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Complex Regional Pain Syndrome
The pain after an injury stays and no longer fits the cause — the sooner it gets a name and the hand or foot moves again, the better it turns out.
Also known as: Sudeck’s dystrophy · reflex sympathetic dystrophy · algodystrophy · shoulder-hand syndrome · CRPS I and CRPS II · pain after a fracture or cast
Open in the tool — with search and all the links →This compilation is for information and replaces neither medical diagnosis nor treatment. If you have symptoms, see a doctor.
After an injury — most often a broken wrist, sometimes a sprain, an operation or a wholly trivial event — the pain does not recede but stays or grows. It no longer fits the cause, and it does not sit only at the injured spot: the whole hand or the whole foot is involved, beyond the territory of any single nerve. Alongside come signs that can be seen and felt — swelling, a different colour and temperature from the other side, altered sweating, later changed hair and nails, stiffness and loss of strength. A touch that would otherwise mean nothing can hurt. There are two forms: in the commoner one no nerve injury can be demonstrated (CRPS I, formerly Sudeck’s dystrophy), in the rarer one it can (CRPS II). Women are affected more often, with a peak roughly between the ages of 40 and 70. How often it occurs depends strongly on which criteria are used for counting — figures in studies differ widely as a result. The diagnosis is made with the person, not in the laboratory: under the Budapest criteria in use today it takes symptoms from at least three of four groups and findings from at least two of them on examination. No blood value and no image proves it; an X-ray or a bone scan can support it, but a normal result does not rule it out. Conversely: having a name for it is already part of the treatment — many people have gone a long time without an explanation. Two widespread assumptions do not hold up. First: CRPS is not imagined and not psychologically caused. The once-suspected “CRPS personality” could not be confirmed in studies. That pain and strain act on each other is a reason for support — not a reason for doubt. Second: sparing it does not help. Immobilising the limb and taking it out of everyday life makes the course worse. Treatment therefore aims at function from the start: pain relief far enough that movement becomes possible, then physiotherapy and occupational therapy below the pain threshold. Mirror therapy and graded motor imagery have studies of their own; there are trials for bisphosphonates in the early phase, and the evidence is thin for blocks of the sympathetic nervous system. Vitamin C after a wrist fracture was long recommended for prevention; later analyses have called that into question — the matter is open today. The course is better than its reputation: many improve markedly in the first year, especially where it is recognised and moved early. Some keep lasting limitations. Which is why one thing counts above all — pain that increases rather than decreases after a fracture or a cast deserves an early look.
The diagnosis rests on the symptoms and the examination, not on a test. Voicing the suspicion early often shortens months of uncertainty — and treatment works best when started early.
Immobilising makes the course worse. Movement below the pain threshold, regular and in small steps, is the core of treatment — not the reward for having improved.
The purpose is movement. Pain treatment is chosen so that practising becomes possible — that is its measure, not freedom from pain as such.
Not stretching at any price, but gripping, holding, rolling through the step, loading. The aim is that the hand or foot takes part in everyday life again.
The healthy side is seen in a mirror as if it were the affected one; or movements are first only imagined and then increased step by step. Both have studies of their own and are started under guidance.
Buttons, laundry, brushing teeth, walking: everyday movements count for more than any exercise programme alone, because they happen daily and have a purpose.
Catching up on good days and then needing days to recover achieves less than a steady, smaller amount every day.
Lasting pain wears one down, and fear of movement keeps the circle going. Pain psychology works exactly there. It does not treat the cause — that does not lie in the psyche.
There are studies on this group of medicines for the early months. Whether it fits in an individual case is a decision for the treating doctor.
No drug cures CRPS. What works in studies works early: bisphosphonates in the first months, vitamin C after a wrist fracture as prevention, cortisone in the hot initial phase. Classic painkillers do little, because the pain comes from processing. What most determines the course is movement despite pain and mirror or imagery training — immobilisation worsens things measurably, and that is exactly the opposite of what feels right.
It occurs in about two to five in a hundred people after a fracture or an operation, most often after a wrist fracture. The signs develop within days to weeks: pain out of proportion to the injury, swelling, differences in colour and temperature, increased sweating. Vitamin C at 500 milligrams a day for fifty days after a wrist fracture lowered the frequency in studies. The best window lies in the first three to six months.
After a fracture or an operation pain normally eases. If it stays the same or grows, that is the first and most important sign.
Not only the injured spot and not the territory of a single nerve — that sets it apart from a nerve injury or a tight spot.
A sleeve, the duvet, a draught: what normally does not hurt can burn. The technical term is allodynia.
Pale, red or bluish; warmer or cooler than the healthy side. Comparing with the other hand or foot is the simplest test.
The hand stays puffy, the ring no longer fits; the skin sweats more or less than on the other side.
Later come restricted movement, tremor and trophic signs: nails grow differently, hair changes, the skin thins.
Not proof of CRPS. To exclude an infection after a fracture or operation, which can look similar — red, warm, swollen. In CRPS it is usually unremarkable.
To exclude an inflammatory or rheumatic cause. Here too: a normal value does not speak against CRPS.
To exclude: an attack of gout in the hand or foot looks similar at first glance — red, hot, swollen, very painful.
To exclude a thyroid disorder, which can favour stiffness and pain in hand and shoulder.
Without B12 the insulating layer of the nerves is not maintained. A lack causes tingling, numbness and unsteadiness in the dark — and it is one of the few reasons for nerve trouble that can be fully undone if found early.
The nerves cover their energy needs through thiamine. It runs short with alcohol, after stomach operations, with long-lasting vomiting and under water tablets.
Here both count: a lack harms the nerves, and too high an intake over months harms them as well. Supplements therefore belong taken in a dose that has a reason.
Works together with B12. Given alone, folate can improve the blood count while the B12 deficiency goes on damaging the nerves — which is why both are looked at together.
Long recommended for prevention after a wrist fracture; later analyses have questioned the benefit. The evidence is regarded as open today.
Clearly worthwhile and well supported when deficient — vegan, older adults, certain drugs. No energy boost without a deficiency.
In pregnancy clearly established against neural-tube defects, otherwise mainly with deficiency. Can mask a B12 deficiency — watch both.
In the early, inflammatory phase — weeks to a few months — cortisone showed an effect in studies. Later it does not. That is one of the few points in this condition where timing decides everything.
The affected hand or foot changes colour and temperature — the sympathetic nervous system is involved. This is why cold and agitation worsen the complaints, and why movement helps more than resting.
The bone in the affected area loses density quickly — patchy on the X-ray. Bisphosphonates, otherwise osteoporosis medicines, have been used here in studies with benefit.
In several studies 500 mg vitamin C daily for 50 days after a wrist fracture reduced the occurrence of CRPS. Later work found the effect smaller — the measure is simple and low risk.
Mirror therapy and graded motor imagery are the best-studied approaches. Immobilising makes the picture worse — the decisive point in CRPS, and often got wrong.
After a wrist fracture 500 mg daily for 50 days reduced the occurrence of CRPS in several studies. Later work found the effect smaller — the measure stays simple and low risk.