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Nerve pain after ATFL surgery

by Trudy
(Dallas, TX USA)

June 2012 I had a complete disruption of my left ATFL, after 3 months in a boot I had surgery. Prior to surgery I had numbness on the outer side of my foot and my last 2 toes. After surgery I have severe nerve pain which has increased since November 2013. Since December 2013 I have been back in a walking boot. My Podiatrist has done 3 cortisone shots since putting back in the boot. After 2 MRI's and several x-rays I have been diagnosed with an impinged nerve at my incision site caused by scar tissue. I had another opinion by a an associate. He has given me 2 options, the first is having another surgery freeing the nerve from the scar tissue and placing tissue over the nerve to help alleviate the scar tissue from growing back and impinging the nerve again. The other option is to kill the impinged nerve in my ankle and foot. Is this a common issue after having this type of surgery? Are the options I have been given the normal treatment to resolve the nerve pain and scar tissue problems? The nerve pain I have been experiencing ranges from pins and needle feeling, stabbing sharp pains, dull constant pain radiating into my left leg, hot burning pain radiating throughout my foot. Numbness in my last two toes and now on the bottom of my foot. In addition to the nerve pain I have been having charlie horse pain on the top of my foot. The muscle belly area of my foot is inflamed. I have been taking a compound cream for anti scarring and nerve pain, in addition to nerve pain medication and anti-inflammatories. I just want to make sure I am on the right path to recovery and not having another surgery to only find out I made the wrong decision about treatment. I want the problem resolved, not just mask the problem. Thank you for any help you can give me. Please email me with responses.


RESPONSE

Hi Trudy,

In answer to one of your questions, nerve entrapments can occur in any type of musculo-skeletal surgery, any where in the body. Yours is of the sensory nerve variety, the lateral dorsal cutaneous nerve variety which runs just under the skin, very close to where you had your incision.

Based on your narrative, it sounds like you had this problem before surgery since you state you had "numbness on the outer side of my foot and my last 2 toes" (prior to surgery). If that was the case, I would have thought your surgeon would have tried to identify the nerve during surgery and try and free it up, but in his defense the impingement may not have been in the area of the incision.

Since it has worsened after surgery, you can assume there is now further impingement of the nerve and thus your symptoms are worse.

I am concerned about the fact that you now have issues on the bottom of your foot. The first thing that comes to mind is a possible tarsal tunnel issue on the bottom of your foot, more than likely due to a change in your gait trying to "protect" the outside of your foot. This is just a guess because I do not have the luxury of examining you. The argument could be made that if the problem on the outside of your foot could be remedied, the pain on the bottom would also resolve, once you got back to walking more normal.

The two treatment options you have been given are fairly standard. The problem with surgery is that 1. your surgeon may have difficulty finding the nerve and certainly the part that is entrapped, and 2. even if he does locate it, and isolate it, it may not work.

Trying to deaden the nerve might prove to be a better option and it is certainly something you should consider trying before any additional surgery. There are various methods available to accomplish this and most of them are minimally invasive.

My favorite is repeated injections of 4% denatured alcohol which attempts to sclerose, or deaden the nerve. If there is no longer nerve transmission, there no longer should be the various neurological pains you are experiencing. The downside is of course, you may now have numbness along the course of the nerve and into the fifth toe as well as part of the fourth toe. Keep in mind, this is a sensory nerve as opposed to a motor nerve, so it will not affect your ability to walk.

I would be remiss if I did not mention physical therapy as one possible treatment option. The problem I have with offering you this as a viable option is that too much time has passed since the surgery and the potential scarring that has occurred is not "fresh" enough to respond to physical therapy, BUT, there would certainly be no harm in trying it before doing anything else.

Lastly, if you still are not sure what to do, I would suggest you get another opinion from a local doctor who is not affiliated with your doctor. You want an opinion from someone who is not biased.

Marc Mitnick DPM
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