Dumb And Dumber: Questioning Risky Treatment In A Case Of Posterior Heel Pain
- Allen Jacobs DPM FACFAS
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In reviewing medical records, I often wonder why some doctors will place themselves into an arena that invites malpractice actions.
Let me present an example, a recent case that I reviewed for a plaintiff. Although I did not feel that there was malpractice in this case, I did find the treatment of the patient interesting.
A relatively healthy middle-aged female consulted a podiatrist for posterior heel pain. She had no prior treatment. Her medical history was significant for controlled hypertension and low thyroid function.
At the initial office visit, the podiatrist diagnosed her with Achilles tendonitis and treated her with an “ultrasound guided” steroid injection. Two days after the injection, she called the office with increased pain in the posterior heel. She returned to the office. X-rays confirmed the initial diagnosis. She started wearing a controlled ankle motion (CAM) walker and received a prescription for a Medrol Dosepak.
She developed increased pain, swelling and redness in the back of her heel, which continued over the next week. When she became concerned about this, she presented to the office of the podiatrist but the office staff would not see her without an appointment. She therefore asked for her records and left the office.
The patient followed up with her primary care physician. She presented with a history of posterior heel pain, increased redness and swelling. The patient noted the previous treatments of injection and the Medrol Dosepak, The PCP diagnosed an “infection,” started her on cephalexin and ordered magnetic resonance imaging (MRI). The MRI demonstrated marrow edema of the calcaneus at the insertion of the Achilles tendon. The PCP made the diagnosis of “osteomyelitis.” No labs. No fever. No nothing. She got a referral to podiatrist #2.
Podiatrist #2 agreed with the diagnosis. A technetium bone scan lit up the insertion of the tendon. He treated her with IV vancomycin for six weeks. He ordered and monitored the antibiotic. No cultures. No histology.
After six weeks, she remained swollen and tender. After casting, booting, etc., she went to the OR for debridement of the tendon, Haglund's surgery and had two anchors implanted into the calcaneus. Surgeons also used a graft material touted for tendon reinforcement in the tendon itself. The wound broke down and continually drained. A plastic surgeon, a wound care clinic and another orthopedic opinion failed to resolve the problem.
She finally sought the care of a foot and ankle orthopedist who, over a year later, removed all the implanted materials with resolution of the drainage. The patient left with a chronically scarred, swollen and painful heel. She subsequently sought the counsel of a lawyer.
I reviewed the case. My opinion? Dumb and dumber do not a malpractice case make.
Raising Several Issues With The Treatment Plans
Now for my points about the treatment plans. Why would anyone inject steroids for the initial treatment of Achilles tendonitis? What if the tendon ruptured following the injection? While I am not saying that is malpractice, some people would. Why enter that arena? Why was ultrasound needed for the injection? Why would you prescribe oral steroids when, following an injection, there is increased pain, edema and erythema? Wouldn't you worry about an infection or tendon rupture? Why tick off a patient with a poor result and fail to see her because she did not have an appointment?
I can understand the PCP not knowing what is going on. She gave antibiotics, ordered diagnostic testing and referred the patient.
What about podiatrist #2? Why would you give vancomycin without a confirmatory bone biopsy/culture? Why would you want to manage the vancomycin yourself? Why take on that potential risk? Why wouldn't you think that the bone scan and MRI changes were mechanical or non-infectious in etiology?
Why would you implant multiple foreign bodies in an area that you previously diagnosed with osteomyelitis? Why enter that arena? Why go out of your way to do posterior heel surgery, a surgery well documented to be associated with a six-month to one-year recovery?
Neither doctor got sued. At least, that was my recommendation. However, they both came close to a lawsuit. I wonder why either entered into such a dangerous arena. What do you think?