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FRACTURES: MUSCLE DEFORMITY & POSITIVE CLINICAL FINDINGS

Final Year BPT/MPT | Orthopaedic Physiotherapy

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PART A: HOW MUSCLES CAUSE DEFORMITY IN FRACTURES

"The proximal fragment adopts the position dictated by muscles attached to it; the distal fragment is pulled by the muscles attached to it." - Rockwood & Green

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PART B: FRACTURE-BY-FRACTURE: MUSCLES + DEFORMITY + POSITIVE FINDINGS

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1. CLAVICLE FRACTURE (Middle 1/3 - Most Common)

Muscles Responsible for Deformity

Positive Clinical Findings

• Inspection: Patient supports affected arm with opposite hand; head tilted toward injured side (to relax SCM); visible swelling/deformity at middle 1/3 clavicle; shoulder drooping
• Palpation: Local tenderness, crepitus, palpable step deformity; abnormal mobility
• ROM: Painful restriction of shoulder elevation and abduction (deltoid pull aggravates fracture)
• Special Tests: Positive tenderness on direct palpation; piano key sign if ACJ involved
• Neurovascular: Check brachial plexus (especially C5/C6) and subclavian vessels - at risk due to proximity

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2. SURGICAL NECK OF HUMERUS FRACTURE

Muscles Responsible for Deformity

Positive Clinical Findings

• Inspection: Arm held in adduction + IR; swelling at shoulder; bruising tracking down arm within 24-48 hrs (due to gravity) - "Battle sign equivalent" for humerus
• Palpation: Tenderness at surgical neck; crepitus
• ROM: All shoulder movements painful and restricted
• Special Tests: Ecchymosis tracking distally; abnormal contour (loss of normal deltoid roundness)
• Neurovascular: Check axillary nerve (C5) - test regimental badge area sensation; test deltoid power; check radial pulse

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3. SHAFT OF HUMERUS FRACTURE

Muscles Responsible for Deformity

Positive Clinical Findings

• Inspection: Arm shortening; swelling; ecchymosis; Wrist drop (pathognomonic sign)
• Palpation: Tenderness at fracture site; crepitus; abnormal mobility
• ROM: Painful shoulder and elbow movement
• Neurovascular (HIGH YIELD): Radial nerve (C5-C8) runs in the spiral groove - check:
  • Wrist extension (ECRL, ECRB)
  • Finger extension at MCP (ED)
  • Thumb extension (EPL)
  • Sensation - dorsal web space of thumb (superficial radial nerve)
  • "Wrist drop" = CLASSIC radial nerve injury finding

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4. FOREARM FRACTURES (Radius + Ulna)

Muscles Responsible for Deformity

• Fracture ABOVE supinator insertion: Proximal fragment = supinated (biceps + supinator unopposed); Distal fragment = pronated (PT + PQ)
• Fracture between supinator and PT: Proximal fragment = 90° supination; distal = pronated
• Fracture BELOW PT insertion: Less severe - PT counteracts supination forces

• Muscle pull: Brachialis pulls on distal ulna; annular ligament disrupted
• Positive finding: Radial head palpable anteriorly; restricted elbow flexion/supination; check posterior interosseous nerve (PIN) injury

• Muscle pull: ECU, FCU, PQ pull ulnar styloid distally
• Positive finding: Piano-key sign at DRUJ; restricted forearm rotation

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5. COLLES' FRACTURE (Distal Radius - Extra-articular)

Muscles Responsible for Deformity

• Dorsal displacement + tilt of distal fragment
• Radial shortening and radial deviation
• Volar angulation of the wrist on lateral view
• Supination of distal fragment

Positive Clinical Findings

• Inspection: Dinner fork deformity (lateral view); radial deviation; swelling; ecchymosis
• Palpation: Tenderness over distal radius; Lister's tubercle tenderness
• ROM: Restricted wrist flexion, extension, ulnar deviation; restricted forearm supination
• Special Tests:
  • Finkelstein's (rule out De Quervain's as DD)
  • Check for median nerve compression (carpal tunnel symptoms) - most common nerve complication
  • Ulnar styloid tenderness (associated fracture common)
  • Check DRUJ stability
• Grip strength: Markedly reduced

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6. NECK OF FEMUR (NOF) FRACTURE

Muscles Responsible for Deformity

Positive Clinical Findings

• Inspection: Leg shortened; external rotation (foot pointing outward - often 90°); slight flexion at hip; patient unable to lift leg
• Palpation: Groin tenderness; greater trochanter tenderness; Bryant's triangle disruption; telescoping possible
• ROM: Painful restriction of all hip movements especially internal rotation
• Special Tests:
  • Telescoping / Piston sign - positive
  • Bryant's triangle - measurements reduced on affected side
  • Nelaton's line - disrupted
  • Shoemaker's line - disrupted
  • Trendelenburg sign - positive (abductor dysfunction)
  • Thomas test - hip flexion contracture developing
• Neurovascular: Check femoral nerve (quadriceps weakness); femoral artery pulse

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7. INTERTROCHANTERIC FRACTURE OF FEMUR

Muscles Responsible for Deformity

• Greater trochanter fragment: Gluteus medius + minimus pull UPWARD and LATERALLY
• Lesser trochanter fragment: Iliopsoas pulls UPWARD
• Shaft: Adductors pull medially creating VARUS deformity
• Varus malunion = most common complication - leads to abductor muscle imbalance, limb shortening, limp (Campbell's Operative Orthopaedics, 15th Ed)

Positive Clinical Findings

• Inspection: Gross external rotation (up to 90°); significant shortening; limb lies flail; marked ecchymosis (profuse bleeding - can lose 1-2L blood in the thigh)
• Palpation: Tenderness at trochanteric region; abnormal mobility
• ROM: Complete restriction
• Gait: Unable to bear weight; Trendelenburg gait if mobilizing

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8. SHAFT OF FEMUR FRACTURE

Muscles Responsible for Deformity

• Upper 1/3: Proximal fragment - Flexion, Abduction, External rotation
• Lower 1/3: Distal fragment - Posterior displacement (gastrocnemius) causing HYPEREXTENSION at fracture site; popliteal vessel injury risk

Positive Clinical Findings

• Inspection: Obvious deformity; thigh swelling (1-3 litres blood loss possible); shortening; ecchymosis; limb in ER
• Palpation: Abnormal mobility; crepitus; tender thigh; tense compartment (watch for compartment syndrome)
• ROM: Nil active; passive restricted due to pain
• Special Tests:
  • Measure limb length (true + apparent)
  • Popliteal pulse (critical in lower 1/3)
  • Sciatic nerve check (rare but possible)
  • Compartment pressure monitoring

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9. TIBIAL FRACTURES

Muscles Responsible for Deformity

• Anterior compartment: TA, EHL, EDL, Peroneus tertius - most susceptible
• Deep posterior compartment: TP, FHL, FDL - second most susceptible
• Lateral: Peroneus longus, brevis
• Superficial posterior: Gastrocnemius, soleus

• FHL adheres to callus at fracture site = "Checkrein deformity" of great toe (Campbell's Operative Orthopaedics, 15th Ed)

Positive Clinical Findings

• Inspection: Direct visualization often possible (subcutaneous bone); angulation deformity; swelling; open fracture common
• Palpation: Extreme tenderness; tense anterior compartment
• ROM: Restricted ankle/knee
• Compartment Syndrome Signs (5 P's):
  • Pain (out of proportion, passive stretch aggravates)
  • Paresthesia (web space of great toe for anterior compartment)
  • Paralysis (dorsiflexion weakness)
  • Pallor
  • Pulselessness (late and dangerous sign - do not wait for this!)
• Neurovascular: Deep peroneal nerve (foot drop, web space numbness), posterior tibial artery

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10. VERTEBRAL FRACTURES

Muscles Responsible for Deformity

• Paraspinal muscles go into reflex spasm as protective splinting
• Iliopsoas may be involved in lumbar fractures causing psoas spasm and hip flexion posture

• Retropulsion of bone fragment into spinal canal
• Paraspinal extensor muscles: Erector spinae loses its mechanical advantage

Positive Clinical Findings

• Inspection: Kyphotic deformity (gibbus deformity in burst/wedge); list to one side; protective muscle spasm
• Palpation: Point tenderness over spinous process; paravertebral muscle spasm
• ROM: Restricted in all directions; painful axial loading
• Neurological findings (if cord involved):
  • Upper motor neuron signs below level
  • Sensory level
  • Bladder/bowel dysfunction
• Special Tests:
  • Percussion over spine - pain
  • Straight leg raise (if lumbar fracture with nerve root irritation)

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PART C: SUMMARY TABLE - HIGH YIELD FOR EXAMS

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PART D: PHYSIOTHERAPY ASSESSMENT FOCUS

Muscle Assessment After Fracture

1. MMT - test muscles DISTAL to fracture first (neurological screen); test antagonists and synergists post-immobilization
2. Tightness - muscles that were shortened in cast position (e.g. post-Colles' - wrist flexors tight; post-NOF - hip flexors tight from bed positioning)
3. Atrophy - measure girth circumference at fixed points (e.g. 10 cm above/below patella for quadriceps after femur fracture)
4. Proprioception - always assess, especially in lower limb fractures

Expected Positive Physiotherapy Findings Post-Fracture/Post-Immobilization

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⭐ HIGH YIELD VIVA/EXAM POINTS

1. "What deformity occurs in shaft of femur upper 1/3 fracture?"
   • Proximal fragment: Flexion (iliopsoas) + Abduction (gluteus medius) + External rotation
   • Distal fragment: Extension + Adduction + shortening
2. "Why does Colles' fracture cause dinner fork deformity?"
   • Dorsal displacement + dorsal tilt + radial shortening of distal fragment gives the lateral profile appearance of a dinner fork
3. "What nerve is most commonly injured in humeral shaft fracture and why?"
   • Radial nerve - it winds around the spiral groove at the junction of middle and lower 1/3 of humerus
4. "What is the danger in lower 1/3 femur fracture?"
   • Gastrocnemius pulls the distal fragment POSTERIORLY - risk of popliteal artery injury
5. "What is the significance of the Pronator Quadratus in Colles' fracture?"
   • PQ acts as a deforming force pulling the distal fragment volarly and causing supination of the distal fragment
6. "Name the 5 P's of compartment syndrome"
   • Pain (worst, most sensitive), Paresthesia, Pallor, Paralysis, Pulselessness (latest, most dangerous)
7. "What is a checkrein deformity?"
   • FHL adherence to callus after distal tibial fracture causing flexion deformity of hallux
8. Common student mistake: Forgetting to check DISTAL neurovascular status BEFORE and AFTER any fracture assessment - this is mandatory and examiners always ask

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REFERENCES

• Rockwood and Green's Fractures in Adults, 10th Edition (2025) - Muscular Anatomy of the Clavicle; Deforming Forces in Forearm
• Campbell's Operative Orthopaedics, 15th Edition (2026) - Intertrochanteric fractures; Tibial fracture deformities
• Miller's Review of Orthopaedics, 9th Edition
• S. Das - A Manual on Clinical Surgery, 13th Edition
• Bailey and Love's Short Practice of Surgery, 28th Edition
• Apley's System of Orthopaedics and Fractures (standard BPT reference)

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Exam tip: For any fracture question, always state: (1) which fragment is proximal vs distal, (2) which muscles attach to each fragment, (3) the resulting deformity, and (4) which nerve/vessel is at risk. This four-part answer will score maximum marks in both theory and viva.

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REFLEX SYMPATHETIC DYSTROPHY (RSD) / COMPLEX REGIONAL PAIN SYNDROME (CRPS)

Final Year BPT/MPT | Orthopaedic & Neurological Physiotherapy

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✅ 1. DEFINITION AND CLASSIFICATION

• Disproportionate, burning pain
• Autonomic dysregulation (vasomotor, sudomotor changes)
• Trophic changes (skin, nail, bone, muscle atrophy)
• Motor dysfunction

"CRPS represents autonomic and pain transmission dysregulation, resulting in peripheral sensitization with allodynia, dysesthesia, hyperpathia, and a reduced tolerance for pain when using the affected area for basic function." - Campbell's Operative Orthopaedics, 15th Ed

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Classification (IASP - International Association for the Study of Pain)

• Sudeck's atrophy
• Shoulder-hand syndrome
• Algodystrophy / Algoneurodystrophy
• Minor causalgia
• Post-traumatic dystrophy

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✅ 2. ANATOMY AND PATHOPHYSIOLOGY

Anatomical Basis - The Sympathetic System Involved

• Sympathetic chain: T1-L2 pre-ganglionic fibers
• Sympathetic ganglia: Stellate ganglion (upper limb), Lumbar sympathetic chain (lower limb)
• Sympathetic fibers: Travel alongside peripheral nerves to innervate blood vessels, sweat glands, piloerectors in skin
• C-fibers and Aδ-fibers: Nociceptors that become sensitized

Pathophysiology - Three Proposed Mechanisms

• After injury, injured nociceptors develop abnormal adrenergic sensitivity
• Circulating/locally secreted sympathetic neurotransmitters (norepinephrine) trigger painful afferent activity
• "Ephaptic transmission" - abnormal connection between efferent sympathetic fibers and somatic afferent pain fibers at the injury site

• Sustained bombardment by pain impulses from periphery
• Sensitization of dorsal horn neurons (spinal cord)
• "Wind-up" phenomenon - progressively increasing response to repeated stimuli
• Maladaptive neuroplasticity with cortical reorganization

• Release of substance P, CGRP, bradykinin
• Neurogenic inflammation - vasodilation, plasma extravasation
• Pro-inflammatory cytokines perpetuate the cycle

• Phase I: Peripheral short-circuiting of nerve impulses
• Phase II: Short-circuiting through the internuncial pool in the spinal cord
• Phase III: Control by higher thalamic centers

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✅ 3. ETIOLOGY / PRECIPITATING FACTORS

• Female predisposition (3:1 female to male ratio)
• Upper extremity involvement most frequent
• Smoking associated with CRPS
• Immobilization post-injury
• Psychological factors (anxiety, depression)

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✅ 4. CLINICAL PRESENTATION - THREE STAGES (BONICA'S STAGING)

STAGE 1 - DYSFUNCTION (Acute/Sympathetic Overflow Phase)

STAGE 2 - DYSTROPHY (Vasoconstriction Phase)

STAGE 3 - ATROPHY (Irreversible Phase)

"Recovery is possible as long as vasomotor activity with swelling and hyperemia is evident. After the trophic second or third phase is established, the prognosis for recovery is poor." - Firestein & Kelley's Rheumatology

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✅ 5. DIAGNOSTIC CRITERIA - BUDAPEST CRITERIA

• Sensory: Hyperesthesia OR allodynia
• Vasomotor: Temperature asymmetry / skin color change / asymmetry
• Sudomotor/Edema: Edema, sweating changes/asymmetry
• Motor/Trophic: Decreased ROM, motor dysfunction (weakness, tremor, dystonia), trophic changes (hair, nails, skin)

• Sensory: Hyperalgesia (pinprick) OR allodynia (light touch / deep somatic pressure / joint movement)
• Vasomotor: Temperature asymmetry >1°C, skin color change
• Sudomotor/Edema: Edema, sweating changes
• Motor/Trophic: Decreased ROM, motor dysfunction, trophic changes

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✅ 6. MUSCLE-WISE ASSESSMENT

Muscles Affected

MMT (Manual Muscle Testing)

• Stage 1: Reduced due to pain inhibition (Grade 3-4)
• Stage 2: Reduced due to disuse + neurological inhibition (Grade 2-3)
• Stage 3: Severely reduced/absent (Grade 0-2)

Muscle Tightness Assessment

• Wrist flexors, finger flexors (post-Colles' fracture RSD)
• Hip flexors, knee flexors (LE involvement)
• Shoulder adductors and IR (shoulder-hand syndrome)

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✅ 7. EXPECTED POSITIVE CLINICAL FINDINGS

Inspection

• Swelling (edema) - pitting in early stage
• Skin color: Red/erythematous (Stage 1) → Bluish-cyanotic → Pale (Stage 3)
• Skin texture: Smooth, shiny, atrophic in later stages
• Hair loss over affected area
• Brittle, dystrophic nails
• Muscle atrophy (measure with tape)
• Flexion contracture/deformity (Stage 3)
• Patient guards and protects limb - protective posturing

Palpation

• Allodynia - pain with light touch (hallmark sign)
• Hyperalgesia - exaggerated pain to painful stimulus
• Temperature asymmetry - warm (Stage 1), cold (Stage 2-3) vs contralateral side
• Hyperhidrosis (excessive sweating) in Stage 1
• Edema on volumetric comparison
• Tenderness diffuse, NOT localized to one structure

ROM

• Restricted in ALL directions - Stage-dependent
• Passive ROM limited by stiffness/contracture
• Active ROM severely limited by pain and weakness
• Grip dynamometry: Markedly reduced

Special Tests / Clinical Measures

• Thermometry: Temperature difference >1°C between limbs (clinician tactile threshold requires ~5°F difference)
• Volumetry: Submersion water displacement test for edema quantification
• Three-point discrimination test: Sensory deficit assessment
• Tinel's / Phalen's: Rule out associated nerve entrapment (e.g., CTS post-Colles')
• Sympathetic block test (diagnostic + therapeutic): Positive response confirms sympathetically-mediated CRPS

Gait (Lower Limb CRPS)

• Antalgic gait (pain avoidance)
• Foot protection - patient may refuse to weight bear
• Reduced stride length on affected side
• Circumduction to avoid contact

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✅ 8. DIFFERENTIAL DIAGNOSIS

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✅ 9. INVESTIGATIONS

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✅ 10. PROBLEM LIST

1. Disproportionate, burning pain at rest and with movement
2. Allodynia and hyperalgesia - tactile hypersensitivity
3. Restricted ROM of affected joint(s)
4. Muscle weakness and atrophy
5. Edema / limb swelling
6. Autonomic dysfunction (temperature, color, sweat changes)
7. Trophic changes (skin, nails, hair, bone)
8. Functional limitations - ADL, grip, gait
9. Sleep disturbance secondary to pain
10. Psychological distress - fear avoidance, anxiety, depression (kinesiophobia)
11. Risk of joint contracture and irreversible deformity (Stage 3)

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✅ 11. SMART GOALS

Short-Term Goals (0-6 weeks)

1. Reduce pain score from X/10 to Y/10 on VAS within 4 weeks using desensitization and graded touch
2. Reduce limb edema by 20% within 3 weeks using elevation and TENS
3. Achieve pain-free ROM within 50% of normal range within 6 weeks
4. Improve grip strength by 1 MMT grade within 4 weeks
5. Educate patient on pain neuroscience and self-management within 2 weeks

Long-Term Goals (3-6 months)

1. Achieve full pain-free ROM of affected extremity within 3 months
2. Restore grip strength to 80% of contralateral side within 4 months
3. Independent performance of all basic ADLs without pain within 3 months
4. Return to occupational and recreational activities within 5-6 months
5. Prevent recurrence through maintained HEP and lifestyle modification

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✅ 12. PHASE-WISE PHYSIOTHERAPY MANAGEMENT

PHASE 1 - ACUTE / PAIN MANAGEMENT PHASE (Stage 1: Weeks 1-4)

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PHASE 2 - MOBILIZATION PHASE (Stage 1-2: Weeks 4-8)

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PHASE 3 - FUNCTIONAL RESTORATION PHASE (Stage 2-3: Weeks 8-12+)

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✅ 13. MUSCLE-SPECIFIC EXERCISES

A. DESENSITIZATION PROGRESSION (Stage 1)

1. Cotton wool rubbing - proximal to distal
2. Soft cloth - circular strokes
3. Terry towel / rough fabric
4. Tapping with fingertips
5. Vibratory stimulation

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B. MIRROR VISUAL FEEDBACK (MVF)

1. Observe reflection of unaffected limb (brain perceives it as the affected limb moving normally)
2. Perform simple AROM of unaffected limb: wrist flexion/extension, finger opening/closing
3. Progress to bilateral simultaneous movements
4. Sessions: 20 minutes

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C. GRADED MOTOR IMAGERY (GMI) - 3 Stages

1. Left/Right discrimination (Recognize): Look at photographs of limbs - identify left vs right
   • 2 sets of 10 images, 3x/day, 5 min sessions
2. Motor imagery (Imagine): Imagine moving the affected limb without actually moving
   • 10 min sessions, 3x/day
3. Mirror therapy (Move): As above (MVF)

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D. WRIST/HAND ROM EXERCISES (Post-Colles'/Upper Limb CRPS)

• SP: Seated, forearm resting on table, hand beyond edge
• Technique: Flex wrist fully, hold 5 sec, extend wrist fully, hold 5 sec
• Sets: 3 | Reps: 10 | Hold: 5 sec | Frequency: 3x/day
• Progression: Add wrist weights (0.5kg → 1kg)

• SP: Seated, forearm supported
• Sequence: Full extension → Hook fist → Straight fist → Full fist
• Sets: 3 | Reps: 10 each position | Frequency: 4x/day
• Progression: Against resistance using putty

• Touch thumb to each finger tip in sequence
• Sets: 3 | Reps: 10 | Frequency: 4x/day

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E. STRENGTHENING EXERCISES (Stage 2-3)

• SP: Seated, elbow at 90°, forearm on table
• Technique: Knead, pinch, roll putty - full grip to tip pinch
• Sets: 3 | Reps: 15 | Frequency: 2x/day
• Progression: Soft → Medium → Hard putty

• SP: Fist on table, therapist provides resistance at dorsum
• Technique: Push up into extension against resistance, hold
• Sets: 3 | Reps: 10 | Hold: 5-10 sec | Frequency: Daily

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✅ 14. ELECTROTHERAPY

TENS (Transcutaneous Electrical Nerve Stimulation)

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IFT (Interferential Therapy)

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Low Level Laser Therapy (LLLT)

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Ultrasound Therapy

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Spinal Cord Stimulation (SCS)

• Dorsal column stimulator - for refractory CRPS
• Evidence: Zheng et al. 2023 systematic review (PMID: 37436342) supports neurostimulation for chronic pain

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✅ 15. HOME EXERCISE PROGRAM (HEP)

1. Elevation: Keep limb elevated above heart level when resting - 30 min, 4x/day
2. Desensitization: Self-massage with towel, 5 min, 4-5x/day
3. AROM exercises: Wrist/ankle/finger ROM - 10 reps each, 3x/day
4. Mirror therapy: 20 min daily (teach to use mirror at home)
5. Contrast baths: Warm (40°C) × 3 min → Cold (15°C) × 1 min, 5 cycles, 2x/day (Stage 1-2 only)
6. Pain diary: Record pain levels, triggers, and response to activities
7. Relaxation techniques: Diaphragmatic breathing, progressive muscle relaxation - daily
8. Walking/aerobic activity: As tolerated - 10-20 min walk daily (LE involvement)

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✅ 16. MULTIDISCIPLINARY MANAGEMENT

• NSAIDs (acute phase)
• Tricyclic antidepressants (amitriptyline)
• Anticonvulsants (gabapentin, pregabalin)
• Calcitonin + Bisphosphonates (bone protection)
• SSRIs
• Topical agents (lidocaine patch, capsaicin)
• Ketamine infusions (refractory cases)

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✅ 17. COMPLICATIONS AND PROGNOSIS

Complications

• Irreversible flexion contractures (Stage 3)
• Sudeck's atrophy - gross periarticular osteoporosis with fracture risk
• Chronic pain syndrome / Central sensitization
• Depression, anxiety, social isolation
• Loss of employment / functional independence
• Spread to contralateral or other limbs ("spreading CRPS")

Prognosis

• Early diagnosis (<6 months): Good prognosis with aggressive treatment
• Delayed diagnosis (>1 year): Poor prognosis
• Sympathetically maintained CRPS: Better response to sympathetic blocks
• Sympathetically independent CRPS: Poorer response to blocks; needs central interventions
• Recovery possible as long as vasomotor activity (swelling + hyperemia) is present

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✅ 18. CRITERIA FOR RETURN TO ACTIVITY

1. Pain reduced to ≤2/10 VAS at rest AND with activity
2. Full or near-full ROM restored (>80% of contralateral side)
3. Grip/muscle strength ≥80% of contralateral side
4. No allodynia or hyperalgesia on clinical testing
5. Temperature symmetry between limbs (<1°C difference)
6. Independent ADL performance without pain
7. Psychosocial readiness - no fear-avoidance behavior
8. Edema resolved / stable
9. No trophic changes progressing

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⭐ HIGH-YIELD VIVA AND EXAM POINTS

• Type I (RSD): No defined nerve injury | Type II (Causalgia): Defined nerve injury present
• Both share identical clinical criteria

• Triple-phase bone scan - shows increased periarticular uptake

• 4 criteria: Disproportionate pain + Symptoms in 3/4 categories + Signs in 2+ categories + No better diagnosis

• Stage 1: Dysfunction (warm, red, sweating) | Stage 2: Dystrophy (cold, atrophic) | Stage 3: Atrophy (irreversible contracture)

• Desensitization + Graded Motor Imagery + Mirror Visual Feedback - before any aggressive mobilization

• The patient observes the unaffected limb's movement reflected in a mirror, tricking the brain into perceiving the affected limb is moving normally - this reverses maladaptive cortical reorganization (motor cortex remapping)

• Aggressive mobilization increases sympathetic activity, worsens pain, allodynia, and perpetuates the cycle of sensitization. Desensitization must precede mobilization.

• The radiographic appearance of CRPS - patchy periarticular demineralization/osteoporosis, most pronounced around joints of affected limb

• Alternating warm (40°C, 3 min) and cold (15°C, 1 min) immersion for 5 cycles - induces vascular pumping, aids vasomotor re-regulation in Stage 1-2

• Prescribing passive mobilization too early and too aggressively - this worsens allodynia and reinforces pain behavior. ALWAYS start with desensitization and pain neuroscience education FIRST.

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REFERENCES

• Campbell's Operative Orthopaedics, 15th Edition (2026) - CRPS/RSD, Budapest Criteria, Bonica's Stages
• Adams & Victor's Principles of Neurology, 12th Edition - CRPS/Causalgia pathophysiology
• Firestein & Kelley's Textbook of Rheumatology - RSD phases, sympathetic mechanisms
• Rockwood & Green's Fractures in Adults, 10th Edition (2025) - Post-fracture CRPS
• Ríos-León M et al. (2024) - Effectiveness of motor imagery in CRPS: Systematic review with meta-analysis. Pain Pract. PMID: 38265184
• Zheng Y et al. (2023) - Neurostimulation for Chronic Pain: Systematic Review. Neuromodulation. PMID: 37436342
• Mayer TK, Trescot AM (standard physiotherapy textbook reference)
• Stanton-Hicks et al. IASP Classification updates

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Exam tip: In CRPS, always remember the mnemonic "PASTA": Pain disproportionate + Autonomic changes + Sudomotor/skin changes + Trophic changes + Allodynia/sensory changes. If you list these 5 features and the 3 stages correctly, you will score full marks in any theory or viva question on RSD.