leg pain as possible result of injury

Ninety y/o white female in generally good health, well nourished, alert and active.
c/o episodic severe right leg pain.

Wt. 138 lbs, Ht. 62", Temp normal, Resp 18, BP 120/68
Blood sugar: 120mg/dL random
Allergic to PCN
Current medications:
K
Sular
Ziac
Lasix
(Thyroid pill)
Premarin
Ecotrim
Oscal
Hx:  Apx 6 months ago hit the right tibia, apx 12 cm inferior to the patella, on a sharp corner of a low chest. No significant bruising or damage to skin, but significant pain lasting for apx 1 month.
Sx:  Beginning 1 month ago, pain in the area returned with four days of hospitalization required for pain treatment and diagnostic studies in the last two weeks. Pain at that time was alleviated with morphine. Currently vicodin 500 mg po, qid is used for pain control; ineffective.
Onset of pain occurs 10 to 15 seconds after standing with or without weight on foot.
Pain is unremitting while standing and described as a 10 on the pain scale. Without weight on foot, the pain is graded as an 8-9 on the pain scale. Pain is described as severe and cutting with feeling of fullness, pressure and a sensation of "tingling" or "ants crawling" in or on leg. Pain ceases upon seating but other sensations remain. When seated, heat alleviates sensations. Hot bath also is beneficial. Leg is generally uncomfortable at all times, but not painful.
During episodes, the pain may radiate to upper leg and groin area.
Observations:  No obvious deformity on comparison with left leg. During pain, right leg feels cool compared to left. Right leg lividity below area of previous injury is significant with obvious distension of lower leg and foot veins. The muscles in the lower leg do not appear to be in contraction. Small nodule, apx 2.5cm x 1cm was apparent at point of previous injury. It was stated that this was "sore as a boil."
After the episode, an area of blanched skin was noted, beginning at the area of previous injury to a point apx 15 cm inferior and extending apx 2.5 cm each side anterior ridge of the tibia.
Multiple circular lesions on legs, lateral and medial, in stages of healing, attributed by primary care physician as reaction to Pavachol.
Diagnostic studies previously performed:
Radiology
Knee, 3v no abnormalities reported
Tib/fib, 2v no abnormalities reported
Chest, pa/lat no abnormalities reported
Lumbar spine, 3v no abnormalities reported
Nuclear
Bone/joint scan Rt. Knee no abnormalities reported
US
Duplex external veins no abnormalities reported
Lab
Full blood panel no abnormalities reported
Physical therapy
Ten days mixed results, none lasting.

[Kevin Pho, MD]

There has already been a variety of x-rays and other diagnostic studies performed.  If you are continuing to have symptoms despite physical therapy, an MRI of the area or orthopedic referral may be considered.

With sensations like tingling or "ants crawling", this suggests are neuropathic origin of the pain.  If the orthopedic route is not revealing, a neurology referral can be considered.  There are several options for evaluation, including electrodiagnostic testing.  Medications to target neuropathic pain can include Neurontin or tricyclic antidepressants.

Another possibility can be vascular disease.  Changes in leg temperature may point to this etiology.  Tests to evaluate this would include measuring ankle/brachial indicies, segmental limb pressures, and segmental volume plethysmography.  These are all tests to discuss with your personal physician.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Thanks,
Kevin, M.D.

[kevinmd]

I will be away and have limited internet access from December 26th to January 4th.  I wish everyone a safe and happy holiday season.

Take care,
Kevin, M.D.