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.