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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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