DOI: 09/26/2010. The patient is a 63-year-old male route sales representative who incurred a work-related injury to his left foot and ankle due to repetitive job duties.
Based on the progress report dated 03/18/16, the patient presents for reevaluation of his left ankle. He underwent left ankle surgery on 10/15/13. His left ankle has been worse the past two months. The left ankle has also been swelling. He rates his pain as 7/10. The pain is worse when he puts weight on the left foot/leg. The left heel/foot throbs after he stands on his foot for a long time. The pain is aggravated by standing and walking. The pain is alleviated by lying down.
He has not been able to go to the gym for the past two months due to increased pain.
On examination, there is tenderness on the left subtalar region. Left ankle joint active range of motion shows dorsiflexion of 0-10 degrees and plantar flexion of 0-20 degrees.
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IW was diagnosed with left posterior tibial tendon dysfunction/tendinosis with valgus deformity of the left heel as a result of the posterior tibial dysfunction, status post left foot reconstruction, posterior tibial tendon using flexor digitorum longus tendon transfer and left calcaneal osteotomy 05/24/11 and status post surgery on the left foot 10/15/13.
Treatment plan includes x-rays of the left ankle and referral back to Dr. Ghalambor for consultation regarding his increased left ankle pain.
Current request is for 1 X-ray of the Left Ankle between 3/23/2016 and