When Pain Persists: Challenges After Patellar Dislocations In A Runner

HISTORY: Patient is a 19-year-old female collegiate track athlete who presented from physical therapy for right foot pain, swelling and numbness radiating up into her right calf. Patient was told she had no pulses in her right foot and the swelling in her foot was getting worse as well as turning blue. Patient was undergoing physical therapy for recurrent patellar dislocations for the past 2-3 months. PHYSICAL EXAMINATION: General: Tenderness (right foot, right lower leg, right knee, right thigh) present. No swelling, deformity, or signs of injury.Cervical spine: normal range of motion.Skin: warm and dry. Capillary refill is less than 2 seconds. Pedal pulses 2+ bilaterally.Neurological: alert and oriented to person, place, and time.Psychiatric: anxious. DIFFERENTIAL DIAGNOSIS: 1.Compartment syndrome.2.Arterial thrombus.3.CRPS.4.Radiculopathy. TEST AND RESULTS: CT angiogram of aorta and lower extremities: unremarkable.MRI lumbar spine: unremarkable.EMG right lower extremity: normal study. MRI right knee: sequela of transient lateral patellar dislocation with mild thickening of medial patellofemoral ligament and mild marrow contusions of the medial patellar facet and lateral femoral condyle. Edema in superolateral aspect of Hoffa’s fat pad. Mild articular cartilage degeneration of lateral patellar facet and femoral trochlea. Background features predisposing to recurrent patellofemoral instability/patellar maltracking including patella alta and abnormal tibial tuberosity to trochlear groove distance. FINAL/WORKING DIAGNOSIS: Complex regional pain syndrome in the setting of recurrent patellar dislocations. TREATMENT AND OUTCOMES: 1.Patient underwent four months of formal physical therapy with minimal improvement. 2. Underwent right knee arthroscopic lateral release, Fulkerson osteotomy with distalization of the tibial tubercle, and open medial reefing.3.Non-weightbearing for 8 weeks. Patient experienced resolution of CRPS related symptoms.4.Started formal physical therapy at 8 weeks with goal to return to running.