When Lower Extremity Pain Derails An Exercise Plan In A Patient With Diabetes

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Christopher Hendrix, DPM

Formulating The Diagnosis And Treatment Plan

Physical findings and X-ray findings are curious in regards to the broadening of the os calcis and radiographic evidence of trabecular changes without fracture, cyst or tumor. I generated several potential diagnoses. The differential diagnosis list included: soft tissue equinus; post-static dyskinesia; plantar fascia strain and fasciitis; bone contusion; bursitis; and a ancient symptomatic heel fracture. A plethora of other potential diagnoses are possible as well.

   I counseled the patient regarding the physical findings, radiographs, diagnostic modalities and treatment options. I recommended a comprehensive conservative course of care initially and symptomatic relief while awaiting a computed tomography (CT) scan of the right foot and os calcis.

   The patient started on an assertive hip to heel stretching regimen, passive night splint, heel protective shoe wear and no bare feet, contrast bathing and nonsteroidal anti-inflammatory drugs (NSAIDs). We discussed continued smoking cessation, glycemic control and a low-impact aerobic exercise program.

When A Patient Has Paget’s Disease

On a helical CT of the right foot without contrast, the calcaneus was grossly abnormal. Coarse trabecular changes were present throughout the vault of the os calcis with widening of the body of the calcaneus. Mild degenerative changes at the subtalar facets were also visible. All other pedal structures demonstrated normal architecture. No masses were present. The ankle read as normal and the findings were highly suggestive of Paget’s disease of the bone.

   I counseled the patient regarding her ongoing care and progress. She had started an exercise and yoga program, and lost weight while controlling her blood sugars. She had changed her shoe and insert selection, begun a physical therapy program and no longer needed her cane for gait assistance.

   I also counseled her regarding the diagnosis of Paget’s disease and the details of bone metabolism. I instructed her to follow up with her rheumatologist regarding monitoring of her bone markers and bone health, and further diagnostics.

In Conclusion

This case demonstrated a rather interesting physical examination finding on a rather common clinical presentation. This demonstrates the value of radiographs correlated with CT evaluation.

   Dr. Hendrix is a Fellow of the American College of Foot and Ankle Surgeons, and is board certified by the American Board of Podiatric Surgery and the American Academy of Wound Management. He is in private practice at Mid-South Foot and Ankle Specialists in Tennessee.

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