Revista de Medicina Desportiva (English) September 2018 - Page 10

Right from the beginning, the treatment was articulated with the physical trainer of the national team. During the first 4 weeks, the treatment was complemented with mobility and stability train- ing of areas most affected areas. The percutaneous electrostimula- tion (once a week) was kept during the 2 nd month of treatment and he started specific work for strength and endurance. During the first two months it was prescribed gabapen- tin and paracetamol + tramadol to the athlete (administered per Os). A clinical improvement was observed, with decreased pain and progressive recovery of the muscles of the thigh, disappearance of joint edema and temperature normalization of the right knee. He repeated an MRI at the end of March, which revealed almost com- plete resolution of osteopenia and of the local edema (image 2). Given the good clinic evolution in April 2016, he progressed on the training plan with introduction of more specific exercises for improving the perfor- mance in the specific sports and field position. At the end of the third month of treatment the player resumed vol- leyball practice without any restric- tions and in June 2016 he returned to compete in the national volley- ball team. He further carried out all 2016/17 sports season without recurrence of the injury. Discussion The complex regional pain syndrome constitutes a clinical entity of complex physiopathol- ogy, usually with difficult diagnosis and treatment. 1-2 The diagnosis criteria were proposed by IASP in 2007 – Budapest Criteria (auto- Image 1 – MRI before the beginning of the treatment (coronal and sagittal incidences showing osteopenia and local bone deminerali- nomic, motor or trophic, sweat- zation characteristic of the CRPS) ing and vaso- motor criteria). 3 The type I CRPS is character- ized for neu- ropathic pain, with important variability of symptomatic, sensorial, autonomic, and motor changes, which are found without any nerve dam- age. The type II (less frequent) has a similar clinical pattern, but there is Image 2 – MRI after treatment (coronal and sagittal incidences with regression of osteopenia and bone demineralization). nerve damage. 4 8 september 2018 www.revdesportiva.pt According to the literature, the athlete presented: • Sensitive changes – disproportio- nate intensity neuropathic pain for the initial traumatic event; • Autonomic changes – local tempe- rature change and bone deminera- lization; • Motor changes – muscular weak- ness. CRPS primarily affects the distal part of the limbs, appearing after a local trauma, although the causal mechanism is still a controversy and it lacks definitive explanations. There is no correlation between the gravity of the initial injury and the severity of CRPS and any traumatic event is likely to trigger a CRPS type I. Simple punctures or catheteri- zation are described as triggering mechanisms of CRPS. 4 At sports level, the appearance of the CRPS is not frequent and a few cases are described in the scientific literature. It is also believed that the low inci- dence of CRPS in more young people is due to the low degree of suspi- cious on this age group. 5,6 Given the increasing use of PRP, and despite it is a simple therapeutic procedure, CRPS should be present as a diagnostic hypothesis of a com- plications after this procedure, even on high-level athletes, and the diag- nosis should be as early as possible in order to allow timely and effective treatment. 7,8 Emphasis is placed on the need of precocious diagnosis and treatment, as it was found that quite often patients with chronic pain are visiting several physicians imposing a delay on the diagnosis and treatment. 9 The complementary diagnostic examination is especially useful to exclude differential diagnoses. 10 In the present clinical case, MRI was performed because of the real functional disability and incapac- ity to return to sports. The images obtained showed disuse osteopenia, disuse and bone demineralization, with a mottled pattern, which is really surprising on an athlete that just had a local infiltration of PRP and came out showing characteris- tics of patients with CRPS. Usually osteopenia can be seen on the MRI after 4-6 weeks of CRPS evolution. The electromyography allowed to exclude any nervous injury, which