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Help with Diagnosis!

Posted by Debbie G. on 1/27/04 at 07:21 (142928)

Dear Doctors, I am anxious to learn how one differentiates between CRPS and TTS. My 23 yr old daughter has been on crutches for constant pain in right foot for 3 months. X-ray, 2 MRI's, 3 phase Bone Scan, EMG, and blood work are all negative.(tested for Lyme, diabetes, arthritis, gout, etc.) Anti- inflams, elavil, and neurontin, have not helped. PT was too painful. She is a Pharmaceutical Rep. and needs to drive for work. (out of work now). We have seen 3 orthopods, podiatrist and a neurologist. Pod. and ortho. gave TTS dx and want to do surgery ASAP. Ortho in NYC and Neurologist think it could be CRPS. If we agree to surgery and it is CRPS, couldn't that make it worse? Her foot is cold to the touch, but she is not moving it. Don't see any nail or hair abnormalities. Pain seems to be confined to TT area on exam and is very sensitive in that area to touch. We live in NJ and are willing to see someone else if need be. Please advise. P.S. The onset of symptoms was sudden. She woke up on 10/23 with large red circular area on top of foot by 3rd and 4th metatarsals. Later that day, entire bottom of foot turned purple in arch area as if from bleeding. This went away in a few weeks. but pain has remained and actually gotten worse.) Thanks for reading this. Debbie G.

Re: DR.Z can you help Her?PLEASE

Tammie on 1/27/04 at 13:14 (142960)

Hi, I see that you still have questions, I think that Dr.Z who is really helpful and also helped me alot with the RSD and such might be in New Jersey. Not positive tho. please ,yes you are right if it is not tts and it would be rsd or crps if you had the surgery it could very much make it worse!!!! That is exactly what my Dr.s speculation was!!! SO please be sure before a surgery!

Time is nothing when you are searching compared to a LIFE of a painful ofton disabiling dx of rsd or (crps). I really hope Dr. Z sees my post as I trust him very much he is a wonderful compassionate person as well as the pod here that has helped many many others! Surgery is final cant go back,I know there is pain I really understand I urge maybe next to see a pain management Dr. it may make a huge difference. Tho I am not a Dr. and I only represent one side of the case(meaning I am a small percent of those who ended up with RSD ) But as I read more and more are turning up here and it worries me , wondering how come and how come they are not being dx till later,letting it go without urgent treatment to help try to minimize the spread and get the best chance at a remission with alot less damage!

I am sorry to keep going on about this really I am , I just worry so much ,that it could happen to her . If it is the TTS then Dr Z will maybe be able to help you or guide you in next choices! As always Keep posting as will look for updates! Dr. Z Can you help here??/

Re: Help with Diagnosis!

Dr. David S. Wander on 1/27/04 at 20:56 (142998)

Debbie, did any of the treating physicians consider some form of bite that may have started this problem? The sudden onset, with a large red circle would certainly make me consider that she may have suffered a spider bite or other form of insect bite that may have introduced a toxin that has caused a severe reaction. CRPS can occur after any type of trauma and I would be curious to know if anyone considered an insect bite as a possible etiology of her initial symptoms.

Re: Help with Diagnosis!

Debbie G. on 1/27/04 at 23:11 (143010)

Dear Dr. Wander, First of all, thank you so very much for answering my letter. Yes, as a matter of fact, the morning she got the red circular area on her foot on 10/23/03, we saw our primary care physician. He was puzzled and immediately suggested a spider bite as a possible cause. (we do live in an old house). However, since she was just finishing a 1 week dose of oral prednisone prescribed for a bronchial cough, he wondered if she would still react to a bite while on a steroid. He told us to just wait and see and keep him informed. That afternoon, the entire bottom of the foot turned purple as if there was internal bleeding. He sent us to the ER at Hunterdon Medical Center, where they X-rayed and dx a broken toe. It was buddy wrapped and we were sent home. The bruising faded, but she became more lame as time passed. Two days later, we saw an Orthopedic Surgeon. He looked at X-ray and disputed the toe theory. His was Metatarsal Stress Fracture. She was put into an Air Cast. After another week with no resolve, he did an MRI.(normal result,no fracture) He sent us to NYC, to see another Ortho. This one felt it was neurological, possible RSD. Sent us back home saying he didn't treat this. We then saw a Podiatrist who went with TTS, not RSD. He ordered 3 phase bone scan, another MRI (he didn't like the first one) and an EMG. All were normal.

Re: Help with Diagnosis! Part II

Debbie G. on 1/27/04 at 23:27 (143013)

Dear Dr. Wander, I ran out of room on my previous e-mail. I hope you get this half. To finish the story, my daughter also had bloodwork for lyme, gout, diabetes, arthritis, etc. All was normal. New Ortho. in Linden NJ, goes with the TTS theory and wants to do surgical release ASAP since she is in so much pain. He feels it's not RSD because only the TTS area is swollen and painful. It does get cold and discolored occasionally, but he says that's normal for an 'angry nerve'. She was doing PT but it was too painful. Is on low dose of Elavil. Tried Neurontin for three weeks(900 mg.)to no avail. Your thoughts? Should we come to see you or the other doc on this site, or do you feel we've done enough? Please share your expertise. It is greatly appreciated. My daughter, Erica, is still on crutches. Thank you, Debbie G.

Re: Help with Diagnosis!

Dr. Z on 1/28/04 at 23:00 (143145)

Your daughter need to see a pain management specialist for a workup and possible epidural block. This sure sounds like RSD !!!!!