Complex Regional Pain Syndrome following multiple knee surgeries
Ross A. Hauser, MD. Caring Medical Florida
In 2010 I wrote in the Journal of Prolotherapy: (1) “Complex regional pain syndrome (CRPS) is a chronic pain and potentially disabling syndrome which typically affects the extremities. (Or in the case of this article, the knee). It is characterized by a variety of autonomic and vasomotor disturbances (this problems of blood flow and symptoms that this may bring). . . diffuse pain, spreading edema, temperature disturbances, and functional impairment are most prominent.
Complex regional pain syndrome generally appears following a physical injury, (this would include multiple knee surgeries) and is disproportionate to the precipitating event or level of tissue damage, (you have more knee pain than you should) and progresses inconsistently over time. It is a disease with an unpredictable and uncontrollable nature, and is a syndrome covered in controversy and confusion.” Please see our article My doctor says my knee should not hurt me as much as it does, for more information on problems that may cause excessive knee pain that cannot be documented by traditional imaging studies.
We are going to start this article with a case history. This is a story of a patient.
Our patient suffered from a long history of knee trouble. It started with two basketball related injuries. At the tender age of nine, this young fellow tore some cartilage in his right knee, and had it surgically repaired. Then at age 12, he tore his right ACL and also had it surgically repaired. For 20 years he had on and off knee pain, and at the age of 32 he sought care because he wanted to be active with his growing family and be able to maintain his job as a pharmacist. He was told he had meniscal tear, and he was advised to have it surgically repaired. During surgery, evidence was found that the ACL was torn again, so his surgeon tried to repair it with a graft. However, his pain continued, and later that year it was determined that the new graft had torn again, and he went in for yet another ACL reconstruction surgery.
- After the last surgery, the patient’s pain level dramatically increased, and he was diagnosed with reflex sympathetic dystrophy (RSD).
- Reflex sympathetic dystrophy (RSD) is now referred to as Complex regional pain syndrome type I (CRPS I). The diagnostic name implies exactly what it is: “Complex,” “Regional,” “Pain.” and “Syndrome.” A localized, complex pain is a “Syndrome.” A term describing that this is a difficult problem, multifactoral in symptoms with controversial suggested treatments.
Add nerve damage to the problem
- Later, as symptoms worsened the patient was then diagnosed with complex regional pain syndrome. (Complex regional pain syndrome type II (CRPS II) formerly diagnosed as causalgia, is the same as Complex regional pain syndrome type I with the exception that nerve damage has been confirmed in the patient.)
The patient’s knee pain became so severe that an external spinal cord stimulator seemed to help, but it was never implanted. He was referred for “pain management” which consisted of taking 8 Norco® pills (acetaminophen and hydrocodone) per day. Of course this put the patient at risk for side-effects, and, high risk for addiction and dependence. Two problems the patient suffered from were a 60 pound weight gain and he was tired all the time.
Pain and numbness in the knee
The patient’s symptoms included:
- constant numbness in the lateral knee,
- excruciating pain in the medial knee to lightest touch,
- and general constant ache in his whole knee.
His right knee and right leg were colder to touch than the left. He also experienced numbness in both legs from thighs to feet, with numbness in the right 4th and 5th toes, cramping in right great toe, and coldness in all right toes.
The patient came to Caring Medical, and we concurred with the history of Complex regional pain syndrome type I and type 2 diagnosis and told the patient that Caring Medical could most likely help him, but it would take a lot of work.
- The plan was to optimize his healing ability by weaning off narcotics, raising hormone levels, and improving his diet. These are ways to get the body into an anabolic (rebuilding) state from a catabolic (degenerative) state. This would ensure that the patient was in a position to get the maximum benefit from our treatments.
Bad lab results and hormonal and nutritional recommendations
As expected, his labs showed low levels of testosterone, cortisol, and DHEA, and therefore, natural hormone replacement therapy was recommended. For more information on this aspect on hormonal problems related to joint pain please see our articles: Opioids and painkillers cause low testosterone syndrome, and Hormone replacement therapy and degenerative joint disease.
Nutritional counseling and diet recommendations were also suggested. For general recommendations please see our article: What is the best diet for my knee pain?
A low-impact exercise program was also recommended. The patient was a a man of faith and understood the mind, body, spirit connection as it related to his health and he worked on his faith as well as his body. As is common in chronic pain, the patient also had problems sleeping which were addressed with a prescription medication which allowed him to have restful sleep.
This story will continue below. First some explanatory notes:
Do Spinal cord simulators help with knee pain?
Spinal cord simulators can help with lower limb pain but results are varied.
An August 2020 study in the Journal of clinical medicine (2) offered this simple overview of Spinal cord simulators: “The pain-relieving effects of Spinal Cord Stimulation reached significance and were comparable across all modes of stimulation including sham. Spinal Cord Stimulation was characterized by a high degree of placebo effect. No evidence of carryover effect was observed between subsequent treatments.”
Spinal cord simulators tested better than a fake or “sham” treatment. But there was a high degree of placebo effect. The end result is, if it helps it helps and that is a good thing. But a more permanent repair treatment should also be explored.
Stages of CRPS
CRPS is a deteriorating disease and progresses in three stages.
- Stage I is the acute phase. In the acute phase, pain is described as burning or aching and is often aggravated by touch, emotional upset or active/passive movement. The pain of simple injuries is much worse and lasts far longer than it should. For example, if CRPS occurs in the foot, a stubbed toe can lead to excruciating pain for up to two months. The involved limb fills with fluid and may be either hot or cold. A bone scan may show an increase of radioactive phosphate in the affected area, which indicates an increased uptake of red blood cells.
- Stage II is the dystrophic phase. In the dystrophic phase, pain is constant. The pain is exacerbated by simple movement or sensation, such as touching, vibrating, or even blowing on the limb. The affected limb becomes even more edematous (fluid filled) as well as cool and hyperhidrotic (sweaty). There is a decreased uptake of red blood cells and bone scans reveal the initial stages of osteoporosis.
- Stage III is the atrophic stage. In the atrophic stage, irreversible damage to the extremity has occurred. The limb contracts because of limited movement. Skin becomes cool, thin, and shiny. Scar tissue has formed and because of this it is difficult to move the joint at all. Osteoporosis and arthritis run rampant throughout the joint. This leads to a permanently frozen limb. The burning pain subsides, however at this stage, the limb is essentially useless. This process occurs over and over again in the body’s extremities.
Many doctors believe that Complex regional pain syndrome is a lack of or confused communication between the immune system, the inflammatory response and the nervous system. These include the sympathetic nervous system (responsible for getting the muscles ready for intense physical activity), the somatomotor system (coordination and balance), the neuroendocrine systems (metabolism, energy, heart rate), the nociceptive system (our body’s response mechanism to threat or harmful stimulus), as well as an inflammatory response.
However, to date, questions about CRPS continue to be subjects of research and debate
Treating Complex Regional Pain Syndrome in patients post knee surgery
CRPS is one of the reasons I became so fascinated with treating chronic pain patients during medical school. Early in my career, I set out to find treatments that could actually heal the problem, not just cover it up with stronger and stronger pain medications.
CRPS treatment is based on the various mechanisms thought to cause CRPS, however since the cause is controversial, the outcomes of traditional treatment are less than optimal. Due to the disagreement over diagnosis, there are no established treatment guidelines.
- The goal of treatment should be to first correctly diagnose the patient with CRPS.
Options available for CRPS include interventional, pharmacologic, physical/occupational therapy, and psychological techniques.
Are nerve blocks options?
- Interventional means such treatments as sympathetic or somatic nerve blocks.
- The sympathetic ganglion blocks cause an increase in temperature to the limb due to the increased blood flow. Although the patient will experience immediate pain relief, its effect is only temporary.
- The problem with this approach is that it does not repair damaged tissue that may be the lead contributing cause of the patient’s problems.
- CRPS patients may even receive multiple sympathetic blocks to the point of having anesthetic pumps placed in their backs (the spinal cord stimulators mentioned above), or their sympathetic nerves may be severed in an attempt to relieve the pain.
- Pharmacologic includes narcotic pain medications, but these medications do little to restore health and limb function and frequently result in dependence on the medication.
- Physical/occupational therapy are other therapies offered.
- Antidepressants and anticonvulsants are also commonly prescribed.
Assessing the role of ligament damage and weakness in Complex Regional Pain Syndrome following multiple knee surgeries
Let’s return to the patients story at this point. The a detailed description of the treatments will be discussed below.
Over the course of 18 months, the patient we started this article with, received 13 Prolotherapy treatments including bone marrow aspirate injections and Neurofascial Prolotherapy. These treatments comprehensively treated the ligament weakness and damage inside and around the joint capsule, as well as the small sensory nerves that had been on high alert from all the injuries and surgeries.
It took several treatments for the patient to feel incremental improvement in his knee, but he reported feeling much better on lower doses of pain meds, having higher levels of hormones and seeing the weight steadily fall off as the treatments began and progressed.
Toward the end of his course of treatment, he was able to walk for hours with his family at the zoo and even go sledding, something he could not have imagined before starting Prolotherapy. The patient had more than the average number of necessary treatments, but he had an extraordinarily tough case of chronic pain. In addition, he had some setbacks over the course of treatment, including when a screw from one of his many procedures started to pop through his skin and exacerbated his symptoms.
Still, in cases of chronic pain after numerous surgeries and rounds of narcotic pain medications, Prolotherapy and accompanying treatments can allow a person to heal beyond what they thought possible in the “pain management” system.
Prolotherapy treatments for Complex Regional Pain Syndrome following multiple knee surgeries
Prolotherapy is a simple, non-surgical, in office, injection treatment that stimulates the body’s immune system to repair painful joints. A demonstration of the treatment is displayed in the video below.
Prolotherapy is considered an alternative treatment for:
- commonly prescribed anti-inflammatory medications
- pain medications
- cortisone or steroid injection
- surgery and joint replacement
The basic concept of Prolotherapy is simple. A proliferant (something that awakens and ignites the immune system’s healing process) is injected into damaged joint and spinal ligaments or tendons, which leads to local inflammation. Prolotherapy will be used to heal the soft tissue damage such as ligament injury. Prolotherapy involves injections at the site of the damaged ligament. This will initiate a local inflammatory response which will encourage blood to flow to the injured site.
In this video, Ross Hauser, MD explains a Prolotherapy knee treatment as performed at our Caring Medical clinics. This is not typical of the way treatment may be performed in other doctor’s offices.
Video learning and demonstrated points:
- Prolotherapy is an injection technique that stimulates growth factor cells that work to repair ligaments that may have been damaged during periods of excessive immobilization, such the immobilization following knee surgeries.
- In this video, Ross Hauser, MD is seen demonstrating intra-articular (inside the knee) as well as injections surrounding the outside of the knee.
- In addition to knee osteoarthritis, Prolotherapy injections can help patients with problems that will eventually lead to degenerative knee disease.
- Patellofemoral pain syndrome and patellofemoral tracking problems.
- Weakened and damaged ligaments and tendons and their attachments to the bones and muscles that make the knee work.
- In the video, you see that Dr. Hauser is injecting into the
- The Knee’s medial joint line here where the medial collateral ligament is.
- The pes anserine tendon
- The medial patellar retinaculum tendon
- The distal quadriceps attachments
- The lateral joint line where the lateral collateral ligament is located.
- The attachment of the iliotibial band
- The capsular knee ligament attachments
In our experience with CRPS/RSD, if comprehensive Prolotherapy is utilized at any point in the cycle before stage III, the condition is reversible.
Lyftogt Perineural Injection Treatment,™ (or Neurofascial Prolotherapy, Neural Prolotherapy, Subcutaneous Prolotherapy) is a sometimes used side-by-side treatment with traditional dextrose based Prolotherapy in cases of Complex Regional Pain Syndrome. In the case of the patient above, Neurofascial Prolotherapy was used to address the nerve damage.
In a similar situation to that of the patient described, Prolotherapy would be used to stimulate repair of the knee ligaments and meniscus. Neurofascial Prolotherapy would used to address stretching, shearing or tearing of the nerves of the knee. The goal of the treatment is to decrease neurogenic inflammation.
Bone Marrow Aspirate for Knee Pain.
Bone Marrow Aspirate or Bone Marrow Prolotherapy refers to the use of bone marrow concentrate injections into areas of degenerative joint disease to stop and repair degenerative changes.
Would you like to ask a question about your knee pain? Ask our Caring Medical staff
1 Ross Hauser, MD, Brinker D. The theoretical basis for and treatment of complex regional pain syndrome with prolotherapy. Journal of Prolotherapy. 2010;2(2):356-370. [Google Scholar]
2 Sokal P, Malukiewicz A, Kierońska S, et al. Sub-Perception and Supra-Perception Spinal Cord Stimulation in Chronic Pain Syndrome: A Randomized, Semi-Double-Blind, Crossover, Placebo-Controlled Trial. J Clin Med. 2020;9(9):E2810. Published 2020 Aug 31. doi:10.3390/jcm9092810 [Google Scholar]