Complex Pain as a Syndrome

Hidden Pain Causes

We all know about pain—it hurts. But what if that pain does not subside or pain medication does not help? Then, we consider that the injury has failed to heal. This article will introduce you to a painful condition known as a pain ‘syndrome’.

Causes of pain

Pain arises because of insult or injury. A process known as inflammation kicks off, and clinicians recognise redness and swelling as part of the so-called cardinal signs. Complex pain syndrome affects specific regions of the body. The limbs, in particular, are targets, so hands and feet are high on the locations impacted.

During the American Civil War (1861-65), the lasting effect of the aftermath of the battle carnage involved nerves associated with unexplained pain. The route of pain messages is far from simple because it passes through the spine, from where it travels to the brain for processing. However, the spine can resend messages to the limb, confusing the brain and bypassing the control centre. Because the sympathetic pathway is involved, an involuntary part of the nervous system creates a beacon for pain, which slowly subsides as we heal. Nerves are also involved in healing. The skin sweats more than expected in severe cases due to the sympathetic system’s control over the sweat glands. 

Likened to a tap, pain fails to turn off after an injury.

Failed healing

With injuries, we cut our skin, and it heals. In normal circumstances, we would expect that to be the end of the story because there is nothing to show if pain continues despite all other evidence to suggest matters are normal. This is the single reason why hidden pain is the most difficult to deal with.

Once the skin repairs, all that we see is a scar. We fail to see the area below the scar where the healing continues for several months. Scar tissue is deep as well as superficial. As children, we might show off our injuries through the road map of scar–tissue repair. Once the skin is covered with new skin cells, the pain diminishes rapidly as nerve endings are covered. However, the injury sometimes settles slowly, depending on where it arises. It seems that the part of the sympathetic nervous system is at fault. The so-called pain tap does not turn off. Chemicals flood the area, and local pain nerves are excited when they should have settled. These add to both symptoms, alerting us of further damage and bringing in the new building process, expressing a signal that we are not progressing as we should. It is often weeks before we realise that all is not well. Many health professionals say, “Things will settle, but it takes time”.

Clinical Experience and Ignorance

Baptism of fire

Even in the 21st century, we still meet CRPS. Injuries to hands, feet, legs, and arms are the most frequent locations as they are not only distant from the spine but act as radar, informing the body about different sensory stimuli. A seven-year-old child knocked his foot and developed CRPS in his big toe. Although this was one of my earlier experiences, it was not the first.

As a junior (podiatric) surgeon (FRCPodS), I saw my first CRPS in 1986 after being referred a 14-year-old patient with the after-effects of a failed ingrowing toenail surgery. She developed pain after I revised the sides of the toenail.

Somewhat disturbed by these medical failings, I came across a friendly anaesthetist specialising in chronic pain because we shared the same operating theatre. So my baptism came about in a way I could never have realised, and even after retiring, my passion for the condition had never waned. Sadly, I saw more CRPS during my career, and my caseload recorded higher numbers of CRPS than my colleagues because I was so focused on the diagnosis. Some accused me of overcounting, but anyone with a series of unexplained pain that continued for more than 2 months was categorised at risk.

Has medicine reflected on the condition?

Medicine now recognises the condition more receptively and with an improved balance of sympathy. Still, as a whole, the condition and the effect of having a fractured wrist or the simplest of surgeries can provoke a holocaust of inflammatory symptoms. I attended meetings for patients and colleagues and ran tutorials and seminars. One with an actor trained in medical care delivery. How to handle distraught patients and advise them of the journey they would most likely follow. Even I was surprised to learn symptoms could be so severe as to increase the sensitivity of the female erogenous zone, as one professor of pain management from Bristol advised. When I discovered one of my patients with heightened arousal, embarrassment had stopped her from informing her husband, who now listened with shock. However, my abiding memory came from the very worst the condition could deliver, which is worth telling.

Advanced stage complex pain syndrome

Burning pain is also called causalgia

For more than 20 years since my first suffering opened my clinical door and mind, I realised several stages, from mild to moderate and then severe. The latter creates wasting of the limb, arm or leg, hand or foot. The skin changes colour and texture. Pain arises through a rush of air, a sudden sound, or injudicious movement of the affected limb. The nature of pain is hot to burning. As one sufferer said at a conference I had organised, ‘pain is like putting your whole arm in a bucket of hot water and not removing it.'

Causalgia is a term used to describe this side of the syndrome. In the advanced stage, the limb becomes stiff through disuse, and those with the worst symptoms end up in wheelchairs. And so to my story…

Asked to help a woman by a different pain specialist to the one I had first worked with. I was asked if I could make a splint to prevent the inevitable contractures. This has to be conducted under general anaesthetic.

We watched with amazement as the limb straightened from a curled-up part of the anatomy with its mottled hue to a fresh colour that looked pink and healthy together with a straight leg. Once the anaesthetic, which works on the brain, wore off, the leg reversed its pattern. The leg bent, and the skin changed tone and colour returning to the awful state before.

Have we learned from these salutary lessons?

When  Foot Health Myths, Facts & Fables – Podiatry Reflections, in 2020, I researched current stories. Much as I am against amputation, a case was cited by the Daily Mail online, a British tabloid that applies a sizeable latitude to podiatry. A 19-year-old sued the NHS after being treated for an ingrown toe (2012) and had an amputation that the tabloid suggested resolved her pain. The report by Kate Pickles in 2016 arose 30 years after my initial case. It is newsworthy for one reason alone. That reason exemplifies that simple treatment can lead to untold consequences, and as clinicians, we are often helpful at supplying the best management. The surgeon who causes the problem is not doing so out of negligence but is often insufficiently trained to make any difference. The pain specialist might be an anaesthetist or a rheumatologist, but the reality is that the box of tricks available comes with a simple message.

Trial and Error

In truth, treatment starts with the earliest suspicions, leading to a presumptive diagnosis. The patient must be briefed immediately and counselled on the likely route without false promises. After that, there is a wake-up call: medicine might not believe you. Friends think you are shaming. Employers believe you’re pulling a sicky! Marriages start to creak with destructive forces of altered sensitivity.

Contractures arise because of our reflexes to guard against pain. We stop moving. The skin must be trained and desensitised by light pressure build-up. The brain must be fooled, and mirror therapy can help (see Sayegh 2013). Psychology is essential, and any input from favourable cognitive treatment is necessary. Group therapy is vital as a help network. Sleep management is critical to ensure the brain can cope and depression is averted. Surgery plays a minimal part, while amputations are not advised.

Healing After Injury Requires Careful Management

Indwelling nerve stimulators are now an avenue to managing pain, and this method will grow as technology allows for smaller indwelling devices and keyhole surgery. The modern toolbox must include counselling, pain management, movement, positive psychology, and available support.

IMPACT versus RISK

Risks before surgery are often provided with percentages. An infection risk, a risk of healing, worsening, for example. Let's say an infection risk is 6%. This may be high in a hospital, but the impact might be level 2.

CRPS might be 0.1-2%, so unlikely. But the impact may be 4. What might the impact suggest?

The impact levels have never been trialled and tested but a group of podiatrists combined their clinical experience to offer an indication for impact from surgical treatment in the foot. (Source: PASCOM-10) Royal College of Podiatry. Accessed April 2025.

The truth is that while NHS centres can provide excellent services, even before the ravages of Covid-19, the chronic pain clinic was understaffed and under-resourced. Of most concern is that treatment delays make the condition harder to manage. The best advice I can give is to seek a pain specialist early and not be advised by a non-specialist, GP or surgeon to see how it goes and take strong painkillers alone.

Partnering with physiotherapy and the pain specialist service is important and the team can be strengthened with psychologists. By establishing good protocols to manage CRPS early we can minimise the condition’s progress. Extended consulting clinic times are necessary to provide counselling.

References

Sayegh SA, Filén T, Johansson M, Sandström S, Stiewe G, Butler S. Mirror therapy for Complex Regional Pain Syndrome (CRPS)-A literature review and an illustrative case report.

Scand J Pain. 2013 Oct 1;4(4):200-207. doi: 10.1016/j.sjpain.2013.06.002. PMID: 29913636.Bruehl S, Chung OY. Psychological and behavioural aspects of complex regional pain syndrome management. Clin J Pain. 2006 Jun;22(5):430-7. doi: 10.1097/01.ajp.0000194282.82002.79. PMID: 16772797.Additional (USA) source – National Organization for Rare Diseases (NORD)

PASCOM-10 Podiatry Audit System. Royal College of Podiatry. Open access.

Other resources on this site

Acute and Chronic PainPainkillers for Foot Conditions

and 

 Fiction to Aid Real-Life Conditions – Using clinical conditions in fiction often makes the impact on our lives clearer.

David is a full-time author, blogger and independent publisher of health matters and fictional works. You can find more about him on this site or his author website. Please share this article. You can read the story of Anna Taylor in Fatal Contracts and the Withered Hand, released in October  2024 – from Amazon booksin eBook and paperback. You can also follow David on Facebook @davidtollafield, LinkedIn and X @myfootjourneys.

Thanks for reading ‘Pain with failed healing after injury’ by David R Tollafield

Written for a lay audience, hyperlinks used in this article allow for greater in-depth understanding. 

Published by Busypencilcase Reflective Communications Est. 2015

Published 9th September 2021