Pain Syndrome After Trauma: Diagnosis and Treatment Options

Pain syndrome

Hello: I had a car accident in April of last year, resulting in a fifth metatarsal fracture.
I was in a cast for 40 days, during which my foot was severely swollen and painful.
I thought that removing the cast would improve the situation, but the swelling and pain persisted.
Three months later, I had to seek help from a psychiatrist for sleeping pills to be able to sleep.
Over a year later, bone scans show that the fracture site is normal, but the injured area still shows concentrated pain points.
Walking puts pressure on these pain points, and to avoid the pain, my walking posture has become incorrect.
I am currently undergoing rehabilitation treatment and taking the neurologic medication NEURONTIN 300 mg once a day.
I would like to ask: 1.
Is this post-traumatic pain syndrome? 2.
How can the diagnosis be confirmed? A doctor told me it commonly occurs in the upper arm and rarely in the lower extremities, is that true? 3.
Are there specialists in this area in the country? I have seen many doctors, some of whom say this is a baseless diagnosis, while others suggest just to relax (but how can I relax when every step I take causes pain?).
Is this a new diagnosis? Why are there such polarized views among doctors regarding this condition?

Nìmíng, 40~49 year old female. Ask Date: 2009/05/05

Dr. Gao Chunde reply Neurology

Post-traumatic conditions can lead to a very painful neurological syndrome known as Complex Regional Pain Syndrome (CRPS).
This condition typically presents with changes in the skin at the site of injury, swelling, alterations in hair growth, temperature fluctuations, changes in sweating, blood circulation issues, and even changes in bone density.
It is more common in the hands than in the feet.
Diagnosis is primarily clinical, although some medical centers may offer laboratory tests for sweating and temperature.
Treatment options include medication, nerve stimulation, or nerve blocks, but these can be challenging to manage.
Referral to a pain management specialist may be considered for this condition.

Reply Date: 2009/05/05

More Info

Understanding pain syndromes after trauma, particularly Complex Regional Pain Syndrome (CRPS), is crucial for effective diagnosis and treatment. Based on your description, it appears that you may be experiencing symptoms consistent with CRPS, which can occur after an injury, such as a fracture.
1. Is this Complex Regional Pain Syndrome (CRPS)?
CRPS is characterized by prolonged or excessive pain and changes in skin color, temperature, and swelling in the affected area. It often follows an injury, even if the injury is minor. The pain is usually disproportionate to the severity of the initial injury. Given that you experienced significant pain and swelling after your fracture, and that the pain persists despite the bone healing, it is possible that you are dealing with CRPS.
2. How to confirm the diagnosis?
Diagnosing CRPS can be challenging as it is primarily a clinical diagnosis based on symptoms and medical history. There are no definitive tests for CRPS, but certain diagnostic criteria can help. These include:
- The presence of continuing pain, which is disproportionate to any inciting event.

- Evidence of edema, changes in skin blood flow, or abnormal sweating in the affected area.

- Symptoms that spread to other regions of the body.

A healthcare provider may also use imaging studies, such as bone scans or MRI, to rule out other conditions and assess changes in the affected area.
It is true that CRPS is more commonly reported in the upper extremities, but it can occur in the lower extremities as well. The misconception that it is rare in the legs may contribute to varied opinions among healthcare providers.
3. Are there specialists available for this condition?
Yes, there are specialists who focus on pain management and rehabilitation, including physiatrists (rehabilitation physicians), pain management specialists, and neurologists. It is essential to seek care from a provider experienced in CRPS or chronic pain syndromes. They can offer a comprehensive treatment plan that may include physical therapy, medication management (like your current use of Neurontin), and possibly nerve blocks or other interventional procedures.

4. Why the differing opinions among doctors?
The variability in opinions among healthcare providers regarding CRPS can stem from several factors, including differences in training, experience, and familiarity with the condition. Some may view it as a psychological issue rather than a physical one, leading to recommendations for relaxation techniques rather than medical intervention. This can be frustrating, especially when the pain is severe and persistent.
It is important to advocate for your health. If you feel that your concerns are not being taken seriously, consider seeking a second opinion from a specialist who has experience with CRPS.
In conclusion, CRPS is a complex condition that requires a multidisciplinary approach for effective management. Treatment may involve a combination of physical therapy, medications, psychological support, and possibly interventional procedures. It is crucial to work closely with healthcare providers who understand the intricacies of this syndrome to develop a tailored treatment plan that addresses your specific needs and helps improve your quality of life.

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