Przejdź do treściA sharply localised burning, stabbing or electric-shock-like pain in or next to a surgical scar can come from an irritated or trapped cutaneous nerve and, in some cases, from a painful neuroma. Not every tender scar is a neuroma, however. Normal healing, infection, implant-related problems, local tissue overload and complex regional pain syndrome must also be considered.
What is a postoperative neuroma?
When a nerve is cut or significantly injured, its fibres attempt to regenerate. If they cannot reconnect with the distal segment, a disorganised bulb of regenerating nerve tissue may form at the nerve end. This is a traumatic neuroma. Similar symptoms can also occur when a nerve remains anatomically continuous but becomes tethered in dense scar tissue or repeatedly irritated during movement.
Which symptoms suggest neuropathic scar pain?
- a very small, clearly defined point of maximal tenderness within or next to the scar;
- burning, stabbing, shooting or electric-shock-like pain;
- pain radiating along a nerve distribution when one specific point is pressed or tapped;
- numbness, hypersensitivity or pain from light contact such as clothing;
- symptoms aggravated by stretching the scar, moving the nearby joint, footwear or a brace pressing on the area.
During the first weeks after surgery, local tenderness, a small patch of numb skin and altered sensation may improve gradually without additional treatment. A neuroma becomes more likely when the pain has a distinctly neuropathic quality, persists or worsens, and can be reproduced consistently by pressing one focal point.
How is it investigated?
What does an orthopaedic surgeon assess during examination?
The scar itself is examined together with the distribution of sensory change, muscle strength and the expected course of the nerve. The clinician may also check whether tapping the painful point reproduces radiating symptoms. It is useful to know whether the nerve could have been cut, mobilised or placed at risk during the original operation.
High-resolution nerve ultrasound
High-resolution ultrasound can demonstrate focal nerve enlargement, loss of continuity, tethering to scar tissue and the relationship to tendons, implants or vessels. Dynamic examination may show whether movement stretches or displaces the symptomatic segment. A normal ultrasound does not completely exclude pain arising from a very small cutaneous nerve branch.
Other tests
MRI, including MR neurography in selected cases, may be helpful for deeper lesions. Nerve conduction studies and electromyography are more useful when pain is accompanied by muscle weakness or sensory loss in the territory of a larger peripheral nerve. A selective local anaesthetic injection can sometimes help test whether a particular nerve segment is generating the pain, but the result still needs to be interpreted in the context of the full examination.
How are painful scars and neuromas treated?
Treatment depends on the time since surgery, the severity of symptoms and whether the nerve is thought to be divided, tethered or temporarily irritated. Early management may include protecting the area from pressure, gradual desensitisation, scar mobility work and appropriate medical treatment for neuropathic pain. Aggressive massage directly over a very painful focal point before the diagnosis is clear can aggravate symptoms.
Selected patients may benefit from diagnostic or therapeutic injections, sometimes performed under ultrasound guidance. Evidence for hydrodissection and other injection-based techniques remains limited, so these procedures should not replace an effort to identify the underlying pain mechanism.
Surgery may be considered when pain is persistent, well localised, functionally important and has not improved with appropriate conservative treatment. Options include freeing a nerve from scar tissue, excising a neuroma and protecting or reconstructing the nerve end. The technique depends on the anatomy and on whether meaningful nerve continuity can be restored; no procedure guarantees complete relief.
When is urgent assessment needed?
Do not assume that worsening scar pain is a neuroma if the wound is hot, red or draining, if fever develops, swelling is increasing rapidly, or pain suddenly becomes much more severe. New or progressive muscle weakness, widespread numbness, a cold or pale limb, or severe pain associated with marked colour or temperature change and swelling of the whole region also require prompt assessment. Sudden neurological weakness should be investigated without delay.
Key point
A painful neuroma is one possible cause of persistent scar pain after surgery, but the diagnosis requires a consistent symptom pattern, clinical examination and—when appropriate—imaging or a diagnostic block. Treatment is most useful when it targets a specific mechanism rather than simply attempting to “break up” the scar.
References
- Zhou L, Huo T, Zhang W, et al. New techniques and methods for prevention and treatment of symptomatic traumatic neuroma: a systematic review. Front Neurol. 2023;14:1086806. DOI: 10.3389/fneur.2023.1086806.
- Hendrickson NR, McDonald JR, Kennedy SA, et al. Treatment of Postsurgical Neuroma in Foot and Ankle Surgery. Foot Ankle Orthop. 2023;8(3). DOI: 10.1177/24730114231188125.
- Grimm A, Décard BF, Athanasopoulou I, et al. Nerve Ultrasound in Traumatic and Iatrogenic Peripheral Nerve Injury. Diagnostics. 2021;11(1):30. DOI: 10.3390/diagnostics11010030.
Content prepared by: Tomasz Poboży - orthopaedic surgeon.