Limb pain in the elderly

Chapter 37 Limb pain in the elderly



Case 37.1


An 80-year-old man presents with pain at the base of his big toe. The pain has been developing over the last few days, starting reasonably abruptly while walking over an uneven footpath. He points to the painful and tender area on his big toe on the plantar surface at the first metatarsophalangeal joint. When you passively dorsiflex his big toe, the pain is exacerbated. You observe that he also has bilateral hallux valgus, as shown in Figure 37.1.


image

Figure 37.1


(Source: Abrahams PH, Boon J, Spratt JD. McMinn Lower limb Hallux Valgus [6th edn DVD]. Edinburgh: Elsevier; 2007: 355)




Questions



1. What are the possible causes of his pain?

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

3. What factors predispose an individual to hallux valgus?

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

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.

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


Case 37.2


A 75-year-old man complains of pain in the middle of his heel. It is worse when he places weight on his heel. The pain has developed gradually, and he denies any episodes of trauma.




Questions



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

2. Why does it occur?

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

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?

b What are the possible causes of this disorder?

c What movement could reproduce the pain?


Case 37.3


A 73-year-old woman presents with an ulcer on her leg, which has been present for 3–4 weeks. Prior to this, she has noticed a gradual change in her skin colour and texture in that area. This is shown in Figure 37.2.


image

Figure 37.2


(Source: Mir, MA. Atlas of Clinical Diagnosis [2nd edn]. Edinburgh: Saunders; 2003: 219, Fig 11.19)




Questions



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

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

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

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

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


Case 37.4


Your grandfather complains of a very painful big toe. He asks you to have a look at it. You observe considerable inflammation on the medial aspect of the nail, a small amount of pus, and what appears to be skin growing around the sharp end of the toenail. It is very tender.




Questions



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

2. What are the possible causes of this condition?

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

4. What do you recommend to your grandfather?


Case 37.5


An 80-year-old female presents to you with severe, acute right hip pain. Two months ago she had a right hip replacement, and therefore, has a prosthetic hip. Although the pain has come on over the past few days she cannot recall a specific mechanism of injury. The pain is present at rest and while weight bearing. Range of motion (ROM) is remarkably restricted. She also states that her thigh is red and feels warm.




Questions



1. What is your differential diagnosis?

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?

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

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

5. Do you need to refer this patient?

6. What is the prognosis for this condition?


Case 37.6



History


Barry is a 59-year-old fishmonger who you see intermittently for mechanical low back pain. This morning he awoke with a painful right calf and swollen right lower extremity. On arriving at work, Barry calls your office and arranges an appointment for later that morning.


He reports that the previous day he stood for an unusually long period of time (7 hours), while filleting fish, which made his leg feel ‘tired’.


Further questioning indicates that the pain is increasing, and located diffusely around the medial aspect of his upper calf. He describes the pain as aching, which intensifies on passive ankle dorsiflexion and active weight bearing ankle plantar flexion. He cannot recall any specific trauma to his legs.


Barry denies experiencing chest pain or shortness of breath, and reports no previous health issues. He feels he is generally well, albeit for him carrying roughly 30 kg of excess weight which he attributes to a poor diet and lack of exercise. Barry has a history of intermittent low back pain spanning several decades, which more recently began to radiate to his right lateral calf. Barry has not been medically evaluated since he was a young man.



Questions



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

2. Why was the patient asked about:
a previous day/s activity

b chest pain and shortness of breath

c previous health issues and general health

d other orthopaedic conditions?

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


Physical examination

























Vitals •Pulse rate/min 94, regular
•Respiratory rate/min 16
•Blood pressure mm Hg 170/100
•Temperature (degrees C) 36.6
Limbs The patient is slightly bow legged. Varicose veins transverse the patient’s calves bilaterally
On the right lower extremity

• Swelling was apparent from the knee down to the foot with 1+ pitting oedema

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Dec 26, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Limb pain in the elderly

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