Malingering is always a possibility with workman's
comp cases. However, I tend to err on giving
patients the benefit of the doubt. That said,
exactly what do we know about this case?
a)documented foot crush injury (curious how heavy
buggy is & when injury occurred relative to your
exam?);
b) subjective pain complaint is described with
neuritic descriptors AND out of proportion to
physical signs;
c) patient refuses to move digital extensors =
classic muscle guarding/splinting;
d)CAM walker immobilization is preferred = CLASSIC
sign;
e)patient re-positions foot in adducto-varus to
ambulate = another compensatory sign;
f)negative initial corroboratory diagnostics =
often absent in early stages of...
Does this sound familiar yet?.......This is most
likely a case of early stage CRPS!
In the differential diagnosis is malingering
(possible, but unlikely), and stenosing
tenosynovitis of the EDL. Stenosing tenosynovitis
takes time to develop, while scar tissue adhesions
along the EDL, most likely about the extensor
retinaculum, should be evident on MRI, but false
negatives are not uncommon. Also, ST doesn't
explain the neuritic pain descriptors and signs
about the CPN & PT nerves.
CRPS simply cannot be missed, nor its therapy
delayed!!! Vasomotor changes and diagnostic
corroborators are generally negative in its early
phases, so they cannot be relied upon as
diagnostic indicators. The physical signs observed
in this case, by eliciting subjective complaints
upon percussion of the CPN and PT intimate an over
exaggerated sympathetic nerve response to crush
injury; that certainly fits CRPS. Try re-examining
the patient utilizing your best distraction
techniques to see if those signs are still
elicited during that distraction. If they are
(likely), then this would further imply true
pathology vs malingering.
p
***CRPS requires multi-disciplinary management. As
podiatrists, the longer one delays diagnosis and
referral to competent clinicians for appropriate,
aggressive therapy, the more difficult it is to
resolve. Get this patient to someone with vast
experience diagnosing and treating CRPS sooner,
rather than later.***
Barry Mullen, DPM, Hackettstown, NJ,
yazy630@aol.com
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