Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with localized pain and mild swelling along the medial aspect of the right ankle and hindfoot. Symptoms are exacerbated by prolonged weight-bearing and activity. No history of acute trauma. Patient reports no significant change in foot arch morphology or flexibility at this time.
Clinical Examination Findings
Right foot examination reveals tenderness to palpation along the course of the posterior tibial tendon, distal to the medial malleolus. No evidence of tendon rupture or significant deformity. Hindfoot remains flexible with full range of motion. Single-heel rise test is performed without pain or inability to invert the heel. No clinical signs of pes planus progression.
Treatment Protocol
Conservative management initiated: RICE protocol (Rest, Ice, Compression, Elevation), activity modification, and non-steroidal anti-inflammatory drugs (NSAIDs) as tolerated. Prescription provided for a medial longitudinal arch support or custom orthotic. Referral to physical therapy for strengthening of the posterior tibial muscle and tendon complex.