Mona Amin, MD
Resident Physician - PM&R
Medstar Georgetown - NRH
WASHINGTON, District of Columbia, United States
Michael Wroten, MD
Attending Physician
MedStar National Rehabilitation Network
Washington, District of Columbia, United States
A 39-year-old male with a history of navicular fracture and ORIF surgeries developed Chronic Regional Pain Syndrome (CRPS) in the right foot following a crush injury in mid-2023. Symptoms included severe pain in the lateral ankle and dorsal foot, sensory abnormalities, and vasomotor changes, meeting the Budapest criteria for CRPS. Initial treatments, including nerve blocks and physical therapy, were ineffective. Imaging showed postsurgical changes and mild degenerative alterations, and EMG indicated distal peroneal nerve damage with incomplete reinnervation. Persistent pain and functional limitations despite standard treatments highlighted the need for alternative approaches. Onabotulinum toxin A is emerging as treatment for CRPS, offering pain relief by inhibiting acetylcholine and Substance P, key mediators in pain and inflammation. Studies suggest it reduces pain and improves function by targeting nociceptive and neuropathic components. Its action on Substance P may diminish central sensitization and peripheral pain signaling, addressing symptoms resistant to conventional therapies. This case supports Onabotulinum toxin’s role in managing CRPS, highlighting its potential as adjunctive therapy. Onabotulinum toxin A aims to reduce CRPS-related pain and improve function in patients with refractory symptoms. Although follow-up data is pending, this case demonstrates its potential as an adjunctive therapy for CRPS, particularly for persistent plantar fasciitis-like pain. Further evaluation will determine its impact on pain relief and functional outcomes, potentially supporting broader use in CRPS treatment for patients unresponsive to standard therapies.
Case Description: The patient’s CRPS was resistant to conventional treatments, including gabapentin, nortriptyline, NSAIDs, and nerve blocks. Onabotulinum toxin A was administered into plantar fascia and foot muscles (Extensor Hallucis Longus, Flexor Hallucis Longus, tibialis posterior, medial gastrocnemius) to address pain and spasms. This intervention targeted plantar fasciitis-like pain and spasms unresponsive to prior therapies. The procedure, guided by EMG and E-stim, was well tolerated. A follow-up is planned one month post-procedure to assess response.
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