It is important to realize that the majority of cases (56% to 61%) of CRPS have a myofascial component. Myofascial dysfunction is more prevalent in the affected upper extremity (69-70%) than the lower extremity (42-47%).^{176, 177} Likewise, it is known that patients with known musculoskeletal problems, including myofascial pain syndromes, have exaggerated regional sympathetic responses. When the normal limb is compared in regard to the sudomotor and vasomotor activity including edema, changes in skin floor, decreased electrical skin resistance are profoundly altered in the painful limb.¹⁷⁸ These heightened sympathetic responses are not anomalous reflexes, but modifications of normally operating patterns of somato-autonomic coordination that represent changes in sensory input arising in nociceptors in the injured musculoskeletal tissues.¹⁷⁹ Nociceptors in injured soft tissues such as joint capsules and ligaments have a lowered stimulus threshold to induce pain.¹⁸⁰ These nociceptors can activate the sympathetic nervous system to produce symptoms and also change blood flow to the affected joint which can affect healing.¹⁸¹ In addition, joint instability caused by ligament injury, can affect the firing of nociceptors which then in turn affects proprioception (position sense) and muscle coordination.^{182, 183}  

According to an interdisciplinary expert panel for CRPS, the goal of treatment in patients with CRPS is to improve function, relieve pain, and achieve remission. They go on to state, “increasing evidence suggests that some cases are refractory to conservative measures and require flexible application of the various treatments…There is widespread agreement among experts that patients who do not respond to an acceptable level of treatment by 12 to 16 weeks should be given a trial of more interventional therapies…”¹⁸⁴ Again, to go back to the International Association for the Study of Pain Diagnostic Criteria for CRPS one must have the presence of an initiating noxious event, or a cause of immobilization. Surely ligaments can and probably are injured in most of the initiating noxious events that start the CRPS including the traumas that fracture bones and injure the soft tissues. As discussed, immobilization of a joint itself can cause articular cartilage and joint degeneration as well as set up a scenario whereby the soft tissue injuries including the ligaments, don’t heal. Most patients with CRPS will describe weeks and even months of partial and total immobilization of the painful extremity. If underlying non-healed ligament injury is the primary causative factor for ongoing sympathetic activity, then the only treatment that would have curative effects long-term must address this issue. Most therapies offered to CRPS patients do not address ligament weakness and injury.

TREATMENT

Success in traditional treatment of CRPS is dismal. “No other chronic pain syndrome is as shrouded in confusion and controversy—to the detriment of efforts to rigorously define an evidence-based treatment strategy.”¹⁸⁵ A study of 146 patients found that only 29% were pain free.¹⁸⁶ In another series, 64% of CRPS patients with severe pain lasting more than one year rated their pain as a 7 on a 1-10 scale, with 10 being the highest level of pain.^{187, 188} CRPS was also noted to be present 10 years after a fracture of the distal radius in 9% of patients studied in a review of 100 patients with Colles’ fracture.¹⁸⁹ In a Korean study involving 150 patients, one third had intractable chronic pain even after treatment, and some required a limb amputation. The Korean study noted that the patients had suffered for over two years before being referred to a specialist, and that the intractable chronic pain increases as the time between the onset of symptoms and diagnosis increases. It is not unusual, however, that years go by before the CRPS patient even receives a correct diagnosis, thereby prolonging treatment.¹⁹⁰ This is possibly due to a misconception that the pain is a psychiatric disorder, or unbelief that the patient could possibly have this much pain, or even that such a small injury could lead to total body pain.¹⁹¹