Multimodal pain management in foot and ankle surgery and trauma: a narrative review

Foot and ankle procedures are frequently associated with significant acute pain, with studies reporting moderate-to-severe pain measured on the Visual Analog Scale (VAS) at 5-6, in up to 67% of patients in the first 24 h. Crucially, uncontrolled acute pain is a major risk factor for chronic pain, with an estimated prevalence ranging from 10 to 50%, and a 3% risk of developing persistent neuropathic pain one year post-surgery. Given the complex innervation of the distal lower limb, effective pain management is paramount to prevent central sensitization and chronification. This narrative review provides a comprehensive synthesis of the current evidence on the pathophysiology and management of acute and chronic pain following foot and ankle procedures. The analysis critically assesses the efficacy of multimodal analgesic strategies, including peripheral nerve blocks (PNBs), systemic analgesics, and non-pharmacological interventions, across the continuum of care (pre-, intra-, postoperative, and chronic phases). A multimodal approach is widely recognized as a highly effective approach for acute pain control. PNBs, such as popliteal and saphenous blocks, significantly reduce pain intensity and opioid requirements for up to 24 h. The combination of acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) provides superior analgesia to monotherapy. Postoperative pain with a numeric rating scale (NRS) score greater than 4 is observed in 68% of patients within 24 h, highlighting the need for vigilance. The incidence of chronic post-surgical pain (CPSP) varies considerably (10%-50%), often evolving into complex syndromes such as complex regional pain syndrome (CRPS), which requires early, multidisciplinary intervention. Chronic pain management relies on pharmacological adjuvants (e.g., pregabalin, duloxetine), minimizing long-term opioid consumption. Effective and prompt pain management in foot and ankle surgery and trauma is critical to improve patient outcomes and prevent long-term disability. A personalized multimodal strategy, integrating PNBs, tiered systemic analgesics, and timely recognition of chronification signals, is strongly recommended to optimize recovery outcomes. The integration of non-pharmacological modalities, including physiotherapy and psychological support, completes the comprehensive approach to reduce pain burden and enhance functional recovery.