Question 2 — Clinical Answer

b. Working Clinical Diagnosis (1 Mark)

a. Assessment and Management Plan (8 Marks)

Assessment

• Site & character: Throbbing sensation at the plantar medial aspect of the right heel — the hallmark location of plantar fasciitis, corresponding to the medial calcaneal tuberosity insertion of the plantar fascia
• Onset/aggravating factor: Worsened over 4 weeks following a parkrun — consistent with overuse/repetitive microtrauma mechanism
• BMI/body weight: Overweight — obesity increases load through the plantar fascia, a recognised risk factor
• Footwear: Steel toe-cap boots offer poor cushioning, rigid soles, and inadequate arch support, all contributing to abnormal loading
• Activity level: Moderately active with a sudden increase in impact activity (running)

1. Palpation — localised tenderness at the medial calcaneal tubercle / plantar medial heel; pain reproducible on palpation
2. Windlass test (passive toe dorsiflexion) — dorsiflexing the hallux tightens the plantar fascia; a positive test reproduces heel pain and is highly specific for plantar fasciitis
3. First-step pain — ask about pain being worst with the first steps in the morning after rest (post-static dyskinesia), a classic feature
4. ROM assessment — reduced ankle dorsiflexion / tight gastrocnemius-soleus complex is a common associated finding
5. Foot posture assessment — observe for pes planus (flat foot), which increases medial fascial tension, or cavus foot
6. Gait analysis — observe walking pattern (see part c)
7. Neurological screen — rule out tarsal tunnel syndrome (Tinel's sign along posterior tibial nerve) given the throbbing/burning quality

• X-ray (weight-bearing lateral calcaneus): to identify a calcaneal heel spur (present in ~75% of patients with heel pain); absence of spur does not exclude plantar fasciitis
• Ultrasound: thickening of the plantar fascia (>4 mm at calcaneal insertion is diagnostic); also rules out partial tear
• MRI: reserved for refractory cases; shows fascial thickening and increased signal at the insertion

• Heel spur syndrome (may coexist)
• Tarsal tunnel syndrome (posterior tibial nerve entrapment)
• Calcaneal stress fracture (especially after sudden increase in running)
• Retrocalcaneal bursitis
• Fat pad atrophy

Management Plan

1. Activity modification: Reduce impact loading; temporarily cease running; continue low-impact activity (cycling, swimming)
2. Footwear advice: Replace rigid steel-cap boots with cushioned, supportive footwear where occupationally permitted; add a heel pad or cup
3. Stretching program (evidence-based):
   • Plantar fascia-specific stretch (pulling toes into dorsiflexion before first morning steps)
   • Calf/gastrocnemius-soleus stretching (addresses tight Achilles-plantar fascia unit)
4. Weight management: Refer to dietician/GP for weight reduction program to reduce fascial loading
5. Analgesia: Oral NSAIDs (e.g. ibuprofen 400 mg TDS with food) for 2–4 weeks; topical NSAIDs as an adjunct
6. Ice therapy: 10–15 minutes post-activity to reduce inflammation
7. Foot orthosis: Custom or prefabricated (see part d)
8. Night splint: Maintains the foot in dorsiflexion overnight, preventing plantar fascia contracture during sleep — reduces morning first-step pain
9. Corticosteroid injection (if conservative measures fail at 6–12 weeks): 10–20 mg methylprednisolone + local anaesthetic injected at the medial calcaneal tubercle — provides short-term relief; avoid Achilles area due to rupture risk
10. Physiotherapy referral: Ultrasound therapy, soft tissue release, taping (low-Dye or calcaneal taping offloads the fascia)
11. Extracorporeal shockwave therapy (ESWT): For chronic cases unresponsive to 3–6 months of conservative treatment
12. Surgical fasciotomy: Last resort for cases refractory to all the above (partial plantar fascial release)

"Most cases of plantar fasciitis eventually resolve with nonsurgical management." — Roberts and Hedges' Clinical Procedures in Emergency Medicine

c. Gait Alterations (3 Marks)

1. Antalgic gait / reduced heel strike: The patient offloads the painful heel by shortening the stance phase on the right foot, decreasing the duration of heel contact and transitioning faster to toe-off; this results in an uneven, limping gait pattern
2. Reduced ankle dorsiflexion / equinus compensation: Due to associated gastrocnemius tightness and pain avoidance, the patient may exhibit reduced dorsiflexion at mid-stance, leading to early heel rise and increased forefoot loading; this also increases tension on the plantar fascia with each step
3. Supination / out-toeing compensation: The patient may externally rotate the foot (out-toe) or supinate to shift weight to the lateral border of the foot, away from the painful medial plantar heel; in flat-footed (pronated) individuals, the increased midstance pronation further stretches an already loaded fascia, exacerbating pain — this may lead to compensatory contralateral pelvic drop or hip hike

d. Foot Orthosis Design and Evaluation (5 Marks)

Design

Footwear Compatibility

• Must fit within the patient's work boot (steel toe-cap) — a slimmer, profiled orthosis design is needed
• A full-length device with a thin profile is preferable for occupational footwear

Evaluation

• Reduction in pain VAS score at the plantar medial heel
• Improvement in first-step morning pain
• Patient tolerance and comfort within steel-cap boots

• Foot Function Index (FFI) or Manchester Foot Pain and Disability Index — reassess at 4, 8, and 12 weeks
• Gait re-analysis: assess correction of antalgic gait, heel strike pattern, and pronation control

• Pedobarographic pressure mapping (in-shoe pressure analysis) to confirm offloading of the calcaneal medial tubercle and redistribution of pressure
• Confirm reduction in midfoot pronation

• If pain persists, consider increasing medial heel post angle, or adding additional arch support
• If patient reports lateral border pain, the medial posting may be over-correcting — reduce varus correction

• Worsening pain or new lateral heel pain (consider calcaneal stress fracture)
• Numbness/tingling developing (consider tarsal tunnel compression from orthosis edge)
• No improvement after 12 weeks → escalate to corticosteroid injection or imaging review

Question 3 — Clinical Answer

b. Working Clinical Diagnosis (1 Mark)

Differentials to exclude: early hallux rigidus (structural OA), hallux valgus (1st MTP joint with medial deviation), sesamoiditis, 1st MTP synovitis, gout

a. Assessment and Management Plan (8 Marks)

Assessment

1. 1st MTP joint range of motion (ROM): Non-weight-bearing assessment — normal dorsiflexion is 65–75°; hallux limitus = <50° NWB. Critically, assess weight-bearing ROM (Functional hallux limitus test — Jack's test / Hubscher manoeuvre): with the patient standing, passive dorsiflexion of the hallux will be markedly restricted (positive = hallux limitus is functional); loss of the windlass mechanism
2. Palpation: Localised tenderness at the dorsal 1st MTP joint; assess for dorsal osteophytes (indicates structural change / hallux rigidus); sesamoid tenderness
3. Foot posture assessment: Observe for pes planus / excessive pronation (subtalar and midtarsal overpronation is the most common cause of functional hallux limitus — the plantarflexed 1st ray cannot dorsiflex adequately during propulsion); use the Foot Posture Index (FPI)
4. Callus mapping: Bilateral sub-2nd and 3rd MTH calluses confirm chronic lateral forefoot transfer loading
5. Footwear assessment: Flat, flexible soles — confirm lack of torsional rigidity, low heel, absence of arch support
6. Gait analysis: Observe push-off mechanics, abductory twist, early heel rise (see part c)

• Weight-bearing X-ray (DP and lateral views, left foot): Assess 1st MTP joint space, subchondral sclerosis, dorsal osteophytes (grades structural disease); sesamoid view if sesamoiditis suspected
• Ultrasound / MRI: If intra-articular pathology, cartilage damage, or synovitis suspected; MRI is definitive for cartilage integrity
• Pressure plate / pedobarograph analysis: Objectively quantify plantar pressure under each metatarsal head; will demonstrate elevated sub-2nd/3rd MTH pressures and reduced sub-1st MTH pressure confirming transfer metatarsalgia

Management Plan

1. Footwear modification: Replace flat, flexible shoes with footwear that has a semi-rigid sole and a modest heel raise (10–15 mm); the heel raise plantarflexes the ankle, reducing the required 1st MTP dorsiflexion during propulsion; consider a rocker-sole shoe to assist toe-off without requiring full 1st MTP dorsiflexion
2. Foot orthosis (see part d for full design): Semi-rigid functional orthosis with 1st ray cut-out / kinetic wedge and metatarsal dome — core of management
3. Stretching and mobilisation: Gentle manual mobilisation of the 1st MTP joint (Grade I–II Maitland); joint distraction and dorsal glide techniques to improve joint mobility; plantar fascia and calf stretching
4. Activity modification: Reduce step count and prolonged walking bouts temporarily; consider shorter, more frequent walks for the dog-walking role; footwear must be changed for work
5. Analgesia: NSAIDs (topical diclofenac or oral ibuprofen) during acute flares
6. Callus management: Mechanical debridement of sub-2nd/3rd MTH calluses; once adequately offloaded with orthosis, callus formation will reduce
7. Physiotherapy referral: Intrinsic foot muscle strengthening (short-foot exercises, toe spreaders); proprioception training; peroneus longus strengthening (key plantar flexor of the 1st ray)
8. Intra-articular corticosteroid injection: Consider if synovitis/acute inflammatory flare is present and conservative measures are failing at 6–8 weeks
9. Surgical referral (if structural hallux rigidus confirmed on X-ray): Grades I–II: dorsal cheilectomy (osteophyte removal); Grades III–IV: 1st MTP arthrodesis (gold standard) — position in neutral rotation, 10–15° dorsiflexion, 5° valgus — Miller's Review of Orthopaedics
10. Review at 6 weeks: Reassess ROM, pain scores, callus regression, and gait

c. Gait Alterations (3 Marks)

1. Abductory twist / early heel rise: During late stance (propulsion phase), the body attempts to bypass the restricted 1st MTP joint by externally rotating (abducting) the foot — producing a visible "twist" of the heel medially just before toe-off. This shifts push-off to the medial border and reduces demand on the blocked 1st MTP joint. Early heel rise on the affected side is commonly observed as the patient rushes through the painful terminal stance phase.
2. Lateral weight transfer / reduced 1st ray loading (transfer metatarsalgia gait): Rather than propelling through the hallux, the patient shifts load laterally across the 2nd–3rd metatarsal heads during push-off. This produces the characteristic bilateral sub-2nd/3rd MTH callus pattern seen in this patient. On pressure plate analysis, peak pressure under the 1st MTH and hallux is markedly reduced, with compensatory elevation under the 2nd/3rd MTH.
3. Increased midfoot/arch collapse (pronation compensation) during midstance: In functional hallux limitus, excessive subtalar pronation is both a cause and a consequence — the pronated foot allows the medial column to drop, preventing the 1st ray from properly plantarflexing and locking the windlass mechanism. During midstance and late stance, you may observe increased navicular drop and midfoot pronation, a less stable medial longitudinal arch, and a "bouncy" or uneven propulsion pattern as the foot seeks any available pathway to complete push-off.

d. Foot Orthosis Design and Evaluation (5 Marks)

Design

Evaluation

• Reduction in pain VAS at the 1st MTP joint during and after activity
• Reduction in callus formation sub-2nd/3rd MTH (inspect and debride at review)
• Patient comfort within new footwear during prolonged walking (dog-walking occupation)

• Manchester Foot Pain and Disability Index (MFPDI) or Foot Function Index (FFI) — baseline vs. 6 and 12 weeks
• Goniometric reassessment of 1st MTP dorsiflexion (NWB and WB/Jack's test) — expect improvement in functional ROM if the kinetic wedge is working correctly

• Repeat pedobarograph / pressure plate analysis: expect reduction in sub-2nd/3rd MTH peak pressure and improved 1st MTH/hallux loading
• Gait re-analysis: resolution of abductory twist, improved push-off through hallux, reduced midfoot pronation

• Persistent 1st MTP pain despite kinetic wedge → increase 1st ray cut-out depth or add a Morton's extension (stiff plate extension under the hallux to splint the joint) — Miller's Review of Orthopaedics: "Hallux rigidus — stiff footplate with an extension under the great toe"
• Persistent sub-2nd/3rd MTH callus → increase met dome height or reposition proximally
• Lateral border pain / 5th MTH discomfort → reduce varus rearfoot post angle

• Progressive joint space narrowing on follow-up X-ray → progression to hallux rigidus → surgical review
• No functional improvement at 12 weeks → MRI to assess cartilage integrity and surgical planning