Proactive Care Through an Evolving Diagnosis: A Case Report
 
   

Proactive Care Through an Evolving Diagnosis:
A Case Report

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:
   Frankp@chiro.org
 
   

David D. Juehring, D.C., D.A.C.R.B.*


Proper case management and treatment comprise the ongoing interplay of the patient's subjective complaints and objective findings. These components should be continually monitored to follow the progression of symptoms needed to arrive at a flexible and evolving working diagnosis. In the case discussed here, the initial findings led to the working diagnosis of plantar fasciitis. After a short course of treatment, the findings quickly changed to the potentially serious diagnosis of osteomyelitis, cellulitis,or both. Based on bone scan findings, a course of treatment was prescribed for the cellulitis that led to resolution of symptoms. On resolution, the patient's initial symptoms again were addressed, and the appropriate plantar fasciitis treatment protocols were resumed. Diagnosis and treatment of plantar fasciitis, along with the utility of bone scans, are also discussed. This case report 'supports the idea that even a relatively simple case needs constant monitoring of the patient's response to ensure proper care.



Introduction:

Chiropractors are faced with numerous decisions and complicating factors in many clinical cases, even the relatively simple ones. Constant monitoring and flexibility in terms of differential diagnosis and treatment are a must. Even a Simple, benign presenting condition deserves the chiropractor's utmost respect and knowledge to ensure the best possible care.

Plantar fasciitis is a regular condition seen by the chiropractic physician. Various passive and active treatments are often used to address presenting symptoms as well as biomechanical concerns relating to correction of the condition. [1-7] The general course of symptomatic relief with passive means (e.g., ice, electric muscle stimulation, ultrasound) is used as part of the management program. [4, 6-8] Once there is a reduction of symptoms and a particular modality has succeeded, active therapy can be focused on the biomechanical alterations involving the proper motioning of the ankle and foot articulations, along with the global activity of the involved leg. [2, 4, 5, 7]

Here, a 29-yr-old woman treated conservatively for 1 week using the above protocols had no response to the initial symptom-reduction phase of her plan. This article details the change in her working diagnosis as a result of her subjective reports and changing objective findings. The changes in the working diagnosis resulted in advanced diagnostic testing to determine the pathology, which was used in selecting the most appropriate and effective therapeutic route. The results of the advanced diagnostic testing and treatment led to the ultimate diagnosis of cellulitis. Cellulitis is an infection of the skin and subcutaneous soft tissue, superficial to the deep fascia, caused by organisms such as staphylococci or streptococci. [9, 10] The portal of entry is generally a break in the skin. [9] A review of Medline (1976 through July 1998) found no literature suggesting biomechanical or myofascial dysfunction as an etiology for cellulitis. On successful treatment of the cellulitis, the initial plantar fasciitis treatment protocol resumed, with resolution of symptoms.



CASE REPORT

A 29-yr-old female day-care worker developed insidious mild intermittent right foot and medial plantar arch pain of approximately 1 week's duration. She stated she had not had any current trauma to the involved area, and described the pain and discomfort as a dull, achy sensation. She stated she did not have any change in activities or changes in footwear over the previous week. Walking without footwear exacerbated the symptoms within the arch, whereas nonweight bearing relieved her symptoms. Approximately 6 months earlier, she had fractured the right proximal phalanx of her first toe. A fracture of the distal aspect of the proximal first phalanx was noted on the initial radiograph, along with a central subchon-cyst in the head of the first metatarsal and osteophytosis the first metatarsophalangeal (MP) joint, both indicative of degenerative joint disease of the MP joint (Fig. 1). She reported no residual symptoms or complications since approximately 6 to 8 weeks after the trauma. In the review of her past history, she said she did not have any relevant ankle or foot trauma.

The initial examination was performed on the right mid- and forefoot. No discoloration or visual swelling was present on her medial longitudinal arch or first MP joint. Palpatory findings revealed tenderness localized to the plantar surface of the distal first metatarsal head, along with the entire medial longitudinal plantar fascia. Active and passive ranges of motion of her ankle were compared bilaterally for plantar flexion, dorsi-inversion, and eversion, with all measurements appearing equal bilaterally. Decreased motion was present on dorsiflexion of the right first MP joint by approximately 10 to 15 using bilateral comparison. With dorsiflexion overpressure of this joint, she reported pain and tenderness to the plantar surface of the first MP joint and medial longitudinal plantar fascia. No gross abnormalities were detected on visual examination of her gait. For static evaluation, no excessive pronation was detected. At the end of the examination, a working diagnosis of right foot mild plantar fasciitis secondary to first MP joint osteoarthritis was made.

Because of the patient's work schedule, I recommended that icing the involved structures for approximately 15 minutes four or five times periodically throughout the day at home with minimal weight bearing would yield optimal symptomatic relief. I explained that this approach would be successful at reducing any possible irritation that was occurring and would need to be performed in this acute stage before active corrective measures could be implemented. The patient was scheduled for a re-evaluation at approximately 7 days after the initial examination to monitor her condition and update the treatment plan.



Re-evaluation

On re-evaluation, the patient reported that the pain had escalated in intensity and had become constant. It had begun to awaken her throughout the night, and she was unable to find any positional relief. She stated that icing had no effect on her symptoms despite reported high compliance of icing three or four times per day. She also stated that the pain had begun to localize to the plantar surface of her first MP joint.

The patient's gait was altered to minimize pain on right forefoot dorsiflexion. Over the medial and plantar surface over the first MP joint surface appeared a red, raised discoloration approximately 2 cm in diameter. The patient reported intense localized pain on light palpation of the involved lesion. There was a noticeable elevation in skin temperature at the lesion site. Generalized dorsiflexion and plantar flexion, along with compression and distraction of the first MP joint, resulted in exacerbation of symptoms.

Re-examination of the involved foot resulted in the working diagnosis being changed to cellulitis, postfracture os- or both; this led to the decision for further testing.

WIMP Imaging

Radiographs of the right foot using anteroposterior, oblique, and lateral projections were taken to rule out osteomyelitis. The healing fracture of the proximal first phalanx of the right foot was noted, along with metatarsal head soft-tissue swelling (Fig. 2). Measurement of the first metatarsal subchondral cyst secondary to degenerative joint disease revealed no visible interval change from previous radiographs. No other bony or joint abnormalities were noted. The decision was made to order a three-phase radionuclide skeletal scintigraphy or bone scan to rule out osteomyelitis or cellulitis.

For the bone scan, the patient was imaged multiple times at three distinct time intervals or phases after an injection of Tc- MDP. During phases one and two of the scan, the plantar aspect of the right foot revealed increased radionuclide uptake (Figs. 3 and 4). In the third and final phase of the bone scan, uptake was detected at two distinct sites on the right foot (Fig. 5). Both sites were localized to the dorsal aspect of the foot, focusing on the first MP joint and the distal region of the proximal first phalanx (Fig. 6). Given the patient's past fracture and first MP degenerative joint disease, along with the anatomic proximity to the lesion in question, there was still difficulty in distinguishing between osteomyelitis and cellulitis.

Immediately after the scan, the patient was referred to a medical physician for concurrent care. Per the physician's examination, review of previous findings, and interpretation of the bone scan, osteomyelitis or cellulitis was still in question. Treatment for osteomyelitis would have consisted of a 7-week course of intravenous antibiotic therapy. This option was declined by the patient because she was nursing a baby; she decided to follow a 10-day course of amoxicillin for the cellulitis. At the 3-week follow-up visit, no visual remnants were detected involving the medial and plantar surface of the first metatarsal region. The patient's gait appeared normal, with total reduction of symptoms to the first MP joint. Mild arch pain persisted. At approximately 7 weeks after the initial examination, the patient reported no complicating or residual factors of the lesion site.



DISCUSSION

The initial presentation of this patient led to a working diagnosis of plantar fasciitis. Given the patient's increase in intensity of arch pain on first MP joint dorsiflexion, [12] nontraumatic onset, [5] aggravation of symptoms during gait, and reduction of symptoms during non-weightbearing activities, the initial diagnosis and consequent treatment were merited. Even though the patient did not have classic anterior medial heel pain, [6, 7, 13] I believed that this presentation of medial longitudinal arch pain and plantar surface first metatarsal head pain merited the working diagnosis. [6, 14] Various diagnoses at the initial presentation were considered, with specific attention to midfoot and hindfoot fixations, along with the possibility of excessive pronation. Through chiropractic evaluations, fixation pain patterns of the suspected midfoot and hindfoot joints were unremarkable. The osteoarthritis of the first MP joint was not considered a source of symptomatology because of the low correlation between radiographic findings and patient complaints. Tarsal tunnel syndrome was quickly ruled out because of the reported lack of numbness or tingling sensations, combined with the absence of pain at night. [7, 13] No x-ray or laboratory studies were clinically merited because of the relatively benign initial working diagnosis.

A course of passive therapy was initiated with this working diagnosis. Because of scheduling difficulties and choice of home therapy, cryotherapy and rest was used to minimize symptoms. [6-8] This procedure is classic and well defined in the literature for acute pain reduction and ease of application, using the pattern of 20 minutes on with at least 1 hour before repeated application. During the initial stages of plantar fasciitis, treatment focuses on reducing symptoms before restoration of function is attempted. [6, 7] Passive modalities, such as the abovementioned cryotherapy, along with pulsed ultrasound and various electrical muscle stimulation [4] applications, have been consistently used in the initial stage of acute symptom reduction. Stripping massage is one treatment method that can be used during the beginning of therapy. [4] However, because of the patient's acute condition, additional irritation to the plantar fascia and the head of the first metatarsal did not appear to have clinical merit. With the reduction of symptoms, ranging from approximately 3 days to 2 weeks, the transition from passive care to active care could occur.

Active treatment of plantar fasciitis consists primarily of mechanical stretching of the plantar fascia. [4, 7] This can be accomplished by passive or active stretching techniques that focus on dorsiflexion of the MP joints. [4, 7] One such technique is accomplished by having the patient stand while dorsiflexing the MP joints against a wall and flexing the involved-side knee into the wall. The patient should feel a mild stretch to the plantar fascia and a centralized stretch to the medial longitudinal arch. Ankle dorsiflexion should also be addressed by stretching the soleus and gastrocnemius muscles [2-5, 7] of the involved leg. Each muscle should be stretched individually. [5] One method involves having the patient stand on the edge of a stairstep while producing ankle dorsiflexion. The majority of the stretch is focused on the gastrocnemius muscle by keeping the knee in extension, whereas with knee flexion the soleus can be more readily stretched. Treatment after icing is used to minimize iatrogenic pain and irritation.

Although pertinent at the onset of this case, the initial working diagnosis and differentials were clinically not relevant after reevaluation. New differential diagnoses were developed because the patient's symptoms were unresponsive to treatment and indeed increased; this led to new objective findings of alteration of gait and discoloration with warmth over the plantar surface [17] and medial area of the first MP joint, along with added information regarding her past history. On subsequent focused questioning, she revealed that approximately 2 to 3 months previously she had cut very deep into her skin while trying to remove a piece of callus from the undersurface of her great toe. She did not recall any bleeding or discharge that occurred at the site. These changes in the patient's subjective and objective findings and past history narrowed the possibility to osteomyelitis or cellulitis as the two major differential diagnoses of importance. Because of her previous fracture site and its possibility of infection, plain radiographs of the region were taken to determine whether osteomyelitis was present. [17] This decision was based on possible visualization of lytic destruction of the old fracture site, with the chance of enlargement or changes of density in the area of the geode. As previously stated, the radiographs appeared negative for these possibilities. A three-phase bone scan was ordered to rule out osseous involvement as a result of the relatively short duration of symptoms, which may not be reflected on plain radiographs and the potential severity of osteomyelitis.

As mentioned previously, a bone scan is a series of multiple images taken at three time intervals. Various types of radionuclide injections can be used for specific diagnostic functions. In this case, the standard Tc-99m MDP was used. In hindsight, a technetium-99m-labeled or indium-111-labeled leukocyte scan should have been used due to their specificity for areas of infection and osteomyelitis. During phase one of the bone scan, the radionuclide angiogram, images are taken every 2 seconds of the involved structure for the first 40 to 60 seconds after injection of the radionuclide tracer. In phase two, the blood pool stage, static images are taken for 1 to 3 minutes after the phase one radionuclide angiogram. Phase three (delayed bone phase) images are taken 3 hours after the injection. [11, 19]

Each phase is accented by increased tracer uptake indicating the involved histology. With cellulitis, there is increased activity detected during the first two phases of the scan, whereas the third phase is negative for activity. Immediately after the injection of the radionuclide tracer, areas of increased blood flow, such as in an infection, will localize the tracer to that site; with osteomyelitis, there is increased uptake during the first two phases but also in phase three. The difference during phase three is localization of the tracer to areas of increased bone activity. Healing fracture also has a similar imaging appearance in all three phases. Degenerative joint disease has focal increased tracer uptake only during phase three. [11, 19]

Laboratory work was another option entertained but was not used because of the urgency of clinical consequences, its lack of sensitivity in detecting early bacterial changes of such a small focal site, and the ease of obtaining a bone scan.

When using the bone scan in this case, there were numerous underlying complicating conditions that made it difficult to rule out osteomyelitis as a pathology. With the increased radionuclide uptake during the third phase from the degenerative joint disease of the first MP joint (see Figs. 5 and 6), uptake during all three phases in the region of the proximal first phalanx (see Figs. 3-6), and the positive images during the first two phases of the scan from the potential cellulitis (see Figs. 3 and 4), all of these conditions could be explained. Because osteomyelitis yields tracer uptake in all three phases, and given the proximity of the above conditions, the small size of the involved structure, and the limitations of bone scan image clarity, difficulty in diagnosis persisted. Plain film radiographs could not conclusively rule out osteomyelitis as a source of a positive finding on a bone scan.

Because of the potential seriousness of this condition, and based on the physical examination findings, the patient was referred to a medical physician. From the physician's examination findings and interpretation of the imaging reports, two treatment options were recommended: 7 weeks of intravenous antibiotic therapy to address the potential osteomyelitis, [17, 20]or a 10-day course of amoxicillin to address the possible celluli- osteomyelitis, or both. At the patient's reques t,the latter treatment was used. This course of treatment proved to be effective in reducing symptoms and was also a major determinant of the ultimate diagnosis of cellulitis. As discussed previously, the patient reported no symptoms of the involved cellulitis site at a 3-week follow-up visit.

On the chiropractic follow-up, the patient continued to have plantar fascia tightness and tenderness. The working diagnosis of plantar fasciitis was again made, and because of her lack of acute symptoms the active phase of initial therapy was started. She followed a daily regimen of passive stretching to the plantar fascia, gastrocnemius, and soleus muscles. This program was performed daily for a 3-week trial, with the patient reporting total reduction of symptoms of the plantar fascia at the end of the treatment period.



CONCLUSION:

This case is a reminder to chiropractic clinicians about the evolution of case management. Although the patient's original diagnosis of plantar fasciitis proved to be correct after her cellulitis treatment, proper monitoring of objective and subjective findings and how they related to the treatment plan was paramount in determining the potential seriousness of the added condition. This proved far different from the initial diagnosis. In this case, it would have been very difficult to determine whether the patient's initial symptoms were based solely on plantar fasciitis or in combination with the development of cellulitis. This case is a prime example of the importance of proper monitoring of patient progress through a treatment plan. Any unresponsiveness to therapy should lead to a change in the working diagnosis for the ultimate benefit in patient care.



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