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