HPI: The patient is a 49 y/o male with pain along the right ankle. He relates that his pain is predominately along the posterior aspect of his ankle in the area of his achilles tendon, as well as along the anterior aspect of his ankle and his anteriolateral midfoot. He does suffer from Charcot Marie Tooth disease, and demonstrates a significant deformity to the right lower extremity. Over a year ago, the patient had developed ulcerations along the lateral aspect of the right foot in the area of the 5th metatarsal phalangeal joint, which progressed to osteomyelitis which necessitated surgical debridement and IV antibiotics. At that time, he underwent a partial resection of the distal aspect of the 5th metatarsal (following debridement for osteomyelitis and obtaining clean surgical margins) and since that time he has had no further ulcerations along the lateral aspect of the right foot. Most recently, he underwent a percutaneous Achilles tendon lengthening to address a posterior equinus that he demonstrated, which was contributing to a persistent complaint of metatarsalgia and difficulty ambulating within the custom AFO that had been formulated for his use. Upon presentation, the patient is currently approximately 3 months out from his percutaneous tendoachilles lengthening.
PMH: CMT, HTN, hyperlipidemia FAM: CMT, diabetes MED: Ultram, Norvasc
ALL: “Topical antibiotics” which cause a rash. VS: 138/84, HR 85, RR 18, Temp: 98.3
Physical Exam: Upon physical exam, the patient is alert and oriented, he demonstrates an appropriate body habitus, is well nourished, and demonstrates appropriate mood and effect. Upon exam of the patient’s right lower extremity, he demonstrates the classic findings in a patient with CMT—inverted champagne-bottle shaped legs with muscle wasting noted. He has essentially no power in eversion or dorsiflexion, and demonstrates an exaggerated steppage gate with ambulation. In weight bearing, he demonstrates a cavo-varus foot type and evidence of a previous surgical site along the lateral aspect of his right foot from his previous partial 5th ray resection. He demonstrates appropriate palpable pedal pulses at the dorsalis pedis and posterior tibial arteries, and capillary refill is less than 3 seconds in the digits. He is focally tender to palpation along the posterior aspect of his ankle along the Achilles tendon (his incisions from his TAL have healed without incident), as well as tenderness along the lateral aspect of the foot and along the antero-lateral aspect of the midfoot. There is no erythema, no focal temperature changes, and no swelling.
Radiographs (click on the images below for a larger view):
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