CHART NOTE
The patient’s claim for total disability benefits had been reviewed, and the company was unable to extend benefits, as the patient was said to be not totally disabled as defined by the patient’s policy/certificate.
Initially came under my care, from the orthopedic standpoint, complaining of pain in her left fore- and midfoot, particularly in the third and fourth metatarsal area and of numbness of the lateral 3 toes of the left foot at times. She noted the onset of symptoms while doing a lot of walking at the mall wearing tennis shoes. Initial treatment was at the urgent care center.
The patient was seen by me in orthopedic followup, and at that time my diagnosis tentatively was sprain/strain, left ankle and foot. I took the patient off work and started her on physical therapy. The patient has been seen by me on a regular basis since that time. Treatment has included modalities of physical therapy, use of nonsteroidal anti-inflammatory drugs, application of a fiberglass short leg walking cast with cast boot, etc.
Although I initially thought the patient had a sprain/strain of the left ankle and foot, it would appear that a more definitive diagnosis is a tendinitis at the medial and lateral aspects of the left ankle in association with probable Morton neuromas of the left forefoot.
As of the last visit to my office, she was having throbbing at the medial and lateral aspects of the left ankle and through the central rays of the left forefoot. She was using crutches p.r.n. to ease weightbearing stresses on the foot. She was taking plain Tylenol. She was tender along the posterior tibial tendon and along the peroneal tendons behind the medial and lateral malleoli of the left ankle, and there was increased fullness behind both malleoli, which was greater at the left ankle than the right ankle, with the patient having some increased subcutaneous fatty deposition in both ankle regions.
I am considering possible excision of Morton neuromas of the patient’s left forefoot area if she is having persistent symptomatology indicative of Morton neuroma. I have considered the patient to be disabled for work through my next planned recheck of the patient.
FOOTNOTE
Line 13. Alternative: Left forefoot and midfoot.
PT Scooter Stool
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