this was my imo from my doctor let me know what u think
un fortunatly when i went to the doctor in the past i only have one time where i complained of heal pain in jan of 2001 and i have allways been told the same stuff streach take motrin so i did not complain i would take motrin for my knees and that took care of my ankles to a point i hate doctors and do not like to go to them unless i want major surgery to fix my issues no way
Patient: XXXXX Account No:XXXXXX Date 5/10/2012
Chief Complaint: Pt presents with longstanding foot and ankle pain. Pt has had foot and ankle pain for about 17 years and this is ongoing even through treatment. Pt was first diagnosed with Achilles tendonitis on August 21, 1995. Pt was in boot camp at Paris Island, SC at the time of diagnosis. Pt had been pain free prior to entering camp. Pt had been training and fell with large backpack and injured his right patella and had pain in knee. Pt was seen for this problem and was put in the medical rehab platoon and was there about 3 months. While in rehab, pt noticed tightness and pain in both legs. Pt was then sent for physical therapy and was given stretching instructions as well as ice for inflammation. Pt also had therapeutic ultrasound done for these problems. This was all in the spring and early summer of 1995.
Pt was running and walking during rehab for bilateral leg pain when he started to have tightness and pain in back of calves and heel areas. Pt was seen August 21, 1995 for pain in feet and shoe irritation as well as blister formation from all of the rehab exercise and diagnosed with Achilles tendonitis and was told to rest. September 26, 1995 pt returns to clinic and was given a diagnosis of shin splints a this time, and told to ice and stretch. In November, 1995 according to a medical review pt is still dealing with Achilles tendonitis and taking NSAID for treatment. Pt was seen on May 21, 1996 and July 24, 1997 and while he was still having problems with his Achilles, his knee pain was greater and this was the focus of the visits. However, his ankles were still painful swollen and documented by his marking the box of painful and swollen joints. This box was not specific to his knee or his ankle. Pt went to Marine Reserves and went back to school. Pt was limited in his activity and had increasing pain because of his Achilles tendonitis and subsequently was gaining weight. Pt got married and started a family and his pain never completely resolved. Pt has been and was at the time taking Ibuprofen regularly. Pt was see by his family doctor January 11, 2001 and was still complaining of heel pain esp in right. Pt has been seen at this office since August 26, 2010. Pt had been complaining of shooting pain and sharp pain in both legs and this was exacerbated by walking and standing. Pt had a long history of Achilles tendonitis. Pt was told about shoegear changes, given ¼ heel lifts, told to stretch and changed his NSAID. Pt returned February 11, 2011 for follow up and was cast for custom molded orthotics and told to continue to stretch. Pt picked up orthotics about 1 month later and also received an ankle foot orthosis for his right ankle and heel. Pt admits some minor improvement through the stretching activities given to him by our office. After usage of custom molded orthotics, pt did obtain increasing relief, however this will not be a permanent change and he will likely have continued pain throughout his lifetime.
Medications: Fish Oil-capsule, Ibuprofen 800 mg tablet
Past Medical History: Admits Unremarkable.
Past Surgical History: Admits hernia repair.
Past family and Social History: Denies alcohol and tobacco use
Height: 69 inches Weight 273 pounds BMI 40.31 pulse: 74/min Sitting Blood Pressure: 125/90
- Vascular: Dorsalis pedis and posterior tibial pulses are graded at 2 with digital hair growth present bilateral. CFT with the leg elevated was less than 3 seconds at the distal hallux bilateral. There is no evidence of ischemic skin changes. Temperature was warm at anterior tibia to warm at the distal digits bilateral.
- Lymphatic: No popliteal lymphadenopathy noted
- Neurolgical: Pt oriented X3, with appropriate affect, no anxiety or depression. Coordination WNL to right and lefty lower extremity. Exam reveals epicritic sensation is intact along defined dermatones to protective threshod, symmetrical Achilles tendon and patellar deep tendon reflexes with a negative clonus and down going toes. Patient is able to heel and toe walk with ease. Normal sharp/dull, vibratory, proprioception, light touch sensation to right and left foot. DTR Achilles 2/4 right, 2/4 left.
- Dermatological: No edema, erythema, ecchymosis, open lesions, interdigital macerations or signs of infection evident at this time bilateral.
- Musculoskeletal: Good muscle strength to all prime movers of the foot and ankle with adequate muscle tone and symmetry bilateral. Decreased ht in medial long arch BL decrease with wt bear. Pain on palpation posterior heel at insertion of Achilles tendon BL. Decreased dorsiflexion in ankle BL with pain at end ROM.
- Xray analysis: Diagnostic lateral BL x rays show large, mature posterior heel spurs BL with possible fracture line in left posterior heel spur. Decreased caldaneal inclination angle BL with degeneration STJ BL. Plantar heel spur right.
- Equinus, BL
- Achilles tendonitis, BL-chronic. I believe that this is very likely to be connected to his time in the service by approximately 90% level of certainty. This is because before entering the military there was a health evaluation that made no mention of lower extremity pain or problems.
- 3. Early STJ DJD BL
- Diag lateral BL x ray
- Long discussion on eitiology, treatment and prevention of Achilles tendonitis.
- Discuss treatment options for Achilles including physical therapy, home stretching, shoe and insert changes and ultimately surgery either to lengthen Achilles or to inject with platelet rich plasma or use of radiofrequency conlsyion
- I believe that the examiner from February 14, 2012 failed to understand the chronicity of the injury and the fact that he never fully recovered from the initial pain. Pt had other problems from his service including patellar injury at about the same time which were higher priorities at the times of exam in the mid/late 90s therefore his heel pain, even though stil present was not mentioned in the exams. In Aubust, 2010 it was documented that he had gradually gotten worse over the previous month or so, but this condition is intermittently worse at certain times and can be aggrevated by activity or weight as well. However, without the first episode and without full resolution of symptomatology, this would not have been an ongoing issue to this date.
- Pt to return as needed for follow up
- Pt to continue stretching and orthotics/good shoegear