CRPS in the Foot: Everything You Need To Know
CRPS in the foot can cause numbness, pins, and needles. Learn about the symptoms, causes, and treatment options for this condition. We explore the science, biology, and anatomy behind this condition to help you gain a better understanding.
Complex regional Pain Syndrome (CRPS) is a syndrome characterized by pain, swelling, and numbness, especially of the limbs. The pain is out of proportion to the stimulus. There are two main types of this syndrome. In CRPS 1, there is no history of any kind of nerve injury, whereas, in CRPS 2, there is a history of nerve injury either due to trauma, surgery, or stroke. There are two stages of this syndrome, one is the acute phase in which there are signs of inflammation, so the extremities are warm. The other one is chronic (symptoms for more than 06 months).
The injury can be due to trauma, fracture, or surgery. According to several studies [1-3], the incidence of CRPS in the lower limb after surgery of the tibia is 31% and 4.4% after surgery of the ankle and foot; whereas 30% of people who had a fracture of the tibia, 15.2% of people who had ankle fracture and 2.9% of people who had a fracture of 5th metatarsal developed CRPS.
Pathophysiology:
In the last 2 to 3 decades, there are a number of studies published on finding the Pathophysiology of the disease. The Pathophysiology of this syndrome is complex and involves multiple factors rather than a single factor. It involves an interplay between inflammation, nervous system sensitization, and autonomic dysfunction.
These factors influence each other in the progression of the disease. Understanding these mechanisms is necessary for diagnosis and effectivemanagement of this complex syndrome:
● Inflammation: Inflammation plays an important and fundamental role in this syndrome’s development. After trauma or injury to the limb, the immune system of the body initiates an inflammatory response. However, in patients with CRPS, this response becomes dysregulated causing excessive and prolonged release of inflammatory mediators. These inflammatory mediators, such as cytokines activate inflammation, which results in painful, warm, and swollen limbs. Some of these mediators also increase the sensitivity of pain receptors to normal stimuli. Inflammation mainly plays a role in the acute phase of the syndrome, in which the limbs are warm.
● Autonomic Dysregulation: There is also dysregulation of the autonomic system mainly the sympathetic system, which normally causes constriction of vessels. In the acute phase of CRPS, due to improper functioning of the sympathetic system, the blood vessels remain dilated and cannot be constricted despite cooling the limb. As a result, the limb is warm and swollen as compared to other limbs. In the chronic or cold phase, the sympathetic system becomes hyperactive. This causes constriction of blood vessels, resulting in decreased blood supply to the limb. As a result, the limb is cold and clammy.
● Sensitization of the nervous system: Both the peripheral and central nervous system’s sensitivity to pain increases, meaning a small stimulus that does not cause pain in normal individuals causes pain in patients of CRPS and out-of-proportion pain for a mild pain stimulus. Changes also take place in synapses of the brain causing tremors, jerks, and exaggerated reflexes
Some other factors such as genetic predisposition and psychological factors also play a role in the Pathophysiology of this syndrome.
Pathophysiology of CRPS
Clinical presentation:
Symptoms of CRPS can be characterized into different categories such as:
● Sensory: The sensitivity of pain receptors for the perception of pain is increased, so pain is out of proportion to the stimulus. The normal painless stimulus also causes pain.
● Motor: It includes muscle stiffness, muscle weakness, restriction of movements, and tremors
● Temperature: The limb which has CRPS is warm as compared to other normal limbs.
● There is swelling and edema
Diagnosis:
It is a tricky disease to diagnose. There is no single definitive method to diagnose that a patient has CRPS. Its diagnosis involves taking a complete history from the patient about symptoms, the nature of the injury, the type of injury, or any recent surgery. The affected limb is examined to check for signs of swelling, increased temperature, movement restriction, muscle stiffness, and tremors. Additional tests can also be performed, such as bone scans, sweat tests, X-rays, and MRIs.
BUDAPEST CRITERIA FOR COMPLEX REGIONAL PAIN SYNDROME (CRPS) FOOT DIAGNOSIS
All of the following criteria must be fulfilled to have a proper diagnosis of CRPS
● Continuous pain which is disproportionate to trauma
● At least, 1 sign from 2 or more categories mentioned below
● At least, 1 symptom from 3 or more categories mentioned below
● No other diagnosis explains the signs and symptoms better
No. Category Sign and Symptoms
1. Sensory Pain from things that are usually painless (light touch, temperature, deep pressure, movement of joints), also called allodynia.
Too much pain on painful stimuli like a pinprick, also called hyperalgesia.
2. Vasomotor The difference in skin temperature (more than 1 degree Celsius) and skin color difference between affected and non-affected feet.
3. Sudomotor/ Oedema Changes and differences in swelling and sweating between two feet.
4. Motor/ Trophic Decreased range of movement, tremors, weakness, dystonia, and changes in hair, skin, and nails.
Management:
Its management involves physical therapy, occupational therapy, NSAIDS, steroids, neuropathic pain medicines, bisphosphonates, and anti-epileptic medicines. Other treatment modalities include sympathetic nerve block, spinal cord stimulation, and psychotherapy.
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References
1. Beerthuizen A, S. D. (2012). Demographics and medical parameters in the development of complex regional pain syndrome type 1 (CRPS1): a prospective study on 596 patients with a fracture. Pain.
2. Rewhorn MJ, L. A. (2014). Incidence of complex regional pain syndrome after foot and ankle surgery. J Foot Ankle Surg.
3. Sarangi PP, W. A. (1993). Algodystrophy and osteoporosis after tibial fractures. J Bone Joint Surg.