Plantar Case Studies

DOI: 7/7/2015. The patient is a 48-year-old male cleaner who sustained a work-related injury to his back while moving a heavy bookcase. As per OMNI, the patient was diagnosed with lumbar degeneration, thoracic or lumbosacral neuritis and myofascial pain.

Per medical report dated 01/23/15, the patient reported of middle and lower back pain and bilateral leg pain with tingling. He was diagnosed with thoracic compression fracture and lumbar spondylolisthesis.

The patient is a 50 year old male construction worker who sustained a work-related injury while lifting heavy boxes of metals. In an office visit dated 12/14/13, patient complaints of intermittent severe low back pain which radiates to bilateral lower extremities. The claimant had an epidural injection, which significantly alleviated right leg pain for a short period of time. Unfortunately pain has returned. It is in the right leg as well as severe pain in the lower back. The claimant wishes to consider surgical intervention due to severity of pain. Objective examination reveals weakness in the right extensor halucis longus and anterior tibialis which are 4+/5. The claimant has diminished sensation along the dorsum of right foot. The claimant has a positive straight leg raise.

On examination, cervical and lumbar spine is restricted in all planes with increased pain. Muscle guarding is also noted. The patient is not able to heel and toe walk. He is obese and deconditioned. Straight leg raise (SLR) is positive bilaterally. Muscle guarding is noted along cervical paraspinal and trapezius muscle groups bilaterally. Sensation is normal to light touch, pinprick, and temperature along all dermatomes of the bilateral upper extremities, except right C6-8, decreased to

DOI: 12/3/2012. The patient is a 49-year-old male route sales representative who sustained a work-related injury to his lumbar spine and shoulders while lifting a bread rack out of his truck. Patient is status post bilateral L4-5 laminotomy, complete facetectomy and foraminotomy on 01/14/15.

Treatment plan includes follow-up with orthopedics, follow-up with psychology, Dr. Gandolfo for additional treatments for major depressive disorder, additional PT 2 x 3 sessions to treat the lumbar spine, additional PT for vestibular rehabilitation, follow-up with neurologist, referral for psychology and follow-up with primary care physician (PCP).

DOI: 12/23/2013. The patient is a 64-year-old male foreman who sustained injury when he was involved in a motor vehicular accident. Per OMNI, he has had multiple injuries to the right shoulder, right knee, back and right arm/elbow. He is status post arthroscopic surgery for the right shoulder on 05/30/2014.

DOI: 06/23/2011. This is a case of 41-year-old male maintenance worker who sustained injury to the low back while taking off a sliding door of a patio. As per OMNI notes, patient is diagnosed with lumbar disc disorder with myelopathy. MRI of the lumbar spine dated 6/28/15 revealed recurrent left paramedian L4-5 disc herniation with caudal extrusion of a 10 mm fragment into the left L5 lateral recess. As per office notes dated 7/25/16, the patient is status post redo left L5-S1 discectomy performed on 4/20/16. It was also noted that the patient had a prior L5 laminotomy several years ago. He subsequently did well. However, he had recurrence of his pain. Pain is radiating into his left leg worse on the right leg. This was unresponsive to conservative

Per PT treatment log dated 11/18/15, the patient has attended 19 PT visits for the thoracic and lumbar spine from 08/27/15 through 11/13/15.

According to the treatment plan, Allana returned to see Dr. Scott on 08/03/15. She told him that she had a bad headache yesterday, and her low back pain was really cranky. According to the treatment plan, she was to go back and see Dr. Scott about two times a week after the August 3rd appointment. The chiropractic visits consisted of repetitive treatment to her cervical spine and to her low back. She told Dr. Scott at times that she thought she felt better, and then on other dates of treatment, she talked about how her

On 12/19/2017, the claimant presented with lumbar pain. She had continued constant nagging pain with radicular pain in the left lower extremity. She had weakness and numbness. In 2012, she underwent L4-S1 fusion. She had lumbar medial branch block in 04/2017, which helped with the axial low back pain by more than 50%, but the radicular pain becomes severe. She stated that the previous bilateral L5 and left S1 selective nerve root block on 06/21/2017 provided 100% pain relief for 3 days before the pain gradually returned. She also had epidural steroid injection and trigger point injection, which did not help with the pain. The alleviating factors include medication, rest, heat, and TENS unit. The previous physical therapy and chiropractic care had helped significantly. Objective findings showed positive straight leg raise test on the left with tenderness in the left lower lumbar area and bilateral

Treatment plan includes additional sessions of physical therapy for shoulder stabilization and strengthening program for 6 visits, in-office medical acupuncture for 6 visits for temporary anti-inflammatory purpose, and continuation with Voltaren gel and Zorvolex. IW will discontinue ibuprofen, Percocet and Conzip. IW was provided a refill tramadol 50 mg 1 tablet every 8 hours as needed #45 for temporary symptomatic pain relief.

MRI of the lumbar spine without contrast dated 07/14/16 revealed a 5 mm right paracentral protrusion at L5-S1, with moderate right lateral recess stenosis. Abutment of the descending right S1 nerve root was seen. Clinical correlation for right S1 radiculopathy was recommended. Mild right foraminal stenosis was seen. At L4-5, central and right foraminal disc protrusions were noted with an annular bulge eccentric to the right. Mild bilateral foraminal

MD did focus on the left hand side. Plan is for one right L4-5 and L5-S 1 radiofrequency facet ablation. It was further noted that the IW has had the following: severe pain that has failed to respond to six months of conservative management (e.g., physical/chiropractic therapy, oral medication, activity modification); pain is not radicular, it is confined to the low back; clinical findings and imaging studies do not suggest another obvious cause of the pain; and most importantly, a diagnostic, lumbar medial branch block with local anesthetic under fluoroscopic guidance has resulted in at least an 85% reduction in pain for the duration of the specific local anesthetic

As per progress report dated 5/2/16, the patient returns for lower backache. She rates her pain with medications as