Walking with CRPS in the Foot: What to Do and Not to Do?

CRPS (Complex Regional Pain Syndrome) in the Foot: What is it?

Regardless of the term used from the list to describe the issue you are experiencing, the information provided in this article applies.

• Complex Regional Pain Syndrome (CRPS) type 1 or 2
• Reflex Sympathetic Dystrophy (RSD)
• Chronic Pain Syndrome
• Nerve Disorder Pain
• Chronic Regional Pain Syndrome
• Causalgia
• Sudeck’s Atrophy
• Amplified Musculoskeletal Pain Syndrome
• Neurovascular Dystrophy

These terms all refer to the same condition.

Now, let’s delve into the main symptoms of CRPS in the foot and how the diagnosis is made.

Symptoms of Foot CRPS

CRPS can occur in any joint of the body, often affecting the extremities, but not exclusively.

The foot is the most common location for CRPS.

The symptoms of CRPS in the foot include:

• Intense and continuous pain, disproportionate to any mechanical or physiological problem that may have triggered the condition.
• Sensory or circulatory disturbances in the skin of the foot, toes, ankles, or the malleoli, accompanied by ankle swelling and red, warm skin (at least initially) or, conversely, a sensation of extreme coldness with impaired blood circulation.
• Impaired motor function, making it difficult to move the foot (toes, ankle) as before.
• Stiffness; the ankle joint or the foot as a whole, including the toes, becomes less mobile than before.

Is an MRI Necessary for Foot CRPS Diagnosis?

In modern times, imaging studies such as MRI, X-rays, or bone scintigraphy are no longer essential for diagnosing CRPSin the foot (RevMed 2019).

The patient’s medical history and clinical examination are sufficient for diagnosis.

When imaging studies are still conducted, they often reveal bone demineralization in the foot or ankle. However, identifying this does not offer more specific treatment options. Therefore, imaging can be avoided.

The diagnosis of CRPS is established based on the presence of significant and unexplained pain in the foot, accompanied by other symptoms like sensory, circulatory, or motor disturbances.

What are the common causes of CRPS in the foot?

CRPS in the foot mainly occurs after:

1. An injury to the ankle, toes, or foot (fracture, surgery, sprain, etc.).
2. A stroke (cerebrovascular accident – CVA).

This is particularly the case when an extremely severe pain is observed (rated above 5/10 by patients) within 1 week of the trauma, or when the traumatized foot has been underutilized or immobilized excessively.

Sometimes, CRPS can also occur without any identifiable triggering factor.

CRPS of the foot is more commonly caused by an injury to a limb or a stroke. In some cases, it is impossible to identify a specific triggering element.

CRPS after bunion surgery (hallux valgus) ?

Are there clinical studies showing that CRPS is a relatively common complication (or, on the contrary, very rare or absent) after hallux valgus surgery?

Indeed, foot CRPS is one of the complications that is regularly reported in studies following individuals after hallux valgus surgery.

• Deenik 2007: Among 83 people who underwent hallux valgus surgery, 5 were diagnosed with algodystrophy in the aftermath.
• Rouveyrol 2021: 3 cases of algodystrophy out of 96 operated feet.
• Rink-Brüne 2004: 3 cases of algodystrophy out of 78 people operated on for hallux valgus.

So, more than 1 person out of 100 who undergo hallux valgus surgery receives a diagnosis of foot CRPS in the aftermath. (However, the vast majority do not have this condition!)

See also my blog post on How to Fix Bunion Without Surgery

CRPS after foot surgery or fracture?

Any surgery, even when performed with arthroscopy (with only tiny incisions), causes some tissue damage and triggers inflammation, a natural process of the body to repair damaged tissues.Therefore, any operation performed at the ankle or foot level can potentially lead toCRPS in the foot.

Here are the operations for which a risk of CRPS is most often observed in the post-operative period (although it remains a very rare complication):

• Ankle fracture surgery;
• Tarsal tunnel release, due to tarsal tunnel syndrome (similar to carpal tunnel syndrome but in the foot);
• Surgery for heel spur.

The frequency of CRPS after an ankle fracture (whether operated or not) is only 0.3%: 1 person out of 306 individuals who have had an ankle fracture.

According to a research team that studied the frequency of CRPS after foot surgery:

“Based on our results, we recommend that middle-aged women and individuals with a history of anxiety or depression, who will undergo non-urgent foot surgery, be informed about the risk of developing complex regional pain syndrome during the consent process.”

Rewhorn 2014

CRPS indeed occurs more frequently in women around the age of 40, especially if they suffer or have suffered from anxiety and depression. Hence, it is essential to inform them about this before “optional” surgery (e.g., in the case of hallux valgus).

Source: Harris 2004, Bullen 2016, Rewhorn 2014

I frequently encounter patients undergoing rehabilitation for ankle fractures who have received a “CRPS” diagnosis after a brief consultation (for something else) with a doctor they only saw once. These patients may not have fully recovered and remain in pain 2-3 months after their fracture.

However, I am not convinced that quickly labeling it as CRPS adds real value to the management. When my patients ask for my opinion, I share this view with them and reassure them that they don’t have an additional problem. It’s just that some people recover a bit more slowly, which is common, and things will eventually improve.

CRPS following ankle sprain?

There are some case reports in the medical literature on CRPS that have occurred after an ankle sprain, including in children and adolescents.

See also my blog post on Recovery Time after Ankle Sprain

Foot CRPS after Knee Arthroscopy?

At least one case of CRPS after knee arthroscopy has been reported (Evans 2022).

CRPS in the Foot and Walking: What to Know

Many people diagnosed with CRPS in the foot wonder:

• If they are allowed to walk
• If walking might worsen their condition
• How to manage walking despite the pain or lack of flexibility

I will address these questions.

Walking is not prohibited or contraindicated. When dealing with CRPS in the foot, walking is not contraindicated.

There is no bone lesion that would be at risk of worsening by walking (as is the case with a displaced ankle fracture that has not yet healed).

However, walking may sometimes increase the pain:

• Either during walking.
• Or after walking: in the hours or night following, or the next day.

That’s why many people are afraid to walk with CRPS in the foot.

Nevertheless, walking does not lead to the development of CRPS in the long term. On the contrary, there are good reasons to believe that staying as active as possible (including walking) actually improves your chances of a quick recovery.

Finding the right balance is essential! Let’s explore this further.

How to Walk Despite CRPS in the Foot and Ankle?

Here are several things you can do to make walking easier despite your CRPSin the foot:

• Relieve pressure on the foot by walking with walking poles, crutches, or even a walker.
• Try out different shoes to find the ones that feel most comfortable for you.
• Gradually increase the distance or speed of your walks. For example, go from walking a maximum of 3 minutes to 4 minutes, then 5 minutes, 7 minutes, 10 minutes, and so on.
• Keep track of your daily progress, even if it’s not much. You can write it down on a piece of paper, use an app, a notepad on your smartphone or computer, or your agenda. Whatever works for you to stay motivated and keep moving forward.
• Consider other low-impact physical activities to gradually reintroduce movement to your foot and body, such as cycling, swimming, etc.
• Seek support from trusted professionals who can help you gradually resume walking, such as physical therapists, sports coaches, etc.

Walking with CRPS in the ankle or foot is possible with adaptations: using walking poles, gradually increasing duration, adjusting footwear, etc.

What is the recovery time for CRPS in the foot?

There are significant variations in the duration of CRPS in the foot among individuals, and there is no way to predict how long it will take for a person to heal.

For example, the medical journal Prescrire states:

The evolution of algodystrophy is highly variable, ranging from spontaneous regression in a few weeks to pain persisting for several years.

Prescrire Review, 2009

A recent publication analyzed data from 22 studies following individuals with CRPS (Johnson 2022). It showed that:

• 51 to 89% of people still experience pain and motor impairment one year after the onset of symptoms. (This means there is a potential 50% chance of having no pain within a year.)
• On average, ankle range of motion is reduced by 25% one year after the onset of symptoms.
• 30 to 40% are still on sick leave after one year, and 27 to 35% have returned to work with adaptations.

Here’s some good news for you: CRPS in the ankle or foot typically lasts for a shorter duration than CRPS in the knee (van Bussel 2016).

On average, 1 out of 2 people experiences no pain or impairment at all within one year after the onset of CRPS symptoms.

What is the treatment for CRPS in the foot and ankle?

How can you relieve, treat, and cure CRPS in the foot?

This is a completely legitimate question to ask.

Many treatments for CRPS have been proposed and tested in small studies, primarily to alleviate symptoms and improve autonomy rather than cure CRPS.

CRPS often heals “on its own” with time, and there is no specific treatment that can be definitively attributed to its cure.

There are several suggested treatments for CRPS in the foot, encompassing both medications and non-pharmacological therapies, including home remedies and natural treatments.

Below are the main treatments recommended for CRPS in the foot, with an indication of the ✅ symbol when there is some evidence (all of very low quality) of a slight superiority over a placebo in reducing pain.

• Various analgesic medications
• Bisphosphonates ✅
• Calcitonin ✅
• Daily intravenous ketamine treatment ✅
• Morphine
• Corticosteroids
• Physical therapy
• Occupational therapy
• Graded motor imagery ✅
• Mirror therapy (after a stroke) ✅
• Transcutaneous electrical nerve stimulation (TENS)
• Scottish shower (contrast baths)
• Continuous peripheral nerve blocks (administration of pain medication around a nerve)
• Biofeedback
• Relaxation
• Acupuncture
• Homeopathy
• Osteopathy

Please note that any treatment, whether natural or not, carries the risk of side effects and undesirable effects. They are not mentioned here.

I will have the opportunity to discuss the treatments for CRPS in more detail in a future article. However, the essential list is already provided above: unfortunately, there is currently no miracle treatment for CRPS.