Chronic Pain After Foot Surgery

Chronic Pain After Foot Surgery: What You Need to Know

Foot and ankle surgeries are commonly performed to relieve pain and improve mobility. However, for a significant number of patients, pain doesn’t always resolve with surgery. Instead, some continue to experience chronic postoperative pain (CPOP)—pain that persists long after the surgical wound has healed.

What Is Chronic Postoperative Pain?

Chronic postoperative pain (CPOP), sometimes called chronic postsurgical pain (CPSP), is defined as pain that:

  • Persists for more than 2–3 months after surgery, even after normal healing is complete.
  • Cannot be explained by other causes like infection or fracture.
  • May or may not have neuropathic characteristics (nerve-related symptoms like burning or electric shocks).

While commonly studied in major surgeries like thoracotomy or joint replacement, this condition is now increasingly recognized in foot and ankle surgery patients as well​

How Common Is Chronic Pain After Foot Surgery?

A major study of 260 patients who underwent scheduled orthopedic foot surgery found that:

  • 21% had moderate-to-severe pain at rest one year after surgery.
  • 43% experienced moderate-to-severe pain while walking.
  • Only 3% had confirmed neuropathic pain one year post-op.

These findings suggest that chronic pain after foot surgery is as common as it is after major surgeries like hip or knee replacements, though nerve pain is rarer​.

What Increases the Risk of Chronic Pain?

1. Pain Right After Surgery

If patients experience moderate-to-severe pain within the first 24–48 hours post-op, they are at a significantly higher risk of having pain one year later. Acute pain is a well-documented trigger for chronic pain development​
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2. Revision Surgeries or Past Foot Trauma

Patients who had a prior surgery or an old trauma in the same area were nearly four times more likely to have chronic pain during walking a year later​

3. Surgical Complexity

Interestingly, the type of surgery (whether on toes, midfoot, or hindfoot) did not significantly alter the risk of chronic pain. This contradicts the belief that more proximal or complex surgeries always carry higher risk​

What Are the Effects of Chronic Pain?

Chronic foot pain can be life-altering. Patients with moderate-to-severe pain:

  • Are more likely to use strong pain medications, such as opioids.
  • Experience reduced mobility, often needing walking aids.
  • Report difficulty wearing regular shoes and completing daily activities.
  • Suffer from a poorer quality of life overall.

Even in cases where surgery was performed successfully from a structural standpoint, lingering pain significantly impairs long-term outcomes​

Is the Pain Neuropathic?

While neuropathic pain (pain caused by nerve injury or dysfunction) is common in other types of surgeries, it is rare in foot surgery, affecting only 3% of patients in the study. This may reflect:

  • The specific nerves involved in foot surgeries.
  • Effective pain control methods used during and after the procedure.

The low rate may also be due to the limitations of telephone-based assessments, which can miss subtle nerve dysfunctions without physical exams​

Current Approaches to Pain Management

A second major review of the literature found very limited research on long-term pain management in elective foot and ankle surgeries​.

1. Multimodal Analgesia Helps

The use of multiple pain control strategies—like nerve blocks, NSAIDs, acetaminophen, and ketamine—helps reduce opioid use and may lower the risk of chronic pain.

2. Regional Anesthesia Is Crucial

Most studies reviewed used popliteal sciatic nerve blocks, and some used additional femoral or saphenous blocks. These approaches:

  • Reduced opioid requirements.
  • Delayed the need for additional pain medications.
  • Improved pain control during the hospital stay.

However, most studies only followed patients for 48 hours after surgery—too short to assess true chronic pain outcomes​.

Gaps in Research and the Need for Better Definitions

  • Only one study in the review followed patients up to six months. There is no standardized definition of CPSP in foot surgery across disciplines, which makes data inconsistent and hard to compare​
  • Patients who used opioids before surgery were often excluded from studies, yet they represent a high-risk group that needs more attention in future research.

What Can Patients and Surgeons Do?

For Patients:

  • Report all pain levels honestly during recovery, especially within the first 48 hours.
  • Stay on schedule with prescribed medications.
  • Use walking aids or orthotics if needed, to reduce stress on the healing foot.
  • Ask your doctor about nerve blocks and multimodal pain control before surgery.

For Surgeons:

  • Prioritize early and aggressive pain management, especially in high-risk patients.
  • Consider earlier surgical intervention before the condition becomes severe.
  • Include follow-up beyond 6–12 months to better track long-term outcomes.
  • Evaluate pain using standardized tools like the DN4 questionnaire for neuropathic features.

Conclusion

Chronic pain after foot surgery is more common than most people realize, affecting nearly 1 in 5 patients at rest and nearly half while walking. Although neuropathic pain is rare, chronic discomfort can impact mobility, mental health, and quality of life. Early, consistent pain control, careful patient selection, and long-term follow-up are essential to reducing the burden of this under-recognized complication.