Introduction

What is residual limb pain (RLP)? This is the pain that originates from the remaining part of your limb. It can be caused by a variety of conditions related to your surgery, or it can be caused by conditions you had before your amputation. You and your healthcare team will want to work together carefully to understand the origin and cause of your pain in order to successfully treat it.

Normal postoperative pain

After surgery, your postoperative pain will subside during the first few weeks. After you leave the hospital, you can still take pain pills, but you should be able to reduce the number of pills fairly quickly. Methods to reduce swelling will also help reduce your pain, including elastic wraps and residual limb stockings, light massage and finger tapping, and cold packs.

Residual limb pain is different from this normal postoperative pain. For example, it commonly occurs after your post-operative pain has stopped. It is often described as sharp, painful, throbbing or burning in nature. Your entire health care team, including your doctors, therapists, and prosthetists, will work with you to determine the cause of this pain and decide what treatments may be most effective.

Possible causes of residual limb pain include:

• Underlying disease process such as skin problems and infection and nerve pain (neuropathy), especially if you have diabetes or circulation problems
• Surgical trauma, including reduced blood supply to your limb or poor tissue coverage at the end of the bone
• Neurotransformation
• Entrapment of nerves in scar tissue.

Underlying disease processes

The key to managing symptoms of pain related to a pre-existing condition such as diabetes is to ensure that the condition is managed as well as possible.

If you have diabetes, for example, keep your blood sugar under good control. If you have poor circulation, follow your doctor’s instructions for diet, exercise and medication.

Management of pre-existing conditions after surgery is as important as ever.

Surgical trauma

Poor tissue coverage can be caused by the bone at the end of your remaining limb not being trimmed properly at the time of surgery, and this can cause pain when you wear your prosthesis. If padding and other methods are unsuccessful, surgery may be needed to revise your remaining limb to reduce your pain and allow you to wear your prosthesis.

Neuromas

A neuroma is a collection or bundle of nerve endings that forms under the skin of your remaining limb. Think of it as a tangle of hair. It can become very sensitive, especially if the tangle presses against your prosthesis.

Because neuromas are made up of nerve endings, possible treatments include medications that help with nerve pain, such as:

• Non-steroidal anti-inflammatory drugs
• Specific antidepressants and anticonvulsants that have been shown to be effective for
• nerve pain
• Steroid injections.

Non-medical options include:

• Ultrasound, which is essentially a machine that uses sound waves to generate heat in a body part. It can help increase blood flow so inflammation and swelling can be reduced
• Massage, which also helps reduce inflammation and also helps desensitize your remaining limbs to touch
• Vibration, which creates a gentle shaking to contract the muscles and reduce inflammation and pain
• Percussion/finger tapping on the pain point, which also helps desensitize your residual limb
• Acupuncture, the manipulation of thin, solid needles that have been inserted into specific pressure points in the skin, which has been helpful for some
• TENS (transcutaneous electrical nerve stimulation), which produces a sensation of mild pins and needles that overrides some of the pain your body produces.

It may also be helpful to change the socket of the prosthesis to prevent rubbing of the sensitive part of your limb.

Unfortunately, surgery to remove neuromas is usually not successful because they often just reform.

Heterotopic bone

Occasionally, excess bone forms abnormally around the end of the amputated limb; this is sometimes called a “bone spur”. The “extra” bone can cause pressure points that interfere with the fit of your prosthesis; this occurs more frequently in children than in adults. If the problem cannot be solved with changes to the prosthesis, surgery can remove the excess bone. For children, this is best done when the bone stops growing.

Entrapment of nerves in scar tissue

As your incision begins to heal, your doctor will let you know when you can begin massaging your remaining limb. This will help prevent nerves from getting “trapped” in scar tissue. You will also be taught how to wrap your limb with elastic. This not only helps prevent scarring, but also aids in prosthetic fitting.

Management of pain

Regardless of the cause of residual limb pain, there are some principles that can be followed to help you manage your pain.

• Begin exercises as soon as your surgeon allows. Standing, walking and stretching muscles not only improves your overall health, but also interrupts pain signals.
• Desensitize your remaining limb by following the instructions of your physical or occupational therapist; this includes both massaging and wrapping your remaining limb.
• Keep a pain journal. Keeping track of your symptoms and sharing them with your healthcare team will help you find the right treatments for you.
• Practice relaxation. We know that tension and stress increase pain. It is estimated that 50 percent of pain can be reduced by relaxation.

About the Amputation Coalition

The Amputee Coalition is a donor-supported, nonprofit volunteer health organization serving the over 5.6 million people with limb loss and limb disparity in the United States.

For more information, please call 888-267-5669 or visit amputee-coalition.org.

Recognitions

This project was supported in part by Grant No. 90LLRC0001-01-00 from the Administration for Community Living, US Department of Health and Human Services, Washington, DC 20201. Grantees undertaking projects under government sponsorship are encouraged to freely express their findings and conclusions. Views or opinions therefore do not necessarily represent official Administration for Community Living policy.