Do No Harm?

First Name

D.

Case and Visit Number Date of Visit

06/26/2019

Subjective

Last Name

O.

Case Number

1

Date of Birth / Age

SPC Program

None

Visit Number

Client: D.O. (1673)Basic Information

Jun 26, 2019

Review of Patient Findings and Suggestions for Treatment

D. has multiple structures that cause pain over her primary area of symptoms (proximal and distal to the 2nd metatarsal head). She wears boots with orthotics which she reported as the only tolerable shoe wear.

Key Exam Findings:
Gait: absent forefoot and toe rocker on left foot. Increased use of hallux during midstance.
Basic Clinical Exam: Hypomobile midfoot. Pain free 2nd digit with passive flexion and extension. Palpation: Severe pain with concordant sign with palpation of the flexor digitorum brevis, abductor hallucis, lumbricals, second metarsal head. Repeated pressure resulted in lingering symptoms over the primary area of symptoms. No pain with palpation of the 1st, 3rd, 4th and 5th metatarsal plantar heads.

Treatment: Patient reported no improvement with use of wool to reduce pressure on sensitized tissue. No improvement with modified low dye taping to reduce bending stresses in weight bearing over the second metatarsal. Mild increase in pain with soft tissue massage to the flexor digitorum brevis and abductor hallucis.

Suggested treatment:
I do not believe manual alone or gait changes will be effective without a mild reduction in pain. I believe D. has multiple pain generators that increase pain over the previous surgical area. While a plantar plate rupture could be involved, I do not believe it is the sole cause of pain nor would it explain the reproduction of pain with other tissues such as the FDB or AH.

She has hyperalgesia as demonstrated by the severe pain reported with light touch. With any weightbearing, she will be doing significantly more than I used for palpation. Orthotics will not be sufficient to off load this area.

I would suggest the following:
1. Inject the FDB and AH to reduce its effect on her current pain presentation.
2. Augment her current foot bed to unload the second metatarsal head.

3. Increase her exercise load in non weight bearing activity. I can provide a suggested regimen.

4. Change shoes that aid in forefoot and toe rocker. This is currently not aided with her boots.

5. Begin gentle massage over the lumbricals on plantar side over the 1st, 3rd, 4th, and 5th metatarsal shaft.
6. Teach a forefoot abducted gait pattern to reduce bending stresses of the 2nd metatarsal.

Due to the clear peripheral sensitization, treatment effect will be more difficult gauge.

Subjective Symptoms and History

D. O. is a patient visiting from New York who presents with intense left sided foot pain. She is currently a patient at Sierra Tucson. This pain started when she had 2 foot surgeries 10 years ago. One surgery was to repair her plantar plate, and another was to remove the plate and screws they put in originally. For 7 years her feet felt fine. One year ago she stepped on something at the beach, and her foot has been very painful ever since. She is limited to two pairs of shoes that she can wear comfortably, both of which are roomy and flexible. The only thing she thinks that helps is her orthotics with metatarsal pads and boots that are wide. When she is weight bearing on her foot it is painful. She has been prescribed orthotics, and has tried PT, and nothing has helped. She has also tried cortisone injections and these were not helpful. She has numerous professionals for this problem with varied diagnoses and treatment plans.

Pain is described as sharp and local, right underneath the base of the 2nd toe. Weightbearing on her left foot in any way will lead to intense increase in symptoms. Once her foot is painful due to weightbearing her foot may hurt the rest of the day. If she moves her toes she will also feel intense foot pain. She also notes frequent, painful cramping of the foot.

The symptoms started

Over time

Description Pain Pattern

with activity

Description

Traumatic

Previous trauma to joint in the foot or ankle

Foot / Ankle/ Lower Leg

Dorsal Foot

Pain/Symptom description

Ache

Previous treatment for these issues:

Physical therapy

Fore Foot

Sharp

Physician (General)

Focal

Surgery

Physical Therapy: What was diagnosed by the physical therapist? What treatment was performed? Results?

No diagnosis. Tried foot STM and orthotics with little improvements.

Surgery: What specific surgery was performed?

Original surgery to repair L plantar plate. Second surgery to remove hardware from original surgery.

Physician: What was diagnosed by the physician? What treatment was performed? Results?

Original diagnosis 10 years ago was plantar plate disruption. Unclear what current diagnosis is. Has tried cortisone injections with no improvement.

Medical History and Treatment Medical History

See medical history.

Primary reason for seeking physical therapy?

With physical therapy D. would like to eliminate chronic foot pain and return to walking, NOT running, and cycling.

ICD 10 Codes

ICD 10 Code

M25.572 – Pain in left ankle and joints of left foot

Objective Findings

Additional Pathologies

Foot and Ankle Clinical Exam: Select any findings that were noted in the exam. If not selected, it indicates normal findings unless otherwise indicated.

Passive Motion Resistive Testing Observation/Swelling/Temperature Palpation

Foot and Ankle: Observation

Foot and Ankle Passive Motions End Feel: Soft End-feel examples: Elbow and Hip Flexion. Firm End-feel examples: Shoulder ER and Hip Abduction. Hard End-feel Examples: Elbow and knee Extension

Foot and Ankle Resistive Testing

Foot and Ankle Palpation

Abductor Digiti Minimi Flexor Digitorum Brevis Abductor Hallucis

Metatarsals 2nd Metatarsal Head
Exquisite tenderness abductor hallucis and FDB bilaterally. Exquisitely painful FHB and lumbricals on left.

Movement Testing: Select for testing performed.

Walking Gait

Walking Gait

Gait: absent forefoot and toe rocker on left foot. Increased use of hallux during midstance.

Treatment performed during visit:

Diagnosis and Assessment

Foot and Ankle
Structural Diagnosis (Primary)

Flexor Digitorum Brevis Tendinopathy

Structural Diagnosis (Secondary)

Abductor Hallucis Tendinopathy

Are there other possible differential diagnoses that need to be considered?

Yes

Is there a functional diagnosis?

Yes

Other possible differential diagnoses that need to be considered:

Lumbrical Myogenic Pain, Chronic plantar plate rupture

Functional Diagnosis

Abnormal gait

Treatment and General Activity Plan, Recommendations, and Referral

Treatment will focus on:

Reducing pain of the painful structures with focused manual therapy including mobilizations, traction, cross fiction, and massage.

Therapeutic exercises will focus on reducing pain by strengthening and normalizing motor control.

Neuromuscular Reeducation to improve movement and activity.
Patient education to reduce pain and improve symptoms.
Gait training to normalize movement and reduce pain in the short term.
Taping and/or bracing to unload painful structures, allow for recovery, and eventual return to

activity without tape.

Physical activity:

Physical activity needs to stop and patient will be provided with another activity to allow for continued movement.

Prognosis

Recovery may be limited and require modification for long term success.

Primary Recommendation/ Referral
Referral to physician for further follow up

Plan

Plan

Secondary Recommendation/ Referral

Referral to Dr. D. for further follow up. I will continue to work with D. as she and her team at S. T. would like.

Consent to treatment

Following the evaluation and extensive patient education regarding diagnosis, prognosis, and treatment goals, the patient (parent/guardian, power of attorney holder) actively participated in the creation of the current goals and agrees to the current treatment plan.

Additional files / images / videos No files were attached