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M25.675 Stiffness of left foot, not elsewhere classified

Diagnostic Studies: 
Xray series of the foot including A/P, lateral and oblique views taken today was personally evaluated by me and demonstrates the following: Fracture (s) and/or Dislocation(s): None .  Alignment: Normal .  Joint space(s): Normal .  Soft tissues: Normal .
Physical Exam: 
General Appearance: Well-nourished, well developed in no acute distress.  Orientation: Oriented to person, place and time.  Mood / Affect: Calm.  Gait: antalgic Coordination: normal Ankle / foot Exam (Bilateral). Inspection / Palpation LE (R/L): nontender.   Dorsiflexion (R/L): 25º / 25º.  Plantarflexion (R/L): 50º / 50º.  Strength LE: 5/5 EHL, tibialis anterior, plantar flexion bilaterally.  Sensation: subjective normal distal sensation bilateral LE.  Vasculature: <2 second distal capillary refill bilaterally.  Skin and lymph: appears normal in the affected extremity.                 
Assessment: 
Stiffness of left foot
Plan: 
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions were answered. 

Category:

ICD-10: 
M25.675
ICD: 
M25
ICD-10CM Year: 
2019