Stanley Kalish, DPM

HISTORY: 60 y/o Caucasian female, heavy smoker in acute distress with pain and swelling in foot. Seen at Atlanta foot and leg clinics – post foot injury with painful and edematous foot. Our initial diagnosis upon history and physical examination was sinus tarsitis with grade 1 ankle sprain. Her initial pain scale was 8/10.

PHYSICAL EXAM

Head and Neck: Neck and thyroid -no lymphadenopathy, supple.

Chest: Clear to A&P with no wheezes. No Rhonchi or Rales, Cardiovascular-normal s1-s2 with no murmurs normal sinus rhythm

Gi: No hepato-splenmegaly. No masses palpable.

Neurological: Alert and well oriented. Central nervous system II XII grossly intact. Non-focal examination.

Skin: Erythematous right foot compared to left.

Extremities: No clubbing. Positive edema 4+ right compared to left. Foot is cold with no palpable pulses compared to the left foot

Vascular studies: Normal arterial pressures. ABI's 1.04 right and 1.01 left . TBI's .90 [r]ight and .80 [l]eft.

Nerve conduction studies: Low velocity medial and lateral plantar nerves with nerve conduction velocities 40 m/sec [r] and 38m/sec[l]. The latencies and amplitudes are normal. The medial plantar nerve velocities are 41m/sec [r] and 37m/sec [l]

ASSESSMENT

The assessment at the time of the original injury was tarsal tunnel syndrome and possible grade I rupture of the anterior talo-fibular ligament of the right ankle.

Mri's: Right foot and ankle revealed edema with soft tissue swelling and evidence of bone bruising involving the talus, navicular and calcaneus. There was no gross evidence of dislocation of the foot.

After several weeks of observation and treatment we referred this patient to the center for pain management, with a possible need for spinal cord implant for pain control.

TREATMENT

An initial diagnosis of RSDS with CRPS I was made. The patient was placed on gabapentin 300mg TID, fosamax and folic acid.

After several weeks of observation and treatment, we referred this patient to the center for pain management, with a possible need for spinal cord implant for pain control.

Lumbar sympathetic blocks using a C-ARM intensifier at the level of l-3. The skin was infiltrated subcutaneously with 5ml of xylocaine . Using a #22 gauge chiba needle, it was advanced with tunnel views from the skin through the lateral border of the vertebra at l-3. 3ml of isovue were injected showing excellent dye spread behind the PSOAS muscle in front of the anterior body. Subsequently, the area was injected with 15ml of marcaine 0.25% plain in an incremental fashion.

SUMMARY

This patient was initially seen and treated by a podiatric physician with a complaint of what appeared to be a simple grade 1 ankle sprain with inflammatory sinus tarsitis.

After evaluation of the medical history and physical examination with particular assessment on a heavy cigarette smoker, this patient was diagnosed with RSDS with CRPS I. She was referred for lumbar sympathetic blocks and ultimately spinal cord implant for intractable pain.

This is a classical example of a patient with chronic pain syndrome following an ankle and foot injury whose treatment regimen by the podiatric physician was unable to relieve symptoms and progressive disease. This type of patient was most benefited by referral to a anesthesiologist or neurosurgeon who can take the treatment to the next level of lumbar blocks and possible spinal cord simulator.

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