Working Diagnosis:
1) Healing distal fibula fracture. 2) Complex Regional Pain
Syndrome Type One (no demonstrable nerve injury). 3) Osteoporosis.

Treatment:
1) Physical Therapy referral. 2)Gabapentin 300 mg at night with instructions to increase to three times daily over 3 weeks.
3) Capsaicin cream topically.
4) Elevation, lace up ankle brace, and ice as needed.
5) Follow up in 6 weeks.

Outcome:
6 week followup: Patient reports no improvement. Pt was never called by physical therapy. We started Metoprolol 25 mg PO twice daily for sympathetic symptoms/hypertension. Gabapentin was increased to 600 mg twice daily. Fosamax was started at 70 mg weekly. We also arranged for physical therapy to call patient as soon as possible.
9 week followup: Patient much improved. Pain now two out of ten, and is able to walk 300 meters without crutches. He no longer has erythema, swelling, or allodynia. Pt cleared to return to housekeeping. 13 week followup: No pain with activity. Gabapentin and Fosamax discontinued. Continue Metoprolol for hypertension. 7 month Follow up X-ray of foot and Ankle: Prior Fracture of the lateral malleolus appears to have healed with slight angulation of the the lateral malleolus seen following healing. Bony demineralization noted previously shows significant improvement. Case Photo #8 .

Author's Comments:
This was a classic case of Complex Regional Pain Syndrome. We were lucky that conservative management with gabapentin, physical therapy, fosamax, and metoprolol were successful , as this patient was uninsured and further interventions (more invasive) would have been difficult to arrange.

Complex Regional Pain Syndrome (CRPS) is a painful disorder of one or more extremities that usually follows a physical injury. CRPS is divided into two categories: type 1 where the patient has no nerve lesion and type 2 where a nerve lesion is present.

There is no clear understanding of the mechanism of CRPS. Most authors recognize that CRPS represents a complex entity involving sympathetic nervous system dysfunction, inflammation, hypoxia, and psychological and behavioral aspects.

Treatments are either symptomatic (anti-depressants, anti-eleptic, or opiods) or aimed at underlying etiologies (steroids, sympathetic blocks, free radical scavengers (Dimethyl sulfoxide cream)) or supportive (physical therapy.

There is limited evidence-based support for any treatments for CRPS.

Gabapentin, pegabalin, and calcium-channel blockers are commonly used as first line treatments.

Physical therapy is helpful to maintain function and mobility of the affected extremity.

Editor's Comments:
This case is an excellent reminder of the breadth of pathology presenting to sports medicine physicians following injury. Two key components must exist for the diagnosis of complex regional pain syndrome: 1) An inciting traumatic event, and 2) pain out of proportion to the extent of injury. Soft tissue injury is the most common precipitating event (40%) followed by fracture (25%). However, in up to 35% of cases no precipitating event is found.
CRPS has three clinical phases, starting with pain out of proportion to exam, hyperemia, and rubor. Patients then progress to edema and muscle wasting before finally exhibiting decreased range of motion and bone demineralization (as in our case).
Limited evidence indicates CRPS can be prevented by vitamin C supplementation after fracture and early mobilization after stroke.
As the authors alluded, there is no definitive treatment for CRPS. In addition to the therapy above, there is limited evidence for the use of corticosteroids and calcitonin. Although more costly forms of therapy are available, most patients get better with treatment or spontaneously with a mean duration of symptoms for 6 months. Fracture-related CRPS has the highest likelihood of resolution, 90%.

References:
Complex Regional Pain Syndrome.� 1)DynaMed. Available at www.ebscohost.com/dynamed/. 15 April 2010.
2)Complex Regional Pain Syndrome.� Up To Date. Available at www.uptodate.com. 15 April 2010.
3) Current Understandings on Complex Regional Pain Syndrome. de Mos, M et al. Pain Practice (2009) 9(2):86-99.
4) Complex Regional Pain Syndrome. Birklein, F. J Neurol (2005) 252 : 131-138.

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