Differential diagnosis of a soft tissue mass in the calf

Superficial peroneal nerve compression due to peroneus brevis muscle herniation

Muscle hernias of the extremities most commonly occur in the leg, between the knee and ankle. Symptomatic muscle hernias in the leg are rare cause of chronic leg pain and neuropathy, and not routinely encountered in surgical practice. Although this condition is especially an esthetic problem, with palpable subcutaneous soft tissue mass, it can lead to spontaneous pain, cramp, local tenderness or potentially neuropathic symptoms. Moreover, among leg muscles involved in this process, peroneus brevis is less frequent than tibialis anterior. Magnetic Resonance Imaging is the method of choice in establishing the diagnosis. Symptomatic cases can be treated surgically in different ways, the preferred one is nerve releasing with fasciotomy. The purpose of this case report is to present the Magnetic Resonance findings of a superficial nerve compression due to a peroneus brevis muscle herniation.

Giant Cell Tumor of the Distal Femur

A 24-year-old woman presented to a physical therapy clinic reporting a 4-month history of constant left knee pain of insidious onset. In the setting of nonlocalized, nontraumatic chronic knee pain, the physical therapist ordered radiographs, which revealed an osteolytic lesion along the distal anterolateral femur, suggesting a giant cell tumor. The radiologist then recommended computed tomography for better appreciation of the lesion and magnetic resonance imaging to investigate any soft tissue abnormality. J Orthop Sports Phys Ther 2016;46(11):1011. doi:10.2519/jospt.2016.0419.

Physical therapists referring patients to physicians: a review of case reports and series

STUDY DESIGN

Descriptive.

BACKGROUND

An important role for physical therapists in the healthcare delivery system is to recognize when patient referral to a physician or other healthcare provider is indicated. Few studies exist describing physical therapists' evaluative and diagnostic processes leading to patient referral to a physician.

OBJECTIVE

To summarize published patient case reports that described physical therapist/patient episodes of care that resulted in the referral of the patient to a physician and a subsequent diagnosis of medical disease.

METHODS

A literature search identified 78 case reports describing physical therapist referral of patients to physicians with subsequent diagnosis of a medical condition. Two evaluators reviewed the cases and summarized (1) how and when patients accessed physical therapy services, (2) timing of patient referral to a physician, (3) resultant medical diagnoses, (4) physical therapists' role in referral of patients for diagnostic testing, and (5) relevant patient symptom description, health history, review of systems, and physical examination findings.

RESULTS

Fifty-eight (74.4%) of 78 patients had been referred to a physical therapist by their physician, while the remaining 20 patients accessed physical therapy services via direct access. The patients' primary presenting symptoms included pain (n = 60), weakness (n = 4), tingling/numbness (n = 2), or a combination (n = 12). Patient referrals to a physician occurred at the initial physical therapy session in 58 (74.4%) of 78 cases. A majority of patient referrals to a physician (n = 65) were related to primary presenting symptoms, including manifestations inconsistent with physician diagnosis, recent worsening without cause, unusual accompanying symptoms such as fatigue and/or weakness, and inadequate response to treatment. Resultant diagnoses included neuromusculoskeletal disorders (n = 53; fractures and tumors most common), visceral disorders (n = 14; cardiovascular involvement most common), and medication-related disorders (n = 3).

CONCLUSIONS

This review of published patient case reports provides numerous examples of physical therapists using effective multifactorial screening strategies for referred and direct-access patients, leading to timely patient referrals to physicians. The therapist-initiated patient referral to a physician led to subsequent diagnosis of a wide range of conditions and pathological processes.

Deep vein thrombosis in an athletic military cadet

STUDY DESIGN

Resident's case problem.

BACKGROUND

A 21-year-old healthy athletic male military cadet with complaint of worsening diffuse left knee pain was evaluated 4 days after onset. The knee pain began 2 hours after completing a long car trip, worsened over the subsequent 3 days, and became almost unbearable during the return trip. The patient reported constant pain, limited knee motion, and difficulty ambulating. In addition, he was unable to perform physical military training or attend academic classes due to the severe left knee pain. Past medical history revealed a mild left lateral calf strain 21/2 weeks prior, which completely resolved within 24 hours of onset.

DIAGNOSIS

Our physical examination led us to either monoarticular arthritis, pseudothrombophlebitis (ruptured Baker's cyst), or a lower leg deep vein thrombosis (DVT) as the cause of knee pain. Diagnostic imaging of this patient revealed a left superficial femoral vein thrombosis and popliteal DVT, with bilateral pulmonary emboli (PE).

DISCUSSION

A systematic differential diagnosis was undertaken to rule out a potentially fatal DVT diagnosis as the cause of knee pain, despite minimal DVT risk factors. The physical therapist in a direct-access setting must ensure timely evaluation and referral of a suspected DVT, even when patient demographics cause the practitioner to question the likelihood of this diagnosis. The physical examination findings, clinical suspicion, and established clinical prediction rules can accurately dictate the appropriate referral action necessary.