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248: PAGET DISEASE

Eric Shamus, PhD, DPT, PT, CSCS; Christopher C. Felton, DO, ATC

CONDITION/DISORDER SYNONYM

  • Osteitis deformans

ICD-9-CM CODE1

  • 731.0 Osteitis deformans without mention of bone tumor

ICD-10-CM CODE2

  • M88.9 Osteitis deformans of unspecified bone

PREFERRED PRACTICE PATTERNS3

  • 4A: Primary Prevention/Risk Reduction for Skeletal Demineralization

  • 4B: Impaired Posture

  • 4C: Impaired Muscle Performance

  • 4F: Impaired Joint Mobility, Motor Function, Muscle Performance, ROM and Reflex Integrity Association with Spinal Disorders

  • 4G: Impaired Joint Mobility, Muscle Performance, and ROM Associated with Fracture

PATIENT PRESENTATION

A 55-year-old male presents to the office with complaint of worsening low back pain over the last 2 months. He describes the pain as “bone pain” consisting of a deep, dull, constant ache in the region of his lumbar spine. He also has noticed over the last week, short episodes of numbness in his left lower extremity (LE) when he stands for long periods of time. It is relieved with lying supine or sitting. A 14-point review of systems was otherwise negative. Past medical history is unremarkable. His temperature is 98 degrees F, BP is 124/74, HR is 70 bpm, RR is 16 breaths/min, and O2 sat is 100%. On exam, there is tenderness to palpation over transverse processes of L4 and L5 as well as increased warmth to the skin in the same region. Lumbar spine ROM is limited in flexion and extension secondary to increased pain. Strength is 5/5 in his LE bilaterally, as well as 2+ reflexes at L4 and S1. Overall, lumbar lordosis is decreased. The patient is referred to the physician. Serum alkaline phosphatase (ALP) is mildly elevated, with normal calcium and phosphate. X-ray shows the L4 and L5 vertebrae to be enlarged and an ivory appearance to them.

KEY FEATURES

Description

  • Osteometabolic bone disease

  • Excessive reabsorption of bone by osteoclasts, followed by vascular and fibrous tissue filling in the bone marrow

  • Weakening of the bones

  • Slow progressive enlargement of the bones

  • Accelerated bone remodeling

FIGURE 248-1

Radiograph of a 73-year-old man with Paget disease of the right proximal femur. Note the coarsening of the trabecular pattern with marked cortical thickening and narrowing of the joint space consistent with osteoarthritis secondary to pagetic deformity of the right femur. (Reproduced with permission from Fauci AS, Kasper DL, Braunwald E, et al. Harrison’s Principles of Internal Medicine. 17th ed. © 2008, McGraw-Hill, New York.)

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Essentials of Diagnosis4

  • Phase 1: Osteolytic phase

    • Prominent bone reabsorption and hyper vascularization

  • Phase 2: Sclerotic phase

    • Decreased cellular activity and vascularity

  • Phase 3: Mixed phased

    • Both active bone reabsorption and bone formation

    • Bones become weakened

General Considerations

  • Can be asymptomatic

  • Managed ...

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