Complex Pain After Nail Surgery

ConsultingFootPain's David Tollafield writes to help clinicians and patients.

Two clients wrote to consultingfootpain for advice. Cases N and M are discussed.

Could this reality be you?

A client wrote in to ConsultingFootpain for advice. Albeit rare, it is clear that the condition of complex (regional) pain syndrome [CRPS] can be missed and treatment encountered later than ideal.

You can also read other articles covering CRPS on this site. Complex Pain as a Syndrome and Dupuytren's and Complex Pain and Pain after Injections for Nail Surgery

CASE N - FEMALE AGE 57. CANADA

Case N

I hope you can give me advice after my big toe surgeries. I have 2 surgeries on my big toe in May and October last year. The second podiatrist has removed regrown nail at the same place in October. Phenol is used for both surgeries. I still have a lot of pain around the nail edge. The area is red and swollen.  The second podiatrist thinks there is no new nail, but a nerve might be damaged or trapped inside the scar tissue. Please see the attached picture. He is suggesting to inject saline solution to the area. I already have steroid injection in February but it didn't help.

Reply DRT

Two nail surgeries close together can sometimes cause long-standing pain, although this is uncommon. Phenol is toxic and can lead to deep-seated pain, although it is the correct approach for nail destruction as first-line treatment. 

From your photo, the phenol appears to have worked, and the tell-tale is the uneven edge. It is unlikely that a nerve has been trapped, let alone scar tissue. An injection of saline is unlikely to work, and I presume this has been suggested to dilute the toxicity. As it was last October (2024), this would be a waste of time and an unnecessary risk.

My approach would be to consider a topical steroid for 2-3 weeks to see if this could reverse the sensory discomfort. If this failed, an X-ray would be advised. You could also approach your GP. 1% hydrocortisone is available over the counter, but stronger corticosteroids will require a prescription. 

Previously Undisclosed Information

CASE N replies

I have done x-rays and CT scans in March, and everything was normal. MRI was done in January and it showed some granulated tissue. I am currently taking Gabapentin for nerve pain,  and ibuprofen for pain. I will ask my GP for a steroid cream. Do you think that I should see a neurologist? If you have any other suggestions for my pain,  swelling and redness, please let me know. Thank you, N

 Reply DRT

I had not appreciated that you had moved to the neuroleptic drug Gabapentin. This would have been the next course. You are now treading into the area of regional complex pain syndrome (CRPS). This is a condition that arises through any form of trauma, and the nerves that conduct pain fail to switch off.

You are spot on and should see either a neurologist or a pain specialist. Podiatrists (in Canada) are usually DPM or doctors of podiatric medicine, while Canada also has chiropodists. It is doubtful that a podiatrist can do any more for you, and a word of warning. Avoid any further surgery because, cent to a dollar, you will worsen. I assume the rest of your body has not been affected except for your state of anxiety, as this is not a pleasant condition.

Please be sure to get a diagnosis as best you can. I don't know what granuloma tissue is on an MRI without seeing the report, as this is skin-related. If it is CRPS, then there is limited treatment, and time alone is required. Avoid wearing any shoes that irritate the toes. 

CASE N replies

Can you please let me know why Gabapentin is not good idea. Does it slow nerve recovery?

I would try a steroid cream, and try to get an appointment with a neurologist although the waiting time is very long. I guess there is nothing else I can do except to give it a time.

Reply DRT

Gabapentin is indicated for nerve-like pain, or pain created by nerves when standard painkillers fail. I used this drug for similar cases. The drug does have side effects, and the dosage has to be monitored. Too low and it is ineffective. Too high and the side effects increase. I would have used steroid cream before Gabapentin, but it is worth a try. I am sorry, but long waiting times are very frustrating for patients. We have the same problem in the UK.

Thanks for reading Complex Pain After Nail Surgery by David R Tollafield

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