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PAIN FROM A CRUSHED ANKLE, FOOT

Q: My husband's ankle and foot were crushed a year ago. They got very swollen and bruised. He has had three MRIs, three sonograms, bone scans, CAT scans and a lot of other tests. He's now been diagnosed with reflex sympathetic dystrophy.

He has tried many therapies, but nothing worked. The pain management doctor wants to try a spinal column stimulator. If that doesn't work, the orthopedist said we should think about a sympathectomy or maybe amputation. Please give me your opinion on reflex sympathetic dystrophy and treatments?

-- Worried in Texas
A: Unremitting pain can be almost intolerable. This diagnosis is often overlooked, and treating it is one of the most frustrating and challenging problems for any health professional.

Reflex sympathetic dystrophy syndrome (RSDS) is probably the most difficult pain syndrome to understand, let alone to manage. This complexity is reflected in a new name that is being given to RSDS: complex regional pain syndrome (CRPS) type 1. CRPS type 2 is the new name for another similar condition that was called causalgia.

Whatever name is used, in essence the syndrome is due to nerve damage accompanying injury to an extremity, and the pain and other symptoms are much more severe than would ordinarily be expected.

It appears that a lot of the symptoms and complexity is related to involvement of the part of the sympathetic nervous system that controls such things as blood vessels and sweating. But it's unknown how this part of the nervous system interacts with the nerves that transmit pain signals to the brain.

Crushing injuries are the most common injuries resulting in CRPS. But this pain can also be seen with simple fractures and cuts, burns, and even some surgeries.

Early symptoms include pain that is often described as burning or aching, plus tenderness and numbness localized at the injury site. The site may become warm, dry, red and swollen. Changes at the injury site area can include muscles wasting, osteoporosis and stiffening of the affected joints.

Later, the pain can spread beyond the injury site. And, like so many other types of pain, it's often worse at night. As with all people who suffer from chronic pain, people with CRPS will exhibit substantial psychological stress, depressed mood, anxiety and anger.

Early diagnosis increases the chances of managing the pain and other symptoms. Treatment of CRPS begins with repairing the injury that's causing the pain. However, that is easier said than done.

Immediate treatment includes physical and occupational therapy to restore function, steroids to relieve inflammation, and painkillers for the pain. Calcium channel blockers have been used to improve circulation in the area affected.

Drugs and some form of counseling to treat the psychological problems should be implemented when needed. Psychological support has been shown to help with the mental health problems caused by the pain, as well as the pain itself.

If these treatments don't work, or if the condition is more severe, surgical procedures such as implanting a spinal cord stimulator, or anesthetizing or severing parts of the sympathetic nervous system, may be recommended.

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