103 - Scarred and Sensitive: Ankle Pain From a Hidden Neuroma

A 23-year-old male with chronic left ankle pain and paresthesias, seven years after open reduction and internal fixation for distal fibula fracture with syndesmotic injury presented with worsening leg pain with activity, fluctuating distal leg palpable nodule, and numbness adjacent to the surgical scar and in the 4th–5th toes. Physical exam showed positive Tinel’s at the distal fibula and palpable nodule. Orthopedics suspected irritation caused by surgical hardware, muscle herniation, or fascial defect and recommended hardware removal or debridement. Diagnostic ultrasound revealed a 1.04 × 0.37 × 0.51 cm3 hypoechoic non-compressible mass at the distal leg, consistent with a traumatic superficial fibular nerve neuroma. The patient underwent ultrasound-guided nerve hydrodissection with dextrose 5% in water (D5W) injection.

Discussions:

Ultrasound confirmed a neuroma, avoiding repeat surgery and guiding targeted injection therapy. Current literature notes that post-surgical neuromas are a recognized cause of chronic pain and disability, with both traditional surgical treatments (e.g., nerve stump burial in bone vs. muscle) and emerging minimally invasive, image-guided techniques (like hydrodissection with D5W) demonstrating promising outcomes. Additionally, ultrasound-guided interventions—such as steroid injections, phenol instillation, and cryoablation—have been shown in clinical studies to effectively reduce neuroma-related pain in many patients while minimizing surgical morbidity. This case highlights ultrasound’s diagnostic and therapeutic role in post-surgical neuromas and the importance of PM&R, sports medicine, and orthopedics collaboration.

Conclusions:

Peripheral post-surgical neuromas require accurate imaging and multidisciplinary management to optimize outcomes and quality of life.