Dan PreeceCSPM Class 2009

Case Presentation

CC: Chronic pain at the medial right ankle.

HPI:53 yo female who presented on 11/08/06 w/ chronic pain and swelling at the medial R ankle that begin with hiking during the previous summer. X-rays were taken that summer that were read as “normal”.

Received tx by acupuncturist and a chiropractor who made recommendations as to correct shoe gear, orthoses/inserts and RICE. Following podiatric evaluation 11/08/06, night splints, ankle bracing and heel injections were attempted.

Pain continued until last month. Is worse with athletic shoes, improves somewhat with high heels. Has tried ibuprofen with moderate pain relief.

Pt points to medial R ankle, and b/l plantar heels as site of pain. Pain/discomfort continue disrupting her normal active life style.

Illnesses: Hypothyroidism

Meds: Levothyroid

Allergies: NKDA

Surgical Hx: Hysterectomy, cholecystectomy, uterine cyst.

Social EtOH use, denies tobacco.

PE:Gen: PT WD/WN in NAD, moderately obese. ROS and general exam non-contributory.

LE:Neurovascular: intact/non-contributory

Derm: Mild erythema medial 1st MTPJ b/l. No open sores or discontinuities.

MSK: Ankle joint ROM is 20 deg b/l with knee extended and flexed. Other major joints

including STJ, 1st MTPJ, mid-tarsal joint show significant and above average ROM with apparent ligamentous laxity. Muscle strength 5/5 in all quadrants b/l. HAV with bunion deformities b/l. Hallux abutting 2nd digit, pain free and full ROM at 1st MTPJ b/l. Pain on palp. of R PT tendon w/o edema or ecchymosis . Mild pain w/ palpation of med/plantar calc. tubercle, R>L.

WB exam: Increased bunion deformities, collapse of medial arches, RCSP is 5 deg eversion b/l,

single/double heel raise intact b/l, too many toes sign.

X-ray findings: Lateral placement of WB calcaneus on hind foot

alignment views R>>L.

Increased Talar declination and decreased calcaneus inclination angle b/l.

Increased IM angle R>L.

Medial arch collapse b/l.

Mildly elevated 1st ray R.

A:Pes planusPT disfunctionBunion deformityPlantar fasciitis

P: Surgery scheduled for 10/24/08.Lapidus bunionectomyMedial slide calcaneal osteotomyGastroc recession as needed.FDL transfer/repair as needed.

Hardware:3.5 fully threaded screws (x 3).

Hardware: 3.5 fully threaded screws (x3), interference screw for FDL transfer to navicular, 4.5 fully threaded cannulated screws (x2).

Intra-Operative findings: PT tendon hypertrophy

3.5 screw placed across 1st and 2nd metatarsal bases following lapidus procedure to further reduce IM angle.

Post Op Plan: Pt to remain in house 24hrs-2 days PRN for pain control and hemostasis. Pt to remain NWB 6-8 weeks on the R LE.

2 weeks post op.