CONTACTS
SUBJECTS
VA Podiatry Review Metatarsalgia Pain Balls of Feet Enable Physical
1703 -
1703 - ..
1704 - Summary/Objective
1705 -
170501 - Follow up ref SDS 90 0000. ref SDS 89 0000.
170502 -
170503 -
170504 -
170505 -
170506 -
170508 - ..
1706 -
1707 -
1708 - Background
1709 -
170901 - Meeting Doctor Tang in Podiatry on 140805 1030. ref SDS 36 NU4G
170902 - Progress Notes for meeting on 140805, call for return to clinic after
170903 - receiving FFO. ref SDS 36 IJ4G A few days after meeting on 140805,
170904 - received letter from VA scheduling follow meeting today on 140820
170905 - 1000.
170907 - ..
170908 - On 140828 meeting with Doctor Kevin Daun and later with Doctor Mihara,
170909 - attending developed solution to blister on inside of big toe on left
170910 - foot, ref SDS 44 W74O, that required stopping 11 mile hike after 8
170911 - miles and calling for a ride home, shown in case study on 120101 0900.
170912 - ref SDS 9 BO6F
170914 - ..
170915 - On 140904 0900 meeting with Doctor Cynthia Lieu and Doctor Tang,
170916 - attending. ref SDS 47 AK6J Doctor Tang said orthotics can be trimed
170917 - to fit a smaller shoe size, if necessary; he has scheduled a meeting
170918 - after orthotics inserts are received. ref SDS 47 4M3H
170920 - ..
170921 - On 150115 0845 meeting with Doctor Tang and Doctor Goodman, the doctor
170922 - ordered a 2nd set of orthotic inserts to recover from and prevent
170923 - recurrance of metatarsalgia. ref SDS 52 BG6I
170925 - ..
170926 - On 151215, met with Doctor Hewitson in Podiary. ref SDS 58 AK6J He
170927 - modified the Prolab orthotic inserts applied with Hoka Stinson Lite
170928 - shoes size 10 worn today, and for the purpose of improving routine
170929 - walking gait. ref SDS 58 9B6I Observation of walking tests, and
170930 - placing the doctor's hands on the patient's hips while standing to
170931 - evaluate body alignment, indicated to Doctor Hewitson that this
170932 - initial modification did not correct defect in walking gait, so he
170933 - removed that modification and instead raised the heel of the left
170934 - orthotic. ref SDS 58 NC7M
170936 - ..
170937 - Doctor Hewitson said to bring in the other pair of orthotic inserts on
170938 - the next meeting in Podiatry for adding modifications that make both
170939 - pair the same. ref SDS 58 1J98
170941 - ..
170942 - On 151215 1000 Progress Notes explain modifications to orthotics -
170943 - Improved gait by decreasing early heel off L, increased L knee
170944 - extension, and decreased R recurvatum. ref SDS 59 ZA9I
170946 - ..
170947 - On 151215, Doctor Hewitson and his team made molds of the feet to make
170948 - new orthodic inserts. They will be shipped in a few weeks. When new
170949 - orthotics are received, notify VA to schedule follow with Doctor
170950 - Hewitson to review effectiveness, and to make modifications as needed,
170951 - and as done on 151215.
170953 - ..
170954 - On 151215 1000 Progress Notes confirm follow up meeting will occur
170955 - after receiving orthotic inserts. ref SDS 59 PK6L
170957 - ..
170958 - On 140101 0600 case study reporting on 151222, developed new blister
170959 - on left side little toe left foot, possibly related to changed
170960 - orthotics. ref SDS 15 IE9O
170962 - ..
170963 - On 160202 1540 reported injury to right knee, very painful; Doctor
170964 - Tang recommended not using adjusted orthotic inserts, until meeting
170965 - with Doctor Hewitson in Podiatry Biomechanics can evaluate adjustments
170966 - to avoid right knee injury. ref SDS 65 WG59
170968 - ..
170969 - On 160325 0443 letter to VA notifies Doctor Tang that orthotic inserts
170970 - ordered by Doctor Hewitson on 151215, have been received, so meeting
170971 - can be scheduled for Doctor Hewitson to configure the new inserts,
170972 - ref SDS 66 AK6J, as planned by the doctor during the prior meeting on
170973 - 151215. ref SDS 58 HM8J
170975 - ..
170976 - On 160503 1130 encountered Doctor Hewitson in the cafeteria; he agreed
170977 - to provide care after lunch at 1300 in Podiatry. 160503 1256,
170978 - ref SDS 69 9A34
170980 - ..
170981 - On 160503 1300 meeting Doctor Hewitson in Podiatry. Since this
170982 - meeting was ad hoc, we did not have the 3 sets of orthotic inserts
170983 - which he planned to modify, shown in the record on 151215 1000.
170984 - ref SDS 58 1J98 Scheduled another meeting on 160516, for Doctor
170985 - Hewitson to improve alignment of ankles, knees and hips. 160503 1256,
170986 - ref SDS 69 TN94
170988 - ..
170989 - On 161212 meeting with Doctor Alexis Dang in Orthopedics, the doctor
170990 - recommended review by Podiatry to correct Tailor's Bunion. ref SDS 72
170991 - OG4N
170993 - ..
170994 - On 161219 2208 wrote letter to Doctor Tang and Doctor Hewitson,
170995 - ref SDS 74 V13J, requesting care for Tailor's Bunion, ref SDS 74 X659,
170996 - and prescription for liquid Naproxen. ref SDS 74 X65V
170998 - ..
170999 - On 161220 0927 Doctor Tang offered prescription for diclofenac gel to
171000 - replace Naproxen to control inflammaton to feet and joints from
171001 - hiking. ref SDS 75 0657 Letter to Doctor Tang requested prescription.
171002 - ref SDS 75 J99T The doctor notified that he ordered diclofenac gel,
171003 - and can pick it up at Pharmacy today. ref SDS 75 L668
171005 - ..
171006 - On 161221 0730 xray both feet evaluate Tailor's Bunion, and other
171007 - injuries to feet. ref SDS 76 JT6G
171009 - ..
171010 - On 161221 0822 received prescription from VAMCSF Pharmacy for
171011 - diclofenac gel to replace Naproxen to control inflammation during
171012 - hikes. ref SDS 77 Z38F
171014 - ..
171015 - On 161222 1519 Doctor Tang called and reported xray found no evidence
171016 - of Tailor's Bunion, nor other severe injury to feet. ref SDS 80 HQ5O
171018 - ..
171019 - On 170315 1146 submitted letter to Doctor Tang in Podiatry, thanking
171020 - the VA for timely care, and asking for the name of the treatment that
171021 - may be offered in clinical trial for metatarsalgia. ref SDS 87 F64G
171023 - ..
171024 - On 170317 0847 letter to Gina who gave Supartz injections, ending on
171025 - 170206, and requesting meeting for few minutes, ref SDS 88 H84K, also,
171026 - called and left message for Gina on meeting, purpose is to request
171027 - assistance expediting meeting on Supartz treatment for metatarsalgia.
171028 - ref SDS 88 F97H
171030 - ..
171031 - On 170318 1113 received call from Moses in VA Orthopedics; scheduled
171032 - meeting with Doctor Thuillier to consider treatment in clinical trial
171033 - for using Supartz in right foot. ref SDS 89 HQ5O
171035 - ..
171036 - On 170327 1430 meeting with Doctor Dan Thuillier in Orthopedics,
171037 - ref SDS 90 HQ5O; doctor advised VA does not support clinical trial
171038 - applying Supartz for metatarsalgia. ref SDS 90 D33N; Doctor Thuillier
171039 - explained shoes with stiffer forefoot, like Hoka Stinson 3, help
171040 - prevent metatarsalgia injuries. ref SDS 90 W44I Doctor Thuillier
171041 - diagnosed possible plantar plate tear, ref SDS 90 I54I, and
171042 - demonstrated Plantarflexion taping to prevent further injury during
171043 - hiking, and he submitted a letter with a video showing procedure for
171044 - plantarflexion taping. ref SDS 90 774N
171045 -
171046 -
171047 -
171048 -
171049 -
171050 -
171052 - ..
1711 -
1712 -
1713 - Progress
1714 -
171401 - Prior MRI study on both knees reported on 160805 0800. ref SDS 71 K05I
171402 -
171403 - MRI study today on both feet to evaluate for metatarsalgia, and on
171404 - right foot plantar plate tear, ordered by Doctor Thuillier, reported
171405 - on 170327 1430. ref SDS 90 OH9L
171407 - ..
171408 - Issue today is requirement for contrast medium. Letter to Doctor
171409 - Thuillier requested clarification of requirement for contrast medium,
171410 - reported on 170329 1127. ref SDS 91 M239
171412 - ..
171413 - Subsequently, Caroline seemed to say MRI on right foot will be without
171414 - contrast medium, reported on 170329 1127. ref SDS 91 HQ5O
171416 - ..
171417 - Meeting with Jane in Orthopedics yesterday indicated MRI can be done
171418 - with or without contrast medium. 170411 1141, ref SDS 95 N589
171420 - ..
171421 - Today, working with Annette. She said contrast medium was needed
171422 - with older MRI equipment to diagnose plantar plate tear injuries.
171423 - The new equipment used now at the VA can readily identify plantar
171424 - plate tears without contrast medium.
171425 -
171426 - [On 170417 0820 letter notified Doctor Thuillier that MRI
171427 - was done without contrast; Annette said VAMCSF has newer
171428 - MRI technology that does not require contrast to diagnose
171429 - plantar plate tears. ref SDS 96 2X83
171431 - ..
171432 - In the MRI room, worked with Kim who set the patient up on the MRI
171433 - traveling table.
171435 - ..
171436 - There was some difficulty positioning the leg that was not being
171437 - scanned in a comfortable position. Kim did a good job adjustng
171438 - support to ensure favorable conditions for doing the scans.
171440 - ..
171441 - VA medical records Internet address...
171442 -
171443 - https://www.myhealth.va.gov/
171445 - ..
171446 - Customer....
171447 -
171448 - User ID..................... rodwelch
171449 - Password.................... Poims&7cm
171450 -
171452 - ..
171453 - Analyst's report stored MRI report at...
171454 -
171455 - F:\05\00003\SM\CC\AGMJ\20170412-080000\mhv_WELCH_20170418_1410.txt
171456 -
171458 - ..
171459 - MRI Report Right Foot Performed 170412
171460 -
171461 - MRI study today follows up prior xray on both feet on 161221 0730.
171462 - ref SDS 76 524L
171463 -
171464 -
171465 - 1. Procedure/Test Name: MRI FOOT W/O GAD
171466 - Date/Time Exam Performed: 12 Apr 2017 @ 0855
171467 - Ordering Location: San Francisco CA VAMC
171468 - Requesting Provider: THUILLIER,DANIEL U
171469 - Reasons for Study: see other order
171470 - Clinical History:
171471 - see other order
171473 - ..
171474 - 2. Performing Location: San Francisco CA VAMC 4150 CLEMENT STREET, SAN FRANCISCO 94121
171475 - Radiologist: SRINIVASAN,RAMYA
171476 - --------------------------------------------------------------------------
171477 - RADIOLOGY REPORT
171479 - ..
171480 - 3. Report:
171481 - MRI OF THE RIGHT FOREFOOT
171483 - ..
171484 - 4. CLINICAL HISTORY: Evaluate for plantar plate tear
171486 - ..
171487 - 5. COMPARISON: Foot radiographs 12/21/2016........ 161221 0730, ref SDS 76 TH43
171489 - ..
171490 - 6. TECHNIQUE: Using a 3 Tesla magnet, multiplanar/ multisequence
171491 - imaging was performed of the right foot without contrast
171492 - administration.
171494 - ..
171495 - 7. FINDINGS:
171496 -
171497 - 1. PLANTAR PLATE:
171498 -
171499 - The plantar plate and intersesamoid ligament of the first
171500 - MTP joint are not well-visualized, compatible with chronic
171501 - tears. The second MTP joint plantar plate is discontinuous
171502 - at its lateral phalangeal insertion with associated T1 and
171503 - T2 intermediate signal within the second interspace located
171504 - eccentrically along the second MTP. The third through
171505 - fifth MTP plantar plates are intact without signal
171506 - abnormality.
171508 - ..
171509 - Seems to be saying right foot long toe shows evidence of plantar plate
171510 - tear.
171511 -
171512 - [On 170417 1330 Doctor Thuillier advised that
171513 - plantarflexion care for right foot long toe will protect
171514 - plantar plate from further injury and enable healing
171515 - during heavy exercise, ref SDS 97 I45H, and despite mild
171516 - pain < 5 during hiking. ref SDS 97 8A6N
171518 - ..
171519 - 2. Intermetatarsal bursal fluid distention in the first and
171520 - third interspace. No additional interspace lesions are
171521 - identified.
171523 - ..
171524 - 3. LIGAMENTS:
171525 -
171526 - The medial and lateral collateral ligaments of the first
171527 - MTP are attenuated, likely degenerated. Additional
171528 - nonvisualization of the lateral collateral ligament of the
171529 - second MTP, compatible with a tear. The remaining medial
171530 - and lateral collateral ligaments are intact without signal
171531 - abnormality.
171533 - ..
171534 - 4. Lisfranc ligament is intact.
171536 - ..
171537 - 5. OSSEOUS AND CARTILAGINOUS STRUCTURES:
171538 -
171539 - Hallux valgus with degenerative changes at the MTP and
171540 - hallucal sesamoid articulations with subchondral cysts and
171541 - osteophyte formation, with associated lateral subluxation
171542 - of the hallucal sesamoid. The tibial hallucal sesamoid
171543 - demonstrates an obliquely oriented cleft with edema within
171544 - the sesamoid.
171546 - ..
171547 - 6. Remaining bone marrow signal is within normal limits.
171549 - ..
171550 - 7. TENDONS AND MUSCLES:
171551 -
171552 - Edema is seen within the medial head of the flexor hallucis
171553 - brevis tendon and surrounding muscle, compatible with
171554 - strain. The remainder of the flexor and extensor tendons
171555 - are intact with out evidence of tendinosis or tear.
171556 -
171558 - ..
171559 - Impression:
171560 -
171561 - 1. Second MTP plantar plate and lateral collateral ligament
171562 - tears with intermediate signal within the second
171563 - interspace, which likely represents pericapsular fibrosis
171564 - versus less likely a small neuroma.
171566 - ..
171567 - 2. Degenerative changes of the first MTP with chronic tear of
171568 - the plantar plate and intersesamoidal ligament.
171570 - ..
171571 - 3. Obliquely oriented cleft and edema within the tibial
171572 - hallucal sesamoid, which likely represents a subacute to
171573 - chronic fracture versus bipartite sesamoid with stress
171574 - related changes.
171576 - ..
171577 - The images were personally reviewed by Ramya Srinivasan MD who
171578 - agrees with the above interpretation.
171580 - ..
171581 - Primary Diagnostic Code:
171582 -
171583 -
171584 -
171585 - =========================================================================
171586 - Procedure/Test Name: MRI FOOT W/O GAD
171587 - Date/Time Exam Performed: 12 Apr 2017 @ 0811
171588 - Ordering Location: San Francisco CA VAMC
171589 - Requesting Provider: THUILLIER,DANIEL U
171590 - Reasons for Study: ? plantar plate tear on the right
171591 - Clinical History:
171592 - 1) Does the patient have one of the following
171593 - devices?:No
171594 - - cardiac pacemaker
171595 - - cardiac defibrillator
171596 - - implanted device or pump
171597 - - neurostimulator
171598 -
171599 - 2) Has this patient had surgery for a brain
171600 - aneurysm?:No
171601 -
171602 - 3) Will this patient need sedation?:No
171603 - - Sedation orders are the responsibility of the ordering
171604 - provider
171605 - and should be placed at the time of imaging request.
171606 -
171607 - 4) Is there anything within this patient that you are unsure
171608 - about in
171609 - regards to MR safety?: (foreign body, metal object, etc):
171610 - No
171611 - - If yes, please put in a short description below:
171612 -
171613 -
171614 -
171615 -
171617 - ..
171618 - Performing Location: San Francisco CA VAMC 4150 CLEMENT STREET, SAN FRANCISCO 94121
171619 - Radiologist: SRINIVASAN,RAMYA
171620 - --------------------------------------------------------------------------
171621 - RADIOLOGY REPORT
171623 - ..
171624 - Report:
171625 - MRI OF THE LEFT FOOT
171627 - ..
171628 - CLINICAL HISTORY: Evaluate for plantar tear
171630 - ..
171631 - COMPARISON: Foot radiographs 12/21/2016
171633 - ..
171634 - TECHNIQUE: Using a 3 Tesla magnet, multiplanar/ multisequence
171635 - imaging was performed of the left foot without contrast
171636 - administration.
171638 - ..
171639 - FINDINGS:
171641 - ..
171642 - PLANTAR PLATE: The plantar plate and intersesamoid ligament of
171643 - the first metatarsophalangeal joint are not well-visualized,
171644 - compatible with chronic tears. There is attenuation and
171645 - intermediate signal of the lateral aspect of the second MTP
171646 - plantar plate compatible with degeneration without discrete tear.
171647 - Remaining plantar plates are intact.
171649 - ..
171650 - This seems like good news, i.e, left foot 2nd MTP (long toe) shows
171651 - "degeneration without discrete tear."
171653 - ..
171654 - This may reflect that hiking presents less stress than running.
171655 -
171656 - [On 170417 1330 Doctor Thuillier advised that
171657 - plantarflexion care for right foot long toe will protect
171658 - plantar plate from further injury and enable healing during
171659 - heavy exercise, ref SDS 97 I45H, and despite mild pain < 5
171660 - during hiking. ref SDS 97 8A6N
171662 - ..
171663 - Findings for MRI on left foot continue...
171664 -
171665 - Intermetatarsal bursal fluid distention of the first
171666 - metatarsophalangeal interspace.
171668 - ..
171669 - LIGAMENTS: The medial and lateral collateral ligaments of the
171670 - first metatarsophalangeal joint are attenuated, likely
171671 - degenerative. The remaining collateral ligaments of the second
171672 - through fifth toes are intact and demonstrates normal signal
171673 - appearance.
171675 - ..
171676 - This seems to align with diagnosis of metatarsalgia.
171678 - ..
171679 - Findings for MRI on right foot continue...
171680 -
171681 - Lisfranc ligament is intact.
171683 - ..
171684 - OSSEOUS AND CARTILAGINOUS STRUCTURES: Hallux valgus with
171685 - degenerative changes of the first metatarsophalangeal joint and
171686 - hallucal sesamoid articulations, with associated lateral
171687 - subluxation of the sesamoids. Degenerative changes of the second
171688 - MTP joint with subchondral cyst formation.
171690 - ..
171691 - Bone marrow signal is otherwise within normal limits. No discrete
171692 - fracture or chondrocalcinosis.
171694 - ..
171695 - TENDON: Normal appearance of the flexor and extensor tendons of
171696 - the foot without evidence of tendinosis, tear, or tenosynovitis.
171697 -
171698 -
171700 - ..
171701 - Impression:
171702 -
171703 -
171704 - 1. Degeneration of the lateral aspect of the second MTP plantar
171705 - plate without discrete tear.
171707 - ..
171708 - 2. Degenerative changes at the first MTP joint with chronic
171709 - tears of the first metatarsophalangeal joint plantar plate
171710 - and inter-sesamoidal ligaments.
171712 - ..
171713 - Thus, right foot big toe has chronic deformaties (tears), but present
171714 - no pain during hiking, per above. ref SDS 0 JI37
171716 - ..
171717 - MRI on right foot continue...
171718 -
171719 - The images were personally reviewed by Ramya Srinivasan MD who
171720 - agrees with the above interpretation.
171722 - ..
171723 - Primary Diagnostic Code:
171724 -
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1718 -