Complex Regional Pain Syndrome

Also called RSD — reflex sympathetic dystrophy — and causalgia.

The rule that decides these cases:

The AMA Guides require the examiner to personally observe at least eight of eleven objective signs before CRPS can be rated.

Personally observe. Not "the treating physician diagnosed it." Not "the records reference RSD." Observed, at the evaluation, and documented.

Most CRPS cases in California fail at that step, and the failure is almost always preventable.

The eleven signs

The Guides group the objective findings into four categories:

At least eight of the eleven must be personally observed by the evaluating physician.

This is a strict criterion and it has been criticized as unrealistically strict. It requires a level of simultaneous objective finding that many genuinely affected patients do not display on any single day — CRPS fluctuates, and treatment suppresses signs. At least one state supreme court has refused to apply the criteria for exactly that reason.

In California the criteria are applied. So the question is not whether the standard is fair. It is what to do about it.

What to do about it

Get the examination scheduled and prepared for.

Objective signs of CRPS are strongest when the limb is unmedicated, unsplinted, and has not just been through a sympathetic block. Several of the eleven — color asymmetry, temperature asymmetry, sweating asymmetry, edema — are transient and observer-dependent. If the evaluator does not look for them, they are not in the record.

Get the objective testing done.

• Three-phase bone scan — one of the eleven, and the closest thing to an objective imaging marker.
• Plain radiographs looking for patchy demineralization.
• Infrared thermography for temperature asymmetry, where available.
• Quantitative sudomotor testing for sweating asymmetry, where available.

Document the signs across time. A single examination catching six of eleven, plus treating records documenting the other findings on other dates, is a materially different record from a single examination and nothing else. The treating physician should be documenting these findings at every visit — and usually is not, unless asked.

And photograph the limb. Color and trophic changes are visible. Contemporaneous, dated photographs are evidence.

The single highest-value action in a CRPS case is making sure the physician knows the eight-of-eleven criterion exists before the examination — not after the report comes back at zero.

Where the impairment comes from

Once the criteria are satisfied, CRPS is rated in the extremity chapters, and the pathway is different in the upper and lower limbs.

In the upper extremity, CRPS is rated by combining the sensory and motor deficits and the loss of motion, using the peripheral nerve methodology.

In the lower extremity, CRPS and causalgia are one of the thirteen enumerated methods, and the mutual-exclusivity rules in that chapter apply — including the instruction that where more than one method applies, the method producing the higher rating should be adopted.

Two things get left out routinely:

The contralateral limb. CRPS spreads. Mirror-image symptoms in the opposite limb are documented in the literature and are a compensable consequence.

The psychiatric component. CRPS is one of the most psychologically destructive orthopedic conditions there is, and for post-2013 injuries § 4660.1(c)(1) bars adding it to the rating unless an exception applies. CRPS is not one of the four injuries the Legislature named, so the route is the Wilson factors — and CRPS lines up well against them: intensity and duration of treatment, poor outcome at permanent and stationary, and severe impact on activities of daily living. In severe cases it may also be argued as "an incurable and progressive disease," which is the fifth Wilson factor. How that works.

The treatment fight

CRPS treatment is where utilization review does the most damage in these cases, because the two mainstays are both heavily gate-kept.

Spinal cord stimulators are not recommended in the treatment guidelines, and the "potential indications" pathway is a gauntlet: documented chronic radiculopathy with supportive electrodiagnostics, failed prior surgery, at least six months in an interdisciplinary functional restoration program, an independent psychological evaluation, and at least 50% pain reduction on a two-to-three day trial.

A denial of a spinal cord stimulator is therefore a substantive denial, not a paperwork defect — which means the appeal has to be built on why this worker satisfies the pathway, with the documentation assembled in advance.

Sympathetic blocks face repetition and response-documentation limits. Where a block produced a documented, measured, sustained response, that documentation is what supports the next authorization. Where the response was never measured, the next request fails.

Check every denial for procedural defects anyway — timeliness, the reviewer's qualifications, and whether the decision addressed the actual request. How to check a UR denial. · How to appeal through IMR.

Apportionment

Expect: pre-existing pain condition, fibromyalgia, psychiatric history, and smoking.

And expect the harder argument, which is causation rather than apportionment: that CRPS did not occur at all, or that the symptoms are not organic. That is an attack on the diagnosis, and it is answered with the objective findings — which is the same reason the eight-of-eleven documentation matters at both ends of the case.

Where apportionment is asserted, the ordinary rules apply. Under Escobedo, an opinion has to explain how and why a non-industrial factor caused a percentage of the disability, not merely name a risk factor.

How CRPS starts

It follows trauma, and frequently minor trauma. The recurring patterns in California work injuries:

Crush and fracture of the hand, wrist, foot, or ankle. Post-surgical — after carpal tunnel release, after ankle or wrist fixation, after knee arthroscopy. Amputation and degloving. Burns. Immobilization — a limb casted or splinted for an extended period. Nerve injury, which is causalgia specifically.

The disproportion between the injury and the outcome is characteristic, and it is also why these claims are met with disbelief. A wrist fracture that healed on imaging, followed by a permanently useless hand, is exactly what CRPS looks like.

Frequently asked questions