What is the next step in managing a 52-year-old female patient with a history of type 2 diabetes (dm2) presenting with a one-week history of pain, redness, and swelling in the foot, with unremarkable complete blood count (CBC), normal lactate levels, and no fever, and radiographic evidence of soft tissue swelling, polyarticular osteoarthritis, and calcaneal spurs?

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From the Guidelines

The next step for this 52-year-old female with diabetes presenting with foot pain, redness, and swelling should be to initiate conservative management for plantar fasciitis, which is suggested by the calcaneal spur on X-ray, while also carefully examining her feet to rule out infection or ulceration, as recommended by the guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2023 update) 1.

Key Considerations

  • The patient's symptoms of pain, redness, and swelling, along with the radiographic evidence of soft tissue swelling and calcaneal spurs, suggest a mechanical or inflammatory etiology, such as plantar fasciitis.
  • The normal CBC, lactate levels, and absence of fever make acute infection less likely, supporting a mechanical/inflammatory etiology for her symptoms.
  • As a diabetic patient, careful foot examination is crucial to rule out infection or ulceration, and blood glucose control should be optimized as poor glycemic control can delay healing.

Management

  • Treatment should include NSAIDs such as ibuprofen 400-600mg three times daily or naproxen 500mg twice daily for 1-2 weeks to reduce inflammation and pain, as well as rest, ice application, and plantar fascia stretching exercises.
  • Proper footwear with arch support and cushioning is essential, and custom orthotic inserts may be beneficial.
  • Physical therapy referral should be considered for guided exercises and modalities like ultrasound.
  • The patient should be educated on appropriate foot self-care, including daily foot examination, proper footwear, and avoidance of walking barefoot or in thin-soled slippers, as recommended by the IWGDF guidelines 1.

Further Evaluation

  • If conservative measures fail after 6-8 weeks, consider corticosteroid injection or referral to podiatry or orthopedics for advanced interventions.
  • The patient's risk of foot ulceration should be assessed using the IWGDF risk stratification system, and regular screening should be performed to monitor for signs of peripheral neuropathy and peripheral artery disease, as recommended by the IWGDF guidelines 1.

From the Research

Management of Osteoarthritis

The patient's presentation of pain, redness, and swelling in the foot, with radiographic evidence of soft tissue swelling, polyarticular osteoarthritis, and calcaneal spurs, suggests a diagnosis of osteoarthritis (OA) 2. The absence of fever, unremarkable complete blood count (CBC), and normal lactate levels rules out infectious or inflammatory causes.

Treatment Options

The treatment of OA focuses on symptomatic relief, as there is no disease-modifying medication available 3. Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to reduce pain and inflammation in OA 4, 5. Acetaminophen may also be effective in reducing pain and synovitis in OA knees 6.

Next Steps

The next step in managing this patient would be to:

  • Consider prescribing NSAIDs or acetaminophen to reduce pain and inflammation 4, 5, 6
  • Refer the patient to physical therapy to improve joint functionality and reduce pain 3
  • Monitor the patient's response to treatment and adjust the management plan as needed
  • Consider further evaluation or referral to a specialist if the patient's symptoms persist or worsen despite treatment

Key Considerations

When managing OA, it is essential to consider the potential gastrointestinal and cardiovascular side-effects of NSAIDs 4 and to weigh the benefits and risks of treatment. Regular follow-up and monitoring of the patient's condition are crucial to ensure optimal management and to prevent complications.

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Research

Diagnosis and clinical presentation of osteoarthritis.

Rheumatic diseases clinics of North America, 2013

Research

The therapeutic benefits of NSAIDs and physical therapy in knee osteoarthritis.

Romanian journal of morphology and embryology = Revue roumaine de morphologie et embryologie, 2024

Research

Why and how to use NSAIDs in osteoarthritis.

Journal of cardiovascular pharmacology, 2006

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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