The patient was a 45-year-old woman who was referred to a physical therapist and a physiatrist in a rehabilitation medicine department for evaluation and treatment of severe bilateral lower leg, ankle, and foot pain. The patient’s past medical history was significant for sickle cell disease and she had undergone an allogeneic stem cell transplant 4 months prior with Sirolimus prescribed to prevent rejection. Magnetic resonance imaging of both lower legs revealed extensive bone marrow edema, as well as soft tissue swelling about the lower legs and ankles. These findings, along with the patient’s presentation (constant bilateral pain and erythema of the lower legs within 6 months of transplantation) were found to be consistent with an atypical condition called posttransplant distal limb syndrome.

J Orthop Sports Phys Ther 2011;41(6):458. doi:10.2519/jospt.2011.0412

KEY WORDS: ankle, foot, leg, magnetic resonance imaging, radiography

STUDY DESIGN: Resident’s case problem. BACKGROUND: Kaposi’s sarcoma (KS) is the most common form of cancer in patients with human immunodeficiency virus (HIV) infection. Although KS is often initially asymptomatic, this neoplasm may progress to affect multiple organ systems, including structures of the musculoskeletal system, which can produce symptoms similar to those associated with common orthopaedic conditions. This resident’s case problem describes the evaluation and differential diagnosis of a 45-year-old male with HIV and KS, referred to physical therapy with an initial diagnosis of radiographic osteoarthritis (OA) and patellofemoral pain syndrome (PFPS) of the left knee. His primary complaint was knee pain during end range knee flexion. DIAGNOSIS: The history, systems review, and examination suggested a source of pain of a nonorthopaedic origin. Differential examination ruled out clinical OA, PFPS, ligament/cartilage derangement, and tendonitis. Avascular necrosis of the medial femoral condyle was also considered as a possible source of pain. Recent blood tests indicated a high viral load and low CD4 count, which might have increased susceptibility to opportunistic infections or KS tumor progression. The patient was referred back to his physician for additional follow-up. Magnetic resonance imaging (MRI) of the knees were consistent with a systemic inflammatory process such as KS. A true-cut biopsy was subsequently scheduled, which confirmed KS lesions at the left knee. DISCUSSION: Physical therapists who manage orthopaedic conditions should be aware of the disablement that may result from acquired immunodeficiency syndrome-related KS. A thorough joint-specific examination, with a broad differential diagnosis, should be employed for patients having known systemic diseases. LEVEL OF EVIDENCE: Differential diagnosis, level 4.

J Orthop Sports Phys Ther 2009;39(8):612-617. doi:10.2519/jospt.2009.2961

KEY WORDS: human immunodeficiency virus (HIV), Kaposi’s sarcoma, knee pain, physical therapy

Rheumatoid arthritis frequently affects foot and ankle function, leading to pain, difficulty with ambulation, and disability. The purpose of this article is to describe common foot and ankle deformities associated with rheumatoid arthritis and present state-of-the-art, nonsurgical management strategies. Physical impairments thought to be commonly associated with limitations of function and practical interventions for alleviating those impairments or reducing the impact of the impairment on ambulation are identified. Examples of rehabilitation interventions discussed include prescription footwear, custom and premolded foot orthoses, hindfoot orthoses, ankle-foot orthoses, shoe modifications, therapeutic exercises, and patient education. Early and aggressive attempts at prevention, delay, or correction of foot and ankle pathomechanics related to rheumatoid arthritis may play a key role in helping patients maintain an active ambulatory lifestyle.

J Orthop Sports Phys Ther. 1999;29(12):703-717.

Key Words: arthritis education, exercise, footwear, gait, orthoses, rehabilitation, shoe modifications