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When the Pain Is Out of All Proportion to the Injury
CRPS (complex regional pain syndrome) is pain that keeps escalating after a hand or wrist injury instead of settling, with swelling, color and temperature changes, skin that can’t bear touch, and stiffness that builds week on week. It usually shows up in the first weeks after a fracture or an operation. Caught early, and treated by keeping the hand moving, most people improve substantially over months.
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 color, unbearable to touch, and stiffening week on week.
Two things to say straight away, because both matter.
First: this is a real, physical, recognized 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 recognized and how early the hand starts moving again.
Miss it, and the pain may still fade over months…but the fingers you stopped moving while you waited don’t necessarily come back with it.
What is CRPS, actually?
After any injury, your body runs a standard program: 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-signaling 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 color 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. Doctors split it into two types: type 1 without a confirmed nerve injury (the common one), and type 2 where a specific nerve was damaged. The treatment principles are the same.
What are the early signs of CRPS in the hand?
Usually within the first weeks after the injury or operation. The picture is a cluster, not one sign:
- Pain out of proportion. Clearly more than the injury explains, and getting worse rather than better past the first two weeks.
- Things that shouldn’t hurt, hurting. Light touch, clothing, cold air, water in the shower.
- Color changes. Red, mottled, purple or unusually pale, and often shifting through the day.
- Temperature difference. A clear difference against the other hand, warmer or colder.
- Swelling that won’t settle on the normal schedule, often puffy across the back of the hand. See swelling after a hand injury.
- 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.
A tight cast and severe pain in the first days are among the things linked to it. If your cast feels too tight or your fingers are puffy and dusky inside it, say so the same day. Don’t sit on it.
How is CRPS diagnosed?
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.
- The Budapest criteria. The checklist most clinicians use: ongoing pain out of proportion to the injury, plus symptoms and visible signs across the categories above (sensation, color and temperature, swelling and sweating, movement and skin, hair or nail changes), and no other condition that explains it better.
- Ruling things out. Infection, a blood clot, a nerve compression, a fracture that isn’t healing, or a cast that’s simply too tight can all mimic parts of it. Bloods, X-rays or ultrasound are often used to exclude those.
- Supporting tests. An X-ray can show patchy thinning of the bone, and a bone scan is sometimes used. They support the picture. They don’t decide it.
Color change on its own, especially white then blue fingers in the cold with no injury, is a different story. See Raynaud’s.
How long does CRPS last, and why does the calendar matter?
The pain, in most people, does settle over months. For many it’s substantially better within the first year. A smaller group carries pain for longer, and that group is where early recognition matters most.
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.
In Closing Window terms: the pain usually runs on an OPEN window. Time is on your side there. The joint range is the one that closes. In my experience the first 3 months are where range comes back most readily, and once fingers have been held stiff for many months, the goal changes from getting it all back to getting back as much as the joints will still give.
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 is the treatment for CRPS in the hand?
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, a light compression glove if your therapist fits one, and using the hand in normal daily tasks rather than carrying it like it’s made of glass.
- Desensitization. Repeated, graded exposure to the textures the hand over-reacts to, working from tolerable towards unbearable over weeks.
- Graded motor imagery and mirror therapy. These work on the brain’s map of the limb rather than the tissue itself. They sound odd. They have decent support.
- Medication, by your doctor. Usually aimed at nerve-type pain rather than ordinary painkillers. Standard anti-inflammatories often underperform here. The choice and the dose belong to your doctor, not to a website.
- 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 low-risk.
Ask yours rather than treating it as settled either way.
What exercises help CRPS in the hand?
Your therapist will set the dose to your hand. A typical starting shape, little and often rather than one big painful session:
- Tendon glides. Straight hand, hook fist, full fist, flat fist, straight fist. 5 to 10 slow reps of each, every 1 to 2 hours while you’re awake. See tendon glides.
- Wrist and forearm range. Bend, extend, turn palm up and palm down, 10 slow reps, several times a day, unless your fracture protocol says otherwise.
- Desensitization. Pick 3 to 4 textures from soft (silk, cotton wool) to rough (towel, velcro). Rub or tap the sensitive skin with the one you can just about tolerate for 2 to 5 minutes, 3 to 4 times a day. Move up a texture when it stops bothering you.
- Mirror therapy. Sore hand hidden behind a mirror, good hand moving in front of it while you watch the reflection. A few minutes at a time, several times a day. Stop if it spikes your pain.
- Real use. Light tasks with the sore hand every day: drying dishes, buttons, holding a cup with both hands. Function is exercise.
- Load, gradually. Scrubbing a table top with a brush while leaning lightly through the hand, or carrying a light bag, for a few minutes twice a day. These loading programs are a recognized part of CRPS rehab, but start them with a therapist.
The rule of thumb: a flare that settles within an hour or two is acceptable. A flare that lasts into the next day means the dose was too big, not that the plan was wrong.
Can I work and drive with CRPS?
- Work: often yes, on modified duties. Staying at work with lighter tasks usually helps more than weeks at home with the hand on a cushion. See returning to work after a hand injury.
- Driving: when you can grip the wheel firmly and control the car in an emergency, and your meds don’t make you drowsy. Check with your doctor and your insurer.
- Sport and gym: graded, guided by your therapist. Pain is a guide here, not a stop sign.
What a hand therapist does differently
- Names it early. The cluster is easy to miss in a busy fracture clinic and hard to miss in a hand therapy room, cos we see the hand every week.
- Measures it. Joint angles, swelling, grip, and how far the sensitivity has spread, so progress isn’t guesswork.
- Doses the movement. Enough to keep the joints, not so much the system flares for days.
- Keeps the stiffness from becoming the real injury. See stiff hand after a cast or surgery.
If the pain has outlasted the healing by months without this picture, read persistent hand pain after healing too.
Get it checked today if
- Your fingers go white, blue, cold or numb inside a cast or splint, or the cast suddenly feels much too tight. That’s an emergency department visit now, not tomorrow.
- Severe pain, swelling and redness with a fever, or a red streak spreading up the arm. Infection first, until proven otherwise.
- Sudden swelling of the whole arm with pain in the forearm or upper arm.
Get it checked if
- Pain is escalating instead of settling after week 2, especially with color changes, temperature difference or skin that can’t bear touch.
- Fingers are getting stiffer week on week, not looser.
- Swelling that hasn’t started to settle by around 4 weeks after the injury or surgery.
- You’ve been told to rest it completely and it’s getting worse. Ask for a hand therapy referral.
The pain usually leaves on its own. The stiffness only leaves if you keep the hand moving while it hurts.
Written by Nigel Chua, hand occupational therapist in practice since 2005. 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.
Part of: Recovery after hand, wrist and elbow surgery: every week-by-week guide
Every article on this site is written using the Closing Window Method: name the window your condition runs on, find where you are in it, and act while it’s still open.