BOUNCE PHYSICAL THERAPY, PC
BOUNCE PHYSICAL THERAPY, PC
4205 Longbranch Road, Ste. 8
Liverpool, NY 13090
LETTER OF MEDICAL NECESSITY
DATE:
NAME: PHONE:
ADDRESS:
DOB:
PHYSICAL THERAPIST:
Crystal A. Duda, MSPT PHONE: (315) 214-3431
Head Physical Therapist
Facility: Bounce Physical Therapy, PC
4205 Longbranch Road, Ste. 8
Liverpool, NY 13090
Please accept this correspondence as a statement justifying bilateral, insert orthotics to address calcaneal valgus and prolonged, bilateral ankle, foot, knee and hip pain. .
In standing, _________________ demonstrates genu valgus and calcaneal valgus. Further in standing, her degree of pronation is allowing pronation in both the frontal and transverse planes. As a result, increased lateral rotation of tibia and fibula is occurring. Regarding her hip, she has greater than expected medial rotation in standing. This combination of genu valgus, hip medial rotation and lateral tib-fib rotation puts her patella at risk for lateral subluxation/dislocation.
See photo #1 and #2
It is medically necessary that _______________- receive bilateral, custom insert orthotics to support her medial longitudinal arch in order to align her calcaneus with her tib-fib in the frontal plane and align her forefoot in the sagittal plane during weight bearing. This is the only way to support the ligaments of her forefoot and midfoot from further collapse and align her knees out of valgus deformity to allow normal patellar tracking as she grows.
Physician: Dr.
Physician Signature: _________________________________ Date: _________________
Address:
[pic]
PHOTO #1
Note transverse plane pronation, bilaterally.
Note lateral tib-fib rotation as medial malleolus is anterior to the lateral malleolus.
[pic]
PHOTO #2
Note bilateral calcaneal valgus.
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