Skip to Main Content

CASE STUDY

CASE STUDY

The patient is a 20-year-old cross-country runner in her junior year of college with complaints of right heel pain for the past few months. The team physician diagnosed her with plantar fasciitis. He prescribed meloxicam, a nonsteroidal anti-inflammatory drug (NSAID), to take on an “as needed” basis to decrease pain and inflammation and referred her to physical therapy. The patient has no other significant medical problems. Upon examination, the physical therapist noted that the patient had pain with palpation of the right calcaneal plantar fascia insertion, decreased active and passive talocrural joint dorsiflexion, and decreased passive ankle dorsiflexion with the knee extended (indicating decreased flexibility of the gastrocnemius-soleus complex). Finally, the therapist noted that the patient’s running shoes provided little pronation support and were worn beyond their functional life span.

REHABILITATION FOCUS

The cortical region of the adrenal gland produces and releases many corticosteroids into the blood. Corticosteroids comprise two major physiologic and pharmacologic groups: glucocorticoids and mineralocorticoids (Figure 23-1). A common mistake is for clinicians to use the term “corticosteroid” when their intent is to specifically discuss only the glucocorticoid subclass of corticosteroids, the steroids that have significant anti-inflammatory and immunosuppressive effects. In this text, the appropriate term “glucocorticoid” will be used, but the reader should be aware that in literature and in verbal communication, the broader term corticosteroid is frequently used instead.

FIGURE 23-1

Classification of drugs that mimic or block the effects of endogenous corticosteroids. Prototype drugs are in parentheses.

The glucocorticoid class of pharmacologic agents significantly influences the clinical practice of physical therapists for several reasons. First, many patients referred for rehabilitation have previously taken or are currently taking glucocorticoids. Local glucocorticoid injections are commonly used in the treatment of a wide variety of musculoskeletal conditions such as shoulder impingement syndrome, adhesive capsulitis, De Quervain’s tenosynovitis, trochanteric bursitis, as well as osteoarthritis of the knee, hand, hip, and spine. While these agents decrease pain and inflammation at the site of tissue injury, repeated injections may weaken connective tissue. Physical therapy interventions are often necessary adjuncts to pharmacotherapy if optimal outcome with minimal recurrence is to be achieved. Second, long-term use of glucocorticoids, especially when administered systemically, often results in adverse effects that may require the physical therapist to modify the plan of care. For example, prolonged systemic glucocorticoid use increases the incidence of type 2 diabetes mellitus, hypertension, muscle wasting, thinning of the skin, poor wound healing, and increased risk of infection. In an attempt to mitigate these adverse drug reactions (ADRs), the therapist may prescribe exercise programs to improve glycemic control, decrease blood pressure, and promote muscle hypertrophy (or at least ameliorate drug-induced muscle wasting). The prudent therapist may decrease the intensity of soft tissue mobilization and avoid taping to decrease the risk of delayed ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.