RSD?

Posted by Meghan on May 03, 1999 at 13:02:10
     I was given a diagnosis of Reflex Sympathetic dystrophy about a month ago.  However, based on what I have read I'm not completely convinced (nor is my physical therapist) that I have it.
     My injury occurred in December '98 when hanging Christmas decorations.  I do not recall any precipitating event, but I woke up the next morning with horrible, throbbing pain in my foot.  My foot didn't look particularly swollen and since I've also had plantar's fasciitis since October, I chalked it up to that, took a couple of naprosyn, and went on with my life.  
Upon examination the next week, my physical therapist suspected that something more was wrong and sent me to an orthopedist. He pretty much took a quick history, pressed on my heel, said "Let me go talk to my boss."  and came back a half an hour later with a diagnosis of PF and a prescription for NSAIDS.  While the NSAID killed the pain completely, I still could not walk properly- I was pretty much walking flat footed and could not push off of the ball of my foot.  My PT continued treatment and sent me back to the orthopedist in February.  At this time, there was redness and swelling over the base of my fifth metatarsal and EXTREME tenderness to even light pressure.   I also noticed bouts of stabbing pain in the area from time to time, usually when I was just sitting around.  The orthopedist suspected a stress fracture, but X-rays were negative.  Nonetheless, he put me in a short-leg walking cast for two weeks, because "although he could do a bone scan, he was SURE it was a stress fracture."  While in the cast, I noticed that I would have transient bouts of stabbing pain in the area of the fractue which radiated as a pins-and-needles feeling over the top of my foot.  Also, when I first got out of bed in the morning, my casted leg would shake for a couple of seconds when I tried to stand.  Since I had never broken a bone before, I figured all this was normal.  I returned to the orthopedist, who removed the cast. I returned a couple of days later still unable to walk. He decided that I had "reinjured" my foot and casted me for another two weeks.  
When the cast was removed, I could walk better, but was still having some pain at the base of my fifth metatarasal (although it was much improved). I was sent for a bone scan, which showed increased uptake in five bones in my midfoot, but according to the radiologist, my fifth metatarsal looked normal.   My orthopedist then diagnosed me with RSD, and told me to walk normally regardless of the pain and to come back in a month. What strikes me as odd is the fact that when he made the diagnosis, my foot was feeling better than it had in a long time.  Although there is still some redness and swelling over the base of my fifth metatarsal, the pain is practically gone (only hurts with deep pressure). I can usually walk normally and am not on any pain meds.  Ocasionally, there will be some increased redness in the foot as compared to my other one.  But the awful, searing, constant pain that I have read about just isn't there.  With deep pressure, I'd only categorize the pain as a 3 at worst(on a scale of 1-10) and any pain I have is far from being constant and really has never been constant.  Is it possible to have mild RSD?  Does this sound like it might be RSD to you, or are there other conditions you think may need to be considered?  I realize that this is nothing to mess around with, and am in the process of seeking a second opinion.  However, I am having difficulty finding a specialist with expertise in RSD diagnosis/management.  Do you know of any specialists in the state of North Carolina who specialize in this and could help me?  I am currently a grad student at U of North Carolina, and I have not found anyone here who treats it on a regular basis (I checked neurology, neurosurgery and anesthesiology).   I apologize for the extremely long posting, but I wasn't sure what or how much of my medical history would be pertinent and I really don't know where else to turn for help right now.  I'd really appreciate any input and advice you can give me.  
Meghan  

Posted by CCF MD GS on May 05, 1999 at 11:37:06
Thanks for the question Meghan and sorry to hear about the problems you have been having but it sounds like things are coming togeather. It also sounds like your doctor treated you without knowing exactly what was going on and has jumped to certain conclusions alsong the way. From the evidence you give I'm not hearing a great story for a foot fracture? RSD goes under a number of names including Sudeck strophy, post traumatic osteopenia and shoulder hand syndrome. It is an excessive or abnormal response of the sympathetic nervous ssystem to injury of the shoulder or arm and less frequently the leg. While we do see cases of foot involvement it is rare. Patients usually have protracted pain with cyanosis or pallor, swelling, coolness, pain with passive motion and osetoporosis (bone thinning). At CCF this condition is usually treated by one of our anesthesiologist who specializes in this disorder. I'm not sure exactly what you have or had but it is not a great story for RSD. I'm afrain I don't know anyone in your area who specilizes in this disorder. I'm gland you foot is doing better. At this point we would recommend continued activity as tolerated and follow as recommended. If the symptoms persist you should see a neurologist locally. Good luck
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