TARIN KRZYWOSINSKI

Group B
PBL Session #1
Case 1
SUBJECTIVE
20 y/o male PTC with a non-radiating, throbbing pain and tingling in his right ankle. Pt also states that his R knee is
painful at the lateral aspect. Pt describes the pain as constant and rates it an 8/10. The pain has been present for 6
months and is getting worse. Pt states that he has tried wearing Spenco arch supports and softer soled shoes but
neither has helped. Pt states that Tylenol also does not relieve the pain. Pt states that walking and rollerblading makes
the pain worse.
Allergies: Penicillin: gets itching and a rash
Medications: 3 units of regular insulin in the AM
Diagnosed Diseases: uncontrolled DM type 1, diagnosed 3 years ago
Childhood Disease: none
Immunizations: UTD
Surgical History/Hospitalizations: none
Social History: Pt denies smoking and illicit drug use. Pt states he is a social drinker and has 3 beers on the
weekends. Pt states he is single. Pt denies being employed and states he lives with one of his parents.
Family History: Dad died at age 50 of DM complications and alcohol abuse. Mom is alive and has uncontrolled
HTN.
ROS: Pt denies weight loss, N/V/D, fatigue, changes in vision or hearing, sore throat, headaches, rashes, SOB, chest
pain, murmurs, changes in urination, abdominal discomfort, muscle weakness, mood changes. Overall the review of
systems is unremarkable.
OBJECTIVE
Vitals: Ht: 62; W: 185 lbs; other vital signs are normal
General: AOx3
Integument: HPK on 2nd met head at the plantar aspect, bil. Hair to the level of the digits. Nails are normal thickness
and color digits 1-5, bil.
Vascular: DP/ PT pulses 2/4, bil. No varicosities noted. Mild edema at the medial aspect of the R ankle. Erythema
noted medial to the TNJ, right. No varicosities noted.
Neurological: sharp/dull and proprioception intact, bil. SWMF and vibratory sense diminished, bil. Achilles and
patellar reflexes 2/4, bil.
MSK/Gait: Hammer digits 4-5, bil. Muscle Strength 5/5 for all muscle groups but weakness at the Tibialis Posterior,
R. POP noted along the navicular and cuneiform joint, at the medial aspect of the ankle, and at the peroneal tendons,
bil. Pain during passive inversion. Negative heel raise test.
Biomechanical Exam:

Angle of gait: R: 24 abducted, L: 12 abducted

Limb length: L: hip tilted, superior to R hip = L superior static pelvic tilt
Hip: R: Knee Extended: 20 int/23 ext, L: 21 int/24 ext
Knee Flexed: R: 24 int/26 ext, L: 24 int/28 ext
Malleoli: R: 13 ext, L: 15 ext
STJ ROM R: 0 in/6 ev; L: 20 inv, 10 ev = limited ROM on R
STJNP, R: 4 valgus
STJNP, L: 0
MTJ: R: 4 inv; L: 6 ev
Ankle DF: KE 5 and KF 10, bil
1st Ray: 5 DF and 5 PF, bil
1st MTP: R: unloaded 55, loaded 30; L: 60 unloaded, 32 loaded
TI: R: 0, L: 0
NCSP:

R: 4 valgus + 0 = 4 valgus
L: 0 + 0 = 0 degrees
Max Pronation:
R: 6 everted + 0 = 6 everted
L: 10 everted + 0 = 10 everted
RCSP
R: 4 valgus, fully compensated
L: 6 varus, fully compensated
Labs/X-rays:
Harris & Beath Projection, bil: open middle and posterior STJ on L, narrowed middle and closed
posterior STJ facets on R consistent with posterior STJ coalition
Lateral Projection of the Foot, bil: halo sign, talar beaking, rounding of lateral talar process and
noted osseous fusion of posterior STJ consistent with coaltion. Flat foot noted with decreased
calcaneal inclination angle consistent with pes planus, bil.
DP Foot Projection, bil: HAV, bil but more pronounced on the L
Lateral Oblique Ankle Projection, bil: L: talar dome is intact.
ASSESSEMENT
1. STJ Coalition of the posterior facet, R
2. Structural Hallux Limitus, bil
3. HAV, bil.
4. HDS 4-5, bil
5. Gastrocnemius equinus, bil
Other Possible Differentials:
1. PTTD
2. OCD
3. Tarsal Tunnel Syndrome
4. Peroneal Spastic Flatfoot
5. Lateral Ankle Sprain
PLAN
Performed focused podiatric H&P. Discussed conservative Tx options with pt. Instructed pt to RICE the area and
immobilize his foot as much as possible. Prescribed Naproxen 600 mg q 6 hrs and accommodative orthoses for the pt
and instructed him to wear his orthoses in his shoes. If pain persists and conservative Tx fails, discussed the
possibility of STJ arthrodesis. Pt RTC in 2 weeks.
Orthotic Prescription: cast pt pronated, because cant get the pt to neutral

NOTES:
Case 2
SUBJECTIVE
30 y/o African American male PTC complaining of pain on the bottom of his left arch and heel. Pt states that the
problem started 2 months ago when he started training for the Chicago Marathon. Pt states pain reaches a 6 or 7/10
on the pain scale. Pt states that the pain is worse after standing for a long period of time and after running long
distances. Pt states his normal routine is 3 miles 3 times a week. Pt states he has tried new running shoes but that has
not seem to help. Pt states nothing seems to make it better. Pt states he has not had this problem before.
Allergies: Nickel and Chrome gives him a rash
Medications: Prednisone 10 mg for 3 months
Diagnosed Diseases: Sickle Cell Anemia, Sarcoidosis diagnosed 1 year ago, Gouty Arthritis
Childhood Disease: unknown
Immunizations: Pt states they are UTD
Surgical History/Hospitalizations: Hospitalized for a Sickle Cell Anemia Attack 4 years ago
Social History: Pt works as a ticket agent for American Airlines. Pt denies smoking and illicit drug use but drinks
alcohol socially. Pt states he lives alone.
Family History: Brother- Juvenile Rheumatoid Arthritis, Father- flat feet, was discharge from the military. Mother+ for sickle cell trait.
ROS: Pt denies any weight gain, respiratory changes, neurological manifestations, or GI issues. Positive findings
associated with his systemic diseases.
OBJECTIVE
Vitals: unremarkable
General: well nourished, cooperative male, AOx3 in moderate distress
Integument: Diffuse callus noted at the plantar aspect of met heads 3-5, bil. Hair to the level of the digits, bil. Skin is
warm, bil.
Vascular: DP and PT 2/4, bil. Mild edema, erythema noted at the plantar medial heel, left.
Neurological: Intact sharp/dull and proprioception bil. Patellar and Achilles reflexes 2/4, bil.
MSK/Gait: POP at the plantar and medial aspect of the left heel. No pain is present with AJ ROM. Muscle strength
5/5 in all muscle groups, bil. Contracted digits 4-5, bil with mild varus rotation of the 5 th toe, bil.
Biomechanical Exam:

Limb length:
True R: 87.5 cm, L: 88.5 cm
Apparent R: 97.5 cm, L: 98 cm
Hip: 45/45 int/ext, bil
Knee: genu valgum
Malleoli: 15 ext R, 18 ext L
STJ R 16 inv/6 ev; L: 26 in/6 ev
STJNP: 4 inv, bil
MTJ: 3 inv, bil
Ankle DF: 5 KE, 10 KF, bil
1st ray R: 5 mm DF, 3 mm PF; L: 5 mm DF, 5 mm PF
1st MTP: R: 50 DF unloaded /25 PF; L: 50 DF/25 PF
Tibial Influence 4 inv, bil
NCSP:
R: 4 varus + 4 varus = 8 varus
L: 4 varus + 4 varus = 8 varus
Max Pronated:
R: 6 everted + 4 inverted = 2 everted
L: 6 everted + 4 inverted = 2 everted
RCSP:
R: 2 valgus, partially compensated with the FF 1 degree still off the floor
L: 2 valgus, partially compensated with the FF 1 degree still off the floor

X-ray: lateral foot: osteoporosis, increased trabecular pattern in the calcaneus, heel spur, left
ASSESSEMENT
1. Pagets Disease
2. Pathologic Calcaneal Fracture, left
2. Combined Partially Compensated Limb Length Discrepancy, R limb shorter
3. Gastrocnemius Equinus, bil
4. Structural Hallux Limitus, bil
Other possible Diagnoses:
1. Plantar Fasciitis, L
2. AVN of the Calcaneus, L
3. Medullary Infarct of Calcaneus, L
4. Osteitis of Garre of Calcaneus, L
5. PTTD, L
PLAN
Performed a focus podiatric H & P. Discussed possible treatment options with patient. Ordered serum alkaline
phosphatase and ESR labs. Recommended to pt to RICE and stop running at this time. Prescribed Ibuprofen 800 mg
1 tab PO q6h and Alendronate 40 mg QD 30 min before meals for 6 months. Also prescribed orthoses for the pt. Pt is
to RTC in 2 weeks for f/u.
Orthosis prescription: functional, cast pt in neutral, post to RF deformity (because really not much deformity
in the forefoot), extrinsic post and intrinsic post combo so not so much into the foot, Kirby skive: 1mm=2
degrees**** 4 mm Kirby=8 degree post (intrinsic post) and a 3 degree FF post to keep the STJ in neutral after
heel lift
Medical management: Pagets aka Osteitis Deformans, phalens test: evert the foot and try to put pressure on
the medial side of the foot (to r/o baxters nerve entrapment), watch for hat or shoe size changes, other
bisphonate risondronate (Ectanol). Know the phases of pagets for the EXAM, males greater than females,
continually monitor because it can become malignant osteosarcoma. Know the drug etindronate

Case 3
SUBJECTIVE
25 y/o male PTC complaining of a sharp and nagging heel pain. Pt states it is located at the medial and lateral plantar
aspects of the L heel. Pt states that the pain fluctuates but has been constant since he had reconstructive surgery for
his flat left foot 6 months ago. Pt states that standing or walking for a long period of time makes the pain worse. Pt
states he was referred here to get orthotics by the surgeon who performed the reconstructive surgery. Pt states that the
surgeon who performed the surgery was a podiatrist.
Allergies: NKDA
Medications: denies
Diagnosed Diseases: denies
Childhood Disease: denies
Immunizations: UTD
Surgical History/Hospitalizations: denies
Social History: Pt states he is unemployed and denies tobacco, alcohol, or illicit drug use. Pt states that he exercises
on a regular basis in his gym shoes that very worn out and over two years old.
Family History: Non-contributory
ROS: Pt denies weight loss, headaches, N/V. EENT: Pt states he wears glasses MSK: Pt states he has arthritis in his
L shoulder, ankle, and thumb.
OBJECTIVE
Vitals: T: 97.9 F, RR: 18 bpm; Pulse: 78 bpm; BP: 145/88 mmHg; Height: 60, W: 380 lbs.
General: cooperative, obese, and euthymic, AOx3, alert in moderate distress
Integument: Diffuse HPK sub 1st and 5th met heads, R. Diffuse plantar medial heel, bil, pinpoint nucleated planter
posterior heel, L. Surgical scars dorsal medial ankle, left. 3cm lateral calcaneus, L.
Vascular: PT, DP 1/4, bil. CFT<3 sec all digits, bil. Minimal non-pitting edema noted at L ankle.
Neurological: proprioception, vibratory, and sharp/dull intact, bil.
MSK/Gait: decreased medial arch, bil L>R. POP at medial and lateral aspect of L heel. Prominent styloid process
bil. Pain at anterior aspect of L ankle with ankle DF. Gait: apropulsive with adductory twist, L foot with decreased
angle of gait, bil. Marked pronation with everted calcaneus, bil. 1st MTPJ and IPJ plantarflexed during midstance, L.
Biomechanical Exam:

Postural: unable to evaluate

Hip Joint: deferred due to size
Knee: marked abduction of tibia on femur, bil
Malleolar:13 ext, bil
STJ R: 3 inv/0ev; L: 8 in/0ev
STJNP: R: 4 inv; L: 2 inv
Midtarsal Joint: R: 10 inv, L: 12 inv
Ankle R: -4 KE, -4 KF; L: 4 KE, 5 KF
1st ray: 2mm DP, 5 mm PF, bil
1st MTP: unloaded R: 28 R; L: 25 L
TI : R: 4 ev; L:6 ev
NSCP:
R: 4 inverted + 4 everted = 0
L: 2 inverted + 6 everted = 4 valgus
Max Pronated:
R: 0 eversion + 4 everted = 4 valgus
L: 0 eversion + 6 everted = 6 valgus
RCSP:
R: 4 valgus, partially compensated with FF still off the floor 6 degrees
L: 6 valgus, partially compensated with FF still off the floor 10 degrees

Xrays:
AP, bil. Nonunion of 1st cuneonavicular arthrodesis, L. Increased metatarsus adductus angle, L>R. Decreased
joint space of 1st MTPJ, L.
Lateral foot, bil: talonaviuclar fusion, L. Healed osteotomy of calcaneus indicated by sclerotic line, L. Screw
backing out of the posterior calcaneus, L
ASSESSEMENT
1. Metatarsus Adductus, bil
2. 1. Nonunion of cuneionavicular fusion, L
3. FF Supinatus, bil
4. DJD 1st MTP, L.
5. Gastro-soleal equinus, bil.
6. Genu Valgum
7. Plantarflexed 1st ray, bil
8. Structural hallux limitus, bil
Other differentials:
1. Tarsal Tunnel
2. CRPS
2. DJD Secondary to surgery
3. Tendinitis
4. Plantar Fasciitis
5. Pes Planus
PLAN
Performed a focused podiatric H & P. Discussed treatment option with patient on how to conservatively address the
patients chief complaint. Refer pt back to surgeon for further assessment to address metatarsus adductus. Prescribed
the pt a CAM boot to offload the L foot and debrided the nucleated lesion on the posterior heel, left. Informed the pt
that once metatarsus adductus is addressed by his surgeon and his screw in his heel is removed, he should come back
for casting of orthoses. Referred the pt to a local nutritionist to provide him with dietary modifications to assist him
in losing weight. Pt to RTC in 2 weeks for f/u.
NOTES: FUNCTIONALS WILL NOT WORK FOR THIS PT. Accommodative casted pronated.
Orthotic: accommodative pronated device, partial WB, take the screw out and
***KNOW THE PROCEDURES for this deformity (surgery), HHS (<3 y/o), osseous procedures for this (fowler)
Berman-Gartland, Lepird, McCormick and blount, staytler and VanDerWalt, Peabody and Muro, Johnson, Cotton,
Koutsigiannas
Medical Management: shortened the medial column and lengthened the lateral column, by fusing it youre taking
away the pronation the pt needed to compensate, so he is going to continue to pronate through it and cause a nonunion, want him to lose weight before you do another surgery, sent him to a nutrionist, Sx failed because he had met
adductus that wasnt addressed, he was overweight, he has equinus, surgeon picked a procedure that took away his
means of compensating for the deformity, consider FF supinatus with a FF varus of equal to or greater than 8.
For this pt, accommodative casted pronated would have worked best. With orthoses, this pt achieved an 80%
reduction in pain, the only thing causing him pain still was the screw backing out.

Case 4
SUBJECTIVE
44 y/o African American female PTC for f/u of an ulcer on her L foot. Pt states the ulcer is located underneath her
big toe. Pt states she has had the ulcer for 10 months and it hasnt gotten worse to her knowledge. The ulcer does not
cause her any pain or discomfort. She was previously treated for the ulcer with casting, surgical shoes, debridement,
and antibiotics. Pt states the ulcer had healed but now it is back again.
Allergies: NKDA
Medications: NPH 30 units QD
Diagnosed Diseases: DM Type 2 for 4 years
Childhood Disease: denies
Immunizations: UTD
Surgical History/Hospitalizations: denies
Social History: Pt states she is a PE teacher and coaches extracurricular sports. Pt states she works out with the
team. Pt relates to being single, has no children, and lives alone. Denies tobacco, alcohol, and illicit drug use.
Family History: noncontributory
ROS: Pt denies weight loss, fatigue, headaches, vision changes, hearing problems, SOB, palpitations, and diarrhea.
OBJECTIVE
Vitals: stable; Accucheck: 148 mg/dl 2 hours post-prandial

General: AOx3, NAD

Integument: no HPKs noted. Plantar proximal L hallux Wagner Grade 2 ulcer, 1 cmx1cmx0.2cm. Beefy red
granulation tissue with mild odor, hyperkaratotic border, and mild serous drainage from the wound. No tissue
necrosis noted.
Vascular: DP, PT palpable, bil. CFT< 2 sec in all digits. No varicosities noted. Slight edema at the L hallux.
Neurological: SWMF 6/10, L and 8/10, R. Proprioception intact. Decreased sharp/dull and vibratory intact to the
level of the midfoot, bil.
MSK/Gait: Severely pronated, bil. Digits 2-5 contracted at PIPJ, bil. No POP or with ROM in all pedal joints, bil.
Biomechanical Exam:

Angle of gait: R: 15 abd, L: 18 abd

Base of gait: 3 inch, bil
Contact & propulsive phases decreased and midstance increased. IP joint was symmetrical, bil.
Malleoli: 18 ext bil
STJ: R: 20 inv/8 ev, R, 2 inv NP; L 18 inv/7 ev NP 2 inv L
STJNP: R: 2 varus; L: 2 varus
Midtarsal: R: 2 inv, L: 4 inv
Ankle DF: KE 0, KF 2, bil
1st ray R: 5 mm PF and DF; L 6 mm DF, 4 mm PF
1st MPJ: R 50 NWB, 34 WB; L 34 NWB, 20 WB
Tibial Influence 2 inv, bil
NCSP:
R: 2 inverted + 2 inverted = 4 varus
L: 2 inverted + 2 inverted = 4 varus
Max pronated:
R: 2 inverted + 8 everted = 6 everted
L: 7 everted + 2 inverted = 5 everted
RCSP:
R: 2 varus, fully compensated
L: 4 varus, partially compensated with the FF still 3 degrees off the ground
X-ray
Lateral Projection foot, bil: Pes Valgus, bil. Decreased area of density noted at the distal
phalanx of the hallux consistent with an MTJ fault and arthritis
ASSESSEMENT

1. Wagner Grade 2 ulcer, L hallux

2. Structural Hallux Limitus, bil
3. Gastrosoleal Equinus, bil

Differentials:
1. Pes Planus
1. Structural Hallux Limitus
2. OM, L hallux
3. Charcot
PLAN
Discussed treatment options with pt. Debrided ulcer on L hallux and applied Silvercell to the area. Applied an Unna
boot to the patients left leg to relieve pressure around the ulceration. Pt RTC for f/u in 1 week. Prescription for
orthoses will be given after the ulcer heals for long term care.
Orthotic: accommodative cast PWB, shoes- toe rocker or FF rocker, do NOT do a sweet spot because will actually
cause more sheer forces on the area (digits are just too hard to control)
Medical management: VIPs of wound care, cardinal signs of infection debridement, wound care products (silver
product, regranix- PDF in a gel form) Shimmy shoe- shoe with a metatarsal bar that can be moved or adjusted. Toe
rocker shoe modification, check albumin to see if tissue will heal (normal 3.5-5), Total contact cast, instant total
contact cast
Know Wagner classification; would be grade 2, colonized but not infected
Need growth factors and vascularity in order for granulation tissue to form, can be inhibited by MMPs; debride and
irrigate in order to remove some of the MMPs, may also consider products such as silvadene, isosorb, calcium
alginate with silver, restore ag, acticoat (can stay on for up to 3 days; acitcoat 7 lasts 7 days), silverlon (nylon
interwoven with silver, very expensive), prisma (promogran is the version w/o silver), hydroferro blue (non-silver
product, very effective against MMPs, acts like sponge to remove exudate, kept on for 2-3 days, if it turns from blue
to white, then it needs to be removed), granX (contains only 1 growth factor, must be kept refrigerated), Accuzyme &
Panafil (both removed from the market but were very effective
Bio-engineered substrates: Dermagraft, Apligraft, Graft jacket (cadaveric tissue), Oasis; (Procine and bovine
products, need to watch out for allergies and religions that dont use pork), Medahoney (leptosporine bees honey,
remove the spores, its pro-granulation substance and inhibits bacterial growth)

Case 5:
SUBJECTIVE

47 y/o female PTC with pain on her medial left ankle. Pt is unsure of when it started but states it is a
constant pain that has gradually been getting worse over the last few months. Pt states when the pain is the
worst it is a 5/10. Pt states she is having difficulty walking at the end of the day after her daily aerobics
class. Pt states she has tried taking Advil and has changed her shoes. Pt states her PCP referred her to your
office.
Allergies: NKDA
Medications: Norvasc 5 mg, Metformin 500 mg QD
Diagnosed Diseases: DM 2 for 5 years, HTN
Childhood Disease: denies
Immunizations: UTD
Surgical History/Hospitalizations: denies
Social History: Pt states she is a lawyer and teaches aerobics twice a week. Pt relates to having 3 glasses of wine a
week but denies use of tobacco. Pt states she lives by herself.
Family History: Mom has RA, Father died of a heart attack.
ROS: Pt denies fatigue, weight loss/gain. ROS is unremarkable other than DM and HTN.
OBJECTIVE
Vitals: stable, non-contributory. Accucheck: 128 mg/dl 4 hours post prandial
General: AOx3
Integument: non-contributory
Vascular: DP/PT 2/4, bil. Hair to digits, bil.
Neurological: Epicritic sensation intact, bil. SWMF 10/10, bil.
MSK/Gait: POP along navicular and inferior to medial malleolus at the L. Pes planus, bil but greater on the

L. FF Abduction of L foot in stance during gait. Muscle strength: 5/5, bil. but 4/5 for PT on the left. PT
tendon is central to the medial malleolus which is more apparent on the L. Contracted 5th digit, bil.
Biomechanical Exam:

Base of gait R: 2 in, L: 5 in

Limb length: True R 98, L 99; Apparent R 101, L 101. Shoulder drop L. Asymmetric arm swing L
Hip: R: 25 int 30 ext KE, 30 int 32 ext KF; L: 23 int 28 ext KE, 26 int 30 ext KF
Malleoli: R: 14 ext; L: 20 ext
STJ: R: 24 inv/10 ev, np 0; L: 22 in/14 ev; NP 2
STJNP: R: 0
L: 2 everted
MTJ: R: 2 ev, L: 4 ev
AKJ DF: 5 KE, 10 KF, bil
1st ray 3 DF, 7 PF, bil
1st MTP r: 50 unloaded, 30 loaded; L 45 unloaded, 25 loaded
TI 2 inverted, bil
NCSP:
R: 0 + 2 inverted = 2 varus
L: 2 everted + 2 inverted = 0
Max Pronation:
R: 10 everted + 2 inverted = 8 everted
L: 14 everted + 0 = 14 everted
RCSP:
R: 2 varus, fully compensated
L: 4 varus, fully compensated
X-ray
AP foot, bil: subchondral sclerosis of 1st MTP, bil consistent with DJD of 1st MTPJ. Mild HAV on
the R. Digitis equinity varus, bil.

Lateral L foot: mild breech at the MTJ, Anterior displaced cyma line consistent with a pronated foot
structure. Moderate MPE. R: mild breech at MTJ, narrowed TNJ, cyma line is anteriorly displaced.
ASSESSEMENT
1. PTTD Stage 2, Left
2. True Fully Compensated Structural Limb Length Inequality with shorter R limb
3. DJD 1st MTPJ
4. Plantarflexed 1st ray, bil
5. HDS 5th digit, bil
6. Gastrocnemius equinus
Other possible diagnoses:
1. OA
2. Tarsal Tunnel Syndrome
3. Accessory Navicular bone, left
4. Spastic Flat Foot
PLAN
Performed focused podiatric H & P. Discussed treatment options with the pt. Prescribed orthoses for the pt and
instructed her to RICE and offload foot. Prescribed Naproxen 600 mg q6hrs. Taped the pts left foot in a high dye
fashion to provide support for the foot. Discussed surgical options if pain progresses and STJ becomes rigid. Pt to
RTC 1 week for f/u.
Orthoses: R: RF deformity is WNL, so post with heel perpendicular, and really no FF post, L: 4 degree intrinsic post
with reverse motons extension or metatarsal bar (2mm bar), 2 degrees on the right, 4 on the left (cant do 1 st ray cut
out because FF valgus, toe would go into the floor) need to make sure they fit into her shoes, fluffy wedge
Medical management: Johnson and Strom Classification, Rosenburg Classification (radiographic, ultrasound), Conti
Classification, single/double heel raise test, jack test, Hinterman test, too many toes sign, Positive Helbings sign
(lateral bowing of the Achilles tendon), check muscle strength against Plantarflexion and inversion, palpate the
tendon. Obesity, HTN , DM causes glycosylation of collagen fibers to decrease elasticity. High Dye (low dye with
cross over J) and low dye.
Possible tx: physical therapy, Richie brace, NSAIDs, taping, CAM boot

Case 6:
SUBJECTIVE

14 y/o male PTC with his mother who states her son has a high arch and difficulty walking. Pt states he
first noticed it 2 years ago when he was running, and it happens when he plays basketball. Pt states it is
getting worse and is constant in both feet. Pts mother says the pediatrician told her he suspected Beckers
Muscular Dystrophy and that she should take her son to get a work up from another doctor. Pts mother
states that her son has currently not had any treatment. Pts mother states she wanted a second opinion and
thought the podiatrist could help because it involves his feet.
Allergies: seasonal allergies; dogs and cats
Medications: Zyrtec 10 mg for allergies PRN
Diagnosed Diseases: Denies
Immunizations: UTD
Surgical History/Hospitalizations: PE tube at 4 y/o
Social History: Pt states he is in 8th grade and loves to play basketball. Pt denies tobacco, alcohol, illicit drug use.
Family History: Pt states he is the first born of 3 total children and that his younger brother and sister are healthy.
Pts mom states that she and the boys father are alive and well.
ROS: Pt denies F/C/N/V. Pt relates to persistent UTIs at age 6 but no pathology revealed. Pts mother states

her son had a UPT that showed normal collection and a normal IVP.
Obstetrics: Pts mother states she delivered the boy by C section at term due to fetal tachycardia. Pts
mother denies any postnatal complications or resuscitation. Pts mother states the birth weight was 7 lbs 14
oz and his milestones are as follows: Sat: 6 mo, Walked: 11 mo, potty trained at 2.5 yrs.
OBJECTIVE
Vitals: T 98.6 F, P 100 bpm, RR 16 bpm, BP: 126/80 mmHg
General: AOx3 NAD
Integument: color, texture, temp all normal.
Vascular: DP/PT, popliteal and femoral 1/4 bil.
Neurological: DTRs absent, bil. Sharp/dull intact, bil. Vibratory intact, bil. Normal muscle tone. CNs intact.
MSK/Gait: intrinsic muscles in hands are atrophied. STJ in version 35, eversion 3, bil. Ankle DF: 0 KE and

KF, bil. Spine is straight & hips are stable. Proximal strength: 5/5 in all extremities but distal strength 4/5 in
all extremities. Gait: toe-to-hell pattern, bil. Feet in cavo-varus position with inverted heels, bil.
Biomechanical Exam:

AJ DF: KE, 0 bil; 10 KF, bil.

STJ: R 35 inv, 3 ev; L 35 inv, 3 ev
STJNP: R: 8 varus
L: 9 varus
MTJ: 6 valgus 1-5 and 2 valgus 2-5, bil.
1st ray: 0 DF, 12 PF, bil
1st MTJ: R: 65 unloaded, 35 loaded; L: 68 unloaded, 30 loaded
TI: 2 varus, bil
NCSP
R: 8 varus + 2 varus = 10 varus
L: 9 varus + 2 varus = 11 varus
Max Pronation
R: 3 eversion + 2 inverted = 1 valgus
L: 3 eversion + 2 inverted = 1 valgus
RCSP:
R: 1 valgus, partially compensated with the FF 1 degree still off the floor
L: 1 valgus, partially compensated with the FF 1 degree still off the floor
X-ray
DP, bil: open growth plates, metatarsus adductus, bil, laterally deviated talar head

Lateral Foot, bil: Decreased talar declination, increased calcaneal inclination angle, posteriorly
displaced cyma line
Labs: CPK 135 (normal 200), Aldolase 5 (normal 2.7-8.8), NCV in Tibial and common peroneal was 10
m/s (normal 5) EMG: neuropathic
ASSESSEMENT
1. Becker Muscular Dystrophy
2. Congenital Rigid Plantarflexed 1st ray, bil
3. Metatarsus Adductus, bil.
4. HDS
Other Possible Diagnoses:
1. CMT Disease
2. Duchennes Muscular Dystrophy
3. Emery Dreifuss
4. Myasthenia Gravis
PLAN
Performed focused podiatric H & P. Discussed treatment options with pt and his mother. Referred pt to muscular
dystrophy clinic. Prescribed AFO and physical therapy for pt. If contractures become problematic, surgical release of
the soft tissue structures were discussed. Pt RTC in 3 weeks.
NOTES: WOULD NOT SEE THE DIMINISHED NVCs with BECKERS, which is probably why it is NOT Beckers.
Orthotic prescription: has a foot drop, dorsiflexory assist or spring leaf brace to fix it)
Medical Management: weakness was proximal instead of distal, CPK outcome, NCVs,
Sx. DFWO, Koutsi, Steindler stripping, Watkins procedure, transferring TA is contraindicated because muscle is
already weak; Dwyer
HNPPfoot stays asleep for long time (similar to CMT Type 1A)
Initial tx: Richie brace with dorsiflexory assist, physical therapy; probably wouldnt use an orthotic rx

Case 7
SUBJECTIVE
45 y/o male PTC complaining of heel pain in both heels. Pt states the pain started 2 months ago on the bottom of his
heels. Pt describes the pain as a constant and that is the worst when getting out of bed in the morning. Pt rates it as
8/10 and states he has tried wearing gym shoes but it does not seem to help.
Allergies: NKDA
Medications: Lasix, Metformin, Atenolol, Simvastatin
Diagnosed Diseases: HTN, DM type 2, hypercholesterolemia
Childhood Disease: denies
Immunizations: unknown
Surgical History/Hospitalizations: denies
Social History: Pt states his is an inventory stocker at home depot. Pt states he smokes but denies drinking and

illicit drug use. Pt states he is single.

Family History: Pt state his mother and father died of abdominal cancer
ROS: Pt denies F/C/N/V but relates to lower back pain but has not been evaluated or treated.
OBJECTIVE
Vitals: unremarkable
General: AOx3. Moderate distress.
Integument: unremarkable
Vascular: DP/PT are 2/4, bil. CFT < 3 sec. No edema noted.
Neurological: Sensation is grossly intact. SWMF: 10/10, bil
MSK/Gait: POP of the medial tubercle of calcaneus, bil. Pain on POP of central heel bil; POP of peroneal

tendons. Negative Tinels sign. ROM: limited ankle DF; unable to attain 90 degrees with knee extended or
flexed. Gait: normal and propulsive.
Biomechanical Exam:
Angle: 15, bil
Base: 2 inch, bil
Postural: R: 95.7 T, 106.0 A; L: 96.0 T, 106.0 A
AJ DF KE: -12 R, -15 L; KF: -1 R, -12 L
STJ: R: 18 inv, 5 ev; L: 15 inv, 4 ev
STJNP:
R: 4 varus
L: 3 varus
MTJ: 1-5: R: 9 varus; L: 8 varus
MTJ 2-5: R: 7 varus; L: 5 varus
1st Ray: R: DF: 12 mm, PF: 8 mm; L: DF: 11 mm, PF: 5 mm PF
NP: R: 2 mm DF; L: 3 mm DF
1st MTPJ: R: 38 unloaded, 8 loaded; L: 35 unloaded, 10 loaded
TI: R: 3 varus; L: 2 varus
NCSP:
R: 4 inverted + 3 inverted = 7 varus
L: 3 inverted + 2 inverted = 5 varus
Max Pronated:
R: 5 eversion + 3 inversion = 2 valgus
L: 4 eversion + 2 inversion = 2 valgus
RCSP:
R: 2 valgus, partially compensated with the FF still 5 degrees off the ground
L: 2 valgus, partially compensated with the FF still 1 degree off the ground

X-rays:
Lateral foot: Calcification at insertion of Achilles and plantar fascia, peroneal tendons seen on lateral and
DP, worse on left than right, entheseopathy
DP: accessory sesamoids and calcification of 1st MPJ capsule-R

L: hyperostosis on medial aspect of distal phalanx of hallux and calcification lateral to fibular
sesamoid
Spine: bamboo spine
Labs: HLA B27 Positive, increased ESR
ASSESSEMENT
1. DISH
2. Entheseopathy of Achilles causing Boney/Soleal Equinus, bil
3. MPE, bil.
4. Combined structural and functional hallux limitus, bil.
5. DJD 1st MTPJ
6. Digniti Equinti Varus, bil.
Other possible Diagnoses:
1. Ankylosing Spondylitis
2. Plantar Fasciitis
3. Reiters disease
4. Myositis ossificans
PLAN
Performed focused podiatric H & P. Discussed treatment options with pt regarding short term and long term care.
Referred pt to rheumatologist for a consult. Prescribed PT, orthoses, and Ibuprofen 600 mg q6hrs for the pt. Low dye
taping applied to both of the pts feet. Discussed possible steroid injection at future visit. Pt to RTC in 2 weeks for
f/u.
Orthotic Prescription:
1. functional orthotic- posted 6 degrees (according to his #s, I think mine are different)
Refer to the rheumatologist (HLA-B27 generally positive in many autoimmune dz)
Accommadative partial WB

Case 8
SUBJECTIVE
37 y/o male PTC complaining of a non-healing ulcer after a left foot transmetatarsal amputation that occurred a
month ago. The pt states there is no pain associated with the ulcer, but that it has gotten worse since he was
discharged from surgery. Pt states he has noticed drainage and gangrene near the ulcer. Before he was discharged, he
states he was diagnosed with a MRSA infection. He is currently taking IV vancomycin. Pt stated he arrived at the
office using a transportation serve and states he wears a wedge rocker shoe most of the time.
Allergies: NKDA
Medications:

Humulin 70/30- SubQ suspension 15 units at bed time, and 20 units in the morning
Nephedapine 30 mg QD
Renvela 800 mg TID
Sensopar 30 mg QD
Baby Aspirin 81 mg QD
50 mg Atenolol, QD
20 mg Enalopril BID
2.5 mg Midoxidil BID
20 mg Omeprazole QD
Diagnosed Diseases: DM 2 w/neurological manifestations, end stage renal disease, dialysis for renal failure,

HTN, GERD, recent MRSA infection

Childhood Disease: denies
Immunizations: UTD
Surgical History/Hospitalizations: Pt states he had surgery on Dec 7, 2012 for transmetatarsal amputation of the L
foot and a digital amputation previously
Social History: Pt states he is on disability and lives with family members
Family History: non-contributory
ROS: Pt denies fevers, chills, sweats, palpitations, SOB, arthritis, headache, sinus issues, or urinary issues.

Pt relates to having kidney failure.

OBJECTIVE
Vitals: unremarkable
General: AO x3
Integument: Warm & dry. Serosanginous & serous drainage from the L foot. 5 cmx19.4x5.5cm. Sinus tracts

3cm at 8 oclock, 4.5 cm at 2 oclock, 4 cm at 12 o clock. Depth is varied. Moderate tunneling and
undermining. Necrotic and gangrenous tissue within the wound and at the periphery of the wound.
Hypergranulation and fibrin deposition but nonviable tissue due to orientation of the sinus tract. No
epithelization noted. There is exposed muscle, tendon, and fascial layers. Edema around the wound
w/callus around the periphery. Escher with gangrenous tissue along the wound edge.
Vascular: Left PT is nonpalp; monophasic & strong on Doppler; all others are normal. Edema noted around
the wound. No heart murmurs and normal rhythm.
ABI: DP and PT could not be calculated on R or L leg. Noncompressible suggesting calcific
arteriosclerosis.
Arterial Doppler: non-diagnostic due to incompressible vessels and elevated pressure in the L leg.
Suggested other arterial imaging modalities such as CT or ultrasound.
Neurological: neurotrophic due to DM 2; decreased sharp/dull sesnsation
MSK/Gait: Normal ROM, strength. No tenderness in foot or ankle.
X- rays: negative for OM (we were not shown these)
ASSESSEMENT
1. Previous Ulcer with MRSA (Wagner Grade 4), Left
2. Previous OM, left hallux

3. Monckebergs Arteriosclerosis
PLAN
Performed focused podiatric H & P. Discussed both short term and long term treatment options with pt. (Note: pt
eventually healed after wound vac use so now discussed the next step with the healed foot.) Discussed with the
patient the use of custom molded shoes with a heel to toe rocker and orthoses. Prescribed orthoses for the patient and
a toe filler. Pt RTC in 2 weeks for f/u.
Orthotic prescription: TMA filler, custom molded high top/extra depth shoe, MILD support at the ankle
2. solid AFO with custom molded shoe, could do severe rocker, could do extended shank
AFO, with filler and rocker is best for this pt