Hypnotherapy Case Studies

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DOI: 4/24/2013. This is a case of a 59-year-old female customer service representative who sustained injury to her left ankle when she got up after her foot “fell asleep”. As per OMNI notes, patient underwent ligament reconstruction with Brostrom repair on 1/16/2014 and left knee arthroscopy on 10/8/2014. As per office notes dated 6/21/16, the patient returns for interval followup visit. The patient has been working more and is explaining to me that she is having exacerbation of symptoms. The patient admits to increasing neuropathic pain secondary to complex regional pain syndrome. It was mention that the patient has been on Topamax and tramadol which allow the patient to get some improvement. She admits 40% improvement in the pain and she also …show more content…

It was noted that the patient has had increase range of motion and decrease in allodynia due to injection. The patient’s injection has worn off and is in more pain as well as decrease in range of motion noted due to not having the injection performed. It was also mentioned that the patient is doing self-therapy. Currently, the pain is rated as 6 with medication and as 8 if without medications. The pain is located at left knee and ankle. The patient describes it as aching and increased. Physical examination revealed that on palpation of the lumbar facet revealed pain on both the sides at L3-S1 region. There is palpable twitch positive trigger points are noted in the lumbar paraspinous muscles. Motor strength is grossly normal except pain inhibited 4/5 on the left foot eversion and plantar flexion. Examination of the extremity revealed mild increase swelling in ankle and in the 3rd/4th metatarsals. Left ankle reveals increase allodynia and hyperalgesia. Dorsiflexion is 10 degrees. Plantarflexion is 30 degrees. Subtalar joint inversion is 4 degrees secondary to pain. Inversion is 5 degrees, forefoot abduction is 10 degrees, abduction of 20

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