Pain 8 months after surgery, but no inflammation?

by Jim
(California)

Greetings Dr. Mitnick,

I had bunionette surgery on left foot roughly 8 months ago, but for some reason the foot still hurts whenever standing or walking (often with some pain also when not on my feet). The pain is mainly on and around the osteotomy area (with extra pressure there).

I have had my foot examined by three foot specialists and none of them could tell why it still hurts.

X-rays look normal and I had an MRI (multiplanar, multisequence with and without IV contrast); the "Result Impression" was:
1. Status post varus and lateral resurfacing osteotomy of the distal neck and head of the 5th metatarsal with residual postsurgical changes.
2. Mild dorsal subluxation of the 5th proximal phalanx with poor visualization of the plantar plate.
3. Bipartite medial hallux sesamoid with trace edema in the proximal pole.
4. Nonspecific edema in the tuft of the 1st distal phalanx. Correlation with plain film is recommended.

From what I can tell, there is no inflammation found in the osteotomy area (only some in the big toe).

What could be causing this aching pain around the osteotomy area whenever I stand or walk?

Could the "residual postsurgical changes" (#1 above) have anything to do with it?

I use orthotics and they help, but not enough (still pain and discomfort when walking or standing).

I am concerned that it still hurts and does not seem to be improving (been about the same for the last 5-6 months).

Have you seen this kind of situation before?

What would you recommend?

Thanks,
Jim

RESPONSE

Hi Jim,

One would hope that eight months down the road you would be looking at this surgery through your "rearview mirror" and unfortunately, you are not.

Obviously, I am at a distinct disadvantage because I cannot actually examine you but perhaps I can offer a little insight and you might go back and get verification from one of the foot specialists you have already seen.

"Status post varus and lateral resurfacing osteotomy of the distal neck and head of the 5th metatarsal with residual postsurgical changes." What this means to me by post surgical residual changes is that perhaps the osteotomy is not completely closed. An MRI would be better at picking this up than an x-ray.

If the osteotomy is not completely closed then that could be one factor that would account for your ongoing pain. The only other postsurgical change that I could imagine a Radiologist seeing would be post operative edema and he makes no mention of that, yet, does mention edema in a different part of your foot.

The Radiologist also goes on to mention "Mild dorsal subluxation of the 5th proximal phalanx". That means the fifth toe is riding up the head of the fifth metatarsal. I would be curious to see pre-operative vs. post-operative x-rays to see if the dorsal subluxation is the same, or at least very close to it.

If there is greater dorsal subluxation post-operatively then that would suggest to me that when the osteotomy was performed, not only was the head of metatarsal slid over closer to the fourth metatarsal, but also plantarflexed somewhat, meaning the head of fifth metatarsal was pushed downward. The consequence of this would be more pressure on the head of the metatarsal when it hits the ground, which might translate into pain.

I do not mean to imply this was done intentionally by your surgeon, but if the osteotomy cut is "off" just a little, something like that could happen. So, if the metatarsal head is plantarflexed, it would cause the fifth toe to ride upwards.

Again, you need to compare pre vs. post-op x-rays.

The other possibility is that there is mention of "poor visualization of the plantar plate." The plantar plate is a ligament that attaches the fifth metatarsal head to the base of the fifth toe. If this was cut during surgery, that might also be the source of your pain. If you bend your fifth toe upwards and backwards, and are able to re-create your pain, then that might suggest a plantar plate tear. A tear of this ligament might also cause the fifth toe to dorsally sublux.

Lastly, with any kind of surgery there is also the chance of scarring in certain areas. If your surgical site has some excess scarring, that too, could cause pain.

In summary, the things I would want to rule out are the following:

1. incomplete closure of osteotomy
2. plantarflexed fifth metatarsal head
3. plantar plate tear
4. excessive scarring

Each problem would require a different treatment approach so that is why it is imperative to isolate the problem before undergoing any further treatment.

That is about as far as I can go based on your narrative.

Marc Mitnick DPM
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