Chapter 37 Limb pain in the elderly

Case 37.1

1. What are the possible causes of his pain?

Hallux valgus, hallux rigidus, sesamoiditis.

2. What did you observe, in order to determine the presence of hallux valgus?

There is medial deviation of the head of the first metatarsal relative to the centre of the body, and lateral deviation relative to the centre of the foot.

3. What factors predispose an individual to hallux valgus?

The following factors:

• hereditary factors

• biomechanical instability

• structural deformities

• inflammatory arthritides (eg: gout, rheumatoid arthritis)

• some connective tissue disorders

• past trauma which has compromised normal structure and function

• some neuromuscular diseases.

4. What is the relationship between hallux valgus and a ‘bunion’?

Many people incorrectly assume that these are identical. They are not. A bunion develops in an individual with hallux valgus, usually as a consequence of an overlying bursitis. The area of deformity enlarges, and can become quite painful. Tight fitting shoes and frequent wearing of high heels can exacerbate this condition, and improvement in symptoms can occur with the changing of the type of footwear worn.

Note: Although the type of shoes worn can have a major role in the development of bunions, they are not responsible for the development of hallux valgus.

5. Is the hallux valgus the most likely cause of his pain? If yes, explain why. If not, give your reason, name the most likely condition causing his pain, and explain why it occurs.

No, the hallux valgus is not the most likely cause of his pain. His pain is mainly on the plantar surface, which is the most typical presentation for sesamoiditis. Sesamoiditis is common in individuals with hallux valgus, due to the extra stress placed on the flexor hallucis tendons in these individuals.

Other causes of sesamoiditis, not related to hallux valgus, include overuse of the foot in a plantar flexed position, and excessively flexible footwear. There are some pre-existing deformities which can predispose an individual (eg: pes cavus, a depressed first ray and forefoot valgus).

6. What is the major difference between hallux valgus and hallux rigidus?

Hallux rigidus usually presents with pain on the dorsal aspect of the big toe, and limited dorsiflexion of the big toe. This may be a result of osteoarthritic changes in the first MTP joint; an anatomic abnormality of the foot; an abnormally long first metatarsal bone; pronation of the forefoot or trauma.

Hallux valgus usually occurs in middle-aged and older individuals, whereas hallux rigidus may occur in younger individuals as well.

Case 37.2

1. What is the most likely cause of his pain?

• Fat pad syndrome (aka painful heel cushion).

• A fracture of the calcaneus would be unlikely in the absence of trauma.

2. Why does it occur?

It usually occurs in older individuals, as the fat pad degenerates and disperses laterally, leaving the calcaneus more exposed. Hence there is less tissue present for shock absorption. Pain is the result.

3. Does he require an X-ray of his foot?

No.

4. If his heel pain was more medially located, and radiated along the medial aspect of the plantar surface of his foot:

a What would be the most likely diagnosis?

Plantar fasciitis.

b What are the possible causes of this disorder?

It is believed to be due to repetitive microtrauma, but predisposing features include obesity, pes planus, prolonged standing, heel spurs, and reduced dorsiflexion of the ankle.^[1]

c What movement could reproduce the pain?

Any activity that stretches the plantar fascia.

Case 37.3

1. What is the most likely cause of the ulcer? Why?

Venous congestion: venous dermatitis is evident in the photograph. Venous ulcers are also far more common in that site compared to other types of ulceration.

2. What is the pathophysiological basis for the change to her skin and the eventual ulceration?

Varicose veins involve interference of venous return, and an increased pressure within venules and capillaries around the lower part of the leg. This causes:

• oedema, resulting in inadequacy of blood supply to tissues and poor nutrition to the area, so the skin may break down either spontaneously, or more commonly following minor trauma

• dilation of subcutaneous venules, especially over malleoli, resulting in pigmentation.

The tissue in the area of the malleoli is less vascular than in many other parts of the body, and the support of connective tissue is less than that in the foot. It is for this reason that venous ulcers are more common in this region, as compared to the foot.

3. What other vascular problem is often present in individuals with this disorder?

Varicose veins.

4. What would you examine to determine if it is present?

Inspect the limbs for superficial vessels, especially in the calf region (short saphenous vein) and along the medial aspect of the limb (great saphenous vein).

5. What are other causes of ulcers in this region?

Other causes are:

• ischaemic

• infective

• gummatous (syphilitic), or

• complicating other diseases (eg: ulcerative colitis).

Case 37.4

1. What do you think your grandfather is suffering from?

An ingrown toenail.

2. What are the possible causes of this condition?

Possible causes are:

• incorrect cutting of the toenail (should be cut straight, not rounded)

• wearing tight shoes

• injury to the nail, especially with repetitive trauma

• fungal infection.

3. Is there any familial tendency in the development of this condition?

Yes.

4. What do you recommend to your grandfather?

Make an appointment with a podiatrist.

Case 37.5

1. What is your differential diagnosis?

• Septic arthritis: the pain is severe and acute in nature, with redness and increased temperature indicative of infection. She has also had recent surgery (hip prosthesis).

• Malignancy: common in this age group.

• Fracture, sprain or strain from trauma: falls are common in the elderly population; if she has osteoporosis, any trivial trauma may have caused a bone fracture.

• Rheumatoid arthritis or osteoarthritis: rheumatoid arthritis more commonly commences in younger individuals. Osteoarthritis would be more likely in someone her age.

• Bursitis: may have occurred due to faulty biomechanics following the hip operation, as abnormal forces on muscles, tendons and the underlying bursae during the procedure may have caused inflammation.

• Referred pain from back or pelvis.

2. The laboratory findings show an elevated erythrocyte sedimentation rate (ESR), elevated C-reactive protein (CRP) and a leukocytosis. From the information provided, what is the most likely diagnosis?

Septic arthritis.

3. What is the most common causative agent for this disease?

Staphylococcus aureus.

4. List the potential causes or risk factors for this condition?

Causes or risk factors are:

• intravenous drug users

• iatrogenic — recent surgery (eg: prosthetic joints)

• joint trauma

• immunocompromised (eg: HIV)

• elderly with chronic disease (eg: diabetes, leukaemia, multiple myeloma, rheumatoid arthritis or other causes of chronic joint disease)

• young children with a staphylococcal infection.

5. Do you need to refer this patient?

Yes — immediate hospital referral as septic arthritis is a medical emergency. It is essential to isolate the pathogen for proper management to be initiated.

6. What is the prognosis for this condition?

• Early diagnosis and immediate antibiotic therapy are essential for good outcomes.

• Non-weight bearing is recommended during the recovery.

• Upon resolution, gradual return to function is recommended. Therefore, initially gentle weight bearing activities are encouraged.

Case 37.6

1. Using only this information, list the possible causes of Barry’s leg pain. Justify your answer.

Possible cause	Justification
DDx 1: thrombophlebitis from deep vein thrombosis (DVT)	• Calf pain and swelling • Obesity as a risk factor
DDx 2: pseudothrombophlebitis from ruptured Baker’s cyst	• Calf pain and swelling • Medial posterior knee pain
DDx 3: gastrocnemius muscle strain	• Calf pain and swelling
DDx 4: cellulitis	• Frequently affects skin of lower legs • Resembles thrombophlebitis
DDx 5: tumour	• Painful swollen leg[2]

2. Why was the patient asked about:

a previous day/s activity

Screening for a history of:

• immobilisation which may be associated with deep vein thrombosis (DVT), or

• traumatic onset which may be associated with gastrocnemius muscle strain or Baker’s cyst rupture.

b chest pain and shortness of breath

Symptoms of pulmonary embolus (PE) which may be the first indicator of a DVT.

c previous health issues and general health

Screening for risk factors associated with DVT or tumour.

d Other orthopaedic conditions

Baker’s (popliteal) cysts are commonly associated with arthritic (osteoarthritis or inflammatory arthritidis) changes of the knee.

3. What do you need to examine in this patient? Why?

Examination	Justification
Vitals	• Evaluate cardiovascular/systemic distress
Observation	• Bow leg: indicator of possible knee arthritis • Varicose veins: indicator that the lower limb is subject to high pressure
Palpation	• May reflect extent of pathology
Active/passive/resisted ROM	• To help determine the site and/or type of pathology
Orthopaedic special test	• Homans’ test (passive ankle dorsiflexion elicits pain in posterior calf). Non-specific indicator for DVT • Pratt’s sign: (squeezing of posterior calf elicits pain). Non-specific indicator for DVT • McMurry’s test: for meniscus pathology
Neurovascular status	• Buerger’s test: for vascular insufficiency • Neurological assessment

4. What information can you obtain from these findings? Can you narrow your differential diagnosis?

As orthopaedic tests lack specificity and sensitivity for DVT, Baker’s cyst or calf strain, differential diagnoses 1–3 cannot be definitively eliminated. Cellulitis (differential diagnosis 4) can not be confirmed, as observation does not specifically mention skin appearance. Cautious interpretation of physical assessment remains for differential diagnosis 5 (tumour).

5. Explain the significance of the following signs in light of the differential diagnosis:

a blood Pressure 170/100 mm Hg

Hypertension is a risk factor for atherosclerosis, which can be complicated by thrombosis. However, as veins are not affected by atherosclerosis, it is not a factor in this patient.

b bow legged appearance

With consideration of the patient’s age, this observation may indicate knee arthritis which is thought to be a predisposing factor for Baker’s cyst.

c pitting oedema

Both orthostatic and chronic venous insufficiency may cause pitting oedema.

d lack of palpable mass in the popliteal fossa

Baker’s cyst’s may be associated with a palpable mass which can lead to unilateral venous obstruction. Ruptured Baker’s cyst may limit the ability to palpate a mass. This can lead to haemorrhage and synovial fluid accumulation in the fascial compartments of the lower extremity.

6. You refer Barry to a medical practitioner. What investigations are required? Why? What would you expect, based on the physical examination findings?

Investigation[3]	Justification	Expectations based on differential diagnosis
Ultrasound	To identify structures of fluid accumulation in lower extremity	Haemorrhage of gastrocnemius may be associated with muscle strain. Fluid accumulation surrounding muscle, fascia and sub-cutaneous tissue may be associated with rupture Baker’s cyst
Colour and duplex Doppler ultrasound	To evaluate speed and flow of blood flow in major vessels of the lower extremity	To reveal blood clots in the veins of the lower extremity

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