1302 - Rehabilitation and Pain Management of Diabetic Myonecrosis: A Case Report

Case Diagnosis: 37-year-old female with diabetes, hypothyroidism, and remote left hip osteonecrosis status post arthroplasty admitted for months of right lower limb pain and swelling due to diabetic myonecrosis.

Case Description:

Patient fell two months prior; magnetic resonance imaging (MRI) demonstrated grade 2 strain of right adductor longus and brevis muscles, low-grade strain of right gluteus medius, and diffuse nonspecific soft tissue edema. Symptoms progressively worsened until she required a wheelchair. Laboratory findings notable for blood glucose 439, hemoglobin A1c > 14.7. She is admitted for lower limb edema, splenic infarcts and nephrotic syndrome. MRI shows worsening subcutaneous edema concerning for myonecrosis versus myositis. Muscle biopsy unrevealing. Physical Medicine and Rehabilitation (PM&R) is consulted for excruciating pain now involving bilateral lower limbs and functional deficits. Pain management includes a combination of opioids, gabapentinoids, baclofen, topical diclofenac, and ice.  Although initially felt she would benefit from acute rehabilitation, ongoing pain and myonecrosis prohibits exercises. Focus becomes wheelchair transfer training to discharge home with skilled therapies. Repeat MRI confirms myositis and myonecrosis. As her kidneys improve, indomethacin is added with gradual pain reduction.

Discussions:

Myonecrosis is a rare but serious complication of uncontrolled diabetes characterized by muscle tissue death, believed related to microvascular disease and ischemic injury. In a systematic review of 126 cases, exercise of affected limb(s) worsened the condition and prolonged recovery compared to bedrest plus anti-inflammatories. 

 

Conclusions: Pain management is paramount; a multimodal approach is recommended. Therapy goals included gentle range of motion to prevent contractures, functional motion as tolerated, low air loss mattress with frequent weight shifts to prevent pressure injuries, and wheelchair transfer training to safely discharge home. A multidisciplinary approach including physiatry, internal medicine, physical and occupational therapy, and acute pain management service allowed for optimization of patient care.