When to get a second opinion for foot nerve pain

Most people never need a second opinion for a foot nerve problem. But some do, and they are often the ones who have been told “there’s nothing more we can do” or “it’s all in the normal range” while still hurting. Here is when a second look makes sense, and what it should cover.

Reasons to consider one

• Symptoms that haven’t improved several months after nerve surgery, or that came back after a period of improvement.
• Pain, burning or numbness after any operation or injury that hasn’t settled. See nerve pain after ankle surgery.
• An uncertain diagnosis. You have been treated for one problem, such as plantar fasciitis or a back problem, but the symptoms suggest a nerve, or the other way around.
• Treatment at one site hasn’t helped. Dissatisfaction after treatment at one site may be due to persistent pathology at another site along the same nerve.^[3]
• Tests were normal but symptoms are real. Our guide to normal EMG but still nerve pain explains why that happens.

Why nerve symptoms can persist or return

A second opinion often starts by asking why. Some known reasons:

• The original diagnosis was incomplete or incorrect. After Morton’s neuroma surgery, symptoms may recur because of an incorrect diagnosis, inadequate resection, or pressure on a nerve stump neuroma.^[1] Among primary neurectomies, 50% to 85% of patients obtain relief, and the relief rate after reoperation is similar.^[1]
• The release was incomplete. In a series of eight revisions for failed tarsal tunnel release, insufficient release, especially further down the foot, was found in every patient.^[2]
• A painful nerve end. After a nerve is cut, the end can form a new, sensitive neuroma, especially if it sits where it is pressed on when you walk.^[1]
• A second pinch point or a body-wide neuropathy. A neuropathy can coexist with a compressive neuropathy and contribute to suboptimal results after decompression.^[3] In a series of 14 people with a pinched L5 nerve root and a compressed peroneal nerve, seven still had symptoms after their back had been treated, and releasing the peroneal nerve gave a successful result in 93% of the group, although the series was small.^[6]

What a good second opinion includes

1. Your full story, including the original problem, the operation and how symptoms have changed.
2. Records. Operative reports, imaging and previous test results. Ask your previous surgeon’s office to send them, or bring your own copies.
3. A careful examination, mapping numbness and sensitivity, tapping along nerves and around scars, and checking for other causes such as neuropathy, circulation problems or the lower back.
4. Tests that would change the plan, such as imaging or nerve studies, arranged with other specialists.
5. An honest discussion of options, including non-surgical care.

What the options can be

• Non-surgical care. Footwear and padding changes, desensitization therapy, and medicine for nerve pain managed with your other clinicians. See pinched nerve in the foot: what to try before surgery.
• Revision surgery, when appropriate. For a recurrent Morton’s neuroma, revision often means removing the nerve further back and relocating the cut end into muscle or bone. In a long-term study of revision through a dorsal incision, 17 of 23 patients scored as excellent.^[5,1] For a failed tarsal tunnel release, revision typically means re-releasing the tibial nerve and each of its branches in its own tunnel. In a series of 44 patients, 54% had excellent and 24% good results, and coexisting lumbosacral disc disease or neuropathy predicted poorer results.^[4]
• For painful neuromas after several operations, options include removing the neuroma and relocating the nerve end, reconstructing the nerve, or giving it a target to grow into.^[7] See revision nerve surgery and nerve repair and reconstruction.

Realistic expectations

Revision surgery is more complex than a first operation, and the published evidence consists mainly of small case series. The goal is a meaningful improvement in pain and function; complete relief is not always possible, and it is reasonable to take time to decide.

When to see a specialist

Consider an evaluation if nerve pain, burning or numbness hasn’t improved several months after nerve surgery, or if it returns after a period of improvement.