10/13/2015    

Activity-Induced Edema and Heat, Lower 1/3 B/L Legs

My patient is an educated very active, otherwise
quite healthy, Caucasian female in her early 50s
originally from S. Africa. She initially reported
she began an aerobic step class in June of 2010
which led to the insidious onset of arch pain in
her left foot. Discontinuing the step aerobics
class she went on a trip to South Africa. During
a 100 degree day, she began to experience burning
and swelling in both feet. However, no swelling
was visible to the eye. The sensation of the
edema lasted until the temperature dropped but
the burning continued. Returned home to the U.S.,
she continued to experience tingling and burning
with walking and standing.

In December of 2010, the family took a trip to
Reno, Nevada. The patient stated she wore a pair
of fur boots that “almost drove her crazy”
experiencing burning, hot, and red feet. At that
time, her symptoms were still confined to both
feet. She was seen by podiatrists and physiatrist
without results. MRI of her back and legs were
negative. Two epidurals were performed without
results. Neurologists performed EMG which was
normal. The patient was referred to PT which also
proved to be ineffective.

At this point, she was referred to me for
evaluation. A tentative diagnosis of TTS was made
which appeared to be pathomechanically produced
secondary to excessive pronation. A low Dye strap
relived the patient’s symptoms and she was
ultimately put into a Root Functional orthotic.
All the symptoms subsided for 10-12 months.
On a 1-2 hour hike she again began to experience
a re-occurrence of her original symptoms but this
time the sensation of cold was experienced along
with aching in her ankles characterized as
swollen and puffy ankles. The posterior lateral
heels felt raw. Closed shoes led to a marked
increase in the sensation of heat. She further
experienced redness with engorgement of her
veins. On her return, all the symptoms subsided
but returned 1 week later. The patient elevated
her feet and applied cold compresses which helped
considerably. Again seen in the office with this
new complaint, a biomechanical reevaluation was
performed which revealed a relaxed calcaneal
stance position which was markedly everted in
excess of 5 degrees. The original evaluation the
calcaneus was perpendicular. A Blake inverted
orthotic was prescribed which again relieved her
symptoms for a few months.

Again, the symptoms returned and she was advised
to return to the original vertically poured
orthotics. MRI and x-rays were repeated and
reported as negative. Suspicious of an atypical
CRPS I referred to the pain management dept. at
Stanford Hospital. Reports were negative.
Considering the possibility of an activity
induced compartment syndrome or venous reflux
disease, a comprehensive vascular study was
performed by a local respected vascular
specialist. Pushing the patient I ordered a
venous mapping study both prone and erect. The
distal 1/3 of the GSV and SSV was reported as
incompetent. We then obtained three different
vascular opinions. One recommended ablation of
what he believed to be incompetent SSV and GSV
and the other two believed that ablation was
contraindicated and that tests were inconclusive.
Paxil was prescribed and along with colder
weather symptoms subsided.

With increase in temperatures, ice applied to the
lower 1/3 of the legs decreases her symptoms
which were now characterized as activity induced
hot, red, burning tingling and swelling of both
feet and lower legs. Walking in moderate weather
increases the symptoms which are relieved by
rest. In an attempt to change the function, high
heels were recommended in an attempt to reverse
as much pronation as possible. This proved to be
beneficial, yet the patient continues to
experience symptoms.

I am now at a loss as to where to go from here.
Any suggestions aside from referring the patient
to a psychiatrist? Which, by the way I have
seriously considered. Why, because I have never
clinically observed the heat or swelling the
patient speaks of. What I have observed is a
somewhat boggy sensation around the lower third
of her legs in addition to what I have previously
seen clinically. The shape of which, for an
active and otherwise healthy appearing women of
5’2” and weighing about 105lbs, is surprisingly
somewhat shapeless. My sense is that this is a
real problem for the patient and I do believe she
is telling the truth. I requested the patient to
bring in her husband on her last visit to assist
us in putting this timeline together and to
insure that I did not miss anything. In the back
of my mind was the idea that she was fabricating
and there was possibly something going on in
their marriage. Their togetherness appeared
genuine and her husband did confirm what she is
experiencing as well as the timing of the events.
They are both quite frustrated and continue to
look for answers. While fabrication and social
issues are still on the table and may be a
factor, she does not strike me as a malingerer.

Any ideas?

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