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Reaves v. Martin

United States District Court, S.D. Indiana, Terre Haute Division

October 5, 2016

MARTIN, et. al, Defendants.


          Hon. William T. Lawrence, Judge

         Plaintiff Douglas Reaves, an inmate at the Wabash Valley Correctional Facility, brought this action pursuant to 42 U.S.C. § 1983 alleging that the defendant medical providers failed to properly diagnose and treat his foot pain. He moves for a preliminary injunction that would require medical staff send him to an off-site foot specialist to have a bone spur and spur fragment removed from his left foot. For the following reasons, Reaves's motion [dkt 35] is granted in part to the extent that the defendants are directed to refer Reaves to an outside specialist to evaluate his current condition.

         I. Background [1]

         A. Reaves's Initial Pain Complaints

         On July 16, 2014, Reaves was examined by Dr. Martin for his complaints of left heel pain. Dr. Martin reviewed Reaves's records and labs and performed a physical examination. Upon examination, Dr. Martin determined that Reaves's heel was painful, but there was no obvious cause of the pain. Dr. Martin recommended gel insoles, lifestyle modification (no running and jumping sports), and considering an injection in the future. He prescribed delayed release Ecotrin daily for pain and scheduled Reaves to return in two months.[2]

         On September 4, 2014, Reaves saw Dr. Rajoli in chronic care for his hypertension (“HTN”), GERD, hyperlipidemia, and plantar fasciitis. Dr. Rajoli noted Reaves had tried over the counter foot inserts without much help, and he provided arch supports. Reaves was prescribed delayed release Ecotrin daily for pain and was scheduled to return in three months. On October 14, 2014, Reaves received orthotic arch supports.

         On December 30, 2014, Reaves submitted a request for health care (“HNR”) stating he was having problems with his left foot again and needed to see the doctor. On January 1, 2015, he saw a nurse in response to his HNR. Reaves was prescribed delayed release Ecotrin daily for pain. The nurse referred him to a provider as his foot pain was not improving.

         B. Plantar Fasciitis Diagnosis

         Dr. Byrd saw Reaves for the first time on January 8, 2015 for his complaints of left foot pain. Reaves reported the pain began in his left heel but now covered the arch and midfoot. He had tried orthotics, but the pain was getting worse. Reaves reported mild swelling of the left foot, but no rash, lower leg swelling, chest pain, palpitations, or other complaints. Dr. Byrd performed an examination and noted joint pain and swelling. The left ankle had no cracking sounds or deformity, but was inflexible. He diagnosed Reaves with acute plantar fasciitis[3] and joint and foot pain, and ordered x-rays to rule out a possible stress fracture. Dr. Byrd also continued the daily delayed release Ecotrin and ordered prednisone 20 mg twice daily for pain. On January 9, 2015, Reaves had x-rays of his foot. The x-rays showed no acute bony abnormality but there was a heel spur.

         Inflammation of the tissue on the bottom of the foot, plantar fasciitis, can lead to a bone spur at the underside of the heel bone. Bone spurs may or may not cause symptoms, and they are treated only if they are causing symptoms. Initial treatment is directed toward decreasing inflammation and avoiding re-injury. Anti-inflammatory medications, administered both orally and by local injection, are commonly used, depending on the location of the spur. Mechanical measures such as orthotics, shoe inserts, and bone spur pads might be considered, depending on the location of the bone spur. Shoe inserts take pressure off plantar spurs. Bone spurs that are causing irritation of nerves, tendons or ligaments and are resistant to conservative measures can require surgical operations for treatment. However, this is infrequently done on chronically inflamed spurs.

         On January 30, 2015, Reaves received issued arch supports. Dr. Byrd saw him on February 13, 2015 for a chronic care visit and noted that reported severe left heel pain. He scheduled Reaves to return for an injection into the plantar fascia. In the meantime, he was prescribed Ecotrin and prednisone for pain. On March 13, 2015, Dr. Byrd performed an injection of methylprednisolone acetate into the plantar fascia. This medication is a corticosteroid commonly used in the medical community to treat pain and swelling that occurs with arthritis and other joint disorders.

         C. Podiatrist Consultation and Surgery

         Dr. Byrd saw Reaves again on April 1, 2015. Reaves requested a podiatry visit and reported the prednisone had become less effective and stretching and rehab did not provide relief.[4] Dr. Byrd submitted a request for a podiatrist, which was approved. On May 8, 2015, Reaves had x-rays of his foot, which showed no fracture or dislocation. There was a heel spur but no acute bony abnormalities.

         On May 13, 2015, Reaves saw the podiatrist, Dr. Elliot Kleinman. Dr. Kleinman performed a physical examination and reviewed x-ray results. He noted that x-rays revealed a prior fracture of the left heel spur with approximately a 4mm displacement. He assessed: (1) unresolved acute plantar fasciitis; and (2) apparent prior fracture with calcaneal spur, left heel. Dr. Kleinman discussed a potential surgical procedure for correction of plantar fasciitis including cutting part of the plantar fascia ligament to release tension and relive inflammation. Reaves wished to proceed with the surgery. Dr. Byrd submitted a request for the surgery, which was approved.

         On July 1, 2015, Dr. Kleinman performed the surgery. Dr. Kleinman's post-operative instructions were listed alongside two boxes, one each for “Yes” or “No.” Under “Yes, ” the following instructions applied: (1) Keep foot/feet elevated approximately 6 inches above your hip whenever not walking; (2) keep dressing dry unless otherwise instructed; (3) apply ice packs to the top of the foot/back of the knee 4 times a day, approximately 30 minutes at a time until the first postoperative visit; (4) light ambulation is permitted in your walking boot/surgical shoe only; (5) the walking boot/surgical shoe must be worn whenever weightbearing is permitted; and (6) the walking boot/surgical shoe may be removed whenever not weightbearing. Under the “No” column, the following instructions did not apply: (1) you are to be completely non-weightbearing on the surgically operated foot; and (2) the walking boot/surgical shoe may not be removed until the first postoperative visit. Dr. Kleinman DID NOT order Reaves to be completely non-weightbearing.

         The discharge instructions also stated to follow up with Dr. Kleinman in 10 days to 2 weeks and included aspirin and Norco, which is a combination of hydrocodone and acetaminophen. The postoperative instructions also stated, “DO NOT change the dressing unless instructed by our staff to do so. This is a sterile environment and should not be taken off until your first postoperative visit.” This instruction was included to make sure patients did not remove the bandages on their own in their homes or other non-sterile environments. However, according to Dr. Byrd, the bandages and dressings could be removed in the prison medical unit because it is a sterile environment.

         Reaves saw Nurse MacDonald after he returned from his surgery on July 1, 2015. MacDonald called Dr. Martin and left a message regarding Reaves's return and his Norco prescription. MacDonald educated Reaves on the discharge ...

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