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RSD & Complex Regional Pain Syndrome (CRPS)

Complex regional pain syndrome (CRPS), also called RSD, is a condition in which a limb stays intensely painful, sensitive, swollen or discolored long after an injury or surgery should have healed. There is no cure, but treatment works best when it starts early, and most people slowly improve. Movement-based therapy, pain medicines, procedures and emotional support all have a place.

Get medical care promptly if:

  • You have severe, burning pain with changes in skin color or temperature, or swelling, after an injury, surgery or time in a cast. If pain after an injury seems unusually severe or lasts longer than expected, NINDS advises talking with a doctor (NINDS). The NHS says it is best to get help as soon as possible because early treatment may reduce painful symptoms (NHS). Tell the clinician who is treating the injury. NINDS notes that pressure from a tight cast can injure nerves (NINDS), so MBHA suggests calling about a cast that feels too tight or pain that keeps climbing.
  • The limb looks infected. A limb with CRPS can look hot and red (NHS), but so can infected skin: cellulitis makes skin painful, hot and swollen, and you may feel unwell with flu-like symptoms (NHS). Because the two can look alike, MBHA suggests having a clinician examine a hot, red, swollen limb, especially with a fever. Open sores (ulcers) can also occur, though very rarely in CRPS (NHS). Call 911 if cellulitis comes with a very high temperature or shivering, a fast heartbeat or fast breathing, dizziness or faintness, confusion, purple patches, or cold, clammy or pale skin; the NHS lists these as signs of serious, potentially life-threatening complications (NHS). See our cellulitis guide.
  • You are having thoughts of suicide. During periods of extreme pain, some people with CRPS have suicidal thoughts (NHS). You are not alone and this can be treated. Call, text or chat with the 988 Suicide & Crisis Lifeline at 988, free and confidential, any time of day or night (988 Lifeline). If you are in immediate danger, call 911.

Never wait for a chiropractic, acupuncture, massage or coaching appointment for any of these, and never try an herb or supplement first.

What is CRPS (and what was RSD)?

Complex regional pain syndrome (CRPS) is a condition that usually affects an arm or a leg after an injury and causes ongoing pain that is much stronger than expected, even after the injury has healed. The limb is often so sensitive that even a light touch may feel painful (NINDS). The NHS calls it a poorly understood condition of persistent, severe and debilitating pain (NHS).

You may also hear the older names reflex sympathetic dystrophy (RSD) and causalgia (MedlinePlus). The two types are:

  • CRPS type I (the old RSD) follows an illness or injury that does not cause any specific nerve damage. Most people with CRPS have this type.
  • CRPS type II (the old causalgia) follows damage to a specific nerve (NINDS).

The two types share the same main diagnostic criteria, and the split may not change which treatment is used; it was kept largely for historical reasons (Harden et al., 2022). The exact cause is not known (MedlinePlus); one main theory is a widespread, abnormal reaction to an injury (NHS). The guideline authors stress that CRPS is not a psychological disorder (Harden et al., 2022).

Symptoms

  • Pain. It can feel like a mix of burning, stabbing or stinging, sometimes with tingling and numbness. Flare-ups can last days or weeks, and stress in particular can trigger them (NHS). The pain usually worsens when the limb is used or touched and can spread to most or all of the limb (NINDS). A light touch can hurt intensely (allodynia) (NHS).
  • Skin and temperature changes. The limb may feel warmer or cooler than the other side, and the skin may turn blotchy, blue, purple, gray, pale or red, or become shiny and thin, or thick and scaly (NINDS). Color changes may be harder to see on brown and Black skin (NHS).
  • Swelling, sweating, hair and nail changes. Hair and nails may grow very fast or not at all, and sweating may increase or decrease (NINDS).
  • Stiffness, weakness and movement problems. Joints can stiffen, especially if the limb is held still because of pain; weakness, tremor and, rarely, dystonia can occur. Bones of the limb may thin, often visible on X-rays (NINDS); the NHS adds there is no evidence this leads to fractures (NHS).
  • Odd sensations and sleep trouble. The limb may feel as if it does not belong to your body, or feel bigger or smaller than the other side, and sleep may suffer (NHS). Less often, pain appears in the same place on the opposite side (“mirror pain”), usually milder (NINDS).

Not using a limb can itself cause swelling and skin and nail changes, even without CRPS, so it can be hard to tell which changes come from CRPS and which from disuse. Gentle movement and early physical therapy may help (NINDS).

Who gets it, and what sets it off?

CRPS is more common in women than men and is most often diagnosed in middle age or later; it is rarer in children (NINDS). It seems to be fairly uncommon overall, but many cases may be missed or misdiagnosed (NHS). It usually seems to begin within a month of an injury, minor or serious (NHS). Common triggers:

NINDS lists these risk factors: asthma, certain blood pressure medicines (ACE inhibitors), menopause, osteoporosis, migraine and smoking, and says genes may matter too. Having a risk factor does not mean you will get CRPS (NINDS). The NHS, in contrast, says it is very unlikely other family members will be affected (NHS), and researchers are still studying whether gene changes are linked (NINDS). Never stop a prescribed medicine on your own; see our blood pressure, asthma, migraines and osteoporosis guides.

How CRPS is diagnosed

There is no laboratory or blood test for CRPS. A doctor familiar with nerve and pain syndromes, such as a neurologist, orthopedist or plastic surgeon, diagnoses it from your symptoms and a physical exam (NINDS). Tests such as blood work, X-rays, MRI, bone scans or nerve conduction studies are used to rule out other causes (NHS, NINDS). Nerve conduction studies can detect the nerve injuries linked to type II but usually cannot confirm type I (NINDS). The exam should be gentle so it does not add pain, and if the diagnosis is made or uncertain you will usually be referred to a specialist pain clinic (NHS).

Many doctors use the Budapest criteria, adopted by the International Association for the Study of Pain in 2012. In plain terms, they require all of these (Harden et al., 2022):

  1. continuing pain that is out of proportion to the original injury;
  2. you report at least one symptom in three of four groups: sensory (such as extra sensitivity to touch), vasomotor (temperature or color changes), sweating/swelling, and motor/trophic (reduced movement, weakness, tremor, or hair, nail or skin changes);
  3. the doctor sees at least one sign at the visit in two or more of those groups; and
  4. no other diagnosis explains the signs and symptoms better.

In validation studies the criteria caught nearly all cases (sensitivity 0.99) but were less good at ruling it out (specificity 0.68) (Harden et al., 2022).

What to expect over time

The NHS estimates around 85% of people slowly see less pain and fewer symptoms in the first two years, though some have continuous pain despite treatment and nobody can yet predict who will improve and when (NHS). NINDS says pain and trouble with daily tasks can improve over time, but most people still have some pain after a year, and severe or long-lasting cases can keep a person from working (NINDS). MedlinePlus notes it can get worse or spread, and occasionally symptoms go away, temporarily or for good (MedlinePlus).

The guideline authors add two points that may ease fears: the old idea of three fixed stages is clinical lore that studies have not supported, and the belief that CRPS will necessarily spread through the whole body is not supported either (Harden et al., 2022).

When to see a doctor: see a doctor if you have persistent pain that is stopping you from doing everyday activities (NHS). If you have already been diagnosed, ask about a team: a physical therapist, an occupational therapist, a pain specialist, a psychologist, and a coordinating primary care provider (NHS). Other guides that may help: nerve damage, phantom limb pain (where mirror therapy began), depression, anxiety and sleep problems.

Side by side

Six approaches compared

For every condition we look at the same six approaches: what each involves, what it typically costs, and what a patient can realistically expect.

ApproachWhat it involves Estimated costWhat to expect
Conventional medicine (AMA) A pain specialist-led team: movement-based physical and occupational therapy, mirror therapy and graded motor imagery, pain medicines (several classes, mostly used off label), nerve blocks or implanted stimulators if needed, and psychological support. Medicare Part B covers medically necessary outpatient physical and occupational therapy: 20% of the Medicare-approved amount after the Part B deductible. Other costs: being researched. No cure, but treatment works best started early. Most people slowly improve over about two years. A Cochrane overview found no high-certainty evidence for any single therapy.
Chiropractic Not a CRPS treatment. We found only a single case report of chiropractic care; guideline authors list case studies only. About $55 to $100 per follow-up visit paying cash, per The Pricer. Medicare covers only spinal adjustments for a subluxation. No trials. A CRPS limb may be extremely touch-sensitive and its bones may be thinner. Avoid forceful manipulation near the affected limb, and tell the chiropractor about the diagnosis.
Acupuncture Fine needles, sometimes with a mild electrical current, used with usual rehabilitation. About $90 to $185 per follow-up visit paying cash, per The Pricer. Medicare covers acupuncture only for chronic low back pain. NINDS says it may relieve symptoms in some people. Evidence is very uncertain: small, mixed trials. Ask for gentle technique away from the sore limb.
Herbal medicine Mostly a question of safety. No herb or supplement has been shown to treat CRPS. Cost estimate being researched. St. John’s wort can weaken medicines such as amitriptyline, which is used for CRPS. Vitamin C to prevent CRPS after fracture has mixed, unproven results. Tell your doctor about everything you take.
Massage therapy Very gentle bodywork on nearby muscles, once your care team agrees; no firm touch on the sore limb unless it is tolerable. One national chain: about $70 to $90 a month on a 12-month membership, per The Pricer. Evidence is very uncertain. Even a slight touch can cause intense pain, and rare serious harms from vigorous massage have been reported.
MBHA Wellness Coach Pacing, daily activity, stress and relaxation skills, sleep, quitting smoking and support for family and work, alongside your treatment team. Cost estimate being researched. Supports — never replaces — medical care and therapy. Self-management is one of the four main areas of CRPS treatment.

Approach 1 of 6

Conventional medicine (AMA)

There is no cure for CRPS, but a combination of physical treatments, medicine and psychological support can help manage the symptoms (NHS). NINDS says treatment usually works best when it is started early, and that people may need to try different treatments to find what works (NINDS). The NHS describes four main areas, usually delivered by a team:

  • Education and self-management (see the Wellness Coach section);
  • Physical rehabilitation — see Movement, therapy and retraining the brain;
  • Pain relief — see Medicines by class and Nerve blocks and implanted devices; and
  • Psychological support — see Mood, coping and mental health (NHS).

Be prepared for honest uncertainty. A 2023 Cochrane overview of systematic reviews found no high-certainty evidence for the effectiveness of any CRPS therapy, mainly because studies are small (Ferraro et al., Cochrane, 2023). The authors of the international guidelines say the research is generally low to medium quality and that treatment must be tailored to each person (Harden et al., 2022). Treatment decisions are made by you and your doctors. We don’t list doses.

What it costs

Medicare Part B covers medically necessary outpatient physical therapy and occupational therapy; after the Part B deductible you pay 20% of the Medicare-approved amount (Medicare.gov, Medicare.gov). Other costs: cost estimate being researched.

Find a medical doctor in our directory

Approach 2 of 6

Chiropractic

Chiropractic care is not a recognized treatment for CRPS. The international guidelines mention only case studies suggesting that chiropractic manipulation may reduce pain and improve movement in CRPS, and label that level 4 evidence, meaning case reports and clinical experience (Harden et al., 2022). The one report we found describes a single woman with CRPS type I after a wrist fracture who improved after many chiropractic visits, with the authors stressing the importance of quick diagnosis (Szynkowicz and Petrucci, 2020). A single case cannot show that the care caused the improvement.

Safety

  • Spinal manipulation commonly causes temporary soreness, stiffness or headache; serious problems are very rare, and neck manipulation has been linked to rare tears in neck arteries that can lead to a stroke (NCCIH).
  • In CRPS, any movement or stimulation of the limb can increase pain, swelling and color changes, and too vigorous exercise can aggravate the condition (NHS). NINDS notes that bones in the limb can thin (NINDS). MBHA suggests telling the chiropractor about your diagnosis and asking them to avoid forceful techniques on the affected limb.
  • Guarding the limb can leave nearby muscles, such as the shoulder when CRPS is in the hand, hurting on their own (NHS). We found no studies of chiropractic care for that. See our neck guide.

What it costs

Without insurance, a first appointment commonly runs about $90–$200 and a follow-up visit about $55–$100 (The Pricer). Medicare covers only spinal adjustments to correct a subluxation, not other services a chiropractor orders (Medicare.gov).

Find a chiropractor in our directory

Approach 3 of 6

Acupuncture

NINDS says acupuncture may help relieve symptoms in some people with CRPS (NINDS). The research behind that is thin.

What the research says

  • The 2023 Cochrane overview found only very low-certainty evidence that acupuncture and qigong may reduce pain compared with placebo, and treated this as insufficient to support or refute use. The acupuncture reviews it drew on were judged critically low quality (Ferraro et al., Cochrane, 2023).
  • The 2022 guidelines describe two randomized trials. One tiny trial (14 people) showed no significant difference. A larger one (96 people with CRPS type I after a stroke) found better pain and arm and hand movement 40 days after treatment. The authors say considerably more research is needed (Harden et al., 2022).

Safety

  • Complications have come from nonsterile needles and improper technique, and the FDA requires needles to be sterile and single use (NCCIH).
  • Skin over a CRPS limb can hurt at the slightest touch (NHS). MBHA suggests telling the acupuncturist up front, asking for a gentle approach, and being open to points away from the painful limb. Stop if a treatment sets off a flare-up.

What it costs

About $125–$230 for a first private visit and $90–$185 for follow-ups; community clinics about $50–$90 a visit (The Pricer). Medicare covers acupuncture only for chronic low back pain, not CRPS (Medicare.gov).

Find an acupuncturist in our directory

Approach 4 of 6

Herbal medicine

No herb or supplement has been shown to treat CRPS. A Cochrane review of herbal products for long-term nerve pain found just two small studies (nutmeg spray and St. John’s wort), could draw no conclusions, and called the evidence very low quality (Boyd et al., Cochrane, 2019). Those studies involved diabetic and other nerve pain, and the review left out traditional Asian medicine and cannabinoids. We found little research on herbal medicine for CRPS itself.

Herbs and the medicines used for CRPS

The NHS lists amitriptyline and nortriptyline among medicines widely used for CRPS (NHS). NCCIH warns that St. John’s wort can interact in dangerous, sometimes life-threatening ways with many medicines and can weaken some antidepressants, including amitriptyline (NCCIH). Supplements can also interact with medicines, are held to less strict manufacturing rules than drugs, and some contain undeclared ingredients (NCCIH). Tell your doctor and pharmacist about everything you take.

Plant-derived products you may hear about

  • Capsaicin (from chili peppers): used on the skin for some nerve pain, but it causes burning at the application site, and the guideline authors say in CRPS the extra pain may make it unsuitable (Harden et al., 2022).
  • Cannabinoids: the guidelines say support is emerging for some other nerve pain but they have not yet been trialed for CRPS (Harden et al., 2022).
  • Vitamin C: studied for preventing CRPS after fracture; see Lowering the chance after a fracture or surgery.

We don’t list doses.

What it costs

Cost estimate being researched.

Approach 5 of 6

Massage therapy

Massage is not an established CRPS treatment, and it needs great care. The NHS warns that even a slight touch, bump or change in temperature can cause intense pain (NHS).

What the research says

  • The 2023 Cochrane overview found very low-certainty evidence that manual lymphatic drainage (a light massage technique to move fluid) may have no effect on pain compared with physiotherapy, and that massage combined with electroacupuncture may reduce pain on movement compared with rehabilitation but not disability (Ferraro et al., Cochrane, 2023). Because the second treatment was a combination, it cannot show what massage did on its own. The authors call this insufficient evidence either way.
  • We found little other research on massage for CRPS.

Safety

  • NCCIH says the risk of harm from massage appears low, but rare serious problems — a blood clot, nerve injury or broken bone — have been reported, some after vigorous types such as deep tissue massage (NCCIH). With thinner bones possible in a CRPS limb (NINDS), MBHA suggests gentle pressure only. A swollen, painful, warm leg should be checked by a clinician before any massage; see our blood clots guide.
  • MBHA suggests telling the therapist about your diagnosis, letting you control what is touched, and starting with relaxing work on nearby muscles, such as the shoulder when CRPS is in the hand (NHS), rather than the painful limb itself.

What it costs

At one national chain, memberships run about $70–$90 a month and a 60-minute massage for non-members about $125–$160 (The Pricer). Tips are extra. Medicare does not cover massage therapy ordered by a chiropractor (Medicare.gov).

Find a massage therapist in our directory

Approach 6 of 6

MBHA Wellness Coach

Self-management is one of the four main areas of CRPS treatment. The NHS lists it as learning about the condition, staying active and using the affected body part, handling increases in pain, relaxation, activity management to avoid dips in activity despite pain, continuing rehabilitation exercises (such as desensitization) at home, and local support groups (NHS). A MBHA Wellness Coach can help you build these habits alongside — never instead of — your medical team.

Pacing, stress and sleep

  • Pace yourself. The aim of rehabilitation is to build activity without making the pain worse (NHS). A coach can help you plan small, steady steps and keep to your therapist’s program.
  • Stress and flare-ups. Stress in particular can lead to flare-ups, which is why relaxation and mindfulness training can be an important part of treatment (NHS).
  • Sleep. Difficulty sleeping is a common symptom (NHS). See our sleep problems guide.
  • Smoking. NINDS lists smoking as a risk factor (NINDS), another reason to ask for help quitting.

Family, work and daily life

Guideline authors say family members should be taught why gradual re-activation matters, since fear of any painful activity, or doubt about symptoms such as allodynia, can get in the way (Harden et al., 2022). The NHS notes an employment adviser can help you stay in or return to work (NHS).

What it costs

Cost estimate being researched.

Another approach

Lowering the chance after a fracture or surgery

No step guarantees prevention. What research and guidelines say:

Vitamin C: unproven

Vitamin C has been studied for preventing CRPS after fractures and limb surgery. We did not find a Cochrane review on it. The results are mixed:

  • A meta-analysis of three trials (890 people with wrist fractures) found vitamin C did not significantly reduce CRPS; the authors rated the evidence low quality (Evaniew et al., 2015).
  • A later meta-analysis of eight studies comparing vitamin C with placebo around wrist, foot and ankle surgeries found vitamin C was linked to a lower CRPS rate, with no significant differences in complications, function or pain scores (Seth et al., 2022).
  • The 2022 guidelines point out that a large trial using the earlier protocol found more CRPS in the vitamin C group at six weeks, with no effect later, and conclude its usefulness remains unproven (Harden et al., 2022).

Ask your surgeon before taking vitamin C for this purpose. We don’t list doses.

Another approach

Movement, therapy and retraining the brain

Physical therapy and gentle movement of the affected limb are important in treating CRPS, helping to maintain flexibility, strength and function. Exercise also helps reverse changes in how the spinal cord and brain handle pain signals after disuse. Occupational therapy helps people find new ways to stay active in daily life (NINDS).

  • Go gradually. Any movement or stimulation can increase pain, swelling, color changes and sweating, and too much or too vigorous exercise can aggravate the condition, so work with a therapist experienced in CRPS (NHS).
  • Desensitization. You touch an unaffected area with different textures such as wool and silk while paying attention to the feeling, then gradually apply them to the sore area. It may hurt at first but can lower sensitivity over time (NHS).
  • Swelling. Raise the limb when resting or sleeping; compression sleeves or stockings can limit swelling, especially when standing (NINDS).
  • Mirror therapy and graded motor imagery. These “retrain the brain.” You imagine moving the painful limb without moving it and use a mirror to watch the healthy limb move (NINDS). The graded motor imagery program steps through recognizing left from right limbs, then imagined movement, then mirror therapy (Harden et al., 2022). The NHS says they aim to correct missing or confused information the brain needs for movement (NHS). One study found mirror therapy helped early and intermediate CRPS but had no significant effect in chronic CRPS (Harden et al., 2022).

How strong is the evidence? A 2022 Cochrane review of 34 trials (1,339 people) of physiotherapy and related methods rated every finding very-low certainty and said trials rarely reported side effects (Smart et al., Cochrane, 2022). The Cochrane overview found graded motor imagery and mirror therapy may reduce pain, but with very low certainty; in one small waiting-list trial, some people in the imagery group reported more pain or swelling (Ferraro et al., Cochrane, 2023).

Another approach

Medicines by class

Several medicines can help CRPS symptoms, especially when used early. In the US they are used “off label” — approved for other conditions (NINDS). The NHS says no medicine is licensed for CRPS in the UK, and treatment teams try lower-strength painkillers first (NHS). Classes you may hear about:

Never stop or change a prescribed medicine on your own. See our medication safety guide. We don’t list doses.

Another approach

Nerve blocks and implanted devices

  • Nerve blocks are among the treatments MedlinePlus lists (MedlinePlus). A Cochrane review of sympathetic nerve blocks with local anesthetic found that two small placebo-controlled studies showed no significant short-term benefit, and the evidence overall was low to very low quality, with only minor side effects reported (O’Connell et al., Cochrane, 2016). The guideline authors say blocks lack high-quality evidence, but may give some patients a window of comfort in which to start therapy (Harden et al., 2022).
  • Spinal cord stimulation. A surgeon places small wires near the spinal cord that send mild electrical signals, often felt as tingling, to block pain; you control it with a handheld device (NINDS). The device can be removed (NHS). In the UK, NICE says to consider it only if you still have pain after six months of other treatments and a trial of stimulation succeeded (NHS). FDA approved a 2017 expansion of one spinal cord stimulator system to include CRPS types I and II (FDA). The guidelines call the randomized evidence supporting it a “weak recommendation” and urge shared decision-making (Harden et al., 2022).
  • Dorsal root ganglion (DRG) stimulation targets a cluster of nerve cells near the spinal cord (NINDS). FDA approved it in 2016 as an aid for moderate to severe chronic pain of the lower limbs in adults with CRPS types I and II; in the trial, participants had not gotten adequate relief from at least two drug classes (FDA). In a trial comparing the two, DRG stimulation had a higher treatment-success rate at 12 months (81.2% versus 56.7% with conventional spinal cord stimulation) (Harden et al., 2022).
  • Other options. Deep brain stimulation and implanted pain medicine pumps are used in rare cases (NINDS). Procedures that destroy nerves are rarely recommended because they may worsen pain (Harden et al., 2022).

The Cochrane overview rated the evidence for spinal cord stimulation very low certainty (Ferraro et al., Cochrane, 2023). Implants are surgery, so ask about the risks, the trial period and what happens if it doesn’t help.

Another approach

Mood, coping and mental health

Living with severe, long-lasting pain affects mood, sleep and daily life. Cognitive behavioral therapy (CBT) can teach coping skills, reduce stress and help people stay active, and it can help even without depression or anxiety (NINDS). Depression and anxiety can interfere with rehabilitation (NHS). The guideline authors recommend relaxation training, mindfulness, CBT and acceptance and commitment therapy, plus help with fear of movement and family support, and note psychological factors are usually an effect of CRPS rather than its cause (Harden et al., 2022).

A US database study of adults after surgery for long-bone fractures found those who developed CRPS type I had higher rates of anxiety, mood disorders, insomnia and substance use disorders over two years than matched people without CRPS, with no notable difference in suicide attempts (Mittal et al., 2026). That does not mean this will happen to you, but it is a reason to ask for mental health care early. See our depression and anxiety guides.

If you are having thoughts of suicide, call, text or chat 988 any time (988 Lifeline).

Another approach

CRPS in children

CRPS is rare in children. Type I is more common in girls and in children age 12 or older, and it can follow an ankle or wrist sprain or break. Children are often treated with intensive physical therapy and CBT, and may also receive medicines used in adults. It usually improves within six to eight months, though symptoms can return, and in some children pain continues into adulthood (NINDS). MBHA suggests that a child be seen by a pediatric pain team, and that the complementary approaches above be tried only with that team’s guidance.

Member stories

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This page is for education only and is not medical advice. Costs are typical U.S. ranges and estimates; yours will depend on your provider, location and insurance. Talk with your doctor before starting, stopping or combining any treatment. In an emergency, call 911. See our disclaimer.

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