Subjective
Date of visit
Reason for visit (initial evaluation, follow-up for plantar fasciitis)
History of Present Illness:
Location and duration of heel pain (worse in the morning, improves with activity)
Activities that aggravate the pain (walking, running, standing for long periods)
Any recent changes in activity level or footwear
Past medical history (relevant conditions, previous injuries)
Medications (current medications)
Allergies
Objective
Physical exam:
Gait observation (looking for any abnormalities in walking pattern)
Palpation of the plantar fascia (tenderness to the touch along the sole of the foot)
Range of motion testing of the ankle (assessing dorsiflexion – bending foot upwards)
Ankle stability testing (checking for ligament laxity)
Assessment
Plantar fasciitis (suspected based on history and physical exam findings)
Severity of plantar fasciitis (mild, moderate, severe) – can be based on pain intensity and functional limitations
Consider alternative diagnoses (stress fracture, nerve impingement)
Plan
Treatment options (based on severity and response to initial interventions):
Conservative management:
Rest from aggravating activities
Ice application (20 minutes several times a day)
Non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief
Stretching exercises to improve flexibility of the plantar fascia and calf muscles
Strengthening exercises for the foot and ankle muscles
Supportive footwear with good arch support
Night splints to keep the plantar fascia stretched while sleeping (may be helpful for morning pain)
Physical therapy: A physical therapist can develop a personalized exercise program to address flexibility, strength, and gait abnormalities.
Corticosteroid injection: Injections may be considered for persistent pain not responding to conservative measures.
Extracorporeal shockwave therapy (ESWT): Outpatient procedure using sound waves to stimulate tissue healing – may be an option for chronic cases.
Monitoring plan:
Schedule for follow-up visits to assess response to treatment and pain improvement
Education
Explain plantar fasciitis, the causes, and potential risk factors.
Discuss the importance of rest, stretching, and strengthening exercises for recovery.
Proper footwear selection with good arch support.
Advise on activity modification to avoid aggravating factors.
Follow-up
Schedule for follow-up appointments as determined by severity and response to treatment.
More frequent follow-up may be needed initially, with visits becoming less frequent as pain improves.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of plantar fasciitis.