Case Study: Right Fracture Shaft Fibula With Tibia Closed

On 9/23/16 I met with Mr. Russell at the Covenant Occupational Medicine. Mr. Russell said his pain level is at a 1 to 2 now. He is able to tolerate sitting, standing and walking more since starting physical therapy. He reports he is doing a home exercise program also. Dr. Eckstein said he would increase his work restrictions. He would like him to have 2 more weeks of physical therapy. He hopes at the next appointment to be released.

I met Mr. Eigner at the office of Dr. Taha. Mr. Eigner reports he is not taking any pain medications at this time. He reports he has a jolting shooting pain to the right and left legs only occasionally. He denied any pain to his right forearm. X-rays taken showed good alignment and healing of the fracture. The incisions are all healed except for a couple small spots on the right ankle. There is some swelling to the right ankle which Dr. Taha said is to be expected. The range of motion to the left ankle and toes was good. The range of motion to the right stores was limited. Dr. Taha said there is scar tissue at times from this type of repair and he would like physical therapy to start working on that. He is still going to be non-weight bearing for another 6 to 8 weeks on the right leg. He is now allowed full weight bearing as tolerated to the left leg. Dr. Taha ordered a rolling scooter to aid with ambulation and stop using the wheelchair. I have contacted Reverence physical therapy and faxed the new orders so the service can begin. I will process the rolled scooter with directions from the adjuster. The attendant care and replacement services will continue through to the next appointment.

Patient reports no weight fluctuations. Denies fatigue, malaise, weakness, sweats, night sweats and chills. Patient reports mild left leg weakness secondary to left tibia fracture June 2012, but ambulates well and is able to be active in school sports, hiking, biking, and swimming. Patient reports working on building strength in left leg through sports and recreational activities. Patient reports asthmatic exacerbations with exercise. Patient reports trying to build lung capacity by running and swimming which exacerbates his asthmatic condition and uses inhalers.

An attending physician statement completed by Dr. Peter Chweyah (Internal Medicine), dated 06/16/2016, indicated that the claimant presented with complaints of lower extremity weakness, neuropathy, weight loss, acute renal failure, and gout, as well as anemia. Objective findings showed an extreme weakness of the legs and pain in the feet. He also had diabetes mellitus type 2, chronic kidney disease, and hypertension. It was noted that the claimant was totally disabled from 05/30/2017 through 06/15/2017 and 05/23/2017 - 05/26/2017 secondary to gout.

This is a 35-year-old male with a 9/18/2015 date of injury. The IW sustained the injury, while she was on a business trip in Seattle. She got robbed and ran after the robber in her business suit and high heel, tripped while running, and fell on to her right knee, left elbow and left hip. Her knee took the grunt of the fall and she has scrapes on her elbow and hip.

A visit note from Evan Ross, DPM, dated 09/20/2017, indicated that the claimant presented with pain in her whole leg rated as 10/10. She had plantar fasciitis in the left foot. She was diagnosed with posterior tibial tendon dysfunction of the right foot, ligament laxity, and left foot plantar fasciitis. Physical therapy was recommended.

There is collapse of the medial arch with calcaneal valgus with weight bearing. The IW functions in end range pronation throughout midstance of gait. There is tenderness upon palpation to the posterior plantar aspect of the left heel at the insertion of the calcaneus. There is mild pain with deep palpation to the right foot in the same location. She has pain with dorsiflexion and plantar flexion of the dorsal aspect of the left 1st metatarsophalangeal joint. There is no pain with active dorsiflexion and plantar flexion with resistance.

Patient unable to walk heel to toe, perform the Romberg test, stand on one foot, or perform a shallow knee bend without risk of falling. The patient complains of lower back, hip, and knee pain. . Assessed patient’s pain at this time. Patient states that, “the pain is felt in her lower back, hips, and knees constantly and relieved with ibuprofen” she rated the pain a 4 on a scale from 0 to 10. Patient stated, “lower back always aches.” Described the pain as constant and dull. Affects her activities of daily living because she “isn’t able to cook, clean, or exercise.” In a supine position the patient, with help, was able to extend legs upwards about 40 degree and flex hips with limited range of motion. Patient was able to resist with light resistance when pressure was applied to the legs anteriorly and posteriorly. Sitting back in the patient’s chair, the patient was able to bend at the hip. No pain or tenderness felt when palpating the spinous process. The patient was able to actively flex and extend the ankle joints with limited range of motion and some resistance with support under the lower leg. The patient was able to flex and extend the feet with limited range of motion and some resistance. No pain or crepitus with flexion and extension of the feet and ankles. Inspected the patient’s skin of the anterior and posterior legs, ankles, and feet. The skin of the upper legs were dry, with

Per verification to the provider’s office, the patient has attended 24 PT sessions for the left shoulder from 05/23/16 through

MD noted that the IW’s back pain symptoms are consistent with an annular sprain causing back pain. As a result of back pain, he has developed loss of functional trunk range of motion and deconditioning. He has had 5 sessions of physical therapy which were primarily modality based. MD recommended an aggressive approach with reestablishing functional trunk range of motion and core strength to rehabilitate his lumbar spine and hopefully return to his regular duties. He is agreeable to that plan and would like to proceed. Resumption of formal physical therapy to meet those goals would be appropriate. The patient will be referred to physical therapy, twelve sessions.

Per the medical report dated 09/08/16 by Dr. Livermore, the patient has worsening pain over the left leg, numbness of the left foot and weakness in the left leg.

Per the QME report dated 08/21/14 by Dr. Hurria, the patient has a calculated total whole person impairment grating of 33%. Diagnoses include arthritis of both hips, status post right total hip replacement, cervical/lumbar sprain, radiculopathy to both upper and lower extremities, right cubital tunnel syndrome and impingement of both shoulders. Future medical treatment includes decompression of both shoulder, transfer of the anterior ulnar nerve

Based on the progress report dated 09/13/16, the patient reports unchanged intermittent moderate left foot pain. Patient also notes of intermittent moderate low back pain and left hand pain, that bothers her most. The patient went to a foot specialist last week, who administered an injection that increased pain and seems to have not taken effect yet.

Per the IME dated 03/16/16 by Dr. Shankman, the patient has had PT for ten weeks, which have not helped. She has had no injections and takes no medications. The patient has resolved osteochondral bruise and pre-existing chondromalacia that was aggravated by the injury of record. It was opined that the IW requires no further treatment from an orthopedic standpoint.

Pt to report pain of <3/10 pain level at all times within 2 weeks to assist with increased walking distance and return to sleeping in her own bed undisturbed by pain