Disclosures: Mina K. Shenouda, MD: No financial relationships or conflicts of interest

Case Description: Our patient underwent right knee arthroscopic surgery with partial lateral meniscectomy, prepatellar bursectomy, and lateral release following a fall. Post-operative course was complicated by severe stiffness and pain requiring manipulation under anesthesia, complex regional pain syndrome (CRPS) type 2 with allodynia, and severe dystonic ankle plantarflexion, inversion, toe flexion, and limited active dorsiflexion. Electrodiagnostic studies at 7 months revealed possible deep peroneal nerve axonal injury. She underwent physical therapy, continuous passive motion, serial casting, botulinum toxin injections, sympathetic nerve block, trial of spinal cord stimulator, and various ankle foot orthoses (AFO). She ultimately underwent tendon lengthening surgery that temporarily corrected the deformity; however, the dystonic posture returned with worsened severity.

Setting: Outpatient multidisciplinary pain and spasticity clinic.

Patient: Patient is a 19-year-old athletic, previously healthy woman with right lower extremity dystonia associated CRPS. Assessment/

Results: Patient received diagnostic electrical stimulation-guided and ultrasound-guided tibial nerve blocks at two sites using bupivacaine. Approximately 10 minutes later, the patient experienced pain relief, decreased spasms, and her ankle was passively and actively returned to a neutral position. She maintained comfortable neutral positioning in her AFO. The patient is scheduled to return for botulinum toxin and subsequent physical therapy.

Discussion: This unique case exemplifies the complex nature of dystonia associated CRPS, characterized by aberrant, persistent central nervous signaling following peripheral injury, often refractory to surgical correction. Peripheral nerve blocks may help to assess treatment efficacy. Botulinum toxin and chemical ablations may help differentiate CRPS from psychogenic dystonia; botulinum toxin carries fewer risks of dysesthesias and may be considered first. Ideal management requires a multidisciplinary approach, including therapy, bracing, injections, medication management, and psychological evaluation to manage symptoms, improve functionality, and return to sports.

Conclusion: Dystonia associated CRPS is a poorly understood, debilitating condition. Physicians should consider appropriate indications for orthopedic surgeries and their complications. Treatment is multidisciplinary and patient centered.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/multidisciplinary-physiatric-management-of-refractory-equinovarus-dystonia-associated-complex-regional-pain-syndrome-following-knee-surgery-a-case-report/