, and the posterior aspect of the right medial malleoli and navicular.
ASSESSMENT: Plantar fasciitis of the right heel with associated posterior tibial tendonitis. The patient also has a metatarsus adductus foot type.
TREATMENT PLAN: The treatment provided for the patient today was discussion of the above diagnosis. We recommended that she get a curve-lasted shoe. We gave her a prescription for x-rays of her right foot. We started her on home physical therapy of icing and stretching. We then dispensed an Aircast arch sleeve. We strapped her foot. We modified the insole that she presented to our office with a forefoot valgus self-post and put her gel heel lifts underneath the rearfoot of the insole.
The patient is to try all these above treatments and return to our office in two weeks for followup treatment. She is also to take Motrin 600 mg 3 times a day for 10 days.
Plantar Fasciitis Sample Report #4
SUBJECTIVE: The patient is a (XX)-year-old female who presented to the office today as a followup for the treatment of right heel pain. The patient stated that her right heel pain is significantly better as long as she wears the nighttime brace, the athletic shoes and the Spenco inserts. If she does not wear the nighttime brace, she notices significant amount of pain that day or if she wears the long shoes. The patient has to do a lot of airport travel as well as stand up for speaking engagements and sometimes she needs to wear dressier shoes, which does cause some pain.
OBJECTIVE:
MUSCULOSKELETAL: On exam, there is mild swelling of the plantar medial aspect of the right heel along with pain on palpation. There is still some poststatic dyskinesia but significantly less from when she initially presented. The patient did not take the Lodine because it upsets her stomach. The x-rays the patient brought in of the right foot weightbearing shows decrease in calcaneal pitch or short first metatarsal as well as an anterior calcaneal break.
ASSESSMENT: Plantar fasciitis.
TREATMENT PLAN: The treatment provided for the patient today was we placed her on Motrin 600 mg t.i.d. for 10 days. She is to continue her home physical therapy program of icing and stretching. We showed her how to do a rest strap on her right foot, and we modified the Spenco insoles with a felt varus wedge. The patient is to return in two weeks, and if she is still having significant pain, we may cast for orthotics.
Plantar Fasciitis Sample Report #5
SUBJECTIVE: The patient presented to the office as a followup. She is a (XX)-year-old female who presented two weeks ago with plantar fasciitis today. She presented stating that her plantar fasciitis was approximately 70% improved and that her life is a lot more pleasant. The patient has purchased very stable walking shoes and is wearing the Spenco orthotics. She has minimal pain on the right and only mild achiness on the left. She has significantly decreased pain in the morning and is able to walk much more.
OBJECTIVE:
MUSCULOSKELETAL: On exam, there is no swelling of either foot and no pain on palpation of the medial lateral aspect of the tibia. There was pain on the extreme medial aspect and extreme lateral of the right heel. The patient is still on the Lodine at this time. She has also consulted Dr. John Doe for left knee pain.
ASSESSMENT: Plantar fasciitis and ligamentous laxity.
TREATMENT PLAN: The treatment provided for the patient today was a discussion of her home physical therapy. We showed her how to strap her heels. We checked out her shoe gear and gave her another prescription for 10 days of Lodine for 100 mg b.i.d. She is to return to our office in four weeks after she has finished the Lodine, and we will decide at that time whether we should make her a pair of functional orthotic devices.
