shoes that were found to have a manufacturing de­fect. The study identifies the musculoskeletal patho­logic structure and looks at the possible factors that contributed to this injury. The patient’s specific treat­ment plan is described, and the patient’s response to the treatment is delineated. Suggestions are made for patient education in proper shoe selection and foot support. Clinical guidelines were created and are presented to teach patients how to assess the quality of athletic shoe construction.

  METHODS AND MEASURES

Subject

A 40-year-old male triathiete with a diagnosis of plantar fasciitis was referred to physical therapy by his family physician. The patient complained of the onset of heel pain in his right foot after completing a haif-ironman triathion, which consists of a 2-km swim, a 90-km bike ride, and a 21-km run. The pa­tient was an experienced triathiete, and he described a well-rounded training program. His regimen in­cluded a daily flexibility routine and a biweekly strength training routine. Biking and running work­outs were performed over bridges to simulate hill training, because the patient lived in a flat environ­ment and the race course was hilly.

Interview Data

The patient was familiar with the race course, be­cause he had trained and competed on it previously. Table 1 shows the patient’s training schedule 8 weeks before the race. The patient used the same brand and model of running shoes for more than 2 years, with replacement of worn shoes every 480—800 km. The patient felt the weather conditions during the race were favorable, since it had been cool and over­cast, even though it rained for a short period at the beginning of the run. Several hours after the race, the patient noticed a gradual onset of right infero­medial heel pain, which presented as a dull, constant ache. The day after the race, the patient noticed sharper pain in the same location on the right foot,

especially when taking the first several steps in the morning. These symptoms were severe enough to cause the patient to limp while walking and made it impossible to run. There was no history of heel pain. Rest from weight-bearing activities and icing helped to alleviate the pain. The patient also noted that ini­tially he had minor muscle soreness in the right proximal calf.

Physical Examination

Two days after the race, the patient was seen for an initial physical therapy evaluation. One clinician completed the patient examination. The right lower extremity plantar fascia and soft tissues were exam­ined with palm and fingertip palpation. Varying pres­sures from light touch to deep pressure were used to determine the irritability of the plantar fascia and as­sociated tissues and the patient’s perceived pain. With the toes maintained in passive extension, firm palpation pressure was exerted on the medial border of the plantar fascia along the longitudinal arch. This palpation procedure was repeated with the pa­tient actively dorsiflexing the right ankle and extend­ing the great toe.

The patient’s lower extremity alignment was evalu­ated by measuring the subtalar joint angle in stand­ing, using a goniometer. The therapist measured the angle created by a line bisecting the posterior aspect of the distal third of the lower leg and a line bisect­ing the posterior aspect of the rear foot)° There were 5° of calcaneal eversion bilaterally.

Further musculoskeletal evaluation of the right lower extremity included gait analysis, manual muscle testing, and flexibility testing of the gastrocnemius muscle. The patient’s gait was visually examined, with the patient walking at a moderate pace within his pain tolerance. Gait deviations were compared with the conventional components of a normal gait cycle. Manual muscle testing was completed using the tradi­tional manual muscle testing positions and scale, ac­cording to Daniels and Worthingham’s manual mus­cle testing text.’⁴ Gastrocnemius muscle flexibility testing was completed by measuring the angle of an­kle dorsiflexion with a goniometer, while passively

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