The aim of this case study is to demonstrate and evaluate the treatment of a variety of sports injuries in an appropriate work-based environment. This will include choosing an injury, discussing the initial findings, discussing and evaluating the treatment by producing a treatment plan and explaining the advice that should be given to the client. Performing sports injury to a client helps them return back to their sport or their regular exercise routine as soon as possible, different assessments and analysis' are carried out so the practitioner can find out as much as possible to help treat the injury. According to the Society of Sports Therapists 'sports therapy is an aspect of health care that is specifically concerned with the prevention of sports injury and rehabilitation of the patient back to optimum levels of functional, occupational and sports specific fitness regardless of age and ability.' (The Society of Sports Therapists, 2004)
The term sports injury refers to 'the kinds of injuries that most commonly occur during sports or exercise. Some sports injuries result from accidents; others are due to poor training practices, improper equipment, lack of conditioning, or insufficient warm up and stretching.' (NIAMS, 2009)
Methodology
This section provides a general idea of the methodological approaches taken during this case study. The main sources of research carried out were collected from secondary sources via journals, websites, articles and books.
Data was also collected by carrying out a consultation on the client. This allowed me to find out as much as I could about the client and her injury. A consultation form and body chart was also completed which allowed me to find out about her personal details, her current injury, treatment, medication, exercise regime, previous injuries and medical history (refer to appendix 1).
Over time, plenty of books that have been published that incorporate sports injuries, especially regarding plantar fasciitis, for example, Sports Injuries - Their Prevention and Treatment, by Peterson, L and Renstrom, P.
As already mentioned the internet will be another main source of research, for example, www.sportsinjuryclinic.net and so will sports magazines and journals, such as Runners World. There is a great deal of information surrounding sports injuries via these sources. The information was collected to find out more about the topic of plantar fasciitis and to help complete the case study.
Task 1 - Produce a Brief Description of the Injury
Plantar fasciitis is also known as heel pain as it is a common condition that causes pain in the heel; it runs from the medical aspect of the calcaneus to blend anteriorly with the ligaments attached to the metatarsal heads. The plantar is the thickest facia in the body and when the plantar fascia thickens it causes heel pain (plantar fasciitis is the medical term for the thickening of the plantar fascia). When certain movements occur such as, dorsiflextion or rising up onto the toes it stretches the plantar fasciitis and causes the longitudinal arch to rise. The plantar fasciitis also acts as a shock absorber to the foot. According to the NHS 'heel pain is a very common condition. It is estimated that 1 in 10 people will have at least one episode of heel pain at some point in their life. Two main groups of people are affected by heel pain are people who regularly exercise by jogging or running and in older adults aged 40-60.' (NHS, 2011)
Figure One - Shows the underneath view of plantar fascia (Ortho Info, 2010)
Figure Two - Shows the side view of plantar facia (Hopkins Ortho, Nd)
Plantar fasciitis is mainly caused by sports that involve repeated movements such as running, dancing, jogging, running up an incline and jumping. Also, gradual wear and tear of the plantar fascia can cause heel pain and in manual workers who stand on hard surfaces in poor shoes for long periods of time.
According to the NHS 'the long-term outlook for most cases of heel pain is good, with four out of five cases resolving within a year. However, living with the condition for this long can be frustrating, annoying and painful. And in around 1 in 20 people, the symptoms of heel pain will not respond to the types of treatment listed above. Surgery will be needed to release the plantar fascia.' (NHS, 2011)
Client Details
December 2010:
Client A is a 53 years old woman suffering from plantar fasciitis. She leads a healthy lifestyle and exercises weekly. Currently she runs two to three times a week for an hour each time, she uses professional running trainers and heel inserts when running. Heel inserts are used to help correct posture of the body and position of the feet. Norris, C. states 'sports shoes play an important part of this condition.' (2004)
Furthermore, she contributes in Pilates and aqua-aerobics once a week. She also teaches 'bums and tums' twice a week. It is clear that client A is very active, so when an injury occurs it prevents her carrying out her weekly exercise routine. Therefore, she wants to get back to her routine as soon as possible, however, with a plantar fascia injury it could either take years to heal or it could heal quickly. 'The outcome for people with plantar fasciitis is generally good, with approximately 80 percent of people having no pain within one year.' (Up To Date, 2011)
Client A has suffered from other injuries before, which mainly occurred during exercise. She has already experienced damaging her plantar fasciitis whilst she was playing squash. It occurred on the right foot approximately five years ago and it took six months for it to recover. She has also endured a stress fracture on the second and third metatarsal of the left foot, she explained it to be very painful and even now it can still be uncomfortable, this injury took 14 weeks to recover. Moreover, when client A was 22 years of age she had a plantarmyofalgio, which was a lump in her left foot that caused her a lot of pain, especially when exercising and she was unable to exercise for six weeks. It occurred whilst she was playing squash, in the end she undergone surgery and had the lump removed.
A foot position test was carried out on the client to examine whether her foot position was pronated, neutral or suppinated. It was found that client A suffers from a certain degree of pronation meaning she is flat footed and the foot rolls slightly inwards. In other words 'pronation includes combined calcaneal eversion with adduction and plantarflexion of the talus.' (Norris, C. 2004)
Figure Three - Shows foot positions (IMZKE, 2010)
A reasonable amount of pronation is necessary for the foot to function correctly, however damage and injury can occur within athletes who suffer from excessive pronation as they are more likely to develop an overuse injury or tear in the origin of the fascia.
Nevertheless, client A is more pronated in the left foot which could be one of the reasons why she is suffering from plantar fasciitis as it causes additional stretching of the plantar fascia. According to Creighton and Olson (1987) in the book Sports Injuries Diagnosis and Management 'excessive rear foot pronation will lower the arch and over stretch the fascia, and mobility of the first metatarsal may also contribute to the condition.'
To back up this statement made by Creighton and Olson, Peterson and Renstom explained 'injuries associated with excessive pronation include chondromalacia patellae, tibialis posterior syndrome, plantar fasciitis and trochanteric bursitis.' (Peterson, L. Renstrom, P. 2001)
Figure Four - Shows the inward roll of the foot when a person is running. (Muscle Injury, 2011)
Task 2 - Discuss the Initial Findings by using SALTAPS
SALTAPS
When client A was assessed the practitioner referred to SALTAPS and followed the process. SALTAPS is used to help gain further information and asses the injury. It is also a way of helping to speed up the recovery of the injury. SALTAPS stands for see, ask, look, touch, active movement, passive movement and strength testing.
S - See the injury occur
As this injury was done in the clients own time, the practitioner did not see the injury occur. The client explained that the injury occurred whilst running; it was caused by the plantar fasciitis overstretching when she was in dorsiflexion position. She explained it was a sudden sharp pain in the sole of her foot and heel and she had to stop running immediately. Client A has not run since as it is too painful. This type of injury is an intrinsic traumatic overload injury as it happened suddenly and the client may have overstretched it by falling slightly. .
A - Ask the client what is wrong
Client A explained that there is a pain in the heel and sole of her left foot, she explained that when it occurred it was sharp and intermittent; the pain is currently staying the same but is always worse in the mornings. According to Norris, C (2004) 'pain is often worse when taking the first few steps in the morning until the Achilles tendon is stretched.' She also explained that it was too painful to run, walk or put any weight on the injured foot.
L - Look at the injury site
When the client first presented her injury it was in the acute stage as it occurred two days ago. The injured area was slightly bruised, especially located on the central arch and heel of the foot, which was extremely tender to touch. The bruising was caused from microscopic tears of blood vessels under the skin.
Furthermore, it was swollen which is a normal response to overstretching the fascia. This type of swelling is known as odema, which describes the swelling to be caused by tissue fluid in the area, occasionally it can also involve blood, this type of swelling occurs when there is trauma to the area.
The classification of this injury was a second degree injury, meaning the degree of fibre disruption was minimal to moderate and the signs and symptoms were noticeable.
T - Touch
The practitioner gently palpated the area to feel if there were any abnormalities. The practitioner did not apply much pressure as the area was sore and tender. However, the area felt tight, tender and swollen and it was clear that there was palpable pain. Nonetheless, there was also no loss in sensation in the foot area.
A - Active Movements (client carries out movements herself)
The practitioner asked the client to carry out the following movements to see how the ranges of movements were. First of all the client dorsiflexed and plantarflexed the feet, it was clear that this was painful on the left foot and there was not much movement, especially when dorisflexing as it was uncomfortable for the client because this move stretches the facia. The client then carried out eversion and inversion, this movement was carried out slightly better, although it was still uncomfortable.
P - Passive Movements (practitioner carries out movements)
The practitioner then assisted the client to carry out the same movements, again it was painful and uncomfortable for the client, all of the movements were very restricted, especially dorsiflexion and eversion.
Figure Five - Shows passive movements of dorsiflexion (Webster Ortho Massage, Nd)
Figure Six - Shows passive movements of inversion (Sports Injury Clinic, 2011)
S - Strength Testing
The movements that were carried out during the passive movement stage, inversion, eversion, plantarflexion and dorsiflexion were carried out again, however the practitioner resisted the action of the muscles working over the inured area to make it harder and to allow the muscles to work more.
As the client was able to carry out SALTAPS without excessive amounts of pain, a weight bearing test was also carried out. The weight bearing testing movements were walking forwards unaided and heel lifts. The client was able to walk forward unaided but could not fully lift the left heel off the floor. She also carried out heel raises, where she lifted her heels slightly off the floor, however this was very little as it was too painful for the client, particularly on the left foot.
Body Testing
During the first assessment other areas were also examined, such as, core stability, posture analysis and balance. It is important to test all of these because they all play a role in the body's mechanisms.
Posture analysis
To asses the client's posture analysis a plum line was used. The conclusion of the clients posture was flat back, the practitioner came to the conclusion because:
Head position: Forward
Cervical spine: slightly extended
Thoracic spine: upper part increased flexion; lower part, straight
Lumbar spine: straight
Pelvis: posterior tilt
Hip joints: extended
Knee joints: extended
Ankle joints: slight plantar flexion
Elongated and weak: one joint hip flexors
Short and strong: hamstrings
Figure Seven - Shows the ideal posture compared to flat back posture (NZIHF, 2011)
Core stability
Different core stability tests were carried out on the client. 'Core stability describes the ability to control the position and movement of the central portion of the body.' (CUUH, Nd)
The core stability exercises carried out were:
The gluteus bridge:
Figure Eight - Shows the gluteus bridge position (Maidstone Rugby, Nd)
This was also carried out where the client lifted one leg at a time off the floor, the aim of this exercise is to keep the position and not let the hips drop. However, when the client lifted her left foot off the floor her left side dropped drastically, therefore her core is stronger on her right side. During this exercise care was taken when the client was applying weight onto her left foot as this could have been uncomfortable and painful.
Figure Nine - Shows the gluteus bridge potion with one leg lifted (MBT, 2011)
It is important that the client does these exercises regularly as having good core stability can 'help maximise running performance and prevent injury.' (CUUH, Nd)
Balance
A balance test was also carried out, 'balance is the ability to stay upright or stay in control of body movement.' (Top End Sports, 2011) It is important that balance tests are carried out regularly as they may enhance the sporting activities as well as daily life.
The balance move carried out was standing on one leg on a flat surface:
Figure Ten - Shows standing on one leg balance (Top End Sports, 2011)
Client A was able to carry out reasonable balance on one leg at a time, however it was clear that it was easier for the client to balance standing on her right foot as she was more stable. If the client found this test too hard then she could use objects to help her balance and once mastered the technique, remove the object.
'In theory, by enhancing our balance, we may be able to reduce injury and improve the body's ability to produce force.' (University Sports Medicine, Nd)
Task 3 - Discuss what the initial treatment should be and why?
How Client A currently treats her plantar fasciitis:
It was discovered that after this injury happened the client had been icing it regularly by using an iced cold water bottle and taking ibroprofen regularly to ease the pain and discomfort. She explained she was not able to carry out any stretching or strengthening exercises as it was too painful.
Recommendations for the client:
The practitioner recommended the client to follow the PRICE regime whilst at home. The aim of PRICE is to rehabilitate the injury, reduce pain, swelling, bruising and return the client back to their rapidly.
Protection
It was strongly recommended to the client to stop her weekly exercise routine to prevent any further damage to the injury and to also allow it to heal. Also, the use of crutches, splints or air cast can be used to take the weight off the injury.
Figure Eleven - Shows an air cast (Osteopath-Edinburgh, Nd)
Rest
Most injuries need time and rest to heal, however, there is conflicting research regarding whether rest should be used as a treatment to help heal the plantar fasciitis. Christer Rolf states 'rest will not help, so allow all kinds of sporting activities, with well-fitted shoes. If there is pain on impact, suggest low-impact alternatives such as cycling and swimming' (Rolf, C. 2007)
However, Patient UK explains 'rest should be done as much as possible. Avoid running, excess walking or standing, and undue stretching of your sole.' (Patient UK, 2011)
The client was advised not to continue with any of her daily routine as this could make the injury deteriorate. They should only return back to their sport once the pain has stopped and the plantar fasciitis is healed.
Ice
The practitioner recommended the client to continue to ice the injured area every fifteen to twenty minutes every two hours a day. Icing the injured area will help reduce the pain, inflammation and bring out the bruising.
Compression
Compression may be used to help decrease the swelling and also help to reduce the pain when carrying out normal activities, such as, walking. There are different taping materials and techniques that could be used.
Figure Twelve - Shows taping technique for plantar fasciitis (Sports Injury Clinic, 2011)
Elevate
The practitioner recommended the client to elevate the injury so it is above the heart as it reduces the flow of blood to the area, therefore decreases the swelling. This can be done whilst lying down and using an object to rest the foot on.
Finally, the client was recommended to return in six weeks so the injury can be analysed to see how it is healing and how the client is getting on. The practitioner did not refer the client to the doctor or a specialist as she wanted the client to proceed with the PRICE regime first and see if it helped. If the injury was still painful and the client could not carry out normal day activities, then she would be advised to seek specialist advice.
The main aims and objectives of what the practitioner was trying to achieve during the first consultation was to reduce the pain, protect the injury from further damage, provide home advice and to return them back to her routine as soon as possible.
Task 4
The practitioner gave the client a few stretches and strengthening exercises to complete daily at home to improve the injury. 'Stretching is a good way to strengthen foot muscles and prevent injuries. Stretching helps feet recover from injuries and to increase and maintain flexibility.' (E How, 2011) The exercises given were heel stretches, plantar fascia stretch, plantar fascia stretch by rolling, walking on tip toes, pencil pick-up and towel pull.
Exercise
How to carry it out
Figures
Heel stretches -
This helps to stretch both the plantar fascia and the Achilles tendon.
Stretch the plantar facia by standing on the edge of a step and slowly lower the heels down below the step.
Figure Thirteen (Pain Relief Site, 2008)
Plantar fascia stretch
Helps to stretch and improve flexibility of the foot which will reduce pain from plantar fasciitis
This can be done by pulling the toes towards the body, so they dorsiflex. Stretching mechanisms, for example, resistance bands, can also be used, just lope the mechanism around the foot and pull it towards the body.
An article by Digiovanni, B and Nawoczenski, D in the Journal of Bone and Joint Surgery 'followed up a previous study regarding a specific stretch for the plantar fascia. 94% of participants reported a decrease in pain, even two years after the initial study.' (Live Strong, 2011)
Figure Fourteen (Knoll, 2009)
Plantar fascia stretch by rolling
Stretches the plantar fascia
While sitting or standing, use a ball, preferably a tennis ball and gently roll it along the bottom of the foot.
Figure Fifteen (Five-Minute Yoga, Nd)
Walking on tip toes
Strengthens the plantar fascia and prepares it to support the level of loading when returning back to exercising.
Simply walk about on tip toes, if this is too easy take bigger steps and try carrying it out walking on the heels.
Figure Sixteen (Sports Injury Clinic, 2011)
Pencil pick-up
Strengthens the plantar fascia
Pick the pencil up using the toes. Once this becomes too easy, heavier objects may be used.
Figure Seventeen (Sports Injury Clinic, 2011)
Towel pull
Strengthens the plantar fascia
Use the toes to grasp and pull the towel towards the body. Keep the heel on the floor. Once this becomes too easy, heavier objects may be used.
Figure Eighteen (Sports Injury Clinic, 2011)
February 2011 - Second Assessment
The client returned after 6 weeks and the injury had improved significantly and she explained how much better it was feeling. The client is slowly returning back to her exercise regime as she is now able to run without pain. The swelling and bruising is no longer visible and the tenderness and pain has improved. The client explained that she continually iced the injured area, followed the PRICE regime and carried out the exercises prescribed as often as she could. She started performing the exercises a few days after the injury. The client is also carrying out the core stability tests to strengthen her left side (the test was carried out during the second assessment and her core had definitely improved).
The recommendations given to the client were to carry on with exercises but try using heavier objects to continue to strengthen the plantar fasciitis, which will also help prevent further injury. Another technique advised to client A was massage. As the area can now be touched without too much pain and discomfort, massage is a good technique to help ease the tension and stretch the plantar fasciitis. 'Manipulating and massaging the muscles in your feet is another way to strengthen them and help heal an injury. Foot massage is easy to do by yourself.' (E How, 2011) (Refer to appendix 2).
Now the client has returned to her exercise routine, she should continue to wear her specialised trainers with the heel inserts to help correct the foot position whilst running and also to release the tension placed on the plantar fascia. Some orthotics also helps to re-stretch the fascia whilst moving and also provide acupressure and structural support in the areas that the foot that require the most attention in order to help reverse the condition.
Conclusion
In conclusion, this case study shows if the right regime is carried out and the advice given to the client is followed then the injury usually heals. As the client carried out the correct regime to help heal the injury, the injury healed within two months. The client also carried out the recommended PRICE regime, stretches, strengthening moves and massage techniques to help allow the injury to recover faster, to help reduce the pain and assist the client back to her regular exercise routine. The injury healed well and the client is satisfied as she is now exercising again without any aggravation. This is good as some plantar fasciitis can take up to one year to heal and some cases may not heal at all and will need to undergo surgery. To allow the client to keep on exercising without discomfort or possibility of reinjuring the plantar fascia, the advice given to the client after the injury still must be carried out to continually strengthen and stretch the fascia. Furthermore, the other tests, such as, the balance, core stability and posture tests can also reduce injuries and prevent any from reoccurring.
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References
CUUH (nd) Core Stability [on-line] Available at: www.cuhh.org.uk, Date Accessed 9th February 2011
E How (2011) Foot Exercises for Stretching and Strengthening & Range of Motion [on-line] Available at: www.ehow.com, Date Accessed 1st February 2011
Figure One - Shows underneath view of plantar fascia
Ortho Info (2010) Plantar Fasciitis [on-line] Available at: http://orthoinfo.aaos.org, Date Accessed 1st February 2011
Figure Two - Shows side view of plantar facia
Hopkins Ortho (nd) Plantar Fasciitis [on-line] Available at: www.hopkinsortho.org, Date Accessed 1st February 2011
Figure Three - Shows pronated foot position
IMZKE (2010) Pronated Foot Position [on-line] Available at: http://imzke.blogspot.com, Date Accessed 3rd February 2011
Figure Four - Shows inward roll of the foot
Muscle Injury (2011) Health and Fitness Clinic [on-line] Available at: www.muscle-injury.co.uk, Date Accessed 4th February 2011
Figure Five - Shows passive movements of dorsiflexion
Webster Orthopaedic Massage (nd) Orthopaedic Massage [on-line] Available at: www.websterorthomassage.com, Date Accessed 4th February 2011
Figure Six - Passive movements of inversion
Sports Injury Clinic (2011) Inversion [on-line] Available at: www.sportsinjuryclinic.net, Date Accessed 5th February 2011
Figure Seven - Shows the ideal posture compared to flat back posture
NZIHF (2011) Types of Posture Alignment [on-line] Available at: www.nzihf.co.nz, Date Accessed 1st February 2011
Figure Eight - Shows the gluteus bridge position
Maidstone Rugby (Nd) Physiotherapy [on-line] Available at: www.maidstonerugby.org.uk, Date Accessed 2nd February 2011
Figure Nine - Shows the gluteus bridge potion with one leg lifted
MBT (2011) Exercises [on-line] Available at: http://us.mbt.com, Date Accessed 3rd February 2011
Figure Ten - Shows standing on one leg balance
Top End Sports (2011) Training Methods: Balance [on-line] Available at: www.topendsports.com, Date Accessed 7th February 2011
Figure Eleven - Shows an air cast
Osteopath-Edinburgh (nd) Air Cast Walker [on-line] Available at: www.osteopath-edinburgh.com, Date Accessed 9th February 2011
Figure Twelve - Shows taping technique for plantar fasciitis
Sports Injury Clinic (2011) Taping for Plantar Fasciitis [on-line] Available at: www.sportsinjuryclinic.net, Date Accessed 9th February 2011
Figure Thirteen - Shows heel stretches
Pain Relief Site (2008) Plantar Fascia Stretch [on-line] Available at: www.painreliefsite.com, Date Accessed 6th February 2011
Figure Fourteen - Shows the plantar fascia been stretched
Knoll (2009) Plantar Fasciitis [on-line] Available at: http://knol.google.com, Date Accessed 9th February 2011
Figure Fifteen - Shows the plantar fascia been stretched
Five-Minute Yoga (nd) Five-Minute Yoga Challenge [on-line] Available at: http://myfiveminuteyoga.com, Date Accessed 10th February 2011
Figure Sixteen to Eighteen - Shows stretches and strengthening exercises
Sports Injury Clinic (2011) Stretches and Strengthening Exercises [on-line] Available at: www.sportsinjuryclinic.net, Date Accessed 9th February 2011
Figures Eighteen to Twenty-Four - Shows massage movements
Sports Injury Clinic (2011) Massage Movements [on-line] Available at: www.sportsinjuryclinic.net, Date Accessed 11th February 2011
Live Strong (2011) Plantar Fascia & Calf Muscle Stretching Exercises [on-line] Available at: www.livestrong.com, Date Accessed 11th February 2011
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Norris, C. (2004) Sports Injuries, Diagnosis and Management. Butterworth-Heinemann. United Kingdom: London
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University Sports Medicine (nd) Strive for a Balanced Workout [on-line] Available at: www.ubsportsmed.buffalo.edu, Date Accessed 30th January 2011
