Maarten Vasbinder lives in Isaan. His profession is general practitioner, a profession that he mainly practiced in Spain. On Thailandblog he answers questions from readers who live in Thailand.
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Dear Martin,
I am 74 years old, 182 cm tall, 95/96 kilos, no smoking and no alcohol. Blood pressure 130/80. Do not use any medicines, except for pain on the left side / left leg, being 200mg Celebrex cap and Voltaren emulgel.
History. End of 2019 MRI scan, prostate biops, bone scan, orchiectomy and bone biops. After bone biops it turned out that prostate cancer had not spread but that I have Paget's disease. Before that, after consultation with LMC Nederland, an infusion with Zoledronate was administered. Last check PSA in early November 2020 indicated a value of 0,79.
A few weeks ago I had the idea that my left leg was a bit stiff. At first I blamed cramped driving in the dark and with rain. Thought to be smart so next day on the exercise bike and instead of 1 time 15 minutes done 3 x 15 minutes throughout the day. Wrong choice because I got a lot of pain in my left leg. Couldn't sleep on that side. After a while I went to Bangkok Hospital in Korat because there were all my data regarding my history mentioned above.
First orthopedist: you sit too much, you're a bit older, it's muscle pain and here are some medicines. No improvement. Second orthopedist: presumably you have tendinitis, received the same medicines. I also refer you to Physio. The last remedy is cortisone injection. Because Paget's disease is unknown here, I don't know if a cortisone injection will be the right treatment.
Physio (Bangkok Hospital): given your history, I am unfortunately not allowed to use a laser. So ultrasonic, paddles, massage and hot packs. Did four treatments and no real improvement.
After a visit to the doctor for PSA, immediately to the same (second) orthopedist. Told the story about not being able to use laser. He called the doctor at physio and I was allowed to come by.
Doctor at physio examined me and said: problem comes from gluteal muscle. It is so deep that laser cannot reach it, so she suggested Shockwave and radio frequency treatments in combination with exercises. Again 4 treatments of which I have now completed 3, tomorrow the last time. During the day I felt good but to sleep I needed a sleeping pill. Unfortunately, prostate cancer often causes me to wake up to go to the toilet.
Last night my left hip and left leg hurt so much that I got up at 00.05 am. Some short sleep periods (1,5 to 2 hours at a time) lasted until 04.30 am.
Any idea in which direction I should look now? Is it due to Paget's disease, which has caused possible bone deformation and nerve compression? Could it be sciatica?
Hope you can make sense of my story. Thank you in advance for your response.
Regards,
R.
******
Dear R,
What a situation. Your story is very clear.
Most likely, Paget's disease is causing the pain. This disease is also called Osteitis deformans. Maybe then they'll know what it is.
Here's an article about Paget's disease: emedicine.medscape.com/article/334607-treatment.
Important is the treatment with biphosphonates. The simplest and cheapest is alendronate, which is taken on an empty stomach in the morning with a glass of water (40mg per day). Then do not eat, drink or lie down for half an hour, otherwise irritation of the throat and esophagus may occur. Thereaast Calcium (1500 mg per day) and Vit. D 500 mg per day).
Bone markers in the blood should be checked regularly, starting with alkaline phosphatase. A skeletal scintigraphy is also recommended to see where the bone is affected.
The specialist for this condition is the internist or the rheumatologist and not the orthopaedist. Regular check-ups are important because of the risk of bone cancer, which is more common in Paget's case.
You now have pain, which can indeed emanate from the lumbar spine. It could be that the Paget is also busy there. Incidentally, the disease is usually local and therefore not present in all bones.
Finally, there is the possibility of a circulatory disorder, but I do not choose that first.
Looks like you've had some extremely aggressive treatment for your prostate, but maybe it was necessary. Because you almost stop producing testosterone, the Paget can be more aggressive.
My advice in this is to visit an internist as soon as possible.
Courage,
Yours faithfully,
Dr. Maarten