Transcript Dan Peece CSPM 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 planus
PT disfunction
Bunion deformity
Plantar fasciitis
P:
Surgery scheduled for 10/24/08.
Lapidus bunionectomy
Medial slide calcaneal osteotomy
Gastroc 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.