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Referral to Physical Therapy of a PreviouslyUndiagnosed Ankle Metastatic LesionDana Tew, PT, DPT, OCS, FAAOMPT, Brian Duncan, PT, DPT, OCS, FAAOMPT,Chitra Chandrasekhar, MD
D.T. Department of Rehabilitation-PhysicalTherapy Outpatient Orthopedics, QuentinMease Community Hospital, Harris HealthSystem, 3601 N MacGregor Way, no. 514,Houston, TX 77004. Address correspondenceto: D.T.; e-mail: [email protected]: nothing to disclose
CASE PRESENTATION
A 59-year-old woman was referred to physical therapy with a 5-month history ofprogressive worsening ankle pain after a twisting injury sustained while walking in herhome. The previous diagnostic assessment by her primary care physician and podiatristincluded radiographs that were formally reported as showing degenerative changes andevidence of old bimalleolar fractures (Figure 1). The patient was subsequently referred tophysical therapy for conservative management. At evaluation, she reported worsening ofdiffuse ankle pain, redness, and swelling since the initial injury. In addition, she reported asignificant history of a prior ankle fracture (23 years earlier) and a 30-pack-year history ofsmoking.
At initial physical therapy evaluation, she presented with a warm, edematous ankle, anddecreased global range of motion. The initial treatment included joint mobilizations todecrease pain, a rolling walker to decrease weight bearing, and a compression garmentto reduce swelling. A home exercise program that consisted of active range of motionexercises to improve talocrural and subtalar motion was provided. Upon her follow-upphysical therapy visit 3 days later, the patient reported 50% reduction in pain andimproved ankle mobility. The patient returned to the physical therapy clinic 1 week laterwith worsening pain with weight bearing, along with increased swelling and redness.Because of this recent increase in symptoms with conservative treatment and continuedpain after a seemingly trivial injury, the physical therapist was concerned about the patient’sclinical course and referred the patient back to her physician for further diagnostic imaging.Repeat radiographs performed approximately 7 months after her initial workup revealedprogressive 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 anill-defined lucency of the distal tibia and fibula (Figure 1). Magnetic resonance imagingrevealed a 9-cm enhancing focus that involved the ankle and foot, most concerningfor either metastatic deposit or primary bone neoplasm (Figure 3). A needle biopsy of theankle confirmed the presence of histopathologic changes consistent with an adenosqu-amous tumor. An additional workup denoted a primary nonesmall-cell lung cancerwith metastases to the brain and liver. Multiple treatments, including radiation andchemotherapy, ultimately failed. The patient died 9 months after her initial cancerdiagnosis.
Nonesmall-cell lung cancer comprises 80%-85% of all lung cancers [1]. Patientswith 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 osseoussites for metastasis include the vertebrae (76%), pelvis (68%), femur and/or hip (41%), andthe base of the skull (46%) [4].
B.D. OPTIM Physical Therapists, Houston, TXDisclosure: nothing to disclose
C.C. Department of Diagnostic and Interven-tional Radiology, University of Texas HealthScience Center, Houston, TXDisclosure: nothing to disclose
Submitted for publication June 19, 2013;accepted July 19, 2013.
PM&R1934-1482/13/$36.00
Printed in U.S.A.
ª 2013 by the American Academy of Physical Medicine and RehabilitationVol. 5, 1081-1083, December 2013
http://dx.doi.org/10.1016/j.pmrj.2013.07.0101081
Figure 1. (A) Anteroposterior view of the left ankle, showing anill-defined lucency of the distal tibia and fibula (black arrows);old fracture deformities of the medial and lateral malleoli arepresent (red arrows). (B) Lateral view of the ankle, showingnarrowing of the tibiotalar joint with degenerative changes ofthe ankle joint (black arrow).
Figure 2. Anteroposterior view of the ankle, showing progres-sive destruction of the distal tibia and fibula, with erosion of thetalus and involvement of the ankle joint (black arrows). Markedsoft tissue swelling is present (red arrows).
1082 Tew et al PT OF A PREVIOUSLY UNDIAGNOSED ANKLE METASTATIC LESION
Figure 3. (A) Sagittal T1 Fast Spin Echo (FSE) without contrast image, showing a large, T1, dark, soft tissue mass eroding the distal tibiaand invading the tibiotalar joint and talus (black arrows). Abnormal bone marrow signal is present in the posterior soft tissues of theankle (red arrow). (B) Sagittal T2 without contrast FS image, showing a large T2 intermediate-signal soft tissue mass eroding the distaltibia, invading the tibiotalar joint and talus; T2 bright region indicates central necrosis (black arrows); an abnormal T2 signal is presentwithin the posterior soft tissues of the ankle (red arrow). (C) Sagittal T1 16-mL gadodiamide postcontrast fat saturated image of theankle, showing an enhancing soft tissue mass invading the distal tibia with erosion of the tibiotalar joint. (black arrows); an abnormalbone marrow signal also is present within the anterior process and the body of the calcaneus (yellow arrows); bone marrow edemais present with the tarsal bones (red arrows); an abnormal soft tissue signal is present within the soft tissues of the ankle (blue arrow).
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REFERENCES1. D’Addario G, Früh M, Reck M, et al. Metastatic non small-cell lung
cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment andfollow-up. Ann Oncol 2010;21:116-119.
2. Maheshwari AV, Chiappetta G, Kugler CD, et al. Metastatic skeletal disease ofthe foot: Case reports and literature review. Foot Ankle Int 2008;29:699-710.
3. Morgan J, Adcock K, Donohue R. Distribution of skeletal metastases inprostatic and lung cancer: Mechanisms of skeletal metastases. Urology1990;36:31-34.
4. Coleman RE. Skeletal complications of malignancy. Cancer 1997;80(Suppl):1588-1594.
