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Images Referral to Physical Therapy of a Previously Undiagnosed Ankle Metastatic Lesion Dana Tew, PT, DPT, OCS, FAAOMPT, Brian Duncan, PT, DPT, OCS, FAAOMPT, Chitra Chandrasekhar, MD CASE PRESENTATION A 59-year-old woman was referred to physical therapy with a 5-month history of progressive worsening ankle pain after a twisting injury sustained while walking in her home. The previous diagnostic assessment by her primary care physician and podiatrist included radiographs that were formally reported as showing degenerative changes and evidence of old bimalleolar fractures (Figure 1). The patient was subsequently referred to physical therapy for conservative management. At evaluation, she reported worsening of diffuse ankle pain, redness, and swelling since the initial injury. In addition, she reported a significant history of a prior ankle fracture (23 years earlier) and a 30-pack-year history of smoking. At initial physical therapy evaluation, she presented with a warm, edematous ankle, and decreased global range of motion. The initial treatment included joint mobilizations to decrease pain, a rolling walker to decrease weight bearing, and a compression garment to reduce swelling. A home exercise program that consisted of active range of motion exercises to improve talocrural and subtalar motion was provided. Upon her follow-up physical therapy visit 3 days later, the patient reported 50% reduction in pain and improved ankle mobility. The patient returned to the physical therapy clinic 1 week later with worsening pain with weight bearing, along with increased swelling and redness. Because of this recent increase in symptoms with conservative treatment and continued pain after a seemingly trivial injury, the physical therapist was concerned about the patient’s clinical course and referred the patient back to her physician for further diagnostic imaging. Repeat radiographs performed approximately 7 months after her initial workup revealed progressive destruction of the distal tibia and fibula as well as marked soft tissue swelling (Figure 2). Retrospectively, an independent review of the original radiograph revealed an ill-defined lucency of the distal tibia and fibula (Figure 1). Magnetic resonance imaging revealed a 9-cm enhancing focus that involved the ankle and foot, most concerning for either metastatic deposit or primary bone neoplasm (Figure 3). A needle biopsy of the ankle confirmed the presence of histopathologic changes consistent with an adenosqu- amous tumor. An additional workup denoted a primary nonesmall-cell lung cancer with metastases to the brain and liver. Multiple treatments, including radiation and chemotherapy, ultimately failed. The patient died 9 months after her initial cancer diagnosis. Nonesmall-cell lung cancer comprises 80%-85% of all lung cancers [1]. Patients with nonesmall-cell lung cancer frequently have osseous metastasis, with the foot (acrometastases) being 1 of the rarest sites (0.03%-2%) [2,3]. The most common osseous sites for metastasis include the vertebrae (76%), pelvis (68%), femur and/or hip (41%), and the base of the skull (46%) [4]. D.T. Department of Rehabilitation-Physical Therapy Outpatient Orthopedics, Quentin Mease Community Hospital, Harris Health System, 3601 N MacGregor Way, no. 514, Houston, TX 77004. Address correspondence to: D.T.; e-mail: [email protected] Disclosure: nothing to disclose B.D. OPTIM Physical Therapists, Houston, TX Disclosure: nothing to disclose C.C. Department of Diagnostic and Interven- tional Radiology, University of Texas Health Science Center, Houston, TX Disclosure: nothing to disclose Submitted for publication June 19, 2013; accepted July 19, 2013. PM&R 1934-1482/13/$36.00 Printed in U.S.A. ª 2013 by the American Academy of Physical Medicine and Rehabilitation Vol. 5, 1081-1083, December 2013 http://dx.doi.org/10.1016/j.pmrj.2013.07.010 1081
