United States District Court, S.D. Indiana, Terre Haute Division
DOUGLAS A. REAVES, Plaintiff,
MARTIN, et. al, Defendants.
ENTRY GRANTING MOTION FOR EMERGENCY
William T. Lawrence, Judge
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.
Reaves's Initial Pain Complaints
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
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.
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
Plantar Fasciitis Diagnosis
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 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.
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.
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.
Podiatrist Consultation and Surgery
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. 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.
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.
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
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.
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 ...