DOI: 9/14/2000. The patient is a 60-year old male iron worker who sustained a work-related injury when he tripped over a rocky area. As per OMNI entry, he was initially diagnosed with bilateral knee pain; left ankle pain; and bipolar disorder. He underwent a left ankle surgery in 02/2001; left ankle fusion in 11/2009; knee arthroscopy in 11/2010; and left foot calcaneal osteotomy and removal of retained hardware on 06/03/2013.
Per the PT attendance report dated 07/02/14, the patient has attended 21 visits for the left ankle.
Based on the AME with Dr. Levine dated 06/16/14, the patient is at Permanent and Stationary status with 53% whole person impairment. Future medical care includes intermittent use of non-narcotic analgesics, anti-inflammatory medication, and additional diagnostic testing. He can be provided surgical intervention that could include removal of the retained metal from the left os calcis as well as total knee arthroplasty. …show more content…
Frey, the patient has been seen for the following: status post left subtalar fusion, 11/30/09, with a solid fusion with peroneal tendon weakness and tracking problems of the patella on the left with quadriceps weakness and atrophy; right posterior tibial tendinitis; and status post left calcaneal osteotomy 6/3/13.
The patient was last seen on 03/03/15. He has varus of both hindfeet but more on the left than the right. He does well with the Kunzli boots. These are boots with good medial and lateral support. They also accommodate an orthotic device. He has a prominent screw at the posterior heel on the left, which should be removed. His knee is still bothering him. He has been offloading as a result of his industrial Injury to his left