When the Pain Is Out of All Proportion to the Injury
Complex regional pain syndrome is what happens when the body’s alarm response to an injury doesn’t switch off.
The fracture is healing on the X-ray.
The surgery went fine.
Yet the hand is burning, swollen, changing colour, unbearable to touch, and stiffening week on week.
Two things to say straight away, because both matter.
First: this is a real, physical, recognised condition. It is not you being dramatic, and it is not in your head. I’ve watched too many people get to me having half-believed otherwise, with tears streaming down their face cos no one believes them.
Second: caught early, most people improve substantially. The thing that decides how much function you keep is how fast it’s recognised and how early the hand starts moving again.
What’s actually happening
After any injury, your body runs a standard programme: swelling, increased blood flow, heightened pain sensitivity, protective guarding. It’s supposed to run for days to weeks and then dial back down.
In CRPS, the very same dial doesn’t turn back down.
The pain-signalling system stays amplified, so signals that shouldn’t hurt at all now do…a sleeve, a breeze, a bedsheet. At the same time the automatic controls for blood flow, temperature and sweating in that limb lose their settings, which is where the colour changes and the odd sweaty or bone-dry patches come from.
Then the guarding does the real damage. A hand that hurts to move is a hand that stops moving, and a hand that stops moving stiffens fast.
Which compounds the problem into a very, very, vicious cycle.
It usually follows something: a wrist fracture, a crush injury, surgery. Sometimes something small enough that the mismatch is part of what makes it confusing.
What it looks like
Usually within the first weeks after the injury or operation. The picture is a cluster, not one sign:
- Pain that is clearly out of proportion to the injury, and getting worse rather than better past the first fortnight.
- Things that shouldn’t hurt, hurting. Light touch, clothing, cold air, water in the shower.
- Colour changes: red, mottled, purple or unusually pale, and often shifting through the day.
- A clear temperature difference against the other hand, warmer or colder.
- Swelling that isn’t settling on the normal schedule, often puffy across the back of the hand.
- Sweating changes, clammy or unusually dry.
- Later on: changes in hair growth, nail texture, and skin that looks shiny or thin.
- Stiffness increasing noticeably week on week, not decreasing.
Nobody has all of them.
There’s no blood test and no scan that confirms it…diagnosis is made on the pattern by someone who’s seen it before, which is exactly why getting in front of a hand therapist or surgeon early matters more here than almost anywhere else on this site.
Why your calendar matters a lot.
The pain, in most people, does settle over months.
The stiffness is the part that doesn’t necessarily give itself back. Joints held still in a swollen, inflamed hand tighten down, the capsules thicken, and past a certain point you’re not treating pain anymore, you’re treating a contracture that formed while everyone was focused on the pain.
The pain is what you feel. The stiffness is what you keep.
Which is why the standard instinct here is exactly the wrong one.
Everything about this hand says protect it, sling it, keep it still. That instinct, followed for 6 weeks, is how a treatable flare becomes a permanently limited hand.
What treatment actually looks like
The core of it is uncomfortable and non-negotiable: the hand has to keep moving and keep being used, within tolerable limits, while it hurts. Not pushed into agony, not rested into stillness and stiffness.
Brutal…but I’d rather be direct so you know point-blank what to expect…and more importantly, what you can actually do about it.
Around that:
- Swelling management: elevation, compression, and using the hand in normal daily tasks rather than carrying it.
- Desensitisation: repeated, graded exposure to textures the hand is over-reacting to, working from tolerable towards unbearable over weeks.
- Mirror therapy and graded motor imagery, which work on the brain’s representation of the limb rather than the tissue itself. They sound odd. They have decent support.
- Medication aimed at nerve-type pain rather than ordinary painkillers, prescribed by your doctor. Standard anti-inflammatories usually underperform here.
- Pain specialist input for stubborn cases, sometimes including nerve blocks.
On prevention: taking vitamin C after a wrist fracture has been proposed for years as a way of reducing CRPS risk. The evidence is genuinely mixed and the guidelines disagree with each other. Some surgeons still recommend it, cos it’s cheap and harmless.
Ask yours rather than treating it as settled either way.
The short version
Pain that’s escalating instead of settling after week 2, plus colour changes, temperature difference, swelling that won’t shift and a hand that hurts to touch: that cluster is worth naming out loud to your surgeon or therapist this week, not next month.
It’s real, it’s recognised, and most people get substantially better.
The single biggest thing you control is whether the hand keeps moving while all this is going on. It will not feel like the right thing to do. It is.
Written by Nigel Chua, hand occupational therapist in practice since 2005. Tens of thousands of hands, wrists and elbows assessed and treated. My credentials are here. This article explains; it doesn’t examine. If this describes your hand after a fracture or an operation, say so to your treating team this week.