DOI: 09/26/2010. The patient is a 63-year-old male route sales representative who incurred a work-related injury to his left foot and ankle due to repetitive job duties.
Based on the progress report dated 03/18/16, the patient presents for reevaluation of his left ankle. He underwent left ankle surgery on 10/15/13. His left ankle has been worse the past two months. The left ankle has also been swelling. He rates his pain as 7/10. The pain is worse when he puts weight on the left foot/leg. The left heel/foot throbs after he stands on his foot for a long time. The pain is aggravated by standing and walking. The pain is alleviated by lying down.
He has not been able to go to the gym for the past two months due to increased pain.
On examination, there is tenderness on the left subtalar region. Left ankle joint active range of motion shows dorsiflexion of 0-10 degrees and plantar flexion of 0-20 degrees.
…show more content…
IW was diagnosed with left posterior tibial tendon dysfunction/tendinosis with valgus deformity of the left heel as a result of the posterior tibial dysfunction, status post left foot reconstruction, posterior tibial tendon using flexor digitorum longus tendon transfer and left calcaneal osteotomy 05/24/11 and status post surgery on the left foot 10/15/13.
Treatment plan includes x-rays of the left ankle and referral back to Dr. Ghalambor for consultation regarding his increased left ankle pain.
Current request is for 1 X-ray of the Left Ankle between 3/23/2016 and
When injuries of this type and severity happen to the tibia and thalus the joint rarely returns to its normal function. As the blood supple to the surrounding cartilage is damaged leading to arthritis and the the bones never truly align correctly. Dave will have to be traction to try and straighten the ankle while under heavy medication for both pain and two relax the muscles. 4. Cole's meniscal injury caused a "locked " knee - he couldn't extend his leg fully.
There is decreased sensation of the left anterior thigh. He has forward leaning stiff gait with ability for heel and toe rise.
The infection could not be eradicated and it progressed to osteomyelitis. Mr. Alvarado eventually required a below the knee amputation. I’m asking that you review the records and prepare a report which provides a history on Mr. Alvarado’s foot injury. I also ask that you list all the deviations from the
Activities at home and work worsen the pain. Numbness, tingling, and burning sensation are reported with increased pain throughout the week. The patient is requesting medication refills and reports limitations with gripping, grasping, pushing, pulling, and lifting 10 pounds. Activities of daily living are limited due to pain, as
This has increased in extent on the left. There is complete erosion/destruction of the left acetabular roof. This is a clear indication of a degenerative disease as opposed to a traumatic
He does have a TENS unit, which he uses intermittently. As of this report, the first surgery helped him 10%, and the second surgery had no benefit. On examination of the lumbar spine, standing range of motion is 20 degrees. Straight leg raising is 80 degrees on the right, and 90 degrees to the left. There is diminished right heel/toe walking/raising.
Morton’s toe can also fast track the wearing and tearing down of joints and ligaments. Other associated conditions of Morton’s toe include Metatarsalgia or the ball-of-foot pain, Hammertoes, Bunions or the abnormal bump of bone that is formed at the head of the first metatarsal bone, Morton’s neuroma, and plantar fasciitis. Dr. Morton observed that persons who have Morton’s foot condition experience changes on the way they walk, observed a kind of “walking on ice skates” effect, and changes in
Per medical report dated 06/30/15, patient presented for low back pain with left anterior leg pain. He has not tried PT or injections. He does have weakness in the left leg. At times, he is unable to put pressure on the left side.
In football the majority of ankle sprains are caused during player contact, resulting in the footballer “rolling over” on their ankle. (5….) A sprain to the ATFL occurs due to an inversion of the foot. (1……..) 25% of all injuries are due to inversion and 50% of these are sport related. The range of motion during inversion is limited due to the lateral ligaments of the ankle.
But these thoughts were short lived as someone bumped my foot, causing another gut wrenching streak of pain to shoot up my leg. After I made it back home, I attempted to nurse my ankle to the best of ability but my lack of experience with injuries made it difficult. Waking up the next day I immediately knew my ankle had gotten worse. It was swollen to the size of a baseball and was almost as black as a night in a country town. Standing up was a very difficult task.
Goals are to decrease pain, increase range of motion, increase muscle strength, re-establish optimal functional activities/status and independence in activities of daily living. On the statement of medical necessity on the MG2 form dated 05/01/15. Based on physical examination, the patient has improved but has not reached MMI. MD expects that with extended treatment, the patient will continue to exhibit objective functional improvement.
He is possibly going to need some soft tissue reconstruction type surgeries in the future, though at this time, he appears to be healing well and show more stability than expected. We will base this on his clinical results. Long-term outcome shows a high likelihood of traumatic osteoarthritis of the knee, for which he may need both nonoperative and possibly operative treatments in the future. He understands this as it was discussed with him and all questions were entertained to his satisfaction. We will see him back in two weeks ' time for repeat clinical and radiographic
Sensory neuropathy causes a delay in the activation of the ankle and knee joints during gait due to the lack of afferent input signals6. Combined with hyperkeratosis, a thinned fat pad, and limited motion of the first MTPJ, this ultimately lead to reduction of shock absorption and loss of momentum during gait due to decreased function of the first rocker of the foot, also called the heel rocker6. Midstance is characterized by muscle weakness producing gait instability6. Neuropathy once again reduces the input of sensory signals whilst joint motion limitation obstructs functionality of the second rocker of the foot – the ankle rocker-, further reducing
After Dr. Ahmed finished her residency at UTMB, she completed a Fellowship at the American Sports Medicine Institute (ASMI). During her foot and ankle Fellowship at ASMI, she had the pleasure of working under the guidance of numerous prestigious doctors. These doctors include: Dr. James
In 2010 while walking outside the building where I used to work while mobilize, I was heading to another location when I for no apparent reason twisted my left ankle. When I twisted my ankle I did not immediately feel any pain or discomfort, so I just kept walking. Throughout the day I performed my job like I regularly did and I felt no pain. As the evening approached that day I began to have pain and my ankle began to swell to the point that I could not wear my tennis shoes or walk on it. I took some over the counter pain medication to try to go to sleep that night and the following day went to the troop medical clinic.