Back Pain Doctor
Complex Regional Pain Syndrome (CRPS)
Written by Dr Joshua Hatch, Musculoskeletal GP, RACGP Fellow, Diploma in Musculoskeletal Medicine (FSEM UK).
Complex regional pain syndrome, or CRPS, usually begins after a fracture, sprain or operation. Instead of settling as the injury heals, pain stays out of proportion and the limb may become swollen, discoloured, hot or cold, sweaty, stiff and exquisitely sensitive to touch. Assessment focuses on the pattern of symptoms and signs against the Budapest criteria, and just as importantly on excluding infection, a clot, a circulation problem, a missed fracture, compartment syndrome and nerve injury.
There is no single proven treatment, and published guidelines say so. Care usually combines explanation, graded return to using the limb, pain-science informed rehabilitation such as mirror therapy and graded motor imagery, and medicines chosen with a pain specialist. Early referral helps, because rehabilitation and pain medicine input work best together. Some injections and nerve blocks are used by pain specialists, but the best trials do not show strong benefit.
The GP role is recognising the possibility early, excluding mimics, protecting function and coordinating pain medicine, physiotherapy or occupational therapy and psychological support. Shockwave, needling and similar procedures are not treatments for CRPS. This page is educational information only. Pain, swelling or colour change after an injury or operation that is out of proportion or spreading should be seen by a GP promptly.
Common symptoms
- Burning or aching pain out of proportion to the injury
- Painful response to light touch or movement
- Swelling, and skin colour or temperature different from the other limb
- Stiffness, weakness or tremor in the affected limb
Evidence for twelve treatment options in complex regional pain syndrome (crps)
This is not a fixed ladder or a package of treatments. Every option is assessed independently against this diagnosis, including treatments with limited direct research that may still be reasonable for a clearly defined tissue target. The evidence level, likely benefit, risks, cost and alternatives are weighed at consultation.
Foundation: diagnosis, education and rehabilitation
The part of care with the broadest relevance. For many people it is enough on its own; other options are judged against it, not automatically added after it.
Diagnosis, education and progressive rehabilitation Working out what is driving the pain, explaining what your imaging does and does not mean, and building a graded loading plan you can actually follow. Low-certainty evidence
What it involves
Assessment to identify the likely pain source, an explanation of what the diagnosis means, adjustment of the loads that aggravate it, and a progressive strength and conditioning plan, with weight management where that is clinically relevant.
What the evidence shows
The sources reviewed for this page were the Harden 2022 practical diagnostic and treatment guidelines (Pain Med), the Budapest criteria validation (Harden, Pain 2010), the 2023 Cochrane overview of interventions (Ferraro), the 2022 Cochrane review of physiotherapy (Smart) and the rehabilitation meta-analysis and overview (Shafiee, Clin J Pain 2023). The 2022 Cochrane review of physiotherapy included 34 randomised trials (1,339 participants), mostly small single trials at high risk of bias, and graded the certainty as very low for every comparison (Smart). A 2023 meta-analysis of 33 rehabilitation trials found low-quality evidence that mirror therapy and graded motor imagery may substantially improve pain and disability in post-stroke CRPS, and that pain exposure therapy and aerobic exercise added to physiotherapy may improve pain (Shafiee); an overview of nine reviews found mirror therapy and graded motor imagery the most consistently supported, from a small body of primary evidence.
Pairing reviewed 2026-10-24.
Where it fits
A supportive and often central part of care, directed by a rehabilitation physician or therapist with CRPS experience: graded return to use of the limb, mirror therapy or graded motor imagery where suitable, with the evidence gap stated.
Muscle and symptom-modifying options
Useful only when the examination identifies the tissue they target or when short-term pain control creates a useful rehabilitation window.
Wet needling and trigger point injection (trigger point injection) A fine needle into a tender band of muscle, with a small volume of dilute glucose solution injected through it. Does not treat the condition
What it involves
The needle is placed into the tender muscle band and a small volume of 5% glucose with a very dilute local anaesthetic (0.02-0.08%) is injected. Often done in the same visit as your assessment, and usable where the tender area sits deeper. Dry needling (the same technique with nothing injected) is not offered here.
What the evidence shows
The sources reviewed for this page were the Harden 2022 practical diagnostic and treatment guidelines (Pain Med), the Budapest criteria validation (Harden, Pain 2010), the 2023 Cochrane overview of interventions (Ferraro), the 2022 Cochrane review of physiotherapy (Smart) and the rehabilitation meta-analysis and overview (Shafiee, Clin J Pain 2023). Needling is not among the treatments with supporting evidence in the Cochrane overview or the Harden guideline.
Pairing reviewed 2026-10-24.
Where it fits
Not offered for CRPS. Treatment sits with pain medicine and rehabilitation specialists, and any procedure aimed at the limb is considered only by them.
Ultrasound-guided injections Guidance means the needle can be seen reaching the target. What goes into the needle depends on the diagnosis. Specialist pain medicine
What it involves
The injection is performed under ultrasound so the needle can be watched into the target structure. What is injected is decided by the diagnosis, and corticosteroid is used sparingly, for the reasons set out below.
What the evidence shows
The sources reviewed for this page were the Harden 2022 practical diagnostic and treatment guidelines (Pain Med), the Budapest criteria validation (Harden, Pain 2010), the 2023 Cochrane overview of interventions (Ferraro), the 2022 Cochrane review of physiotherapy (Smart) and the rehabilitation meta-analysis and overview (Shafiee, Clin J Pain 2023). The Cochrane overview found moderate-certainty evidence that lidocaine sympathetic blockade probably does not reduce pain compared with placebo, and only low-certainty evidence for comparisons of nerve blocks with each other (Ferraro).
Pairing reviewed 2026-10-24.
Where it fits
Not offered for CRPS. Treatment sits with pain medicine and rehabilitation specialists, and any procedure aimed at the limb is considered only by them.
V-ACTOR vibration therapy (vibration therapy) Low-frequency vibration applied over tender muscle. Not a shockwave, despite sharing the machine. Does not treat the condition
What it involves
A vibration handpiece is moved over the tender muscle and fascia for a few minutes. It runs from the same STORZ MASTERPULS icon console as radial shockwave but is a separate handpiece delivering a different, gentler form of energy. No needles, no anaesthetic, no downtime.
What the evidence shows
The sources reviewed for this page were the Harden 2022 practical diagnostic and treatment guidelines (Pain Med), the Budapest criteria validation (Harden, Pain 2010), the 2023 Cochrane overview of interventions (Ferraro), the 2022 Cochrane review of physiotherapy (Smart) and the rehabilitation meta-analysis and overview (Shafiee, Clin J Pain 2023). Vibration-based devices are not part of the guideline or Cochrane evidence reviewed for CRPS.
Pairing reviewed 2026-10-24.
Where it fits
Not offered for CRPS. Treatment sits with pain medicine and rehabilitation specialists, and any procedure aimed at the limb is considered only by them.
Energy-based treatment options
Radial pressure wave, focused shockwave and EMTT have different targets and different evidence. They are assessed separately rather than treated as one category.
Radial or focused shockwave? Read the overviewRadial shockwave (radial pressure wave) Broad treatment across tender muscle and fascia, close to the surface. Does not treat the condition
What it involves
A handpiece is moved over the tender tissue while ballistic pressure pulses are delivered, using a transmitter head chosen for the tissue, including heads shaped for fascia and for the muscle either side of the spine. The pulse is strongest at the skin and weakens with depth, so this is mainly a myofascial treatment, though it can reach deeper in some areas. No anaesthetic, no downtime, usually a course of sessions about a week apart.
What the evidence shows
The sources reviewed for this page were the Harden 2022 practical diagnostic and treatment guidelines (Pain Med), the Budapest criteria validation (Harden, Pain 2010), the 2023 Cochrane overview of interventions (Ferraro), the 2022 Cochrane review of physiotherapy (Smart) and the rehabilitation meta-analysis and overview (Shafiee, Clin J Pain 2023). Shockwave is not among the CRPS treatments in the guideline or Cochrane evidence reviewed.
Pairing reviewed 2026-10-24.
Where it fits
Not offered for CRPS. Treatment sits with pain medicine and rehabilitation specialists, and any procedure aimed at the limb is considered only by them.
Focused shockwave (ESWT) A true shock wave converging at depth: for tendon, joint, ligament and bone. Does not treat the condition
What it involves
A focused system generates an acoustic shock wave that converges at a focal point set at a defined depth, concentrating the energy where the target is. This is the form used for tendon, joint, ligament and bone. Typically four to six sessions about a week apart, no anaesthetic and no formal downtime.
What the evidence shows
The sources reviewed for this page were the Harden 2022 practical diagnostic and treatment guidelines (Pain Med), the Budapest criteria validation (Harden, Pain 2010), the 2023 Cochrane overview of interventions (Ferraro), the 2022 Cochrane review of physiotherapy (Smart) and the rehabilitation meta-analysis and overview (Shafiee, Clin J Pain 2023). Shockwave is not among the CRPS treatments in the guideline or Cochrane evidence reviewed.
Pairing reviewed 2026-10-24.
Where it fits
Not offered for CRPS. Treatment sits with pain medicine and rehabilitation specialists, and any procedure aimed at the limb is considered only by them.
EMTT (magnetotransduction therapy) High-energy magnetic pulses applied over the area. Usually painless, no contact. Does not treat the condition
What it involves
You sit with the applicator positioned over the area for a short session. It is usually painless and needs no gel or skin contact. It is usually given as a course, commonly alongside shockwave.
What the evidence shows
The sources reviewed for this page were the Harden 2022 practical diagnostic and treatment guidelines (Pain Med), the Budapest criteria validation (Harden, Pain 2010), the 2023 Cochrane overview of interventions (Ferraro), the 2022 Cochrane review of physiotherapy (Smart) and the rehabilitation meta-analysis and overview (Shafiee, Clin J Pain 2023). Magnetotransduction therapy is not part of the guideline or Cochrane evidence reviewed for CRPS.
Pairing reviewed 2026-10-24.
Where it fits
Not offered for CRPS. Treatment sits with pain medicine and rehabilitation specialists, and any procedure aimed at the limb is considered only by them.
Biologic and joint injection options
Each injection is assessed independently for the named diagnosis. Cost, uncertainty, likely benefit, risks and alternatives are part of the decision.
Platelet-rich plasma (PRP) Your own blood, concentrated and injected under ultrasound guidance. Does not treat the condition
What it involves
Blood is taken from your arm, spun to concentrate the platelets, and injected into the target under ultrasound guidance in the same appointment.
What the evidence shows
The sources reviewed for this page were the Harden 2022 practical diagnostic and treatment guidelines (Pain Med), the Budapest criteria validation (Harden, Pain 2010), the 2023 Cochrane overview of interventions (Ferraro), the 2022 Cochrane review of physiotherapy (Smart) and the rehabilitation meta-analysis and overview (Shafiee, Clin J Pain 2023). Platelet-rich plasma is not part of the guideline or Cochrane evidence reviewed for CRPS.
Pairing reviewed 2026-10-24.
Where it fits
Not offered for CRPS. Treatment sits with pain medicine and rehabilitation specialists, and any procedure aimed at the limb is considered only by them.
Prolotherapy (dextrose) A course of dextrose injections into and around the structure and its attachments. Does not treat the condition
What it involves
Hypertonic dextrose is injected at the tender ligament and tendon attachments, and into the joint where relevant, usually as a series of treatments a few weeks apart.
What the evidence shows
The sources reviewed for this page were the Harden 2022 practical diagnostic and treatment guidelines (Pain Med), the Budapest criteria validation (Harden, Pain 2010), the 2023 Cochrane overview of interventions (Ferraro), the 2022 Cochrane review of physiotherapy (Smart) and the rehabilitation meta-analysis and overview (Shafiee, Clin J Pain 2023). Prolotherapy is not part of the guideline or Cochrane evidence reviewed for CRPS.
Pairing reviewed 2026-10-24.
Where it fits
Not offered for CRPS. Treatment sits with pain medicine and rehabilitation specialists, and any procedure aimed at the limb is considered only by them.
Viscosupplementation (hyaluronic acid) A gel-like injection into an arthritic joint. Widely used, and genuinely contested. Wrong problem
What it involves
One or a short series of hyaluronic acid injections into the joint under ultrasound guidance.
What the evidence shows
The sources reviewed for this page were the Harden 2022 practical diagnostic and treatment guidelines (Pain Med), the Budapest criteria validation (Harden, Pain 2010), the 2023 Cochrane overview of interventions (Ferraro), the 2022 Cochrane review of physiotherapy (Smart) and the rehabilitation meta-analysis and overview (Shafiee, Clin J Pain 2023). Hyaluronic acid is a treatment for osteoarthritic joints and has no role in CRPS.
Pairing reviewed 2026-10-24.
Where it fits
Not offered for CRPS.
Nerve-targeted options
Relevant when examination identifies a superficial neuropathic pattern or a compressed peripheral nerve, not simply because pain is present.
Lyftogt perineural therapy (perineural injection therapy) A series of small dilute dextrose injections just under the skin, over tender superficial nerves. Specialist pain medicine
What it involves
Small injections of low-concentration dextrose, usually 5%, placed just beneath the skin along tender superficial nerves. Given as a series of short sessions.
What the evidence shows
The sources reviewed for this page were the Harden 2022 practical diagnostic and treatment guidelines (Pain Med), the Budapest criteria validation (Harden, Pain 2010), the 2023 Cochrane overview of interventions (Ferraro), the 2022 Cochrane review of physiotherapy (Smart) and the rehabilitation meta-analysis and overview (Shafiee, Clin J Pain 2023). Sympathetic and regional nerve blocks are used by pain specialists, but the Cochrane overview found moderate-certainty evidence that sympathetic blockade probably does not reduce pain more than placebo (Ferraro).
Pairing reviewed 2026-10-24.
Where it fits
Not offered for CRPS. Treatment sits with pain medicine and rehabilitation specialists, and any procedure aimed at the limb is considered only by them.
Ultrasound-guided nerve hydrodissection Fluid placed around a nerve to free it from the surrounding tissue. Does not treat the condition
What it involves
Under ultrasound, fluid is placed in the plane around the nerve to separate it from the tissue that is tethering or compressing it.
What the evidence shows
The sources reviewed for this page were the Harden 2022 practical diagnostic and treatment guidelines (Pain Med), the Budapest criteria validation (Harden, Pain 2010), the 2023 Cochrane overview of interventions (Ferraro), the 2022 Cochrane review of physiotherapy (Smart) and the rehabilitation meta-analysis and overview (Shafiee, Clin J Pain 2023). Hydrodissection addresses a compressed peripheral nerve and is not part of CRPS management in the sources reviewed. Where a definite nerve lesion exists (CRPS type II), it needs specialist assessment.
Pairing reviewed 2026-10-24.
Where it fits
Not offered for CRPS. Treatment sits with pain medicine and rehabilitation specialists, and any procedure aimed at the limb is considered only by them.
This is general information only and suitability is assessed individually. Treatments with limited or condition-dependent evidence may still be discussed, but only with clear explanation of the uncertainty, the expected benefit, risks, cost and alternatives. Red flags, progressive neurological symptoms or suspected serious pathology require a different pathway.
Every treatment above is described in full on the non-surgical treatments page, including what each one is used for and what the evidence supports. Ratings apply to the named diagnosis; an adjacent muscle, tendon, joint or nerve problem is assessed as a separate target. The method behind the ratings, and the treatments not offered, are set out on the evidence page.
Corticosteroid injection is reviewed separately for each diagnosis.
Cortisone reliably reduces pain in the short term, and that can be genuinely useful when pain is stopping you sleeping or moving enough to rehabilitate. Beyond that window the picture changes. A systematic review of 41 randomised trials and 2,672 participants found that corticosteroid injection reduced pain in the short term but that the effect reversed at intermediate and long term; in pooled analysis for lateral epicondylalgia the short-term effect was large (SMD 1.44, 95% CI 1.17 to 1.71) while no intervention was favoured at 26 weeks (-0.40, -0.67 to -0.14) and at 52 weeks (-0.31, -0.61 to -0.01) (Coombes, Lancet 2010). In a randomised trial in lateral epicondylalgia, 83 per cent of the corticosteroid group had completely recovered or much improved at one year against 96 per cent given a placebo injection, and recurrence ran at 54 per cent against 12 per cent; adding physiotherapy made no significant difference at one year (Coombes, JAMA 2013). In joints, repeated corticosteroid injections have been associated with cartilage loss. It does not repair anything.
So treatment plans are not built around it. Where an injection is the right call, the specific diagnosis and target are reviewed, what is being injected and why is discussed, the number is kept low, and it is paired with the loading work that changes the longer-term course.
When it might still be considered
- Pain severe enough to block rehabilitation
- A clear inflammatory or bursal target on imaging
- A specific short-term goal: a trip, a procedure, a return to work
- Diagnostic use, where the response shows where the pain is coming from
When a cortisone injection is worth doing, and when it is not
Other general conditions
Pain in the same area can come from more than one source, and the label matters less than what the examination and history point to. These are the other guides for this region.
Frequently asked questions
How is CRPS diagnosed?
Does it go away?
What helps?
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