Way too often, patients who experience severe chronic pain are shuffled from one doctor to another. They are reflexively given the diagnosis of CPRS 1 or CRPS 2—we’ll define these momentarily—and then all the looking stops because most physicians are not aware, interested, or understand that many of these patients have a trigger that can be addressed.
The medical community too often has simply said to these patients “You have really bad pain – this can’t be fixed, take these medications (and go somewhere else please).” Dr. Williams, though, specializes in trying to actually uncover the source of the driving factor of your chronic pain.
Whereas there are certainly times when the pain cannot be fixed, many of our successfully-treated patients have been told that same thing before we provided the treatment they needed. In some ways, it feels as though the medical community is really dropping the ball on this.
Chronic Post-Traumatic Pain Diagnosis, Causes, and Symptoms
If you’ve been told you don’t have a nerve injury, why does Dr. Williams believe he can help you?
Many patients Dr. Williams successfully treats are told that exact same thing when they ACTUALLY DO have a nerve injury. A careful exam, a careful history can often help identify these. The problem is that they may not show up on some of our traditional testing. Physical exam, history, nerve blocks, sensory testing, and MR neurography may be able demonstrate these injuries. Once the injury is better understood and identified, then there is hope it can be successfully treated.
Chronic post-traumatic neuropathic pain is generally known as Chronic Regional Pain Syndrome (CRPS). There are two types of CRPS that we refer to today – Type 1 and Type 2. While they both have some similar symptoms, there are usually different root causes. We acknowledge that this is a complex topic, and this website does not make an attempt to be the definitive site to understand this controversial and difficult subject. Dr. Williams encourages you to research this thoroughly to better understand the causes and possible treatments for this problem.
- Type 1. Also known as “reflex sympathetic dystrophy syndrome,” this condition occurs after an injury or illness, but there is not believed to be a direct injury to a large nerve of the affected limb. This type is more likely than Type 2 to “spread” outside the site of injury and affect other parts of the body.
- Type 2. As opposed to Type 1, this kind of post-trauma pain follows a distinct nerve injury, and has been called “causalgia.” In this instance, there is felt to be an obvious cause to the pain – an identifiable nerve was injured and is having trouble healing. This type of pain generally stays only in the distribution of the affected nerve.
Patients usually develop these painful symptoms following a forceful trauma to an arm or a leg, such as a crush injury, fracture, or amputation. However, the injury may be much less violent and may occur from something as simple as an ankle sprain or “routine surgery.” One of the largest groups of patients that Dr. Williams sees on a regular basis are those that have been suffering from chronic neuropathic pain after an ankle sprain.
At this time, it’s not particularly well understood why some of these injuries can trigger chronic pain, but it may be explained by a dysfunctional interaction between your central and peripheral nervous systems, along with inappropriate inflammatory responses.
To help illustrate the difference between the two systems, your central nervous system is comprised of your spinal column and brain. The peripheral nervous system is an extensive network of nerves that run throughout the body to collect data and provide information back to the central nervous system for processing and an appropriate response.
Signs and symptoms of this nerve condition include:
- Continuous burning or throbbing pain, usually in your arm, leg, hand or foot
- Changes in skin temperature — at times your skin may be sweaty; at other times it may be cold
- Changes in skin color, which can range from white and mottled to red or blue
- Changes in skin texture, which may become tender, thin or shiny in the affected area
- Changes in hair and nail growth
- Decreased ability to move the affected body part
- Joint stiffness, swelling and damage
- Muscle spasms, weakness, and loss (atrophy)
- Sensitivity to touch or cold
- Swelling of the painful area
Symptoms can change over time and tend to vary from patient to patient. Most commonly, pain, swelling, redness, noticeable changes in temperature, and hypersensitivity (particularly to cold and touch) are observed first.
In time, the affected limb may become atrophied, pale, and cold. The patient might also undergo skin and nail changes, as well as muscle spasms and tightening. Once these changes occur, the condition is often at an irreversible point.
CRPS 1 will sometimes spread from its initial source to other areas in your body, like the opposite limb. At times, the pain becomes worsened by emotional stress.
For some patients, symptoms go away on their own. In others, chronic pain and dysfunction can persist for months or years. Treatment is most effective when started early in the course of the illness. If the condition isn't diagnosed and treated early, it may progress to increasingly disabling signs and symptoms, which include:
- Atrophy (tissue wasting). If you avoid moving an arm or a leg because it hurts, or if you have trouble moving one of your limbs because of stiffness, your skin, bones, and muscles may start to weaken and deteriorate.
- Contracture (muscle tightening). You also might experience tightening of your muscles. This can potentially lead to a condition in which your hand and fingers or foot and toes contract into a fixed position.
Diagnosing and Treating Chronic Post-Traumatic Pain (With or Without the Diagnosis of CRPS)
Diagnosing the cause of chronic post-traumatic pain is based, in part, on a physical exam and your medical history. There's no single test that will definitively diagnose post-traumatic pain, but some procedures can provide important clues, such as:
- Peripheral Nerve Blocks. This procedure can usually be performed in the office setting and is aimed at blocking the suspected cause and trigger of the chronic pain to help determine which nerve may need to be addressed to resolve the symptoms.
- Bone scan. This procedure is used to detect bone changes. We inject a radioactive substance into one of your veins to permit viewing of your bones with a special camera.
- Sympathetic nervous system tests. These kinds of tests look for disturbances in your sympathetic nervous system (like those with your skin’s temperature or the blood flow in affected and unaffected limbs).
- X-rays. Loss of minerals from your bones may show up on an X-ray in later stages of the disease.
- Magnetic resonance imaging (MRI). Images captured by an MRI device may show a number of tissue changes.
Other tests can be used to measure the amount of sweat produced by both limbs. Dissimilar results are a potential indication of post-traumatic pain.
Dr. Williams will tailor your treatment based on your specific case. In addition to surgical options Dr. Williams may be able to provide, treatment plans might entail the use of various medications and therapies. Because these cases are often very complex and receive better care under an interdisciplinary setting, he may refer you to medical pain management specialists to help with these treatments.
Medications and therapies used in treating the symptoms of post-traumatic pain include:
- Pain relievers. Over-the-counter (OTC) pain relievers—such as aspirin, ibuprofen (Advil, Motrin IB, others) and naproxen (Aleve)—may ease pain and inflammation.
Dr. Williams may recommend you to a pain management specialist who will prescribe stronger pain relievers if OTC ones aren't helpful.
- Antidepressants and anticonvulsants. Frequently antidepressants (such as amitriptyline) and anticonvulsants (such as gabapentin), are used to treat pain originating from a damaged nerve (neuropathic pain).
- Corticosteroids. Steroid medications, such as prednisone, may reduce inflammation and improve mobility in an affected limb.
- Sympathetic nerve-blocking medication. Injecting an anesthetic to block pain fibers into affected nerves relieves pain for some people.
- Physical therapy. Gentle, guided exercising of affected limbs may decrease pain and improve strength and range of motion. When the disease is diagnosed earlier, exercises tend to be more effective.
- Spinal cord stimulation. A small electrical current delivered to the spinal cord via tiny electrodes along the spinal cord can sometimes result in pain relief.
- Transcutaneous electrical nerve stimulation (TENS). Chronic pain is sometimes eased by applying electrical impulses to nerve endings.
Recurrences of post-traumatic pain do occur and can be triggered by a repeat trauma, exposure to cold or an intense emotional stressor. In some cases, these recurrences are managed with small doses of an antidepressant or other medication.
Dr. Williams has various surgical procedures he may employ to help relieve your pain. Naturally, the procedures he uses or revises will depend on your unique situation. Your path to treatment for post-traumatic pain and dysfunction starts with a call to his Baltimore, MD office. Simply dial (410) 337-5400 and one of our staff members will be happy to provide information, answer any questions, and schedule your consultation with Dr. Williams. Don’t suffer in agony from this pain – call us today!