Orthotics Assessment

Subjective (S)

• A 42 year old patient attends the clinic regarding bilateral plantar heel pain and progressive medial arch fatigue.

History of Present Illness (HPI)

• Sharp, stabbing pain initially; transitions to a dull ache by end of day.
• 4/10 at present, 8/10 at worst, causing a noticeable antalgic limp after prolonged standing.
• Medial calcaneal tubercle bilaterally (R > L) and proximal plantar fascia.
• 6 months.
• Insidious onset following an increase in work shifts.
• Prolonged weight-bearing on hard surfaces, walking barefoot, and end-of-day fatigue.
• Rest, ice bottle rolling, and naproxen (Aleve®) 250 mg PO BID PRN.
• OTC gel heel cups and calf stretching with minimal relief.
• Marked post-static dyskinesia; first steps in the morning are severely painful.
• No radiation to the digits, ankle, or proximal lower extremity.

Other Active Practitioners (OAP)

• Registered Massage Therapist (RMT) for lower extremity myofascial release; Family Physician (Dr. MacLeod).

Family History

• Maternal history of pes planovalgus and hallux abductovalgus; father has T2DM.

Past Medical History (PMH)

• Pre-diabetes (diet-controlled, recent HbA1c 6.1%), BMI 29.5 kg/m². Right Grade II lateral ankle sprain (12/08/2018), treated conservatively. No surgical history.

Radiology Assessments

• Weight-bearing bilateral foot X-rays (14/02/2026): Small inferior calcaneal enthesophyte noted on the right; joint spaces preserved, no osseous fractures or acute pathology.

Social History

• Retail manager requiring 8–10 hours of standing daily on concrete floors. Walks barefoot indoors at home; wears flat, unsupportive slip-on shoes outdoors. Lives with spouse. Non-smoker, social EtOH (2–3 units/week).

Objective (O)

Dermatological Findings

• Bilateral diffuse hyperkeratosis noted at the plantar medial aspect of the hallux interphalangeal joint (IPJ) and 1st plantar metatarsophalangeal joint (PMPJ), indicative of medial column overload. Skin intact, no ulcerations or tinea pedis.

Musculoskeletal Findings

• Bilateral flexible pes planovalgus; collapsible medial longitudinal arch on weight-bearing with forefoot abductus and wide splay foot type.
• Bilateral gastrocnemius-soleus equinus; ankle joint dorsiflexion limited to 0 degrees with knee extended and 8 degrees with knee flexed bilaterally. No Haglund deformity.
• Subtalar joint (STJ) ROM fluid and pain-free non-weight-bearing; Resting Calcaneal Stance Position (RCSP) is 6 degrees everted on the right and 4 degrees everted on the left.
• 1st metatarsophalangeal joint (MPJ) exhibits functional hallux limitus bilaterally (< 30 degrees dorsiflexion in weight-bearing, 65 degrees non-weight-bearing) with mild crepitus on the right.
• Mild flexible clawing of digits 2–4 bilaterally; no interdigital neuritis.
• Functional leg-length discrepancy noted: R < L by 4 mm secondary to asymmetrical STJ pronation.
• Gait analysis reveals aBilateral apropulsive gait pattern, early heel lift, prolonged midstance pronation, and abductory twist at toe-off. Direct palpation elicits acute tenderness at the medial calcaneal tubercle (R > L). Windlass test positive on the right.

Assessment (A) (Diagnoses)

• Bilateral plantar fasciopathy (R > L) secondary to flexible pes planovalgus, functional hallux limitus, and gastrocnemius equinus.
• Differential diagnoses: Calcaneal stress fracture, Baxter's nerve entrapment (inferior calcaneal nerve), tarsal tunnel syndrome, fat pad atrophy.

Plan (P) / Treatment

• Advised to transition to structured stability running shoes (e.g., Brooks Beast, New Balance 990, or ASICS Gel-Kayano) with a firm heel counter, torsional rigidity, and a 10–12 mm heel-to-toe drop. Strict avoidance of barefoot walking indoors; recommended supportive recovery slides (e.g., OOFOS) for home use.
• Completed full biomechanical assessment and dynamic gait analysis confirming excess pronatory forces straining the plantar aponeurosis.
• 3D optical laser scan captured in subtalar joint neutral (STJN) non-weight-bearing. Prescribed custom functional foot orthoses: semi-rigid polypropylene shell, 4-degree Kirby medial heel skive, 3 degrees bilateral rearfoot intrinsic varus post, 1st ray cut-out to address functional hallux limitus, plantarfascial groove, and Poron/Spenco top cover with cushioned heel apertures.
• Educated on pathology, footwear compliance, and orthotic break-in protocol (increase wear by 1 hour daily). Demonstrated towel-calf stretches and plantar fascia-specific stretching exercises to be performed 3x daily, especially prior to getting out of bed.
• RTC in 3 weeks (08/04/2026 at 10:30 America/Halifax) for custom orthotic dispense and fitting, then 4 weeks post-dispense for review.