DATE OF SERVICE: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male. He has been a prior patient at this clinic a number of years ago, during which time he had a pair of functional orthotics. Since that time, the patient has gotten orthotics from another podiatrist but decided to return to our care. The patient was an active runner and several years ago slowed down his running program, and he wishes to start increasing his mileage again, and the goal is to complete a marathon next year. The patient presents wishing to have new orthotics made, as well as having right foot and right hip pain.
PAST MEDICAL HISTORY: Remarkable for a limb length difference that we diagnosed as well as pain on the plantar aspect of the second MPJ, left foot.
PRESENT MEDICAL HISTORY: Remarkable for high blood pressure; otherwise, the patient has no medical history or a present medical history that is related to his presenting problem.
PODIATRIC HISTORY: Significant for starting to begin a running program. He has a history of fracture of his left foot two times. He denies back pain, except when doing prolonged standing. His regular running shoe gears are the Beast Brooks shoe. He wears desert boots and Men’s Oxfords style dress shoes. The type of orthotics the patient is wearing is the semi-rigid orthotic with a PPT arch fill and forefoot varus correction, bilateral, and a first ray cutout of the left foot, metatarsal pad. There was no wear pattern discernible on his shoes.
PHYSICAL EXAMINATION:
VASCULAR: DP: 3/4 bilateral. PT: 3/4 bilateral. PULSES: Capillary filling time is 2-3 seconds. VARICOSITIES: Mild. EDEMA: None. The feet were both warm.
NEUROLOGIC: Negative Tinel’s, vibratory sense grossly intact, and deep tendon reflex was 2/5 bilateral.
DERMATOLOGIC: Revealed a callus on the medial aspect of the first metatarsal head, left foot.
MUSCULOSKELETAL: Revealed a HAV deformity with a moderate dorsomedial hyperostosis of the first metatarsal head of the left foot much greater than the right. Also, a decrease in the fat pad was noted at the forefoot bilateral. There was no pain on palpation of the plantar aspect of the second metatarsal, left, but there was on exam of the right, though there was no drawer sign. The toes of the left foot were noted to be contracted much greater than the right, and there was a moderate contracture of the second toe of the left foot. The patient was able to raise and invert his left foot though had trouble raising and inverting the heel of his right foot. The first MPJ range of motion was 20 degrees bilateral dorsal and 10 degrees plantar bilateral. The first ray was in a dorsiflexed position, bilateral, and normal range of motion. There was no crepitus on range of motion of the first MPJ. On stance, there was navicular sag of the right foot greater than the left, and there was a too-many-toe sign bilateral. Off weightbearing, there was a normal longitudinal arch, was extremely compressed weightbearing. Subtalar joint range of motion was limited on the left and normal on the right. The resting calcaneal stance position was 5 degrees valgus of the left and 10 degrees valgus of the right. Forefoot position was 4 degrees varus of the left and 6 degrees of the right. Neutral calcaneal stance was 10 degrees of the right with a calcaneal cuboid break and 3 degrees rearfoot varus of the left. Ankle dorsiflexion was -3 degrees left and 0 degrees right. Hip rotation was 50 degrees external and 10 degrees internal. Hamstring flexibility was 90 degrees and quadricep flexibility was 110 degrees. Leg length difference was noted to be equal though the malleoli to floor was 3 cm of the right and 4 cm on the left.
IMPRESSION:
1. Mild capsulitis of the second metatarsophalangeal joint, right foot.
2. Grade I posterior tibial dysfunction.
3. Bunion deformity of the left foot.
4. Leg length difference.
TREATMENT PLAN: The treatment provided for the patient today was discussion of the above diagnoses, and we casted him for a pair of functional orthotics for running and a second pair for his dress Oxfords. He is to return to the office for the orthotics, and at that time, we will do a gait analysis to ensure that the orthotics are functioning properly.
