reflex sympathetic dystrophy syndrome (RSD/RSDS)
Sudeck's atrophy
shoulder-hand syndrome
algodystrophy
peripheral trophoneurosis
sympathetically maintained pain
sympathetically independent pain
post-traumatic pain syndrome
sympathalgia
sympathetic overdrive syndrome

Due to confusion arising from the many names for this set of symptoms, The International Association for the Study of Pain (IASP) developed nomenclature to more accurately describe chronic pain. IASP coined the term chronic regional pain syndrome (CRPS) and broke CRPS into two categories;

CRPS I - Consists of pain, sensory abnormalities, abnormal sweating and blood flow, abnormal motor system function and trophic changes (thickening of the skin and nails, coarse thin hair growth) and atrophy of the superficial and deep tissues (skin, muscle, bone). The most common form is RSD and may not present with an identifiable nerve injury.

CRPS II - Same as CRPS I but presents with an identifiable nerve injury. Symptoms include burning pain made worse by light touch, temperature changes or motion of the limb. These findings are most common in the foot or hand following partial injury to the nerve. The affected area appears cool, reddish, and clammy. The superficial and deep tissue structures may also begin trophic changes.

 

Treatment for complex regional pain syndromes

Treatment of CRPS I and II consists of many different measures, but there is general agreement that the success of treatment depends upon early implementation of treatment. Treatment may include;

Medications
Narcotics- for pain suppression
Anti-inflammatory- non-narcotic control of inflammatory pain
Antidepressants-maintenance of normal sleep cycles, anxiety control
Calcium channel blockers- increased blood flow to extremities
Anticonvulsant- regulation of normal sleep cycle, control of pain

Pain blocks
Peripheral nerve blocks of the affected area
IV regional blocks of the affected extremity
Lumbar sympathetic blocks- given by an anesthesiologist

Physical therapy
Range of motion, strengthening exercises, continuous passive motion
(CPM)
Whirlpool, ultrasound, heat treatment
TENS, nerve stimulation

Steroid injections

Lumbar sympathectomy

Dorsal column stimulation
Morphine pump

Neurectomy - surgical excision of the nerve

Amputation - surgical removal of the affected extremity

The prognosis for patients with CRPS varies greatly and depends upon the degree of symptoms, when treatment is initiated and the type of treatment. Studies have shown that the overall success rate of the treatment of RSD has been 50%. In a study performed by Anderson and Fallat, they found that 3.5 years following the onset of traumatic injury resulting in CRPS, 12 of 13 patients still had pain considered to be moderate to considerable. (1)

Treatment of CRPS requires a team approach to treat not only pain but also the numerous problems associated with chronic pain. These problems include;

Depression.
Disruption of normal sleep cycles.
Inability to walk or bear weight.
Inability to work.
Disruption of relationships with spouse or offspring.

Resources that may be helpful in addition to pain management include psychological counseling, physical therapy and occupational therapy.

Tendon injuries, including peroneal tendonitis, are notoriously slow to heal. The reason that tendons are slow to heal is simply due to the fact that the blood supply to a tendon is limited and extremely fragile. As a result, tendons are poorly supplied with blood and are unable to respond well in cases of injury. When a tendon is injured, the initial response to the injury is that the tendon becomes inflamed.   Inflammation is the primary means by which the body sends out a signal or call for help to manage the injury to the tendon.  Inflammation is a signal that requests increased chemical and cellular responses to the injury.  Inflammation is also the body's tool that is used to bring additional blood flow and oxygen into a specific area.

Why does tendonitis hurt? While inflamed, the tendon is actively working to repair itself. There's an acute influx of blood, oxygen and cells that results in swelling. The arrival of all these cells is a new and unusual activity in and around the tendon causing pain. Pain is simply natures way of limiting physical activity and promoting rest. Although pain is not desirable, pain is our best guide to the nature and degree of injury and will help guide choices used in healing the injury.

Treatment Of Peroneal Tendonitis

As mentioned, tendons are notoriously slow to heal. Therefore, treatment of peroneal tendonitis can take weeks to months before the problem is completely resolved. Most important in the treatment of peroneal tendonitis is the need to decrease the load applied to the peroneal tendons with each step. There are two means by which this can be accomplished.  First, begin by wearing a heel lift and avoiding walking in bare feet. The lower the heel, the tighter the peroneal tendons and subsequently the greater the load carried by the peroneal tendons.  Also avoid low heeled shoes such a loafers, slippers, etc. Calf stretching or the use of a night splint can also be of value.

Second, a lateral sole wedge may also helpful. A lateral sole wedge is a wedge placed under the lateral or outside of the shoe. A lateral sole wedge inhibits the foot from rolling out.  Limiting the outward roll of the foot decreases the load applied to the peroneal tendons.  There are a number of varieties of lateral sole wedges.  Lateral sole wedges can be placed on orthotics.  Lateral sole wedges can also be placed on the outside of the shoe by a shoe repair shop or O&P facility. 

Medical treatment of peroneal tendonitis includes the use of  ice, rest and anti-inflammatory medications.  If oral medications are ineffective, injectable cortisone is often used.  In severe cases, non-weight bearing casts may be necessary.  Walking casts may be used as long as the walking cast is modified with a heel lift.  Walking casts are traditionally very low in the heel.  If a walking cast is used to treat peroneal tendonitis without a heel lift, the low position of the heel may actually contribute to the symptoms of peroneal tendonitis.

During an ankle sprain, as the ankle begins to roll, the peroneal tendons fire to stabilize the ankle and prevent the sprain from occurring. Both tendons are pulling up against the downward force of the lateral ankle. The fibula (lateral ankle bone) becomes a wedge carrying body weight down toward the ground. As the fibula drives downward, the peroneal tendons pull up against the ankle and are compressed. The peroneus brevis tendon is adjacent to the fibula while the peroneus longus tendon runs to the outside of the brevis. A longitudinal tear occurs when the peroneus longus tendon actually pulls so hard that it transects (slices) the brevis tendon into two parts along its' length. This means that the injury is actually caused by one peroneal tendon (the longus) transecting the other peroneal tendon (the brevis).

The peroneus longus tendon is not immune from injury.  Partial and complete ruptures of the peroneus longus tendon do occur but are far less common than injuries seen in the peroneus brevis tendon. The weakest portion of the peroneus longus tendon is the point where it changes direction and rounds the plantar surface of the cuboid. When ruptures of the peroneus longus do occur, they tend to be found just distal to the plantar cuboid and are also longitudinal. Complete transverse ruptures of the peroneus longus tendon are rare.

Another uncommon injury of the peroneus longus tendon is the rupture of the tendon at the site of an os peroneum. The os peroneum is a small accessory bone found within the peroneus longus tendon at the lateral wall of the cuboid. The occurrence of an os peroneum in the general population is reported in the literature to be 5-26%. When present, a healthy, functioning os peroneum will help facilitate the transfer of load carried by the peroneus longus as it rounds the cuboid. Bipartite (two part) os peroneum are common. Bipartite os peroneum and fractured os peroneum can be difficult to differentiate. When viewed on x-ray, a bipartite os peroneum will typically have smooth edges while a fractured os peroneum will display ragged edges.

Treatment Of Peroneal Tendon Ruptures

Initial care of peroneal tendon ruptures includes much of the same care recommended for ankle sprains; rest, ice, elevation, compression and anti-inflammatory medications. A 4-6 week period of conservative care is warranted before obtaining further testing such as an MRI. Use of a walking cast or ankle brace may help to splint the peroneal tendons during conservative care. Most peroneal brevis tendon ruptures do not heal and will require surgical repair.

Following a lateral ankle sprain, if the lateral ankle is still painful at 6 weeks post injury an MRI may help to determine whether the peroneal tendons have sustained an injury.  Alternatively, diagnostic ultrasound may be used to evaluate partial ruptures of the peroneal tendons. MRI is not always 100% accurate when evaluating peroneal tendon pathology.  Many cases of peroneal tears are too small to find with an MRI or ultrasound and can only be found with direct visualization during surgery.  Occasionally, an accessory tendon known as the peroneus tertius is present within the peroneal tendon sheath and is misdiagnosed on MRI as a tendon tear.

The following images show the steps used to perform a repair of a severe longitudinal tear of the peroneus brevis tendon. Image 1 shows pre-operative planning outlining the leg and fibula to the left along with the 5th metatarsal and toes to the right. Image 2 shows dissection through the subcutaneous space and entry into the combined sheath of the peroneal tendons. Image 3 shows the initial appearance of the damaged peroneus brevis tendon. Image 4 shows the dissection of the injury in greater detail. The peroneus brevis tendon shows myxoid degeneration (scaring) and multiple tears. Image 5 shows an intact peroneus longus tendon with mildly reactive synovium lining the inside wall of the peroneal tendon sheath. This reaction is due to chronic inflammation within the tendon sheath. Image 6 show the repaired peroneus brevis tendon. Also very clear in this image is the peroneal retinaculum. And image 7 shows final skin closure.

Surgical repair of a longitudinal peroneus brevis tear can be performed on an outpatient basis using sedation and local anesthesia or general anesthesia. The procedure takes about approximately 45 minutes to complete. Following repair, most doctors will limit ambulation to partial weight bearing for a period of days to weeks. No casting is necessary as early non-weight bearing range of motion is desired. Return to normal activates depends upon the severity of the tear and success of the surgery. Most patients are back to 75% of normal activities by 4 weeks post surgery.

In severe cases of peroneus brevis or peroneus longus tears, including complete ruptures, treatment options do vary. Tenodesis (fixation of the tendon) of the damaged tendon may be completed by permanently attaching the tendon to the cuboid, calcaneus or adjacent tendon. For instance, in cases of severe peroneus brevis ruptures, the peroneus brevis tendon may be permanently attached (tenodesed) to the peroneus longus tendon. Other options include the use of a graft jacket or tendon graft.

In cases of a symptomatic os peroneum or fractured os peroneum, the majority of cases can be resolved with simple excision of the os peroneum. Excision of the os peroneum can be performed with a general anesthetic or a local anesthetic with sedation. Recovery varies and depends upon the integrity of the peroneus longus tendon follow the surgery. The peroneus tendon will be weakened by excision of the os peroneum but will regain full strength over several months. Limitations on ambulation post surgery depend upon the surgeons impression of the status of the tendon post-op. Limitations may include non-weight bearing or partial weight bearing for a period of 6-8 weeks post op.

Cuboid syndrome can also describe a sprain of the CC joint or any of the supporting structure contiguous to the CC joint. These structures include the calcaneo-cuboid ligaments and peroneus longus tendon.

The onset of cuboid syndrome varies and can be abrupt (most common) or insidious in onset. Pain is typically site specific to the plantar lateral cuboid. Indurated (hard) edema may be found. Bruising is uncommon.

The diagnosis of cuboid syndrome is made based upon the location and onset of pain. Plain x-ray should be used to differentiate cuboid syndrome from fractures. MRI is also helpful to define problems that occur in the region of the CC joint (see differential diagnosis below).

Beginning February, 2010, Dr. Oster will be beginning a research study on cuboid syndrome.  Please follow this link for additional information on how you can participate in this study.

Treatment Of Cuboid Syndrome

Cuboid syndrome, when due to subluxation, is treated by reducing (realigning) the subluxation of the CC joint and stabilizing the reduction. Reduction of the subluxation can be accomplished by manipulating the joint. Manipulation is performed with the patient in a prone (face down) position. The doctor cradles the foot in his/her hands and places both thumbs beneath the CC joint. The CC joint is then manipulated by a forceful movement, moving the leg at the knee and the ankle while applying pressure with the thumbs at the plantar (bottom) aspect of the CC joint. This procedure is called a cuboid whip.

Reduction of the subluxation can be maintained with taping and padding. Prescription orthotics (arch supports) are helpful in preventing a recurrence of cuboid syndrome. The application of RICE is common in the treatment of cuboid syndrome. RICE is the acronym standing for rest, ice, compression and elevation. The use of oral NSAID medications is also common. Occasionally, cortisone injections may be helpful in reducing inflammation associated with the subluxation of the CC joint. Patients are instructed to avoid going barefoot or wearing shoes with low heels. Heel lifts (less that 1/2) worn within the shoe can also be helpful. Ankle supports are also helpful.

Treatment of cuboid syndrome, when due to a sprain, is similar to that which was previously described. When cuboid syndrome is caused by a sprain, the cuboid whip is not used in the treatment plan.

Chronic cuboid syndrome is called tarsitis (inflammation of the tarsal bones). Tarsitis results from excessive intrinsic load applied by the calf to the foot. This condition is called CT Band Syndrome (CTBS-1). For additional information regarding chronic cuboid syndrome (tarsitis), please read our article on CT Band Syndrome.

The response to treatment of cuboid syndrome depends upon the etiology and onset of symptoms. Acute onset of cuboid syndrome, say from an ankle sprain, may respond dramatically to manipulation. If cuboid syndrome is due to chronic, excessive intrinsic load (CT Band Syndrome) treatment such as manipulation may be less effective and take longer to see results.

Pain in the ankle can come from a number of different condition. The following links provide additional information regarding ankle pain. The links have been broken into regions of the ankle.

Medial ankle pain

Posterior tibial tendon dysfunction - pain and loss of arch height.

Tarsal tunnel syndrome - nerve entrapment leading to medial ankle pain.

Lateral ankle pain

Ankle sprains - traumatic injury to the ankle. Most commonly found to occur on the lateral ankle.

Peroneal tendon rupture - common reason for chronic pain in the lateral ankle.

Peroneal tendon subluxation - snapping and pain on the lateral ankle.

Peroneal tendonitis - chronic pain of the lateral ankle, especially at the start of activities.

Global ankle pain

Gout - although more common in the forefoot, gout should be considered as a differential diagnosis in treating ankle pain.

Equinus - tightness of the calf can have a significant role in ankle pain.

Sinus tarsi syndrome (sinus tarsitis) - diffuse deep ankle pain with activity.

Talar fractures - a common and sometimes complicated type of fracture.