DOI: 7/20/2015. Patient is a 38-year old female who sustained injury to her ankle as a result of slipping on the floor while putting plates away. Per OMNI, she was initially diagnosed with ankle sprain.
Per the progress report dated 08/18/15, the IW was prescribed with Naproxen and Tyleniol. IW was advised to use home crutches and boot.
MRI of the left lower extremity without contrast obtained on 09/18/15 revealed a splitting tear of the peroneus brevis tendon, 5 mm plantar calcaneal spur and ankle joint effusion.
MRI of the left lower extremity without contrast obtained on 09/21/15 showed degenerative arthritis of the left first and second metatarsophalangeal (MP) joints and probable articular osteochondrosis of the second …show more content…
The IW also points to the ball of the foot, area of the second MP joint is also painful with swelling at the end of the day. The IW continues to have pain and swelling with weakness of the peroneal brevis tendon. As of this report, MRI done in 09/2015 showed a tear of the peroneal brevis tendon that has not healed.
On examination, the second MP joint is painful to palpate and move. The IW is able to grip ground with the second toe on the left foot. The left ankle is painful posteriorly behind the fibular bone of the peroneal tendons. There is pain to palpation. When asked to evert the foot, the IW has a difficult time moving the foot into eversion due to injury to the peroneal brevis tendon. The sinus tarsi area is swollen and painful, as a result of abnormal gait. IW is overpronated on the left foot due to muscle imbalance, probably affecting not only the brevis tendon, but the peroneal longus tendon.
Diagnoses include left ankle sprain, peroneal brevis tendon tear per MRI and injury to the second MP joint with some arthritic
Per the progress report dated 08/18/15, the IW was prescribed with Naproxen and Tyleniol. IW was advised to use home crutches and boot.
MRI of the left lower extremity without contrast obtained on 09/18/15 revealed a splitting tear of the peroneus brevis tendon, 5 mm plantar calcaneal spur and ankle joint effusion.
MRI of the left lower extremity without contrast obtained on 09/21/15 showed degenerative arthritis of the left first and second metatarsophalangeal (MP) joints and probable articular osteochondrosis of the second …show more content…
The IW also points to the ball of the foot, area of the second MP joint is also painful with swelling at the end of the day. The IW continues to have pain and swelling with weakness of the peroneal brevis tendon. As of this report, MRI done in 09/2015 showed a tear of the peroneal brevis tendon that has not healed.
On examination, the second MP joint is painful to palpate and move. The IW is able to grip ground with the second toe on the left foot. The left ankle is painful posteriorly behind the fibular bone of the peroneal tendons. There is pain to palpation. When asked to evert the foot, the IW has a difficult time moving the foot into eversion due to injury to the peroneal brevis tendon. The sinus tarsi area is swollen and painful, as a result of abnormal gait. IW is overpronated on the left foot due to muscle imbalance, probably affecting not only the brevis tendon, but the peroneal longus tendon.
Diagnoses include left ankle sprain, peroneal brevis tendon tear per MRI and injury to the second MP joint with some arthritic