PRESENTING COMPLAINT: The patient is a (XX)-year-old male who presented to the office today for a podiatry visit. He is here with his mother stating that from MM/DD/YYYY he has had chronic knee pain. Initially, the knee pain only hurt him while running and afterwards, but over the years, it has developed into a chronic knee pain that he feels when he gets out of bed and while walking. The patient stated that his knee pain now seems to feel better with activity. Most recently, he removed orthotics that have been made by a physical therapist from his shoes and his knee pain felt better though his feet started to ache.
PAST MEDICAL HISTORY: Fairly significant for being diagnosed with D. fragilis and Blastocystis, and he was treated with antibiotics. Since that time, the patient has had a series of laboratory test and consulted a number of rheumatologists to diagnose the cause of joint pains that he had in his elbows and fingers. Six months ago, he consulted a rheumatologist who diagnosed him with Lyme’s disease. He has been placed on Celebrex and Ceftin for the treatment of the Lyme’s disease.
PRESENT MEDICAL HISTORY: Significant for Lyme’s disease. Also seen by Dr. John Doe for hamstring tendonitis. Two years ago, he had a stress fracture of his right tibia.
PODIATRYÂ HISTORY: Remarkable for having a number of orthotics, some semi-rigid and some semi-flexible having a rearfoot post but none appeared to have a forefoot post on them. The shoe gear the patient regularly wears is running shoes for casual wear and school. The wear pattern on the running shoes appeared normal.
PODIATRY PHYSICAL EXAM:
VASCULAR:
DP: 3/4.
PT: 3/4.
PULSES: Capillary filing time is 2-3 seconds.
EDEMA: None and the toes and foot appeared warm.
NEUROLOGIC: Negative Tinel’s, vibratory grossly intact, and deep tendon reflex 3/5.
DERMATOLOGIC: Nonsignificant.
MUSCULOSKELETAL: Muscle strength was +5/5 with no pain on active or passive range of motion. On exam, there was no tenderness that could be elicited on exam of the medial and lateral aspect of the tibia or posterior malleoli. There was pain on palpation of the Achilles tendon approximately 2 inches proximal to the insertion in the watershed area, but there was no crepitus on exam and no fusiform swelling. Visual exam also revealed a dorsal and medial hyperostosis of the first metatarsal head. There was no pain on range of motion of the first MPJ, no crepitus. The dorsiflexion was 20 degrees and plantarflexion 10 degrees. The first ray appeared to be long and semi-rigid. There was a mild HAV. On stance, there was mild midtarsal joint sag along with the collapse of the longitudinal arch. There was no genu valgum or genu varum. The subtalar joint range of motion was normal. The neutral calcaneal stance was 4 degrees varus, resting was 3 degrees valgus, forefoot position was 4 degrees varus bilateral. Ankle dorsiflexion was –2 degrees knee straight and 10 degrees knee bent. Hip rotation was 70 degrees external and 10 degrees internal. Hamstring flexibility was 70 degrees bilateral and quadriceps 130 degrees. Leg length was equal. The knee exam showed no overt swelling or crepitus on range of motion. There was no instability of the knee, and there was pain on palpation of the anterior aspect of the patellar tendon at the site of the attachment of the plantar tendon. There was no pain elicited on exam of the medial aspect of the knee; although, the patient described having medial knee pain distal to the knee joint.
IMPRESSION:
1. A patient with Lyme’s disease but doubt that the patellar tendonitis is directly related to the Lyme’s disease since he has all the biomechanical components for patellar tendonitis.
2. Contracture of the gastroc.
3. Secondary Achilles tendonitis.
4. Contracture of the hamstring complex.
5. Ankle equinus.
6. Hallux limitus.
TREATMENT PLAN: The treatment provided for the patient today was discussion of findings with the patient and his mother, and we started him on aggressive calf stretching and hamstring flexibility program. He is to ice his knee twice a day and he is to wear some heel lift. We dispensed for about a week and then place in his orthotics again and see if they feel more comfortable. He is to return to the office in 2 weeks for podiatry followup at which time we may do a gait analysis and cast him for orthotics.
