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Complex Regional Pain Syndrome (CRPS)

What CRPS is, why it sometimes follows a wrist or hand injury or operation, how it is recognised and treated, and what recovery looks like.

26 citationsUpdated Sep 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Complex Regional Pain Syndrome (CRPS) is a multifactorial condition whose pathogenesis, epidemiology, genetic involvement, psychological implications, and treatment options require further study [3]. Diagnosis remains a clinical process based on history and physical examination, and it should only be considered a diagnosis of exclusion, with glomus tumors included in the differential for patients presenting with unusual chronic pain or neuropathy [17]. Quantitative sensory testing indicates altered pain mechanisms in CRPS compared to controls, with a pooled standardized mean difference of -0.41 [5]. Early recognition and prompt treatment are critical to minimize permanent loss of function, although patients may still experience permanent impairment and disability despite these interventions [10].

The reported incidence of CRPS is influenced by the choice of diagnostic criteria, study location, and fracture management [13]. Risk factors vary by etiology; following distal radius fracture surgery, elderly patients, females, and manual laborers face higher risks [14], while preexisting neuropathic disorders—particularly traumatic nerve injuries, compressive neuropathies, and cervical radiculopathy—are the strongest predictors [16]. A more active treatment approach appears to lower the incidence of CRPS-1 following distal radius fracture [2]. In other contexts, female sex and release of more than one digit predict CRPS after Dupuytren contracture treatment [8], and scaphoid waist fracture patients, especially women with diabetes mellitus reporting severe pre-treatment pain, are at higher risk for CRPS I [19].

Complication rates differ significantly across procedures. CRPS-related hand lesions developed in 19.4% of patients following arthroscopic rotator cuff repair [18]. Conversely, CRPS following isolated cubital tunnel surgery is exceedingly rare, with an overall 1-year incidence rate of approximately 0.33% [11].

Background & Causes

The diagnosis of complex regional pain syndrome (CRPS) following distal radius fractures remains largely clinical, driven by the poor sensitivity of imaging and the absence of specific laboratory studies [22]. Consequently, CRPS must be treated strictly as a diagnosis of exclusion [17]. When evaluating patients with unusual chronic pain or neuropathy, glomus tumors should be included in the differential diagnosis [17].

Preexisting psychiatric conditions significantly influence post-fracture outcomes. Patients diagnosed with anxiety, depression, a manic episode, or bipolar disorder prior to fracture demonstrated approximately twice the risk of developing CRPS during treatment compared to patients without such emotional distress [24]. Recognizing these preexisting anxiety or mood disorders as risk factors enables more effective screening of at-risk patients and facilitates timely interventions [26].

Quantitative sensory testing provides objective evidence of pathophysiological changes. A systematic review and meta-analysis indicates altered pain mechanisms in CRPS compared to controls, with a pooled standardized mean difference of -0.41 [5].

Symptoms & Presentation

CRPS is a multifactorial condition [3]. In CRPS-I, pain is a highly debilitating symptom [7]. The Hamilton Inventory can be relied upon to assess CRPS symptoms, functional limitations, and psychosocial impacts [4].

Management

Pharmacologic and Interventional

In patients presenting with chronic or refractory CRPS, strong consideration should be given for the use of ketamine [1]. Prednisolone serves as a potential treatment option, particularly in resource-limited settings where more specialized interventions may be unavailable [6]. Topical application of doxepin may represent a simple option for the management of CRPS [23]. For intractable cases, elective transtibial amputation provided meaningful reduction in pain and acceptable function for patients with CRPS, neuropathic pain, and/or high-energy lower extremity trauma in a military population [12]. Patients undergoing elective transtibial amputations for intractable neurogenic pain experienced clinically meaningful improvement in pain [25].

Non-Pharmacologic and Physical Therapy

A more active treatment approach seems to lower the incidence of CRPS-1 [2]. High-intensity laser therapy and mirror therapy offer conclusive evidence of pain reduction in CRPS-I, even after the third HILT treatment session [7]. The methodological quality of non-pharmacological treatment approaches for upper limb CRPS is overall poor [9].

Surgical

A large percentage of patients diagnosed with and treated for CRPS type 1 can have full resolution of their symptoms with carpal tunnel release [15]. Joint releases followed by splinting yield favorable outcomes in CRPS-associated joint contractures [21]. The positive outcome for a patient with Dupuytren's and CRPS-I after collagenase clostridium histolyticum injection is encouraging [20].

Assessment and Diagnosis

Early recognition and prompt treatment are important to minimize permanent loss of function in CRPS, though patients may still experience permanent impairment and disability [10].

Risk Factors and Prognosis

The reported incidence of CRPS is influenced by choice of diagnostic criteria, along with the study location and/or how the fracture is managed [13].

Key Considerations

Diagnosis and Pathophysiology

CRPS is a multifactorial condition that requires further study to better understand its pathogenesis, epidemiology, genetic involvement, psychological implications, and treatment options [3]. Early recognition and prompt treatment are important to minimize permanent loss of function, though patients may still experience permanent impairment and disability [10]. The diagnosis of CRPS should only be a diagnosis of exclusion; glomus tumors should be included in the differential diagnosis for patients with unusual chronic pain or neuropathy [17].

Risk Factors and Incidence

The reported incidence of CRPS within four months of a wrist fracture is influenced by choice of diagnostic criteria, along with the study location and/or how the fracture is managed [13].

Treatment

Non-invasive modalities: High-intensity laser therapy and mirror therapy offer conclusive evidence of pain reduction in CRPS-I, even after the third treatment session [7]. Injection therapy: A positive outcome was observed for a patient with Dupuytren's contracture and CRPS-I after collagenase clostridium histolyticum injection [20].

Key Evidence

  • [L1] In patients presenting with chronic or refractory CRPS, strong consideration should be given for the use of ketamine. [1] (10.1177/15589447221131847)
  • [L3] A more active treatment approach seems to lower the incidence of CRPS-1. [2] (10.1177/1558944719895782)
  • [L4] CRPS is a multifactorial condition that still requires further studying to better understand its pathogenesis, epidemiology, genetic involvement, psychological implications, and treatment options. [3] (10.1007/s40122-021-00279-4)
  • [L4] It can be relied upon to assess CRPS symptoms, functional limitations, and psychosocial impacts. [4] (10.1016/j.jht.2025.02.004)
  • [L1] The systematic review and meta-analysis of quantitative sensory testing outcomes indicates altered pain mechanisms in complex regional pain syndrome compared to controls, with a pooled standardized mean difference of -0.41. [5] (10.1186/s13018-022-03461-2)
  • [L4] The report emphasizes the importance of recognizing CRPS and highlights the potential of prednisolone as a treatment option, particularly in resource-limited settings where more specialized interventions may be unavailable. [6] (10.1186/s12891-024-07333-0)
  • [L1] The study results offer conclusive evidence of pain reduction, a highly debilitating symptom in CRPS-I, even after the third HILT treatment session. [7] (10.1016/j.jht.2025.02.009)
  • [L3] Female sex and release of more than one digit are significant predictors of developing CRPS. [8] (10.1177/1558944720963915)
  • [L1] Methodological quality of non-pharmacological treatment approaches for upper limb CRPS is overall poor. [9] (10.1177/17589983221138610)
  • [L2] CRPS following isolated CuTS is exceedingly rare, with an overall 1-year incidence rate of approximately 0.33%. [11] (10.1016/j.jhsg.2026.101028)
  • [Paper] This CORR Insights article is a commentary on a study by Lansford et al. and does not present original data; it summarizes that the referenced study concluded elective transtibial amputation provided meaningful reduction in pain and acceptable function for patients with CRPS, neuropathic pain, and/or high-energy lower extremity trauma in a military population. [12] (10.1097/corr.0000000000003914)
  • [L1] The reported incidence of CRPS is influenced by choice of diagnostic criteria, along with the study location and/or how the fracture is managed. [13] (10.1177/1758998320910179)
  • [L3] The occurrence of CRPS is the result of many factors, with elderly patients, females, and manual laborers having higher risks. [14] (10.1186/s12891-024-07948-3)
  • [L3] This study demonstrates that a large percentage of patients diagnosed with and treated for CRPS type 1 can have full resolution of their symptoms with carpal tunnel release. [15] (10.1016/j.jhsa.2024.09.024)
  • [L3] Preexisting neuropathic disorders, particularly traumatic nerve injuries, compressive neuropathies, and cervical radiculopathy, are the strongest predictors of CRPS after distal radius fracture. [16] (10.1016/j.jhsa.2026.01.004)
  • [Case_report] Glomus tumors should be included in the differential diagnosis for patients with unusual chronic pain or neuropathy, and the diagnosis of CRPS should only be a diagnosis of exclusion. [17] (10.1177/1558944719895618)
  • [L3] CRPS-related hand lesions developed in 19.4% of patients following ARCR. [18] (10.5397/cise.2021.00080)
  • [L2] Patients suffering from scaphoid waist fracture may be at a higher risk of CRPS I, especially in women with diabetes mellitus who report severe pain before treatment. [19] (10.1186/s12891-021-04977-0)
  • [L4] The positive outcome for this woman with Dupuytren's and CRPS-I after CCH injection is encouraging. [20] (10.1016/j.jht.2024.09.002)
  • [L4] Joint releases followed by splinting yield favorable outcomes in CRPS-associated joint contractures. [21] (10.1016/j.jhsa.2026.01.002)
  • [L5] The diagnosis of CRPS after distal radius fractures remains largely clinical due to poor sensitivity of imaging and lack of laboratory studies. [22] (10.1016/j.hcl.2021.02.013)
  • [L5] This case report suggests that the topical application of doxepin may represent a simple option for the management of CRPS. [23] (10.1016/s0020-1383(01)00054-7)
  • [L3] Patients diagnosed with anxiety, depression, a manic episode, or bipolar disorder before a fracture had about twice the risk of developing CRPS in the course of their treatment than were patients who had not been treated for those kinds of emotional distress. [24] (10.1097/corr.0000000000002958)
  • [L2] Patients undergoing elective transtibial amputations for intractable neurogenic pain experienced clinically meaningful improvement in pain. [25] (10.1097/corr.0000000000003881)
  • [L3] The recognition of a preexisting AMD as a risk factor for CRPS should lead to more effective screening of at-risk patients and facilitate more timely interventions. [26] (10.1097/corr.0000000000002957)

References

[1] Pharmacologic Treatments in Upper Extremity Complex Regional Pain Syndrome: A Review and Analysis of Quality of Evidence. HAND. 2022. DOI: 10.1177/15589447221131847

[2] Treatment of Distal Radius Fracture: Does Early Activity Postinjury Lead to a Lower Incidence of Complex Regional Pain Syndrome?. HAND. 2020. DOI: 10.1177/1558944719895782

[3] Complex Regional Pain Syndrome: A Comprehensive Review. Pain and Therapy. 2021. DOI: 10.1007/s40122-021-00279-4

[4] Psychometric evaluation of the Hamilton Inventory to evaluate signs and symptoms in patients with Complex Regional Pain Syndrome (CRPS). Journal of Hand Therapy. 2025. DOI: 10.1016/j.jht.2025.02.004

[5] Pain mechanisms in complex regional pain syndrome: a systematic review and meta-analysis of quantitative sensory testing outcomes. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-022-03461-2

[6] Complex regional pain syndrome: diagnostic challenges and favorable response to prednisolone. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07333-0

[7] Effect of high-intensity laser therapy and mirror therapy on complex regional pain syndrome type I in the hand area: A randomized controlled trial. Journal of Hand Therapy. 2025. DOI: 10.1016/j.jht.2025.02.009

[8] Separating Fact From Fiction: A Nationwide Longitudinal Examination of Complex Regional Pain Syndrome Following Treatment of Dupuytren Contracture. HAND. 2020. DOI: 10.1177/1558944720963915

[9] Person-centred management of upper limb complex regional pain syndrome: an integrative review of non-pharmacological treatment. Hand Therapy. 2023. DOI: 10.1177/17589983221138610

[10] Complex Regional Pain Syndrome. 2021.

[11] Incidence and Patient-Level Risk Factors for Complex Regional Pain Syndrome Following Cubital Tunnel Surgery. Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2026.101028

[12] CORR Insights®: What Are the Patient-reported Outcomes After Elective Transtibial Amputation? A Comparison of CRPS, Neuropathic Pain, and Other Conditions That Lead to Late Amputation After Limb Salvage. Clinical Orthopaedics & Related Research. 2026. DOI: 10.1097/corr.0000000000003914

[13] What is the incidence of complex regional pain syndrome (CRPS) Type I within four months of a wrist fracture in the adult population? A systematic review. Hand Therapy. 2020. DOI: 10.1177/1758998320910179

[14] Dynamic risk factors for complex regional pain syndrome after distal radius fracture surgery: multivariate analysis and prediction. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07948-3

[15] Outcomes of Median Nerve Release in Complex Regional Pain Syndrome Type 1 of the Hand: A Prospective Case Series. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2024.09.024

[16] A Nationwide Propensity Score-Matched Analysis Identifying Preinjury Predictors of Complex Regional Pain Syndrome Following Distal Radius Fracture. The Journal of Hand Surgery. 2026. DOI: 10.1016/j.jhsa.2026.01.004

[17] An Unusual Case of Periosteal Glomus Tumor at the Metacarpal Base Presenting as Type II CRPS: Case Report. HAND. 2020. DOI: 10.1177/1558944719895618

[18] Clinical outcome in patients with hand lesions associated with complex regional pain syndrome after arthroscopic rotator cuff repair. Clinics in Shoulder and Elbow. 2021. DOI: 10.5397/cise.2021.00080

[19] Determinants of complex regional pain syndrome type I in patients with scaphoid waist fracture- a multicenter prospective observational study. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-021-04977-0

[20] The case of a woman with bilateral Dupuytren’s contractures who developed CRPS-1 after fasciectomy with no relapse on subsequent collagenase clostridium histolyticum injection and manipulation of the other hand: Considerations for implementing a Budapest criteria checklist and assessing vasomotor instability by measuring differences in skin temperature. Journal of Hand Therapy. 2025. DOI: 10.1016/j.jht.2024.09.002

[21] Finger Joint Releases in the Setting of Complex Regional Pain Syndrome: Worthwhile or Risky?. The Journal of Hand Surgery. 2026. DOI: 10.1016/j.jhsa.2026.01.002

[22] Complex Regional Pain Syndrome and Distal Radius Fracture. Hand Clinics. 2021. DOI: 10.1016/j.hcl.2021.02.013

[23] Topical application of doxepin hydrochloride can reduce the symptoms of complex regional pain syndrome: a case report. Injury. 2002. DOI: 10.1016/s0020-1383(01)00054-7

[24] Editor’s Spotlight/Take 5: Patients With Preexisting Anxiety and Mood Disorders Are More Likely to Develop Complex Regional Pain Syndrome After Fractures. Clinical Orthopaedics & Related Research. 2023. DOI: 10.1097/corr.0000000000002958

[25] What Are the Patient-reported Outcomes After Elective Transtibial Amputation? A Comparison of CRPS, Neuropathic Pain, and Other Conditions That Lead to Late Amputation After Limb Salvage. Clinical Orthopaedics & Related Research. 2026. DOI: 10.1097/corr.0000000000003881

[26] Patients With Preexisting Anxiety and Mood Disorders Are More Likely to Develop Complex Regional Pain Syndrome After Fractures. Clinical Orthopaedics & Related Research. 2023. DOI: 10.1097/corr.0000000000002957

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