Foot and ankle surgeries are performed to relieve pain and restore function, but for some patients, pain persists long after healing. This ongoing discomfort is known as chronic postoperative pain (CPOP), or chronic postsurgical pain (CPSP). It can occur even when surgery is technically successful and the surgical wound has healed.
What Is Chronic Postoperative Pain?
Chronic postoperative pain is defined as pain that lasts for more than two to three months after surgery and cannot be explained by infection, fracture, or another identifiable cause. The pain may be dull, burning, or electric-like and may or may not have neuropathic (nerve-related) features. Although CPOP has been studied in major procedures such as hip or knee replacements, it is increasingly recognized as a significant concern in foot and ankle surgery.
How Common It Is and Who Gets It? (Epidemiology)
Studies show that chronic pain after foot surgery affects a substantial number of patients. In one study of 260 orthopedic foot surgery patients:
- 21% experienced moderate-to-severe pain at rest one year after surgery.
- 43% reported pain while walking.
- Only 3% had confirmed neuropathic pain.
Chronic pain after foot surgery is as frequent as that following large joint procedures, though true nerve-related pain appears less common.
Why It Happens – Causes (Etiology and Pathophysiology)
The exact cause of chronic pain after foot surgery is multifactorial and may include both biological and mechanical factors.
- Nerve injury or irritation: Direct trauma, entrapment, or scar formation around nerves can cause persistent pain.
- Inflammation and hypersensitivity: After injury or surgery, nerves can become overactive and send abnormal pain signals.
- Poor bone or soft-tissue healing: Conditions such as nonunion, malunion, or excessive scar tissue can cause mechanical pain.
- Preexisting conditions: Patients with diabetes, neuropathy, or chronic pain syndromes are at higher risk.
- Psychological factors: Anxiety, depression, and high pain sensitivity can increase the likelihood of chronic pain development.
How the Body Part Normally Works? (Relevant Anatomy)
The foot contains 26 bones, 33 joints, and a complex network of nerves. Nerves like the tibial, sural, and peroneal branches provide sensation and movement. During surgery, these structures may be stretched or irritated. If the body’s healing response overreacts, it can result in persistent inflammation or nerve hypersensitivity, producing pain long after normal tissue repair is complete.
What You Might Feel – Symptoms (Clinical Presentation)
Common symptoms include:
- Persistent pain that lasts beyond the usual healing time (more than three months).
- Burning, tingling, or electric-like pain (suggesting neuropathic involvement).
- Hypersensitivity to touch or cold.
- Pain at rest or with walking, even after structural healing.
- Swelling, stiffness, or tenderness at the surgical site.
In severe cases, patients may have difficulty walking, wearing shoes, or performing daily activities.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis involves identifying whether the pain is structural, inflammatory, or nerve-related.
- History and exam: Surgeons review the onset, quality, and distribution of pain. Neuropathic pain may radiate or burn, while mechanical pain tends to localize near the joint or bone.
- Imaging: X-rays assess bone healing and hardware placement. MRI or CT scans can detect scar tissue, soft-tissue damage, or infection.
- Nerve studies: Electromyography (EMG) and nerve conduction tests identify nerve dysfunction.
- Questionnaires: Tools like the DN4 or painDETECT help assess neuropathic pain characteristics.
Classification
Chronic postoperative pain can be classified as:
- Nociceptive pain – pain from tissue inflammation, bone, or joint damage.
- Neuropathic pain – pain from nerve injury or dysfunction.
- Mixed pain – involving both mechanical and nerve components.
Other Problems That Can Feel Similar (Differential Diagnosis)
Other conditions may mimic chronic postoperative pain, such as:
- Infection or osteomyelitis.
- Complex regional pain syndrome (CRPS).
- Recurrent deformity or joint instability.
- Hardware irritation.
- Vascular insufficiency.
A thorough evaluation helps distinguish these from persistent surgical pain.
Treatment Options
Non-Surgical Care
Most cases of chronic pain after surgery can be managed conservatively.
- Medications: NSAIDs for inflammation; neuropathic agents like gabapentin, pregabalin, or duloxetine for nerve pain.
- Physical therapy: Restores strength, flexibility, and mobility, reducing pain through muscle re-education.
- Nerve blocks: Local anesthetic or corticosteroid injections may reduce pain by calming nerve irritation.
- Orthotics: Custom insoles or supportive footwear can relieve mechanical pressure.
- Psychological support: Pain management counseling helps address anxiety or depression that may worsen pain perception.
Surgical Care
Surgery is rarely required but may be considered if a structural problem is identified, such as hardware irritation, nonunion, or trapped nerves.
- Hardware removal: When screws or plates irritate nearby soft tissues or nerves.
- Revision surgery: To correct bone malalignment or instability.
- Neurolysis: Freeing entrapped nerves from scar tissue.
- Scar revision: Removing excessive scar tissue to restore mobility and relieve pressure.
Recovery and What to Expect After Treatment
Recovery depends on the cause of pain and treatment approach. Conservative care often improves symptoms over several weeks to months. After revision surgery or nerve release, patients usually experience gradual relief as tissues heal and inflammation subsides. A multidisciplinary approach, involving physical therapy, pain management, and consistent follow-up, provides the best results.
Possible Risks or Side Effects (Complications)
Persistent pain may continue even with treatment. Other possible complications include wound healing problems, recurrent nerve pain, or the development of chronic regional pain syndrome (CRPS). Early and coordinated management helps minimize these risks.
Long-Term Outlook (Prognosis)
The prognosis for chronic pain after foot surgery varies. Most patients improve with proper diagnosis, physical therapy, and pain management. However, in cases involving nerve injury or underlying disease, some pain may persist long term. Early, aggressive pain control and rehabilitation improve outcomes and quality of life.
Out-of-Pocket Costs
Medicare
CPT Code 64450 – Nerve Block, Ankle or Foot: $16.90
CPT Code 20552 – Trigger Point Injections: $11.93
CPT Code 97110 – Therapeutic Exercises (Physical Therapy): $6.56
Medicare Part B typically covers 80% of the approved cost for these procedures once your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield generally cover this remaining portion, resulting in little to no out-of-pocket expense for Medicare-approved treatments. These supplemental plans coordinate with Medicare to close the coverage gap and limit patient costs.
If you have Secondary Insurance, such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it will act as a secondary payer. These plans typically cover any remaining coinsurance or deductibles, which generally range from $100 to $300 annually depending on your plan and provider network.
Workers’ Compensation
If your nerve block, trigger point injections, or physical therapy are required due to a work-related injury, Workers’ Compensation will cover the full cost of treatment, including therapy and follow-up visits. You will have no out-of-pocket expenses, as your employer’s insurance carrier pays all approved charges directly.
No-Fault Insurance
If your pain or injury stems from an automobile accident, No-Fault Insurance will typically cover the total cost of treatment, including injections and therapy. The only potential out-of-pocket expense may be a small deductible or co-payment as outlined in your insurance policy.
Example
Daniel Harris received a nerve block (CPT 64450) and trigger point injection (CPT 20552) to relieve chronic ankle pain after an injury. His estimated Medicare out-of-pocket costs were $16.90 for the nerve block and $11.93 for the injection. Since Daniel had supplemental coverage through Blue Cross Blue Shield, his remaining balance was fully covered, leaving him with no out-of-pocket expenses for his treatments.
Frequently Asked Questions (FAQ)
Q. What are the common causes of chronic pain after foot surgery?
A. Common causes include nerve injuries, infections, nonunion or malunion of bones, hardware irritation, and scar tissue formation.
Q. How can nerve injuries lead to chronic pain after foot surgery?
A. Nerve injuries can cause symptoms such as burning, tingling, numbness, or shooting pain in the foot.
Q. What role does infection play in chronic foot pain after surgery?
A. Infection can lead to persistent pain, swelling, redness, and warmth, and may require further treatment or surgery.
Q. How do bone healing problems contribute to chronic pain after foot surgery?
A. Nonunion (failure of the bone to heal) or malunion (healing in an incorrect position) can cause ongoing pain and deformity.
Q. Can surgical hardware cause chronic pain after foot surgery?
A. Yes, screws, plates, or other hardware can irritate surrounding tissues or nerves, leading to pain.
Q. What is the impact of scar tissue on chronic pain after foot surgery?
A. Excessive scar tissue can trap nerves or restrict normal movement, causing persistent discomfort.
Q. How is chronic pain after foot surgery diagnosed?
A. Diagnosis typically involves a thorough clinical examination, imaging studies like X-rays, MRI, CT scans, and sometimes nerve studies.
Q. What are treatment options for chronic pain after foot surgery?
A. Treatment options include medications, physical therapy, injections, orthotics, and sometimes revision surgery.
Q. When might revision surgery be necessary for chronic pain after foot surgery?
A. Revision surgery may be needed if there is hardware irritation, nonunion, malunion, infection, or significant nerve entrapment.
Q. How can physical therapy help in managing chronic pain after foot surgery?
A. Physical therapy can improve strength, flexibility, and help reduce pain by restoring more normal function to the foot.
Q. What medications are commonly used to treat chronic pain after foot surgery?
A. Medications can include anti-inflammatories, nerve pain medications, and sometimes pain relievers.
Q. What are some non-surgical interventions for chronic pain after foot surgery?
A. Non-surgical treatments include medications, physical therapy, orthotic devices, and injections.
Q. How important is early diagnosis and treatment for chronic pain after foot surgery?
A. Early diagnosis and treatment are crucial to prevent worsening of symptoms and improve outcomes.
Summary and Takeaway
Chronic pain after foot surgery affects nearly one in five patients and can persist even after the foot structurally heals. Though neuropathic pain is rare, lingering discomfort can impact walking, quality of life, and emotional health. Identifying high-risk patients, managing acute pain effectively, and using a multidisciplinary approach are essential to minimizing long-term complications.
Clinical Insight & Recent Findings
A 2024 study of 260 foot surgery patients found that 21% experienced persistent pain one year postoperatively, and early postoperative pain was the strongest predictor of chronic pain development. Another review showed that multimodal analgesia—combining nerve blocks, anti-inflammatory medications, and regional anesthesia—reduces the risk of long-term pain.
Who Performs This Treatment? (Specialists and Team Involved)
Chronic postoperative pain is managed by orthopedic foot and ankle surgeons, pain specialists, neurologists, and physical therapists working as a coordinated team.
When to See a Specialist?
You should see a specialist if your pain persists beyond three months after surgery, worsens over time, or interferes with walking or sleep.
When to Go to the Emergency Room?
Go to the emergency room if pain is accompanied by severe swelling, fever, redness, or drainage, as these may indicate infection or vascular problems.
What Recovery Really Looks Like?
Recovery may involve a combination of medications, physical therapy, and gradual return to activity. In cases of nerve injury or revision surgery, full recovery can take several months, with gradual improvement in function and pain relief.
What Happens If You Ignore It?
Ignoring persistent postoperative pain can lead to long-term disability, nerve damage, or chronic regional pain syndrome (CRPS), making treatment more difficult later.
How to Prevent It?
Prevent chronic pain by ensuring optimal pain control immediately after surgery, following rehabilitation instructions carefully, and avoiding premature weight-bearing or overuse.
Nutrition and Bone or Joint Health
A balanced diet with sufficient protein, calcium, vitamin D, and omega-3 fatty acids promotes bone healing and reduces inflammation, supporting overall recovery.
Activity and Lifestyle Modifications
After recovery, maintain low-impact activities such as swimming or cycling to improve flexibility and endurance. Avoid high-impact sports until full healing and strength are achieved. Consistent physical therapy helps prevent stiffness and recurrent pain.
Dr. Mo Athar
