Severe Foot Injury with CRPS and Possible Injections: Email Advice

 I received this email today 7/24/13. This patient is in very capable hands, with only some of the facts coming to my attention. My answers are only with great concern for the patient since it is impossible to really know what direction to answer some of the questions. Patients who develop CRPS truly suffer and need to trust their doctors. In my answer I give general guidelines, but they are only guidelines. Every guideline has exceptions, and individual situations sometimes demand taking risks. This patient is in an extreme situation where sometimes risks are worth it. So, in my answer I have many questions. I agonize over what is right.  

 I suffered a severely crushed foot one year ago today. All five metatarsal joints were fractured into many many pieces and soft tissue damage was severe. Surgery to repair them resulted in an external fixator for 8 weeks, hard cast for 2 weeks, boot for another 4 weeks ( non-weight bearing for close to 4 months). Temporary pin was removed 4 months later resulting in confirmed diagnosis of RSD/CRPS which I've been under pain management care, the surgeon's care and continuous PT.

     Foot developed severe arthritis almost immediately with osteoporosis now confirmed this week with MRI. The reason they finally did an MRI last week was because of the continued anterior ankle pain and stiffness that wasn't responding to PT and Massage therapy. I've complained about it repeatedly since I started weight-bearing last November, but no one paid any attention until last week when my foot surgeon ordered the MRI on foot plus one on the ankle. MRI confirmed a "partial thickness longitudinal split tear within the infra malleolar peroneus brevis tendon"..
Dr Blake's comment: This is tough since the peroneal tendon is along the outside of your ankle, and you describe the pain being in the front of your ankle. Also, get an ultrasound imaging of the peroneus brevis, since MRIs miscall this all the time. Let us make sure this is really a major source of your pain. 

     Surgeon immediately wanted to schedule operation to fix the tear then almost immediately remembered I was an active RSD patient. So absolutely "no surgeries" while RSD is active (which clearly could be forever). Even if RSD goes into remission and he could do surgery, it most likely would bring another attack of RSD (which is a horrible horrible disease). I still do not understand how or why the original MRI done when injured didn't mention this tear and the exact pain I have has been the same since first day of weight-bearing, so It didn't happen "latter on". I am also not convinced that this particular injury "may" be the main culprit of my RSD.
Dr Blake's comment: Unfortunately, CRPS can just develop with this scenario of severe injury and immobilization. And definitely you want to have more than one person say with certainity that your symptoms are related with this possible tear. And, if you need surgery, there are pre and post surgery protocols to limit the risk of another attack for RSD patients. 

    So -- he suggested cortisone shot which would not fix tear but "perhaps" would allow for asymtomatic pain relief until such time I could have surgical repair. I immediately said that I "thought" cortisone was harmful to tendons and ligments and he said "only if injected directly into the tendon or ligament -- he is injecting into the tendon "sheath" and that won't cause a problem he says.
Dr Blake's comment: If there is a tear, the cortisone will go into the tendon from the fluid around the tendon where it is injected into. I would be very nervous. Does cortisone going into your tendon cause a rupture all the time, definitely not. I am not sure the odds. 5% or 10%. Please ask the surgeon. You weigh those odds, with the odds of the shot helping you. Only your surgeon would have some idea. I can really only raise the questions, give generalizations, etc. Not a cop out, just reality from where I sit. 

    I am assuming it will be a long-acting cortisone. Also ice can not be used due to the RSD, so your "icing" after injection would not be possible for me. You also say I should be immobilized for 3 days - how??? Put in a brace or something? I saw your blog page where you say "never" inject long-lasting cortisone into a tendon or into it's sheath so now I am extremely confused/ worried/ and scared of more permanent damage as I already live with large level of disability with the RSD, the crushed foot, (and also my back was broken and I had a kyphroplasty to repair two crushed vertebraes).
Dr Blake's comment: Yes, do no harm. One idea is to inject long acting local anesthetic into the sheath, after 30 minutes of Synera Patch, and use an ankle brace to protect the ankle for the next 6 hours. This will tell you diagnostically if the peroneal tendon is the source of your pain. Be prepared for a 4 day flare of RSD which can be eased by the understanding that it will past, meditating, see if you can get sublingual Ketamine for the flare, and getting off your foot for several days. Definitely talk to the pain specialist and surgeon about how you will handle a flare post shot so you all have a plan. 

    Since my surgeon is actually "internationally" well-known as one of the best in the business today, I worry about constantly questioning him or telling him I read this or that that contradicts what he says to me, etc.
Dr Blake's comment: You have to feel that what you are getting done is the best. There are so many conflicting bits of information, that I constantly doubt my decisions, but at some point my patients and I have to make them. There is many rights and many wrongs. And, we all get tunnel vision in one approach. What does the pain specialist say? Does he understand about RSD pre and post surgical protocols? What are all the treatments for CRPS you are undergoing? Are you going to consider Ketamine Infusions? If you can get the CRPS calmed down, I would feel a lot better talking about injections, etc.

   " Short-acting shots normally are beneficial for 3 days and are used to quickly reduce inflammation. They are commonly betamethasone (6mg/ml) or dexamethasone (4mg/ml) formulas. Since even short-acting cortisone can cause damage/weakness to tendons, if given into tendon sheaths the body part should be immobilized for the 3 days. It is the long-acting shots that are the true healers when the inflammation is out of control, and normally what people are talking about when it comes to a cortisone shot. Long-acting cortisone shots should never be given into tendon or tendon sheaths (the covering of the tendon) since they are associated with tendon ruptures. It is important to keep the cortisone as far away from the neighboring tendons as possible." (excerpt from Dr Blake's blog).

    Since your "blog" page is from May of 2010, I am wondering if the cortisone issue has more recently been rethought and would appreciate any updated thoughts you may have. I really have encountered so much conflicting information, I feel like just giving up any hope of returning to how I was before the accident.
Dr Blake's comment: This is still my thoughts, and there has been no change in cortisone makeup or tendon anatomy. I would focus right now on getting a possible local anesthetic shot first as mentioned above, if your pain specialist feels that a shot can be safely given with perhaps sublingual Ketamine, to prove you may be a candidate for peroneal injection. Only then, should be again weigh the odds of cortisone into a tendon sheath. I hope this helps you some. Answering an email like this always makes me feel small, humble, somewhat stupid, and unbelievably touched with a sacredness. Thank you. Rich