Working Diagnosis:
20 year old African-American female with R knee pain likely due to patellar contusion and worsening pain due to complex regional pain syndrome (Amplified musculoskeletal pain/RND –reflex neurovascular dystrophy) and saphenous neuropathy.
Treatment:
The patient was informed and educated about her diagnosis of CRPS (Complex regional pain syndrome). This syndrome is a disorder characterized by pain, sensory and motor disturbances involving the peripheral nerves, which constrict blood vessels and decrease blood flow. This disorder is made worse with immobility (2,3). Therefore, our patient was instructed to immediately discontinue wearing her compressive knee brace and ambulate WITHOUT using crutches. Case Photo #2 . PT was prescribed using a specialized program, designed by Dr. David Sherry, for treatment of CRPS(3,8,9). This program included an individualized program of behavioral modifications during stance and gait; physical desensitization of knee pain with rubbing and massage; fine motor skill retraining and lower limb weight-bearing. She was instructed to follow-up for re-evaluation in 2-3 weeks.
The patient returned to our facility 3 weeks later. She reported having significantly reduced pain after discontinuing the crutches, knee brace, 4 visits with the physical therapist and home exercises. On physical examination, the patient was walking with a mild limp and no crutches. Her ambulation was much more functional than on her first visit. Her R knee showed no marked effusion.
However, she still had tenderness along the saphenous nerve distribution medially. ROM was full and painless. Ligament and meniscal tests were negative. Patient was prescribed Voltaren gel, advised to continue PT, and offered superficial anesthesia/D20 injections over the saphenous nerve. She requested time to consider this mildly invasive option known as neural prolotherapy (4,5,6).
Our patient returned to the office 2 days later for the injections. Tender areas along the saphenous nerve on the R medial knee were identified and marked. ÂĽ cc of D20/1% procaine solution was injected into each tender point.
Within a few minutes after the procedure, she reported almost complete relief of the original pain reported. She was encouraged to avoid limping, continue PT, full –weight bearing activities, and to follow-up in one week. The patient was informed that she may require repeat injections in 2-3 weeks for full pain relief.
She called the office one week after the 1st round of injections and reported that her pain had significantly returned 3-4 days after the injections. The patient was advised that this is a rather common occurrence, and that repeat injections on approximately a weekly basis may be necessary to further diminish and eventually eliminate her symptoms (10,11,12). The patient was returning to college in Buffalo and unable to follow-up at our facility for further treatment. As per her request, she was referred to a sports medicine specialist in Buffalo, NY, for continuing treatment of CRPS.
Outcome:
The patient returned to our office 3 months later
She had not received additional injections while in Buffalo. She was still performing weight-bearing exercises, feeling significantly better, walking well, no limp and very minimal allodynia along the saphenous nerve.
Author's Comments:
Complex regional pain Syndrome (CRPS) is a very painful medical condition. It may become chronic if it is untreated or treated for long periods with immobility (2,9,13). CRPS usually affects a limb but can cause pain in any body part. Pain may occur with or without an acute injury to a specific region of the body. It is characterized by: burning pain, abnormalities of sensory, motor and autonomic nervous systems, pain out of proportion to the history and physical because of amplified pain signals in nerves and muscles(8,14).
Former names for CRPS include: reflex sympathetic dystrophy (RSD), algodystrophy, causalgia
reflex neurovascular dystrophy (RND) – CRPS in children,
amplified musculoskeletal pain and neuropathic pain. In
1995, a consensus conference grouped these disorders under the single heading of complex regional pain syndrome (CRPS) (2,3,7).
The pathophysiology of CRPS is not fully understood. It is believed to be a systemic disease involving both the central and peripheral nervous systems(2). Genetic factors may also be involved(3). It is theorized that
the pain signal becomes amplified due to an abnormal short circuit in the spinal cord. The pain signal travels up to both the brain AND to the neurovascular nerves that control blood flow through the peripheral vessels. These nerves cause the blood vessels to constrict, which decrease blood flow. Decreased blood flow deprives skin, muscles and bones of oxygen. Reduced oxygen causes lactic acid build-up. Decreased oxygen plus increased lactic acid causes pain. This new pain signal also travels across the abnormal reflex causing more reduced blood flow and more pain. Thus, the pain signal is greatly amplified (8,9).
CRPS is diagnosed clinically. the clinical diagnostic criteria are as follows:
1. The presence of an initiating noxious event, or cause of immobilization;
2. Continuing pain, allodynia, or hyperalgesia in which the pain is out of proportion to the history and physical.
3. At least 1 finding of autonomic dysfunction must be present: edema, cyanosis, decreased skin temperature, diaphoresis (2,3).
4. Pain with no improvement or made worse with immobilization.
Lab studies must be done to exclude other conditions presenting with extremity pain: trauma(fracture), inflammatory conditions ( JRA, osteomyelitis)
tumors (osteosarcoma) (2,3,7).
Goals of CRPS treatment include: restoration of function, pain relief, physical and occupational therapy (3,8,9,15).
Our patient benefitted well from this specialized PT for her CRPS. Her saphenous neuropathy, which persisted, was treated successfully with neural prolotherapy. This procedure involves subcutaneous injections along the course of a nerve (4,5,6). Case Photo #3 . Neural prolotherapy, developed by Dr. John Lyftogt, is successful in treating refractory knee, shoulder, and elbow pain(10); achilles tendinopathy(11);and
recalcitrant low back pain(12).
This treatment is based on the concept that subcutaneous nerves can become irritated or inflamed due to injury. Abnormal nerve function may be due to a kink in the nerve as it penetrates muscle and fascia. Injured nerves produce substance P and CGRP (calcitonin gene related peptide). These substances cause blood vessel leakage and pain(4,5,6).
Neural prolotherapy works best when using a ½ inch 25 or 27 gauge needle with dextrose D20/procaine. Dextrose is used because nerves are soft tissue composed largely of connective tissue. Dextrose heals connective tissue, helps improve nerve function, reduces pain and swelling. Based on Hilton's law, the healing of deeper structures may occur if superficial structures are returned to normalcy with weekly subcutaneous injections(5,10,11,12).
Overall, our patient’s amplified knee pain and difficult ambulation improved dramatically after she was correctly diagnosed with CRPS, treated with specialized physical therapy for CRPS,encouraged to mobilize and bear weight on the affected limb as much as on the nonaffected limb.
She was also given neural prolotherapy for her saphenous neuropathy (4,5,6,10). Most importantly, our patient was
diagnosed within one month of symptom onset resulting in no permanent disability or loss of limb function. (2,3,9,13).
Editor's Comments:
This case illustrates the importance of early recognition and treatment of CRPS. Later stages of CPRS can results in muscle wasting, contractures, and diffuse bone demineralization. Treatment success is limited in these stages.
As emphasized by the authors, early mobilization is the key treatment and limiting progression of CRPS. This patient benefited greatly from a physical and occupational therapy protocol which emphasized desensitization and mobilization.
If refractory to PT/OT, other treatment options include cognitive-behavioral therapy, pharmacologic treatment with antidepressants, anticonvulsants, oral glucocorticoids, calcitonin, alpha-blockers, and/or bisphosphonates. More invasive treatments have included regional nerve blocks.
References:
1. Pendergrass,TL. Moore, JH. Saphenous neuropathy following medial knee trauma. J orthop Sports Phys Ther 2004; 34(6): 328-334.
2. Finiss, DG. Complex regional pain syndrome in children and adolescents. European J Pain. 2006: 1-4.
3. Sherry, DD. Complex regional pain syndrome in children. www.UpToDate.com, 18.3: Sept.2010.
4. Lyftogt, J. Neural Prolotherapy. Rehab. Medicine. Jan.2010.
5. Reeves, KD. Neurofascial prolotherapy. Prolotherapy Research. Dr. K Dean Reeves, 2010.
6. Lyftogt, J. Pain Conundrums: Which hypothesis? CNS sensitization vs. PNS autonomy. Australasian Musculoskeletal Medicine. November 2008:72-74.
7. Washington State Dept of Labor and Industries, Medical Treatment Guidelines: Complex Regional Pain Syndrome. Provider Bulletin 97-05; June 1997.
8. Sherry, DD. DVD: Amplified musculoskeletal pain in children. Diagnosis and treatment. A guide for physical and occupational therapists. www.childhoodrnd.org 2002.
9. Sherry, DD. An overview of amplified musculoskeletal pain syndromes. J Rheumatol Suppl. 2000 Apr; 58:44-48.
10. Lyftogt, J. Subcutaneous prolotherapy treatment of refractory knee, shoulder, and lateral elbow pain. Australas Musculoskeletal Med. 2007;12(2):110-112.
11. Lyftogt, J. Subcutaneous prolotherapy for Achilles tendinopathy, Australas Musculoskeletal Med. Nov 2007;12(11);107-109.
12. Lyftogt, J. Prolotherapy for recalcitrant lumbago. Australas Musculoskeletal Med. 2008; 13(5): 18-20.
13. Sherry, DD. Amplified musculoskeletal pain: treatment approach and outcomes. J Pedicatric Gastroenterology & Nutrition; November 2008; 47(5): 693-694.
14. “Complex Regional Pain Syndrome Fact Sheet” NINDS. November 2003; NIH Publication No. 04-4173.
15. Lee B, Scharff, L et al. Physical therapy and cognitive-behavioral treatment for complex regional pain syndromes. J Pediatrics 2002; 141: 135-40.
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