This patient was found to have an elevated serum alkaline phosphatase of bone origin. These are his shoes.
DIAGNOSIS: Paget's disease of bone (osteitis deformans), which has resulted in bowing of the legs and consequent wearing of the lateral soles & heels of the shoes and elevation of the serum alkaline phosphatase. Rickets could cause identical findings, but bowing of the legs is most apt to occur in childhood. Symptoms in osteitis deformans include bone pain, muscle cramps, and impaired cranial nerve function; hearing is most often compromised due to enlargement of the cranium and compression of the 8th nerve. In addition to bowing of legs and cranial enlargement, signs can include a foreshortened spine and angioid streaks in the retina. The soft nature of Paget bone accounts for the bowing of long bones on weight bearing (see photo); the temporal artery can actually groove the temporal bone along its path. Up to 25% of patients with osteitis deformans develop osteogenic sarcoma at sites of disease. Patches of dense sclerotic bone can be seen on standard x-rays, often giving a "moth-eaten" appearance to the bone.
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