CRPS · Complex regional pain syndrome
A syndrome with published diagnostic criteria, routinely diagnosed without applying them.
Complex regional pain syndrome (CRPS) is diagnosed with the Budapest criteria: continuing pain disproportionate to the injury, symptoms across sensory, vasomotor, sudomotor and motor or trophic categories, and signs observed at the examination in at least two of them.
Complex regional pain syndrome is real, well described and heavily contested in litigation — largely because it is so often asserted without reference to the criteria that exist precisely to discipline the diagnosis. Applied properly, those criteria are an asset.
The criteria exist and should be applied
Harden and colleagues published the validation of the proposed diagnostic criteria — the Budapest criteria — requiring continuing pain disproportionate to the inciting event, together with specified symptoms reported across sensory, vasomotor, sudomotor and motor or trophic categories and, critically, signs observed at the time of evaluation in at least two of those categories.
The requirement for observed signs is what separates a documented CRPS diagnosis from an asserted one, and it is the part most often skipped.
Why a careless diagnosis is worse than none
CRPS carries large damages implications, which is why it gets examined hard. A diagnosis recorded without the criteria, without documented observed signs, and without the alternatives excluded, is a liability in the file rather than an asset. When it collapses on cross it takes the credibility of the rest of the record with it.
We apply the criteria explicitly and record which elements were present and which were not. Where the criteria are not met, the record says the criteria are not met.
What corroborates it
- Observed signs documented at examination, ideally serially and photographed where appropriate.
- Sensory abnormality measured against reference values — see quantitative sensory testing.
- Response to a sympathetic diagnostic block where indicated, recorded against timed measurements.
- Exclusion of other explanations, documented rather than assumed.
This practice is not aligned to a side. Its obligation runs to the patient’s health and safety, which is the same reason it is not beholden to any position that would keep it from seeing what is actually there. We do not offer opinions on liability, we do not accept a referral or a review conditioned on reaching a particular conclusion, and we will say plainly when the evidence does not support the claim — whichever party was hoping otherwise.
Common questions
Is CRPS the same as RSD?
Reflex sympathetic dystrophy is the older term for what is now classified as CRPS type I. Both appear in records and mean the same clinical entity.
Does a normal nerve study exclude it?
No. CRPS type I is defined by the absence of a confirmed major nerve lesion; type II involves one.
Is it always caused by trauma?
It usually follows an inciting event, often a relatively minor one, which is itself part of the diagnostic definition — pain disproportionate to that event.
Why do reviewing experts attack it so hard?
Because it is high-value and frequently diagnosed loosely. A criteria-based, sign-documented diagnosis is a much harder target.
Related reading
- Quantitative sensory testing
- Central sensitization
- Objective corroboration
- Records that survive cross
- Reading an independent examination
Ask whether the criteria were actually applied
In most files carrying this diagnosis, the record does not show it. That is fixable while the patient is still treating.
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Sources
- Harden RN et al. Validation of proposed diagnostic criteria (the “Budapest Criteria”) for complex regional pain syndrome. Pain, 2010. PubMed 20493633
- Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain, 2011. PubMed 20961685
- Rolke R et al. Quantitative sensory testing in the German Research Network on Neuropathic Pain (DFNS): standardized protocol and reference values. Pain, 2006. PubMed 16697110
- Raja SN et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain, 2020. PubMed 32694387