Myalgia Case Studies

This is a 52-year-old male with a 9/24/2014 date of injury. A specific mechanism of injury has not been described. DIAGNOSIS: Short Achilles tendon, acquired Primary OA, left ankle and foot 02/12/16 Progress Report noted tat the patient is s/p left calcaneus fixation on 09/24/15. His current pain level ranges from

DOI: 9/18/2000. Patient is a 59-year-old female technician who sustained a work-related injury due to being jostled and jolted in the back of a golf cart which ran over a pothole. As per OMNI, she was diagnosed with post cervical protrusions, facet syndromes with headaches, lumbar facet syndrome and status post right shoulder repair/resection.

This is a 54-year-old male with a 1/17/2012 date of injury. A specific mechanism of injury has not been described. 01/04/15 Pain Management Report indicated that the patient has a right middle trigger finger and left knee pain. He is requesting injection for it. It is achy and occasionally stabbing.

12/19/15 MRA Report demonstrated no focal stenosis or aneurysm in the intracranial vasculature. 12/16/15 Progress Report indicated that the patient wakes up with headaches. She mentioned headache in the frontal vertex or temporal occipital areas. She also feels imbalance. She denies bruxism and has no significant neck symptoms. She reported having some minor neck tightness. She was being treated with acupuncture 2 X per week and craniosacral therapy 2 X per week. She noted that she was able to read better in the past two weeks. She had difficulty scanning a written page in the past. She also mentioned that her insomnia has slightly improved since initiating these 2 therapies. Physical exam showed no palpable spasms in her cervical region over her muscles of mastication. Cervical range of motion: backward flexion 70 degrees and forward flexion 60 degrees. She was able to turn 60 degrees to each side. She is able to tilt 40 degrees to other side. Comments: Based on the absence of objective findings, she has reached a medical end result with no need for any further treatment. No additional treatment or diagnostic testing is

This is a 38-year-old female with a 1/10/2013 date of injury. A specific mechanism of injury has not been described. DIAGNOSIS: Depressive disorder 01/14/16 Psychotherapy session note indicated that the patient has reported increased improvement in mood and stability in anxiety. She continues to feel anxious about not having a job.

As per office notes dated 8/26/16 the patient complains of dull and aching pain of the neck. She rates it as 7 without the medications and at 5/10 with medications. Pain is aggravate with activities and relieved with rest and medications. Neck pain us associated with headaches and radiating pain, tingling, and numbness to bilateral upper extremities. Patient is complaining of having acid reflex ad acute exacerbation of muscle spasm. Lumbar back pain is dull and aching rated at 6 without medications and 4 with medications. Pain is aggravated with activates such as forward back bending, lifting, prolonged sitting, standing, walking, and it is relieved with rest and medications. Lower back pain is associated with radiating pain, tingling, and

This is a 51-year-old female with a 4/6/2015 date of injury. She tripped and fell to right knee.

MRI of the cervical spine obtained on 06/29/16 showed prominent straightening of the cervical lordosis likely due to muscle spasm from the patient’s injuries with associated disc space narrowing and broad based posterior herniation of the protrusion type at the C6-7 level, extending approximately 2.5 mm into the spinal canal partially effacing the anterior subarachnoid space, slightly

This is a 53-year-old male with a 9/3/2015 date of injury. The patient stated that he was at work, slipped on melted ice and fell to the ground. He immediately felt pain in his knee. DIAGNOSIS: Left knee medial meniscus tear, chondromalacia, synovitis 01/26/16 Progress Report documented a follow-up visit for left

DOI: . Patient is a 30- year old -male - who sustained a work related injury

DIAGNOSIS: LBP 01/20/16 Progress Report documented that the patient was last seen on 12/08/15. He has seen Dr. Gammon and is scheduled to have a surgery on 02/01/16. He is planning to do a fusion into the left leg to help stabilize that nonunion. He is on Lyrica 150 mg twice a day and wants to increase that. He also takes Feldene 20 mg once a day, Robaxin 750 mg 2-3 times a day and Miraprex 0.25 mg once a day. He was advised to stop Feldene, 3 days before his surgery. He was also advised to stop any Aspirin products. He takes Aspririn 88 mg once a day.

MRI of the lumbar spine without contrast dated 5/22/14 revealed degenerative disc disease at L3-4 through L5-S1; large central and right paracentral disc herniation and extruded disc at L4-5; there is severe stenosis of the right neural foramen at L4-5 entrapping the right L4 nerve; and severe right and left neural foraminal stenosis at L5-S1 entrapping the right and left L5 nerves.

As per progress report dated 8/05/15, the patient is being seen for chronic right ankle pain and chronic right foot pain. Her current medications include Cymbalta 60 mg, Relafen

O The examination revealed tenderness, spasm, and a decreased range of motion in the cervical spine, thoracic spine, and lumbar spine. Prior treatments included medications, physical therapy, and work modifications.

DIAGNOSIS: Lumbagao, Chronic pain, Myalgia, LS Spndylosis, Sacroilitis, Hip Pain 12/08/15 Progress Report described that the patient presented with pain in lower back and buttocks without radiation to the lower extremities. The patient reported significant pain relief due to intra-articular facet block done on 04/14/14 for his left side. TPIs have been improving his pain. The patient noted exacerbation of low back pain after moving appliances yesterday. Pain level was 7/10 with the use of medications. He would be starting PT next week. The patient underwent right-sided transforaminal ESIs at L4 and L5 levels without any significant long-term pain relief. It was helpful for a short duration. Facet joint injections caused increase in lower back and buttock pain. SI joint injection has improved his pain to 3/10. The lower back pain is aching, sharp, shooting, sore, and throbbing with pins and needles. The pain is constant and the pain aggravates with ambulation and standing. The patient also has bilateral leg pain due to varicose veins. The patient is currently on Elavil, Planquenil, Lunesta, Flexeril, Ompeprazole, compounding cream, Tramadol, Vitamin B12, Gabapentin, Voltaren gel and Duloxetine. Exam revealed an antalgic gait. There was significant tenderness to