Revista de Medicina Desportiva (English) September 2018 - Page 9

Rev. Med. Desp. informa, 2018; 9(5):7–9. Complex Regional Pain Syndrome in High-level Athlete After Infiltration with PRP Dr. Ricardo Aido 1-3 , Dr. Hugo Pinto 1,4 , Dr. Diogo Dias 3,5 , Dr. Mário Simões 6,7 , Dr. Carlos Magalhães 1,3,8 1 Especialista em Medicina Desportiva; 2 Especialista em Ortopedia; 3 Departamento Médico Federação Portuguesa de Voleibol; 4 Competência em Acupuntura OM Portuguesa e British Medical AS; 5 Interno de Formação Específica em Medicina Desportiva; 6 Fisiologista do Exercício Federação Portuguesa de Voleibol; 7 Mestre em Treino de Alto Rendimento da FADEUP, 8 Especialista em Cirurgia Geral. Porto ABSTRACT Subject to several investigations, the complex regional pain syndrome remain, is still an ongoing discussion. Few cases are described in high-level athletes, since it is a clinical rarity the occurrence of this syndrome after knee infiltration with platelet-rich plasma. This clinical case reports the diag- nostic and treatment difficulties that a sports medicine physician faces when trying to return to the play an athlete with complex regional pain syndrome (Type I) at a high level of competion. KEYWORDS Complex regional pain syndrome, platelet-rich plasma, high-level athletes, sports medicine Case Report This is about a 28-year-old male ath- lete, male volleyball, with more than 100 international games playing at the national team, healthy and with no relevant family medical history information. In September 2015, during the pre-season at his club, the athlete performed a magnetic resonance imaging (MRI) because of complaints in his right quadriceps tendon. The MRI revealed a quadriceps tendinopathy and it was proposed to the player a local injection with platelet-rich plasma (PRP), which was performed in October under ultrasound guidance, in order to ensure the placement of PRP on the correct place and to prevent damage of the neurovascular structures. The injection was described by the athlete as painful, but without complications. Despite relative rest on the following days, the player referred increased local pain, with increased sensation of temperature in the knee. In the following weeks he underwent daily physiotherapy and progressive reintroduction of training, although the existence of pain in the right knee radiating to the ipsilateral thigh and leg. The pain was associated with changes in temperature, sweating of the skin over the knee and pre-patellar edema. Because he maintained the same clinical incapacity, he repeated the MRI in December of the same year, which revealed healing of the quadriceps tendinopathy, but showed osteopenia and deminer- alization of the local bone, with is a characteristic pattern of complex regional pain syndrome (CRPS) (image 1). He was recommended to stop training for an additional month and at this time it was requested a reassessment of the athlete. He was observed at the end of January 2016 and on the objective examination it was found the fol- lowing: • He could walk without crutches and he didn’t have significant limp; • Heat over the right knee could be felt and also over the distal third of the ipsilateral thigh and leg, associated with sweating; • He had complete active and pas- sive range of motion (ROM); • The perimeter of the right thigh had two 2cm less when compared with the contralateral thigh; • He referred diffuse pain over the anterior the front of the knee, popliteal area and quadriceps tendon, with discrete pre-patellar edema; • He had pain on palpation of the quadriceps and patellar tendons, when mobilizing the patella, as well as myofascial trigger points in the quadriceps, adductors, sarto- ruis and gracilis muscles. • He also referred pain on palpation of the paravertebral dorsolumbar musculature and of the vertebrae apophyses (T10-L2), which are the segments responsible for the innervation of vessels of the lower limbs and an integral part of the autonomic nervous system; • There was motor inhibition of nerve roots L2-L4 (femoral and obturator nerves), confirmed with the resisted muscle strength tests for the quadriceps and adductors muscles; • There was no pain with the menis- cal tests. There was ligament sta- bility and the distal arterial pulses were large and symmetrical, there wasn’t changes in the color of the skin or other significant findings on the physical examination. An electromyography of lower limbs was performed, and it showed absence of changes. The, diagnosis of complex regional pain syndrome (CRPS) type I, with segmental dys- function of nerve roots of L2-L4 and T10-L2 was made. He started a new treatment program during the first week of February 2016. During the first four weeks the treatment consisted of biweekly sessions of percutaneously elec- trostimulation with needles placed in myofascial trigger points of the muscles innervated by the segments with neurological disorders referred above, as well as perineural stimula- tion of the femoral and obturator nerves, located at the root of the right thigh and responsible for the innervation of the antero-internal musculature of the thigh and of the knee. The paravertebral musculature between the T10-L2 segments was also treated to improve irrigation of the lower limb and to reduce the sympathetic hyperstimulation pre- sented by the athlete. Revista de Medicina Desportiva informa september 2018 · 7