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Chronic pain in ball of foot after bunion surgery (nerve pain?)

by Lars
(CA)

Left foot, fifth metatarsal

Left foot, fifth metatarsal

I am 45 years old, 6'2" and 166 lbs. I had bunion surgery on both feet almost 6 months ago (bunionectomy with fixation). After about 2 weeks, I was able to start walking some and after 3 weeks, the pins were removed. I gradually worked up from a few minutes to 30 minutes; after 8 weeks I was taking daily walks of about 30-45 minutes. There was extra pressure under the fifth metatarsal (especially on the left foot), but was told that it will go away and nothing worry about. It has not gone away.


After about 10 weeks, there was one day when I took two walks of about 45 minutes in the same day; I felt barely any discomfort except for at the end of the last walk when my feet started getting sore and a bit painful. The following days were fine, but about a week after that day I suddenly regressed and my feet became quite painful and I had a hard time walking at all. I stayed off my feet for several days and it calmed down some.

I am not sure if the extra walking that one day had anything to do with it, but I still have not recovered from that regression. I am now over 5 months past the surgery and still cannot walk (or even stand) without discomfort / pain. If I walk more than about 5-10 minutes, it tends to flare up again and hurt more for several days.

The pain is centered around the fifth metatarsal on both feet (the left is the worst), but the whole ball of the foot seems tender and sensitive (with fleeting pain in other areas, such as the first metatarsal). The pain is of an aching, burning kind (slightly prickly - hard to describe).
However, some weeks ago, there was a couple of periods of a few hours when the feet felt almost normal – virtually no discomfort or extra pressure on the fifth metatarsals.

The podiatrist who did the surgery does not know why it still hurts and said it can take up to a year to fully heal.

Since there is absolutely no sign of improvement and this condition is keeping from doing anything that requires more than 5-10 minutes of being on my feet, I am getting desperate and do not want to just sit and wait for it to hopefully eventually go away.

I recently saw a highly regarded orthopedic surgeon for a second opinion. He noted that the fifth metatarsal on the left foot was not correctly set (I do not remember the word he used): the pinkie toe is pointing a bit upwards instead of being flat as the other toes, which make the area where the bone was cut a bit lower than it should; this explains the extra pressure under the left foot fifth metatarsal. I have attached a picture to illustrate.

Question #1: is it common that the surgeon accidentally fixates the metatarsal not quite straight like this?

So there is a mechanical issue with the left fifth metatarsal, but that does not explain why other areas of the foot, as well as the right foot also hurt. The pain in the other areas (not around the fifth metatarsal) is more diffuse (=the ache is usually less intense, but still burning and slightly prickly).

I have tried two pairs of orthotics, but they provide only little relief (even with metatarsal pads); however, perhaps once the nerve issue (or whatever it is that is causing the general diffuse ball of the foot pain) has been resolved, the orthotics will work fine for me.

On the surgeon's suggestions, I have done blood tests for arthritis, lupus, etc. They were all negative.

Question #2: as a last resort if nothing else has worked, what is your opinion on a revision surgery to straighten out the left foot fifth metatarsal? 70% of the pain is in this area.

I did physical therapy for a few weeks, but that only provided temporary relief after each visit (perhaps the ultrasound or massage). Rolling a ball under my foot and calf stretches daily did not seem to help.

Question #3: Do you think Voltaren gel for a couple of weeks could help? The amount of pressure under the fifth metatarsals varies, so perhaps inflammation is causing variation in swelling of the metatarsophalangeal joint?

Your opinion and recommendations would be greatly appreciated.

RESPONSE

Hi Lars,

Question #1: is it common that the surgeon accidentally fixates the metatarsal not quite straight like this?

I am assuming your original pain was on the outside of the fifth metatarsal as opposed to the under side of the metatarsal head. This is usually
the problem.

That being the case your surgeon probably performed an osteotomy, cutting of bone, to move the metatarsal head closer to the fourth metatarsal head. It appears that not only did he move it over, but he also slightly plantarflexed it (moved it downward) when he fixated it. That is why you have the added pressure underneath the head

In foot surgery, when a metatarsal head is plantarflexed, it will force the toe upward. This is why your fifth toe is not touching the ground.

In defense of your surgeon, this type of surgery is not an exact surgery and problems like this can and do happen. I have no hard statistics on how often it happens but I would venture to guess not terribly often, because in most cases the patient does not have any issues even if the alignment is "off" a little bit.

What I do not like about your whole narrative is the fact that you did so much walking early on after the surgery. You mention K wires were removed and I will assume they were the only means of fixation for the osteotomy. If I am wrong let me know.

Call me conservative, but when I do these types of procedures, and use k-wires, I also put my patients in walking boots to further stabilize the osteotomy site and have them rest their foot, not go out on long walks.

That is also the reason I only do one foot at a time when doing an osteotomy, to give the surgical site all the protection it needs to properly heal.

What I am saying here is that all the walking you did with minimal protection may have dislodged the osteotomy slighty and may be part of the problem.

So, unless I do not totally understand the time line here, I am concerned about the instructions you were given after surgery.

I think it is worth mentioning that one possibility for your pain might be from damage to the nerves on the bottom of your foot which may have occurred during surgery. Either excessive dissection or using too large a bone saw blade might have actually done damage to the nerves of the branches of the lateral plantar nerve that pass through that area. Difficult to know from this side of the internet.

Question #2: as a last resort if nothing else has worked, what is your opinion on a revision surgery to straighten out the left foot fifth metatarsal? 70% of the pain is in this area.

First of all, it has only been six months since the surgery and your surgeon is correct that it can take upwards of a year for bone to remodel itself, although I do not think your problem is in the bone, but you never know. You would not consider revision surgery until at least one year has passed.

Making the assumption that the osteotomy site has completely healed, both on x-ray and clinically by pressing on the bone itself to see if there is any pain, my suggestion would be to consider a cortisone injection underneath the head of the bone, or even consider a round of oral prednisone.

I suggest this because over the years when I have had post op patients with "soft tissue" issues of pain, I have found that an injection or a round of oral prednisone can be very effective in alleviating the pain.

As far as revisional surgery goes, you will have to use my "risk vs. reward" formula. What any honest surgeon will tell you is that every time you have surgery on the same spot, particularly a small area such as the fifth metatarsal head, additional surgery could make matters worse usually because of excessive scarring that occurs.

If you do eventually have a second surgery you better make sure the surgeon knows exactly what the problem is, because in these instances the risk vs. reward ratio is working against you.

Question #3: Do you think Voltaren gel for a couple of weeks could help? The amount of pressure under the fifth metatarsals varies, so perhaps inflammation is causing variation in swelling of the metatarsophalangeal joint?

Voltaren is harmless enough to try and probably useless in the long run. I have tried it a number of times and have been underwhelmed by its effect, but there is no downside risk to using it.

Based on what you have written, I do not think this is a joint problem, but again, I do not have the luxury of actually examining you. Joint pain generally does not cause burning. Personally I think an injection or oral prednisone would be a better option.

Good luck.

Marc Mitnick DPM
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Aug 22, 2015
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Chronic pain in foot after bunion surgery & Scar Tissue Release
by: Lars

Hello Marc,

Thanks for your reply!

Re. # 3 (feet burning): yes there is some abnormal sensation in the right foot as well, but I did had the same surgery on that foot (at the same time).

I will get my lower back checked out (I guess even though it all started with the foot surgery, there could have been some asymptomatic condition in my lumbar spine that now has become symptomatic).

Re. forceful manipulation, can I ask a couple of follow up questions?
1a) Do you know many patients that have done this?

1b) Have you seen it make the joint worse or cause issues (how safe is it)?

Thanks again,
Lars

It will not make matters worse, and I have done it a number of times over the years and I will assume any one who does joint surgery has done it as well, on more than one occasion.

Aug 22, 2015
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Scar tissue release
by: Lars

Hello Marc,

It has now been almost a year since my surgery and there has not been any improvement. I would like to provide an update and get your feedback.

The surgeon recommended that I try immobilize the left foot for 6 weeks "to let it heal", but this turned out to be a really bad idea - after 2 weeks of this my left foot felt freezing and using an IR thermometer I found out that the skin temperature on the left foot was 7 degrees lower than the right foot! I started walking again immediately and used hot foot baths, etc. and the skin temperature difference went away. However, the left foot almost constantly _feels_ cold ever since (mainly on top or inside side) and I have to take frequent short walks to keep the coldness in check. I walk about 5 miles a day (broken up into several 10-30 minute walks).

The feet seems over-sensitized some some extent: if I walk more than 30 minutes, the ball of the feet burns (left foot is worst). Even only standing barefoot or with socks on a carpet is a bit uncomfortable - the texture of the carpet / socks feels a bit like fine gravel underfoot.

So the foot is painful / uncomfortable pretty much constantly (either aching pain or feeling cold). But there is usually no pain or discomfort (or very little) when I wake up in the mornings (including when I wake up at night sometimes). One oddity is that whenever I go to the beach and swim some, the feet feel almost normal and I can walk barefoot on rough surfaces with virtually no discomfort afterwards. This lasts for 2-3 hours.

There is still extra pressure under 5th MTPJ (some on right as well), and most of the discomfort is there. A cortisone shot in the area did nothing.

There is an asymptomatic Morton's neuroma in the 3rd interspace (but it might recently have become symptmatic - there is fairly frequent pain around that area now as well). I most likely had this neuroma before the surgery. A podiatrist that specializes in chronic pain (including CRPS) has given me a cortisone injection (with local numbing mixed in) into the neuroma and the foot felt better for a few hours (only). I had additional numbing shots into the neuroma (one of them at the same time as a full ankle block), but that did not give relief (perhaps some for the numbing period). It was after these injections that the neuroma might have become symptomatic - perhaps the repeated poking with needles woke it up...

I am taking gabapentin (900 mg/day) and I think it helps some (but not as much as it did when I first started [on 300 mg/day]).

I have seen a neurologist, but she found nothing wrong in her basic functional testing. I have requested a diagnostic ultrasound to check for nerve impingements around the surgical site (and other areas, in case of issues from compensating when walking for a long time).

I have seen a pain specialist who treats a lot of CRPS / RSD patients and she told me that I do _not_ have CRPS, but that there is central sensitization involved. She did a diagnostic lumbar sympathetic block and the foot immediately got nice and warm and felt comfortable, but it only lasted about 2 hours (=until the local numbing agent wore off). This seems to indicate that the pain is at least partially sympathetically maintained. However, the pain specialist also indicated that there is likely a structural issue as well, given how being on my feet causes discomfort.

I have seen another DPM (very skilled and reputable) that did a second reading of the MRI and told me that I have scar tissue in the 5 MTPJ, which causes the toe to be elevated and the extra pressure underneath the joint (see photo in initial post). He told me that he can release this scar tissue / adhesions under local anesthesia using forceful manipulation. I would LOVE to get rid of the extra pressure and discomfort in the 5 MTPJ (it has been there from right after the surgery), but I am afraid that the pain (once the numbing wears off) will trigger further neurological pain (even though I do not have CRPS, there are similarities).

Questions:

1) What is your opinion about forceful manipulations to release adhesions in the 5 MTPJ? Is it usually safe and successful? Note that I plan to do this the same day as my second lumbar sympathetic block to minimize risk (and perhaps take Hydrocodone every 4-6 hours for a couple of days afterwards as well).

ANSWER: This is the standard treatment for adhesions. Although the area will be somewhat painful afterwards, ice and pain medication should do the trick.

2) A physical therapist told me that he can release the scar tissue by massaging and increasing the range of motion (over repeated sessions). Is this method as effective (in the end) as a forceful manipulation by a DPM?

ANSWER: no harm in trying, probably less downside then forceful manipulation under local anesthesia.

3) Regarding my feet being over-sensitized (burning after being on my feet, etc.), could this simply be that the nerves are still healing from the surgery, or what could this be?

ANSWER: I do not see this as being due to damage to the nerves as a result of the surgery, simply because your whole foot is affected and if I read correctly you also have abnormal sensation in the other foot as well. The neurological aspect of your problem sounds like it is coming from your lower back. I am glad your neurologist has ruled out CRPS because your narrative certainly sounded like it. Have you had a recent x-ray? You might consider one simply to see if there is any sign of bone demineralization, something seen in CRPS.
Although your circulation issue may be neurological in origin, have you had a vascular consult? The foot getting cold and then warming up again could be a sign of an arterial blood clot. You are in your mid-forties and that should be ruled out simply to be on the side of caution.

4) Any other advice you can give me?

I much appreciate whatever advice you can give me on this.

Thanks,
Lars

Mar 14, 2015
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Chronic pain in foot after bunion surgery
by: Lars

Hi Dr. Mitnick,

I just had an MRI done on the left foot (the worst one) and the findings were, "non-specific inflammation."

I think "non-specific inflammation" means general inflammation in the area, but since the test for auto-immune issues (Rheumatoid Factor, CRP, Uric Acid, Sedimentation Rate & ANA) were all negative, I am a bit confused on this. Perhaps you can clarify a bit?

Also, even though it says "non-specific", 80% of the pain and discomfort is by the surgery site (5th metatarsal, forefoot).

Would you say a cortisone shot is still indicated?

Thanks again - I really appreciate your help!!
Lars

Ps. The burning I experienced for a while vanished after I started using new orthotics (Good Feet [works much better than the custom ones I had]). I can now walk longer as well (30-45 minutes instead of only 10-15 before).


Hi Lars,

I am not surprised that your blood work came back negative. It seems to me all your problems are the result of the surgery, not any outside factors.

The MRI just points out the obvious; you have inflammation and that is why you are having pain. A cortisone injection would certainly be an option, as would physical therapy and perhaps oral anti-inflammatory medication. You could even try a topical anti-inflammatory medication like Voltaren gel.

You want to try and get rid of the pain, short term, and hope long term, wearing a good orthotic resolves the excess pressure on the affected area.

Marc Mitnick DPM

Mar 06, 2015
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Chronic pain in ball of foot after bunion surgery (nerve pain?)
by: Lars

Hi Dr. Mitnick,

Thanks a lot for your detailed response!

Regarding the k-wires, yes they were only for fixation for the first 3 weeks.

I asked the surgeon about how much I can walk once I could start walking, and he did not caution me about walking as long as I did it gradually and not if it hurts to do it.

I think you are right about nerve damage. I am trying other orthotics now and can walk slightly longer (about 10-15 minutes) before the fifth metatarsal on the left foot starts aching. But the bottom of my feet burn afterwards (especially the left foot). The burning is mainly on the ball and plantar fascia.

As an aside, even before my surgery I sometimes felt some burning in my feet after long walks (= about an hour in brisk pace), but not nearly this intense.

Will nerve damage from surgery like this usually heal eventually (=within a year or so)?

A friend mentioned neural prolotherapy; do you think this could help in healing the nerves?

I would not mind trying a cortisone shot, if there is a chance that it will break the cycle and resolve the issue (instead of just temporary pain relief).

Lastly, I will have an MRI next week of the left foot.

Thanks again for taking the time to guide me on this!!

Lars

RESPONSE

Hi Lars,

The burning on the ball of your foot and plantar fasciitis are probably not related to the surgery itself but more than likely from having to walk in a surgical shoe or cast during that three week period before the K-wire came out.

If you were having those similar pains prior to surgery, then chances are they may remain an issue and will have to be dealt with separately.

I am familiar with prolotherapy, but have never heard of neural prolotherapy, so cannot offer an opinion.

As I tell my patients regarding a cortisone injection. The relief may range from none at all, to total relief for the rest of your life, to anything in between. There is very little downside to the injection and may end up being a simple solution to your problem.

Good luck.

Marc Mitnick DPM
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