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

The author details the treatment of an obese 48-year-old patient with diabetes whose weight loss and exercise program stalled due to pain and discomfort in her right foot, arch and heel.

A 48-year-old overweight Caucasian female patient presents on referral from her primary care physician regarding pain and discomfort in her feet, arches and heels. She has recently been diagnosed with diabetes mellitus and had started an exercise regimen for weight loss and glycemic control. She began experiencing pain and discomfort in her feet, especially on the right side. Her pain was significant upon standing in the mornings after slumber and after other periods of rest throughout the day.

   She did relate a remote injury back in 1991 involving a fall from a horse but was unable to recall any specific details as related to the current chief complaint. Her past medical history including surgical history, social history, family history, medications and allergies was available for review.

   This patient is a former smoker but currently denies the use of any nicotine products. This patient is well-developed, very well-nourished, alert and well oriented in all spheres. She is 5'3" and her current weight is 276 lbs. Other vital signs were completely normal. She is ambulatory but utilizes a cane for her gait assistance, demonstrates an antalgic gait and favors the right side.

   The patient’s neurovascular status is completely intact. Pulses are easily palpable. Her capillary refill time is brisk to all toes. Hair growth is equal on both feet and all toes. Reflexes are diminished to the lower extremities but they are equal bilaterally. She is fully sensate at dermatome levels L4, L5 and S1. There was no neuritic symptomatology and the Tinel’s sign was negative over the porta pedis. Her range of motion is limited in the sagittal plane bilaterally as the gastroc-soleus complex and heel cord are tight with the knee flexed and extended. She demonstrates a painful response when manipulating the right os calcis, both with direct palpation of the poles of the os calcis and cupping of the bone. She displayed no overt edema, pitting, varicosities or telangiectasias.

   There is no crepitus with range of motion of the foot and ankle bilaterally. The physical examination revealed a broader heel on the symptomatic right side as opposed to the left. This lends to the belief that the fall many years ago could have included a fracture of the calcaneus. Further questioning uncovered no additional details regarding possible fracture. There was no surgical intervention, no casting, etc.

   During the initial office visit, I acquired weightbearing radiographs of the patient’s feet, taking three views of the left foot and three views of the right foot. The left foot films were normal and non-pathologic, demonstrating no fractures, subluxations or dislocation.

   The right foot films revealed significant changes to the os calcis as opposed to the left foot. I noted broadening of the tuber with changes to the trabecular pattern within the vault of the os calcis. There were no discrete fractures, bars, coalitions, cysts or tumors, but there were also no overt fractures or dislocations present.

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.