The patient is a gentleman who was involved in an accident in which he suffered a crush injury to the left ankle. He underwent several surgeries to repair the wound on the ankle. The latest surgery was a muscle flap to the ankle. He is still having had the fracture repair and is awaiting to undergo the repair of the fracture per se. As a consequence of the injury, he has been left with sharp, shooting, pins and needle pain across the front ankle that includes the wounds that he has around the muscle flap. It is very painful to walk and he uses an Ace bandage around. Physical therapy has been helping with the pain but is not enough. TENS units only aggravated the pain. He has been using Mobic which marginally helps with the pain along with Percocet 5/325 mg which helps with the pain. He was asking to have an increase either in the dose or the amount of Percocet because he feels that he is not taking enough medication. I told to him that he needs to combine the use of the Percocet with the anti-inflammatory in order to get the maximum benefit. I will start him on Voltaren gel to be applied in the ankle in addition to the opiates. Additionally, we will not make any changes in the opiate regimen since he will be undergoing surgery. An increase in the medication will only increase his tolerance and resistance to these opiates. My recommendation also was the performance of a sympathetic nerve block to cover the pain in the left ankle and keeping it from becoming chronic. This should also help me determine if this is a sympathetically-mediated pain that may benefit from a spinal cord stimulator and/or treatment with sodium channel blockers. The patient is very constant regarding the financial situation since he does not have a secondary insurance. He would like to hold on any kind of procedures until he can obtain a secondary insurance. In fact, he will be holding the surgery until after he obtains a secondary insurance.
1. Ankle joint pain.
2. Osteoarthritis of the left ankle.
4. Enthesopathy of the left ankle joint.
1. Continue the physical therapy.
2. Voltaren gel to be applied to affected area up to three times a day as needed (400 g with three refills).
3. Percocet 5/325 one tablet p.o. q.8h. as needed (30 tablets).
4. Lumbar sympathetic plexus block on the left side is recommended once the patient obtains secondary insurance.
5. Followup in four weeks.