Phantom limb pain after leg amputation

What phantom limb pain feels like

People describe pain that seems to come from the missing foot, toes or leg. Phantom limb pain is different from phantom sensation, where you can feel the missing part without pain, and from residual limb pain, which is felt in the part that remains.^[2]

How common it is

A pooled analysis of studies from 1980 to 2019 estimated that 64% of people with an amputation reported phantom limb pain, though the studies varied widely. The risk was higher when there had been long-lasting pain before the operation, when the amputation was higher on the limb, with pain in the residual limb, in lower limb amputations, and with phantom sensations.^[1] After amputation for poor circulation, another pooled analysis found 69% reported phantom pain.^[8] Other reviews describe a range of 40% to 80%.^[3]

Why it happens

Researchers think phantom pain comes from several places at once: changes in how the brain and spinal cord process signals from the missing limb, activity in the injured nerve endings, and psychological factors.^[2,3] Because more than one mechanism is at work, treatment often needs more than one approach.

Evaluation

The first step is to find out whether pain is phantom pain, residual limb pain or both. Your clinician will examine the residual limb for tender spots that shoot or tingle when touched, check the prosthesis fit and the skin, and ask about medicines, sleep, mood and daily activity. If a neuroma is suspected, imaging and a diagnostic injection can help; these are arranged with another specialist. See residual limb neuroma pain.

Treatment options

• Medicines. Medicines for nerve pain are commonly used and are managed by your physician. A network meta-analysis of 12 randomized trials found that morphine was linked to a higher rate of side effects.^[4]
• Brain and nerve stimulation. In the same analysis, repetitive transcranial magnetic stimulation gave the largest improvement in pain compared with sham treatment, with moderate-quality evidence. The number of trials was small and long-term results were not available.^[4]
• Mirror therapy and rehabilitation. Mirror therapy uses a mirror to show the reflection of the intact limb where the missing limb would be. Some meta-analyses report benefit, but a review that included only placebo-controlled trials found the evidence too weak to conclude that it works, mostly because of small, low-quality studies.^[5]
• Surgery on the nerves. A randomized trial of 28 people with chronic pain after amputation compared targeted muscle reinnervation with the standard approach of removing the neuroma and burying the nerve in muscle. Phantom limb pain scores improved more with targeted muscle reinnervation over time, and residual limb pain trended in the same direction.^[6] A pooled analysis of 17 studies of targeted muscle reinnervation and regenerative peripheral nerve interface surgery found phantom limb pain improved in 45% to 80% of patients treated, but the studies were mostly small.^[7] See targeted muscle reinnervation and regenerative peripheral nerve interface.

A review of phantom limb pain management concluded that novel surgical methods look promising, and that the long-term efficacy of each option still needs randomized trials.^[3]

Prevention

Pain before an amputation is a risk factor, so good pain control beforehand is worth discussing with your surgical team.^[1] Some surgeons also treat the cut nerves at the time of amputation. See pain after leg amputation.

Living with phantom pain

• Tell your care team about the pain early. It is real, and there are options to try.
• Keep the residual limb protected and the prosthesis well fitted.
• Rehabilitation, good sleep and attention to mood are part of a complete plan.

When to seek care

Consider an evaluation if you have pain in an amputated limb that is not controlled, is affecting sleep or walking, or is accompanied by a tender, shocking spot in the residual limb.