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Complex Regional Pain Syndrome (CRPS)

Reflex Sympathetic Dystrophy (RSD), Causalgia, Sudeck's Atrophy

Complex Regional Pain Syndrome is a poorly understood neurological phenomenon that is even more confusing because it goes by so many different names. It is also known as Reflex Sympathetic Dystrophy (RSD), Sudecks Atrophy and causalgia. The condition is basically a short circuit of the nervous system where nerves misfire thus sending constant pain signals to the brain even though there is no real or limited pain going on. In other words, it is a completely abnormal response by the nervous system to external stimuli.

This condition can occur anywhere on the body but is fairly common in the foot and leg. Pain is out of proportion to an injury; the pain may be severe, constant or burning. There are three stages in the condition.

Stage 1 the traumatic stage, starts immediately or several weeks after injury. The skin becomes dry, and red which then becomes cool and moist within several weeks. The foot and lower leg will begin to swell. There will be limitation of joint movement and constant pain only alleviated by sleep and pain medication. osteoporosis may start at this stage in some cases.

Stage 2 begins about 2-6 months after the injury. The skin becomes further moist, tight and shiny. The nails of the foot will become brittle and cracked. The patient will be walking in a guarded gait because the joint of the foot and ankle will locked.

Stage 3 occurs 6-9 months after the injury. This stage is characterized by irreversible structural changes, notably soft tissue atrophy (wasting) and decalcification of bone. Pain gets worse and may spread beyond the original site. The pain is often intractable. The skin at this point is cool and dry.

Look at the picture of the hands and arms. Note the swollen left hand and arm. You can also see that it is more red and shiny in appearance than the right hand and arm.

The following x-ray reveals the severe osteoporosis that can occur. Look how demineralized the middle of the foot appears.

xray of osteoporosis in crps

There are two types of CRPS, Type I and Type II. Type I is also referred to RSD and these involve cases in which the nerve injury cannot immediately be identified. Type II also referred to as Causalgia involves cases where there has been a major trauma to a distinct nerve.

There really is no laboratory test to diagnose Complex Regional Pain Syndrome. It is diagnosed on clinical grounds particularly to a nerve or soft tissue injury� which does not respond in a normal healing path. A thorough medical history and physical examination are necessary. It should be noted that in this instance surgery can be considered as an injury. CRPS has been seen quite frequently following elective foot surgery where the foot and lower leg required immobilization for a period of time due to the type of surgery performed.

It is estimated that people go to as many as five doctors before the proper diagnosis is made. The problem with this is that valuable time is wasted in beginning treatment. The earlier treatment is instituted , the better the prognosis.

There are basically three types of specialists that should be consulted for treatment. One is a neurologist the others include a physiatrist, and a pain management specialist which is generally an anesthesiologist. Even going to one of these specialists does not guarantee proper diagnosis and treatment. You should ask your physician if he or she is experienced in treating this condition.

Treatment, of course, is based on the severity of the presenting symptoms. Peripheral nerve blocks may be performed in an effort to break up the ongoing pain sensation being transmitted to the brain. A TENS unit is sometimes of value in an effort to break the pain cycle.

Physical therapy such as massage, compression with range of motion exercises to the affected areas.

nonsteroidal anti-inflammatory medication may be used for pain and inflammation. Systemic therapy with oral steroids, propranolol, nifedipine or other mood altering drugs may be helpful.

In severe cases surgical lumbar sympathectomy may be performed as a means to break the pain cycle.

The points to take away from this discussion of Complex Regional Pain Syndrome is that it is a diagnosis that is often overlooked and because of the delay in treatment, permanent pain and disability may arise. Additionally there are only a few types of specialists that are properly experienced to adequately treat this condition.