CONTACTS
SUBJECTS
Hiking 11 - 15 Miles Per Day Patient Profile Curve Significantly Exc
1603 -
1603 - ..
1604 - Summary/Objective
1605 -
160501 - Follow up ref SDS 85 0000. ref SDS 82 0000.
160502 -
160503 -
160504 -
160505 - [On 170315 1146 submitted letter to Doctor Tang in
160506 - Podiatry, thanking the VA for timely care, and asking for
160507 - the name of the treatment that may be offered in clinical
160508 - trial for metatarsalgia. ref SDS 87 F64G
160510 - ..
160511 - [On 170327 1430 during meeting in Orthopedics Doctor
160512 - Thuillier advised there is no clinical trial nor other line
160513 - of care available at the VAMCSF for using Supartz
160514 - injections to treat metatarsalgia. ref SDS 90 D33N The
160515 - doctor diagnosed possible Plantar Plate Tear, and
160516 - demonstrated procedure for Plantarflexion taping that may
160517 - enable recovery while hiking. ref SDS 90 I54I Doctor
160518 - Thuillier MRI studies on both feet to further assess cause
160519 - of forefoot pain. ref SDS 90 OH9L
160520 -
160521 -
160522 -
160523 -
160525 - ..
1606 -
1607 -
1608 - Background
1609 -
160901 - Meeting Doctor Tang in Podiatry on 140805 1030. ref SDS 38 NU4G
160902 - Progress Notes for meeting on 140805, call for return to clinic after
160903 - receiving FFO. ref SDS 38 IJ4G A few days after meeting on 140805,
160904 - received letter from VA scheduling follow meeting today on 140820
160905 - 1000.
160907 - ..
160908 - On 140828 meeting with Doctor Kevin Daun and later with Doctor Mihara,
160909 - attending developed solution to blister on inside of big toe on left
160910 - foot, ref SDS 46 W74O, that required stopping 11 mile hike after 8
160911 - miles and calling for a ride home, shown in case study on 120101 0900.
160912 - ref SDS 11 BO6F
160914 - ..
160915 - On 140904 0900 meeting with Doctor Cynthia Lieu and Doctor Tang,
160916 - attending. ref SDS 49 AK6J Doctor Tang said orthotics can be trimed
160917 - to fit a smaller shoe size, if necessary; he has scheduled a meeting
160918 - after orthotics inserts are received. ref SDS 49 4M3H
160920 - ..
160921 - On 150115 0845 meeting with Doctor Tang and Doctor Goodman, the doctor
160922 - ordered a 2nd set of orthotic inserts to recover from and prevent
160923 - recurrance of metatarsalgia. ref SDS 54 BG6I
160925 - ..
160926 - On 151215, met with Doctor Hewitson in Podiary. ref SDS 60 AK6J He
160927 - modified the Prolab orthotic inserts applied with Hoka Stinson Lite
160928 - shoes size 10 worn today, and for the purpose of improving routine
160929 - walking gait. ref SDS 60 9B6I Observation of walking tests, and
160930 - placing the doctor's hands on the patient's hips while standing to
160931 - evaluate body alignment, indicated to Doctor Hewitson that this
160932 - initial modification did not correct defect in walking gait, so he
160933 - removed that modification and instead raised the heel of the left
160934 - orthotic. ref SDS 60 NC7M
160936 - ..
160937 - Doctor Hewitson said to bring in the other pair of orthotic inserts on
160938 - the next meeting in Podiatry for adding modifications that make both
160939 - pair the same. ref SDS 60 1J98
160941 - ..
160942 - On 151215 1000 Progress Notes explain modifications to orthotics -
160943 - Improved gait by decreasing early heel off L, increased L knee
160944 - extension, and decreased R recurvatum. ref SDS 61 ZA9I
160946 - ..
160947 - On 151215, Doctor Hewitson and his team made molds of the feet to make
160948 - new orthodic inserts. They will be shipped in a few weeks. When new
160949 - orthotics are received, notify VA to schedule follow with Doctor
160950 - Hewitson to review effectiveness, and to make modifications as needed,
160951 - and as done on 151215.
160953 - ..
160954 - On 151215 1000 Progress Notes confirm follow up meeting will occur
160955 - after receiving orthotic inserts. ref SDS 61 PK6L
160957 - ..
160958 - On 140101 0600 case study reporting on 151222, developed new blister
160959 - on left side little toe left foot, possibly related to changed
160960 - orthotics. ref SDS 17 IE9O
160962 - ..
160963 - On 160202 1540 reported injury to right knee, very painful; Doctor
160964 - Tang recommended not using adjusted orthotic inserts, until meeting
160965 - with Doctor Hewitson in Podiatry Biomechanics can evaluate adjustments
160966 - to avoid right knee injury. ref SDS 68 WG59
160968 - ..
160969 - On 160325 0443 letter to VA notifies Doctor Tang that orthotic inserts
160970 - ordered by Doctor Hewitson on 151215, have been received, so meeting
160971 - can be scheduled for Doctor Hewitson to configure the new inserts,
160972 - ref SDS 69 AK6J, as planned by the doctor during the prior meeting on
160973 - 151215. ref SDS 60 HM8J
160975 - ..
160976 - On 160503 1130 encountered Doctor Hewitson in the cafeteria; he agreed
160977 - to provide care after lunch at 1300 in Podiatry. 160503 1256,
160978 - ref SDS 72 9A34
160980 - ..
160981 - On 160503 1300 meeting Doctor Hewitson in Podiatry. Since this
160982 - meeting was ad hoc, we did not have the 3 sets of orthotic inserts
160983 - which he planned to modify, shown in the record on 151215 1000.
160984 - ref SDS 60 1J98 Scheduled another meeting on 160516, for Doctor
160985 - Hewitson to improve alignment of ankles, knees and hips. 160503 1256,
160986 - ref SDS 72 TN94
160988 - ..
160989 - On 161212 meeting with Doctor Alexis Dang in Orthopedics, the doctor
160990 - recommended review by Podiatry to correct Tailor's Bunion. ref SDS 74
160991 - OG4N
160993 - ..
160994 - On 161219 2208 wrote letter to Doctor Tang and Doctor Hewitson,
160995 - ref SDS 76 V13J, requesting care for Tailor's Bunion, ref SDS 76 X659,
160996 - and prescription for liquid Naproxen. ref SDS 76 X65V
160998 - ..
160999 - On 161220 0927 Doctor Tang offered prescription for diclofenac gel to
161000 - replace Naproxen to control inflammaton to feet and joints from
161001 - hiking. ref SDS 77 0657 Letter to Doctor Tang requested prescription.
161002 - ref SDS 77 J99T The doctor notified that he ordered diclofenac gel,
161003 - and can pick it up at Pharmacy today. ref SDS 77 L668
161005 - ..
161006 - On 161221 0730 xray both feet evaluate Tailor's Bunion, and other
161007 - injuries to feet. ref SDS 78 JT6G
161009 - ..
161010 - On 161221 0822 received prescription from VAMCSF Pharmacy for
161011 - diclofenac gel to replace Naproxen to control inflammation during
161012 - hikes. ref SDS 79 Z38F
161014 - ..
161015 - On 161222 1519 Doctor Tang called and reported xray found no evidence
161016 - of Tailor's Bunion, nor other severe injury to feet. ref SDS 82 HQ5O
161017 -
161018 -
161020 - ..
1611 -
1612 -
1613 - Progress
1614 -
161401 - Meeting with Doctor Tang explained significant pain in right foot has
161402 - prevented hiking for some time. Cited example on 170310, shown in
161403 - case study of patient history on 160101 0700. ref SDS 64 205I
161405 - ..
161406 - Consider administer treatment right foot cortosine?
161408 - ..
161409 - On Sunday met customer at Skipolini's who related her father was
161410 - getting cortizone injections to recover from metatarsalgia feet pain.
161411 - The woman said in this case, the treatments are effective for 6
161412 - months. This is equals relief from treatment with Supartz knee
161413 - injections, reported by Eugenia on 170206 1240. ref SDS 83 GT7H
161415 - ..
161416 - Research on Internet found...
161417 -
161418 - Kaiser
161419 - Metatarsalgia
161420 -
161421 - https://thrive.kaiserpermanente.org/care-near-you/northern-california/santarosa/departments/foot-ankle-surgery/foot-and-ankle-surgery/metatarsalgia/
161423 - ..
161424 - Cortisone injections. (Injection of cortisone is a potent way
161425 - to reduce inflammation and expedite the recovery process.
161427 - ..
161428 - Cortisone does not replace the need for supportive shoes, foot
161429 - orthoses, calf stretching, and other physical measures.
161431 - ..
161432 - The risks of cortisone injections for metatarsalgia include,
161433 - but are not limited to: increased pain for 24-72 hours
161434 - following the injection, fat pad atrophy, depigmentation of the
161435 - top of the forefoot, weakening of adjacent joint ligaments with
161436 - potential dislocation of the toe, and infection. Systemic side
161437 - effects of this type of injection are extremely rare.)
161438 -
161440 - ..
161441 - Another source says...
161442 -
161443 - http://www.footeducation.com/page/corticosteroid-injections
161445 - ..
161446 - Today, Doctor Tang advised that cortisone injections to treat
161447 - metatarsalgia arising from hiking high mileage (11 - 15 miles per day)
161448 - in this case presents very high risk of causing irreversible injury.
161449 - He therefore recommends against this line of care.
161451 - ..
161452 - The doctor drew a curve with his finger in the air representing
161453 - percent of people who do daily aerobic exercise...
161454 -
161455 -
161456 - 100
161457 - 90
161458 - 80 x
161459 - 70
161460 - 60
161461 - 50 x
161462 - 40
161463 - 30
161464 - 20
161465 - 10 x
161466 - 9
161467 - 8
161468 - 7
161469 - 6
161470 - 5 x
161471 - 4
161472 - 3 x
161473 - 2 x
161474 - 1 x
161475 - 0 1 2 3 4 6 7 8 9 10 15
161477 - ..
161478 - He said the VA knows of no one else hiking 11 - 15 miles per day, and
161479 - so there is little experience treating injuries from such high level
161480 - activity. This seemed similar to meeting with Doctor Dang last
161481 - December, commenting that VA Orthopedics normally does not treat
161482 - patients having difficulties hiking 11 - 15 miles per day, reported on
161483 - 161212 1632. ref SDS 74 W579
161485 - ..
161486 - Gina made similar comment after giving Supartz injection on 170206
161487 - 1240. ref SDS 83 ZO5K
161489 - ..
161490 - Doctor Tang's graph drawing today, seems similar to Doctor Johnson
161491 - drawing a curve showing Millie lived 4 times longer than other stage
161492 - IV cancer patients, reported on 090325 0830, ref SDS 9 P39M, and so
161493 - Kaiser would refuse further treatment, explained the month before
161494 - presenting the standard insurance delima paying for medical costs that
161495 - compound with response to care, shown on 090213 1140. ref SDS 8 4N5K
161497 - ..
161498 - We reviewed current orthotics that seem to proivde significant arch
161499 - support which reduces pressure on metatrsals at the ball of each foot.
161500 - This indicates further improvemennt likely cannot be achieved with
161501 - orthotics.
161503 - ..
161504 - Doctor Tang presented options of reducing level of effort and/or
161505 - changing extended endurance exercise from hiking to swimming and/or
161506 - biking.
161508 - ..
161509 - Doctor Tang seemed aware that hiking unusually high mileage in this
161510 - case, explained above, ref SDS 0 6D6F, yields significant medical
161511 - benefits raising cholosterol HDL 30 in 2009, to maintaining HDL > 60
161512 - over the past 4 years, and as a result yielding very favorable blood
161513 - pressure cardiology conditions, and that this improvement has not been
161514 - reported using other exercise modalities.
161516 - ..
161517 - The doctor explained that attempting to maintain this level of effort
161518 - with cortisone injections in the feet would cause severe and
161519 - irreversible injury that would prevent any further hiking.
161521 - ..
161522 - Possible solution would be an orthotic with spongy material on the
161523 - ball of the foot, so as the foot rolls forward from heel to toes in
161524 - natural walking gait, pressure from the ground and body weight would
161525 - dissipated in compression and release of cushioning material, rather
161526 - than the ball of the foot.
161528 - ..
161529 - Reviewed favorable results resolving osteoarthritis causing right knee
161530 - pain with 3 injections of Supartz ending on 170206 1240. ref SDS 83
161531 - LL5N Asked about using similar injection treatment to resolve
161532 - metatarsalgia causing right forefoot pain.
161534 - ..
161535 - Doctor Tang said a doctor on staff in Orothopedics Department has a
161536 - few patients getting an experimental injection treatment, similar to
161537 - Supartz that was injected into the right knee, ending on 170206 1240.
161538 - ref SDS 83 7U5G
161540 - ..
161541 - Doctor Tang will make a referral for Orthopedics to consider this case
161542 - for viability getting the trial injection treatment for metatarsalgia.
161543 -
161544 - [On 170315 1146 submitted letter to Doctor Tang in
161545 - Podiatry, thanking the VA for timely care, and asking for
161546 - the name of the treatment that may be offered in clinical
161547 - trial for metatarsalgia. ref SDS 87 F64G
161549 - ..
161550 - [On 170317 0847 letter to Gina who gave Supartz injections,
161551 - ending on 170206, and requesting meeting for few minutes,
161552 - ref SDS 88 H84K, also, called and left message for Gina on
161553 - meeting, purpose is to request assistance expediting
161554 - meeting on Supartz treatment for metatarsalgia. ref SDS 88
161555 - F97H
161557 - ..
161558 - [On 170318 1113 call from Moses in Orthopedics at VAMCSF,
161559 - scheduled meeting to review Supartz injection treatment for
161560 - right foot metatarsalgia; meeting on 170327 1430.
161561 - ref SDS 89 HQ5O
161563 - ..
161564 - [On 170327 1430 during meeting in Orthopedics Doctor
161565 - Thuillier advised there is no clinical trial nor other line
161566 - of care available at the VAMCSF for using Supartz
161567 - injections to treat metatarsalgia. ref SDS 90 D33N The
161568 - doctor diagnosed possible Plantar Plate Tear, and
161569 - demonstrated procedure for Plantarflexion taping that may
161570 - enable recovery while hiking. ref SDS 90 I54I Doctor
161571 - Thuillier MRI studies on both feet to further assess cause
161572 - of forefoot pain. ref SDS 90 OH9L
161573 -
161575 - ..
161576 - Thanked Doctor Tang for good care.
161577 -
161578 -
161579 -
161580 -
161581 -
161582 -
161583 -
161584 -
161585 -
161586 -
1616 -