The local GP has referred Siobhan Holmes to you for an assessment and management of her plantar forefoot pain.
The patient is a 36yo (BMI=22), active female with a four-week history of right plantar 1st MTPJ pain, which was of a gradual onset. Her symptoms increase with exercise and increase in intensity post activity. Nocturnal symptoms are evident if she has run on the day. Symptoms were initially manageable, although in the past week the patient has had to stop all exercise. The patient is a professional athlete (3000m) with the Box Hill Athletics Club and is training for the summer athletics season but running the current x-country season to develop a fitness base. Siobhan is hoping to race at the Rye gift (3000m) in 4 months.
Medical history
The patient has an unremarkable medical history.
Past injury history
The patient reports having sustained a similar injury during the last summer athletics season, although her symptoms dissipated once the season ceased in April (after the Stawell gift carnival) and she had some time to rest.
Social history
• The patient is a part time teacher;
• The patient has a partner and two children.
Training information
Month Training
April racing – 3000m Stawell Gift Athletics Carnival
May Rest
June 4 sessions per week:
1. Hills (8 x 300m; 1-2 minute walk recovery between reps)
2. Fartlek (90 seconds run + 90 seconds jog x 2; 60 seconds run + 60 seconds jog x 4; 30 seconds run + 30 seconds jog x 4; 15 seconds run + 15 seconds jog x 4)
3. 2 minutes run + 2 minutes rest x 6
4. Cross country race (8km)
July Injured
August
Footwear
Runners: ASICS nimbus
Racing flats: Mizuno Woman’s Wave Universe 5
Case study questions
What physical assessments would you need to undertake to determine a diagnosis?
Question 2:
Imaging can be useful in the assessment of plantar 1st MTPJ pain. Below is an image taken of Siobhan’s forefoot. What type of imaging modalities are presented and based on the results, attempt a diagnosis and list 3 other differential diagnoses.
Question 3:
A semi-completed biomechanical assessment form is included in the folder at the beginning of this assessment.
In addition, a video gait assessment and video has been included below. Using this information, and the subjective information recorded above, list and briefly explain (with supporting references) the intrinsic and extrinsic risk factors for the musculoskeletal pathology Siobhan has presented with.
Question 4:
What are your broad immediate and long term goals that will help manage Siobhan’s foot pain and return her to full function?
Question 5:
Construct a detailed, week-by week, management plan that addresses your patient’s goal and risk factors. The design will need to be in the form of instructions that you would give your patient. Therefore, they must be highly specific and include scheduled appointments for review consults.
Remember that a range of treatment and rehabilitation options exist including cold/heat, therapeutic drugs, muscle strengthening and stretching, proprioception and footwear and activity modification, as well as walking boots/braces/orthoses.
Provide a ‘bottom line’ statement as to whether you believe Siobhan will be ready for the Rye gift in 4 months.
Feel free to be creative and construct your own plan or alternatively use the Word Document already established as a guide.
Question 6:
A multidisciplinary approach is useful in the management of many musculoskeletal pathologies, including pain beneath the first MTPJ. Write a brief letter to another professional outlining your findings and request for an additional assessment and/or management

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