THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rod@welchco.com


S U M M A R Y


DIARY: March 14, 2017 09:30 AM Tuesday; Rod Welch

VA Podiatry Doctor Tang and Doctor Hewitson resolve metatarsalgia right foot.

1...Summary/Objective


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CONTACTS 

SUBJECTS
Hiking 11 - 15 Miles Per Day Patient Profile Curve Significantly Exc                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
1603 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1603 -    ..
1604 - Summary/Objective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
1605 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
160501 - Follow up ref SDS 85 0000. ref SDS 82 0000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
160502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
160503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
160504 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
160505 -            [On 170315 1146 submitted letter to Doctor Tang in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
160506 -            Podiatry, thanking the VA for timely care, and asking for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
160507 -            the name of the treatment that may be offered in clinical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
160508 -            trial for metatarsalgia. ref SDS 87 F64G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
160510 -             ..
160511 -            [On 170327 1430 during meeting in Orthopedics Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
160512 -            Thuillier advised there is no clinical trial nor other line                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
160513 -            of care available at the VAMCSF for using Supartz                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
160514 -            injections to treat metatarsalgia. ref SDS 90 D33N  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
160515 -            doctor diagnosed possible Plantar Plate Tear, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
160516 -            demonstrated procedure for Plantarflexion taping that may                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
160517 -            enable recovery while hiking. ref SDS 90 I54I  Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
160518 -            Thuillier MRI studies on both feet to further assess cause                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
160519 -            of forefoot pain. ref SDS 90 OH9L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
160520 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
160521 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
160522 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
160523 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
160525 -  ..
1606 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1607 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1608 - Background                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
1609 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
160901 - Meeting Doctor Tang in Podiatry on 140805 1030. ref SDS 38 NU4G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
160902 - Progress Notes for meeting on 140805, call for return to clinic after                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
160903 - receiving FFO. ref SDS 38 IJ4G  A few days after meeting on 140805,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
160904 - received letter from VA scheduling follow meeting today on 140820                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
160905 - 1000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
160907 -  ..
160908 - On 140828 meeting with Doctor Kevin Daun and later with Doctor Mihara,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
160909 - attending developed solution to blister on inside of big toe on left                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
160910 - foot, ref SDS 46 W74O, that required stopping 11 mile hike after 8                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
160911 - miles and calling for a ride home, shown in case study on 120101 0900.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
160912 - ref SDS 11 BO6F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
160914 -  ..
160915 - On 140904 0900 meeting with Doctor Cynthia Lieu and Doctor Tang,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
160916 - attending. ref SDS 49 AK6J  Doctor Tang said orthotics can be trimed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
160917 - to fit a smaller shoe size, if necessary; he has scheduled a meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
160918 - after orthotics inserts are received. ref SDS 49 4M3H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
160920 -  ..
160921 - On 150115 0845 meeting with Doctor Tang and Doctor Goodman, the doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
160922 - ordered a 2nd set of orthotic inserts to recover from and prevent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
160923 - recurrance of metatarsalgia. ref SDS 54 BG6I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
160925 -  ..
160926 - On 151215, met with Doctor Hewitson in Podiary. ref SDS 60 AK6J  He                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
160927 - modified the Prolab orthotic inserts applied with Hoka Stinson Lite                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
160928 - shoes size 10 worn today, and for the purpose of improving routine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
160929 - walking gait. ref SDS 60 9B6I  Observation of walking tests, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
160930 - placing the doctor's hands on the patient's hips while standing to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
160931 - evaluate body alignment, indicated to Doctor Hewitson that this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
160932 - initial modification did not correct defect in walking gait, so he                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
160933 - removed that modification and instead raised the heel of the left                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
160934 - orthotic. ref SDS 60 NC7M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
160936 -  ..
160937 - Doctor Hewitson said to bring in the other pair of orthotic inserts on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
160938 - the next meeting in Podiatry for adding modifications that make both                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
160939 - pair the same. ref SDS 60 1J98                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
160941 -  ..
160942 - On 151215 1000 Progress Notes explain modifications to orthotics -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
160943 - Improved gait by decreasing early heel off L, increased L knee                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
160944 - extension, and decreased R recurvatum. ref SDS 61 ZA9I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
160946 -  ..
160947 - On 151215, Doctor Hewitson and his team made molds of the feet to make                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
160948 - new orthodic inserts.  They will be shipped in a few weeks.  When new                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
160949 - orthotics are received, notify VA to schedule follow with Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
160950 - Hewitson to review effectiveness, and to make modifications as needed,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
160951 - and as done on 151215.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
160953 -  ..
160954 - On 151215 1000 Progress Notes confirm follow up meeting will occur                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
160955 - after receiving orthotic inserts. ref SDS 61 PK6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
160957 -  ..
160958 - On 140101 0600 case study reporting on 151222, developed new blister                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
160959 - on left side little toe left foot, possibly related to changed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
160960 - orthotics. ref SDS 17 IE9O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
160962 -  ..
160963 - On 160202 1540 reported injury to right knee, very painful; Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
160964 - Tang recommended not using adjusted orthotic inserts, until meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
160965 - with Doctor Hewitson in Podiatry Biomechanics can evaluate adjustments                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
160966 - to avoid right knee injury. ref SDS 68 WG59                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
160968 -  ..
160969 - On 160325 0443 letter to VA notifies Doctor Tang that orthotic inserts                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
160970 - ordered by Doctor Hewitson on 151215, have been received, so meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
160971 - can be scheduled for Doctor Hewitson to configure the new inserts,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
160972 - ref SDS 69 AK6J, as planned by the doctor during the prior meeting on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
160973 - 151215. ref SDS 60 HM8J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
160975 -  ..
160976 - On 160503 1130 encountered Doctor Hewitson in the cafeteria; he agreed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
160977 - to provide care after lunch at 1300 in Podiatry. 160503 1256,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
160978 - ref SDS 72 9A34                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
160980 -  ..
160981 - On 160503 1300 meeting Doctor Hewitson in Podiatry.  Since this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
160982 - meeting was ad hoc, we did not have the 3 sets of orthotic inserts                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
160983 - which he planned to modify, shown in the record on 151215 1000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
160984 - ref SDS 60 1J98  Scheduled another meeting on 160516, for Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
160985 - Hewitson to improve alignment of ankles, knees and hips. 160503 1256,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
160986 - ref SDS 72 TN94                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
160988 -  ..
160989 - On 161212 meeting with Doctor Alexis Dang in Orthopedics, the doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
160990 - recommended review by Podiatry to correct Tailor's Bunion. ref SDS 74                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
160991 - OG4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
160993 -  ..
160994 - On 161219 2208 wrote letter to Doctor Tang and Doctor Hewitson,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
160995 - ref SDS 76 V13J, requesting care for Tailor's Bunion, ref SDS 76 X659,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
160996 - and prescription for liquid Naproxen. ref SDS 76 X65V                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
160998 -  ..
160999 - On 161220 0927 Doctor Tang offered prescription for diclofenac gel to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
161000 - replace Naproxen to control inflammaton to feet and joints from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
161001 - hiking. ref SDS 77 0657  Letter to Doctor Tang requested prescription.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
161002 - ref SDS 77 J99T  The doctor notified that he ordered diclofenac gel,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
161003 - and can pick it up at Pharmacy today. ref SDS 77 L668                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
161005 -  ..
161006 - On 161221 0730 xray both feet evaluate Tailor's Bunion, and other                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
161007 - injuries to feet. ref SDS 78 JT6G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
161009 -  ..
161010 - On 161221 0822 received prescription from VAMCSF Pharmacy for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
161011 - diclofenac gel to replace Naproxen to control inflammation during                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
161012 - hikes. ref SDS 79 Z38F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
161014 -  ..
161015 - On 161222 1519 Doctor Tang called and reported xray found no evidence                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
161016 - of Tailor's Bunion, nor other severe injury to feet. ref SDS 82 HQ5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
161017 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
161018 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
161020 -  ..
1611 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1612 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1613 - Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
1614 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
161401 - Meeting with Doctor Tang explained significant pain in right foot has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
161402 - prevented hiking for some time.  Cited example on 170310, shown in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
161403 - case study of patient history on 160101 0700. ref SDS 64 205I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
161405 -  ..
161406 - Consider administer treatment right foot cortosine?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
161408 -  ..
161409 - On Sunday met customer at Skipolini's who related her father was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
161410 - getting cortizone injections to recover from metatarsalgia feet pain.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
161411 - The woman said in this case, the treatments are effective for 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
161412 - months.  This is equals relief from treatment with Supartz knee                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
161413 - injections, reported by Eugenia on 170206 1240. ref SDS 83 GT7H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
161415 -  ..
161416 - Research on Internet found...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
161417 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
161418 -        Kaiser                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
161419 -        Metatarsalgia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
161420 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
161421 -              https://thrive.kaiserpermanente.org/care-near-you/northern-california/santarosa/departments/foot-ankle-surgery/foot-and-ankle-surgery/metatarsalgia/                                                                                                                                                                                                                                                                                                                                                                                                                                                 
161423 -         ..
161424 -        Cortisone injections.  (Injection of cortisone is a potent way                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
161425 -        to reduce inflammation and expedite the recovery process.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
161427 -         ..
161428 -        Cortisone does not replace the need for supportive shoes, foot                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
161429 -        orthoses, calf stretching, and other physical measures.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
161431 -         ..
161432 -        The risks of cortisone injections for metatarsalgia include,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
161433 -        but are not limited to: increased pain for 24-72 hours                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
161434 -        following the injection, fat pad atrophy, depigmentation of the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
161435 -        top of the forefoot, weakening of adjacent joint ligaments with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
161436 -        potential dislocation of the toe, and infection.  Systemic side                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
161437 -        effects of this type of injection are extremely rare.)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
161438 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
161440 -  ..
161441 - Another source says...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
161442 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
161443 -              http://www.footeducation.com/page/corticosteroid-injections                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
161445 -  ..
161446 - Today, Doctor Tang advised that cortisone injections to treat                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
161447 - metatarsalgia arising from hiking high mileage (11 - 15 miles per day)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
161448 - in this case presents very high risk of causing irreversible injury.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
161449 - He therefore recommends against this line of care.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
161451 -  ..
161452 - The doctor drew a curve with his finger in the air representing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
161453 - percent of people who do daily aerobic exercise...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
161454 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
161455 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
161456 -      100                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
161457 -       90                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
161458 -       80    x                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
161459 -       70                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
161460 -       60                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
161461 -       50        x                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
161462 -       40                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
161463 -       30                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
161464 -       20                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
161465 -       10              x                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
161466 -        9                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
161467 -        8                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
161468 -        7                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
161469 -        6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
161470 -        5                   x                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
161471 -        4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
161472 -        3                        x                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
161473 -        2                             x                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
161474 -        1                                  x                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
161475 -        0    1    2    3    4    6    7    8     9    10     15                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
161477 -  ..
161478 - He said the VA knows of no one else hiking 11 - 15 miles per day, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
161479 - so there is little experience treating injuries from such high level                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
161480 - activity.  This seemed similar to meeting with Doctor Dang last                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
161481 - December, commenting that VA Orthopedics normally does not treat                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
161482 - patients having difficulties hiking 11 - 15 miles per day, reported on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
161483 - 161212 1632. ref SDS 74 W579                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
161485 -  ..
161486 - Gina made similar comment after giving Supartz injection on 170206                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
161487 - 1240. ref SDS 83 ZO5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
161489 -  ..
161490 - Doctor Tang's graph drawing today, seems similar to Doctor Johnson                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
161491 - drawing a curve showing Millie lived 4 times longer than other stage                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
161492 - IV cancer patients, reported on 090325 0830, ref SDS 9 P39M, and so                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
161493 - Kaiser would refuse further treatment, explained the month before                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
161494 - presenting the standard insurance delima paying for medical costs that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
161495 - compound with response to care, shown on 090213 1140. ref SDS 8 4N5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
161497 -  ..
161498 - We reviewed current orthotics that seem to proivde significant arch                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
161499 - support which reduces pressure on metatrsals at the ball of each foot.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
161500 - This indicates further improvemennt likely cannot be achieved with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
161501 - orthotics.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
161503 -  ..
161504 - Doctor Tang presented options of reducing level of effort and/or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
161505 - changing extended endurance exercise from hiking to swimming and/or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
161506 - biking.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
161508 -  ..
161509 - Doctor Tang seemed aware that hiking unusually high mileage in this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
161510 - case, explained above, ref SDS 0 6D6F, yields significant medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
161511 - benefits raising cholosterol HDL 30 in 2009, to maintaining HDL > 60                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
161512 - over the past 4 years, and as a result yielding very favorable blood                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
161513 - pressure cardiology conditions, and that this improvement has not been                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
161514 - reported using other exercise modalities.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
161516 -  ..
161517 - The doctor explained that attempting to maintain this level of effort                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
161518 - with cortisone injections in the feet would cause severe and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
161519 - irreversible injury that would prevent any further hiking.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
161521 -  ..
161522 - Possible solution would be an orthotic with spongy material on the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
161523 - ball of the foot, so as the foot rolls forward from heel to toes in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
161524 - natural walking gait, pressure from the ground and body weight would                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
161525 - dissipated in compression and release of cushioning material, rather                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
161526 - than the ball of the foot.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
161528 -  ..
161529 - Reviewed favorable results resolving osteoarthritis causing right knee                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
161530 - pain with 3 injections of Supartz ending on 170206 1240. ref SDS 83                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
161531 - LL5N  Asked about using similar injection treatment to resolve                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
161532 - metatarsalgia causing right forefoot pain.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
161534 -  ..
161535 - Doctor Tang said a doctor on staff in Orothopedics Department has a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
161536 - few patients getting an experimental injection treatment, similar to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
161537 - Supartz that was injected into the right knee, ending on 170206 1240.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
161538 - ref SDS 83 7U5G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
161540 -  ..
161541 - Doctor Tang will make a referral for Orthopedics to consider this case                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
161542 - for viability getting the trial injection treatment for metatarsalgia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
161543 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
161544 -            [On 170315 1146 submitted letter to Doctor Tang in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
161545 -            Podiatry, thanking the VA for timely care, and asking for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
161546 -            the name of the treatment that may be offered in clinical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
161547 -            trial for metatarsalgia. ref SDS 87 F64G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
161549 -             ..
161550 -            [On 170317 0847 letter to Gina who gave Supartz injections,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
161551 -            ending on 170206, and requesting meeting for few minutes,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
161552 -            ref SDS 88 H84K, also, called and left message for Gina on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
161553 -            meeting, purpose is to request assistance expediting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
161554 -            meeting on Supartz treatment for metatarsalgia. ref SDS 88                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
161555 -            F97H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
161557 -             ..
161558 -            [On 170318 1113 call from Moses in Orthopedics at VAMCSF,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
161559 -            scheduled meeting to review Supartz injection treatment for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
161560 -            right foot metatarsalgia; meeting on 170327 1430.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
161561 -            ref SDS 89 HQ5O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
161563 -             ..
161564 -            [On 170327 1430 during meeting in Orthopedics Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
161565 -            Thuillier advised there is no clinical trial nor other line                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
161566 -            of care available at the VAMCSF for using Supartz                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
161567 -            injections to treat metatarsalgia. ref SDS 90 D33N  The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
161568 -            doctor diagnosed possible Plantar Plate Tear, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
161569 -            demonstrated procedure for Plantarflexion taping that may                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
161570 -            enable recovery while hiking. ref SDS 90 I54I  Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
161571 -            Thuillier MRI studies on both feet to further assess cause                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
161572 -            of forefoot pain. ref SDS 90 OH9L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
161573 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
161575 -  ..
161576 - Thanked Doctor Tang for good care.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
161577 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
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161586 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
1616 -