Post-Fracture Foot Pain: Insights on Rehabilitation and Treatment

Plantar pain due to tibial and fibular fractures?

Hello Dr.
Lee, on February 10, I fractured my left tibia and fibula, and subsequently underwent open reduction and internal fixation surgery.
A bone plate and screws were placed in the fibula, and another bone plate and screws were placed in the tibia near the ankle joint.
I was in a cast for two and a half months.
In early May, the orthopedic surgeon said the bones were healing well, but I experienced significant pain while walking, so I went to a regional hospital's rehabilitation department for hydrotherapy, balance training, and gait training.
By the end of June, the range of motion in my ankle had recovered to about 80%, but I still felt numbness and pain in the entire sole of my foot.
The orthopedic surgeon suggested it might be plantar fasciitis, and the rehabilitation physician also focused on adding treatments for plantar fasciitis.
After rehabilitation until the end of July, I still experienced numbness and pain in the forefoot and heel, with only slight relief in pain.
At the end of July, I visited a rehabilitation clinic (Clinic A) where an ultrasound indicated adhesions of the tibial nerve and superficial peroneal nerve, and there was a small amount of fluid accumulation at the surgical site, but it was not concerning.
The treatment plan was to receive prolotherapy injections (5% dextrose solution + B12) three times a month for one treatment cycle.
In early August, I went to a large hospital's rehabilitation department (Hospital B), where an ultrasound showed swelling and fluid accumulation at the site of the tibial fracture in the ankle.
They advised me to continue rehabilitation and when I inquired about prolotherapy, the rehabilitation physician at Hospital B advised against injections due to the potential risk of infection.

Dr.
Lee, I have a few questions:
Q1: Should I seek treatment at another rehabilitation department or consult a neurologist to determine the cause of my symptoms?
Q2: Given my current situation, do you recommend prolotherapy injections, or should I continue with rehabilitation as advised by the physician at Hospital B? I am concerned that if it is indeed nerve adhesion, delaying the injection might hinder my recovery.

Q3: What is the reason for the potential risk of infection with prolotherapy injections? Is it related to the presence of the metal plate? Thank you, Dr.
Lee, for your patience in reading my questions.
I appreciate it!

Mi Ya, 40~49 year old female. Ask Date: 2020/08/03

Dr. Li Yanheng reply Rehabilitation

1.
It is recommended to continue the current rehabilitation and prolotherapy, but consideration should be given to treating additional related areas to enhance joint stability.
2.
With complete wound healing and the absence of specific infectious factors, along with adequate disinfection, there should be no significant increase in the risk of infection.

Reply Date: 2020/08/03

More Info

Understanding post-fracture foot pain, especially after a significant injury like a fracture of the tibia and fibula, can be complex and multifaceted. Your experience highlights several important aspects of recovery, rehabilitation, and the management of pain and discomfort that can arise after such injuries.

Firstly, it is essential to recognize that pain following a fracture can stem from various sources. After surgical intervention, such as open reduction and internal fixation, patients often experience pain due to several factors, including soft tissue trauma, inflammation, and potential nerve involvement. In your case, the presence of symptoms like numbness and tingling in the foot could indicate nerve irritation or entrapment, which is not uncommon after lower limb fractures.

Q1: Should you seek further evaluation from a different rehabilitation center or a neurologist?
Given your ongoing symptoms of pain and numbness, it may be beneficial to consult a neurologist or a specialized pain management clinic. They can perform a thorough evaluation to determine if there is any nerve damage or entrapment contributing to your symptoms. Diagnostic tests such as nerve conduction studies or electromyography (EMG) can provide valuable insights into the function of the nerves in your leg and foot. Additionally, a second opinion from another rehabilitation specialist might offer new perspectives on your treatment plan.

Q2: Should you consider prolotherapy (injection therapy)?
Prolotherapy, or injection therapy, can be a useful treatment for certain conditions, particularly when dealing with chronic pain and potential ligament or tendon issues. However, the decision to proceed with prolotherapy should be made carefully. While some practitioners advocate for its use in cases of nerve entrapment or chronic pain, others, like the physician at B hospital, may advise against it due to the risk of infection or complications, especially in the presence of hardware (like metal plates and screws) from your surgery.
In your case, if the conservative rehabilitation approach is yielding only minimal improvement, and if there is a strong suspicion of nerve adhesion, prolotherapy could be considered after weighing the risks and benefits. It is crucial to have a detailed discussion with your healthcare provider about your specific situation, including the potential risks of infection and the likelihood of success based on your current condition.

Q3: Why is there a risk of infection with injection therapy?
The risk of infection with injection therapies, such as prolotherapy, can arise from several factors. Firstly, any procedure that involves breaking the skin carries a risk of introducing bacteria into the body. This risk can be heightened in patients with surgical hardware, as the presence of metal can create a niche for bacteria to thrive if an infection occurs. Additionally, if there is any residual swelling or fluid accumulation at the injection site, it may increase the risk of infection.
Moreover, the technique and environment in which the injection is performed play a significant role in infection risk. Ensuring that the procedure is done in a sterile environment by a qualified professional can mitigate some of these risks.

Conclusion
In summary, your ongoing symptoms after tibia and fibula fractures warrant a comprehensive approach to diagnosis and treatment. Consulting with a neurologist may provide clarity on any nerve-related issues, while continued rehabilitation is essential for recovery. The decision to pursue prolotherapy should be made collaboratively with your healthcare team, considering the potential benefits and risks involved. Always prioritize open communication with your medical providers to ensure that your concerns are addressed and that you receive the most appropriate care for your condition.

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