Pain Management



Pain because of leg ulceration can influence the quality of life of patient and can have serious psychological and social effects. The most common leg ulcers are venous, ischemic, and neurotrophic. More than 95 % of chronic leg ulcers fit into one of the recognized categories [1]. The pain may be severe in all types of ulcer with the possible exception of diabetic sensory neuropathy. Pain causes the release of catecholamines via limbic system, increase levels of adrenaline and nor adrenaline and steroids, often decreases appetite, reduces mobility, and may lead to depression. Pain is a response to tissue damage and influences patients’ compliance. The ulcers are quite painful. Nocturnal ischemic rest pain in the distal forefoot is typical of chronic leg ulcers.


Trigeminal Neuralgia Chronic Wound Intermittent Claudication Pyoderma Gangrenosum Rest Pain 
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  1. 1.
    Lu YM, Zhao WJ, Zheng YH. Painful leg ulcers: a misdiagnosed case report with literature review. Wounds. 2007;19(5):124–7.PubMedGoogle Scholar
  2. 2.
    Krasner D. Painful venous ulcers: themes and stories about living with the pain and suffering. J Wound Steamy Continence Nurs. 1998;25(3):158–60.Google Scholar
  3. 3.
    Augustin M, Maier K. Psychosomatic aspects and quality of life in patients with chronic wounds. Dermatol Psychosom. 2003;4:5–13.Google Scholar
  4. 4.
    World Union of Wound Healing Societies. Principles of best practice: minimizing pain at wound dressing-related procedures. A consensus document. London: MEP Ltd; 2004. Available from URL:
  5. 5.
    Wysocki AB, Staiano-Coico L, Grinnell F. Wound fluid from chronic leg ulcers contains elevated levels of Metalloproteinase’s MMP-2 and MMP-9. J Invest Dermatol. 1993;101(1):64–8.CrossRefPubMedGoogle Scholar
  6. 6.
    Melzak R, Wall PD. Pain mechanisms: a new theory. Science. 1965;150:971–9.CrossRefGoogle Scholar
  7. 7.
    Woo KY, Sibbald RG. Chronic wound pain: a conceptual model. Adv Skin Wound Care. 2008;21(4):175–88.CrossRefPubMedGoogle Scholar
  8. 8.
    McCaffery M, Pasero C. Pain: clinical manual for nursing practice. 2nd ed. St.Louis: Mosby; 1999.Google Scholar
  9. 9.
    World Union of Wound Healing Societies. Principles of best practice: minimising pain at wound dressing-related procedures. Wound Care. 2008;21(4):175–88. A consensus document. London: MEP Ltd; 2004.CrossRefGoogle Scholar
  10. 10.
    Johnson L. The nursing role in recognizing and assessing neuropathic pain. Br J Nurs. 2004;13(18):1092–7.CrossRefPubMedGoogle Scholar
  11. 11.
    Doyle D, Hanks G, MacDonald N, editors. Oxford textbook of palliative medicine. 2nd ed. Oxford: Oxford University Press; 1989.Google Scholar
  12. 12.
    McMullen M. The relationship between pain and leg ulcers: a critical review. Br J Nurs. 2004;13(19):S30–6.CrossRefPubMedGoogle Scholar
  13. 13.
    Lindholm C, Bjellerup M, Christensen OB, Zederfeldt B. Quality of life in chronic leg ulcer patients. An assessment according to the Nottingham Health Profile. Acta Derm Venereol (Stockh). 1993;736:440–3.Google Scholar
  14. 14.
    Hayek S, Dibo S, Baroud J, Ibrahim A, Barritault D. Refractory sickle cell leg ulcer: is heparan sulphate a new hope? Int Wound J. 2014; doi:  10.1111/iwj.12217.
  15. 15.
    Noonan L, Burge SM. Venous leg ulcer: is pain a problem? Phlebology. 1998;13:14–9.CrossRefGoogle Scholar
  16. 16.
    Chase SK, Melloni M, Savage A. A forever healing the lived experience of venous ulcer disease. J Vasc Nurs. 1997;15(2):73–8.CrossRefPubMedGoogle Scholar
  17. 17.
    Strauss A, Corbin M, Fagerhaugh S, Glaser B, Maines D, Suzek B, et al. Chronic illness and the quality of life. St Louis: CV Mosby; 1984.Google Scholar
  18. 18.
    Miller JF. Coping with chronic illness. Overcoming powerlessness. 2nd ed. Philedelphia: FA Davis; 1992.Google Scholar
  19. 19.
    Jorgensen B, Firis GJ, Gottrup F. Pain and quality of life for patients with venous ulcer: concept of efficacy of Biatain –Ibu, a new pain reducing wound dressing. Wound Repair Regen. 2006;14:233–9.CrossRefPubMedGoogle Scholar
  20. 20.
    Hafner HM, Thomas SR, Eisner M, Steins A, Junger M. The influence of EMLA cream on cutaneous microcirculation. Clin Hemorheol Microcirc. 2003;28:121–8.PubMedGoogle Scholar
  21. 21.
    Debreceni L, Gyulai M, Debreceni A, Szabo K. Results of transcutaneous electrical stimulation (TES) in cure of lower extremity arterial disease. Angiology. 1995;46(7):613–8.CrossRefPubMedGoogle Scholar
  22. 22.
    Brown L, Tabasam G, BJoordal JM, Jhonson MI. An investigation into the effect of electrode placement of transcutaneous electrical stimulation (TENS) on experimentally induced ischemic pain in healthy human participants. Clin J Pain. 2007;23(9):735–43.CrossRefPubMedGoogle Scholar
  23. 23.
    Jünger M, Arnold A, Zuder D, Stahl HW, Heising S. Local therapy and treatment costs of chronic, venous leg ulcers with electrical stimulation (Derma pulse): a prospective, placebo controlled, double blind trial. Wound Repair Regen. 2008;16(4):480–48.CrossRefPubMedGoogle Scholar
  24. 24.
    Kavros SJ, Schenck EC. Use of noncontact low-frequency ultrasound in the treatment of chronic foot and leg ulcerations: a 51-patient analysis. J Am Podiatr Med Assoc. 2007;97:95–101.CrossRefPubMedGoogle Scholar
  25. 25.
    Ennis WJ, Foremann P, Mozen N, et al. Ultrasound therapy for recalcitrant diabetic foot ulcers: result s of a randomized, double-blind, controlled, multicenter study. Ostomy Wound Manage. 2005;51:24–39.PubMedGoogle Scholar
  26. 26.
    Ennis WJ, Valdes W, Gainer M, Meneses P. Evaluation of clinical effectiveness of ultrasound therapy on healing of chronic wounds. Adv Skin Wound Care. 2006;19:437–46.CrossRefPubMedGoogle Scholar
  27. 27.
    Gehling ML, Samies JH. The effect of noncontact, low-intensity, low-frequency therapeutic ultrasound on lower-extremity chronic wound pain: a retrospective chart review. Ostomy Wound Manage. 2007;53:44–50.PubMedGoogle Scholar
  28. 28.
    Bell AI, Cavorsi J. Noncontact ultrasound therapy for adjunctive treatment of non healing wounds: retrospective analysis. Phys Ther. 2008;88(12):1517–24.CrossRefPubMedGoogle Scholar
  29. 29.
    Porreca EG, Giordano-Jablon GM. Treatment of severe (stage III and IV) chronic pressure ulcers using pulsed radio frequency energy in a quadriplegic patient. Eplasty. 2008;8:49.Google Scholar
  30. 30.
    Larsen JA, Overstreet J. Pulsed radio frequency energy in the treatment of complex diabetic foot wounds. Two cases. J Wound Ostomy Continence Nurs. 2008;35(5):523–7.CrossRefPubMedGoogle Scholar
  31. 31.
    Abejon D, Garcia-del-Valle S, Fuentes ML, Gomez-Arnau JI, Reig E, van Zundert J. Pulsed radiofrequency in lumbar radicular pain: clinical effects in various etiological groups. Pain Pract. 2007;7(1):21–6.CrossRefPubMedGoogle Scholar
  32. 32.
    Martin DC, Willis ML, Mullinax LA, Clarke NL, Homburger JA, Berger IH. Pulsed radiofrequency application in the treatment of chronic pain. Pain Pract. 2007;7(1):31–5.CrossRefPubMedGoogle Scholar
  33. 33.
    Alcaraz MJ, Fernandez P, Guillen MI. Anti-inflammatory actions of the hemeoxygenase-1 pathway. Curr Pharm Des. 2003;9(30):2541–51.CrossRefPubMedGoogle Scholar
  34. 34.
    Devulder J, Lambert J. Gabapentin for pain control in cancer patients’ wound dressing care. J Pain Symptom Manage. 2001;22(1):622–6.CrossRefPubMedGoogle Scholar
  35. 35.
    Salomé GM, Ferreira LM. Impact of skin grafting of venous leg ulcers on functional status and pain. World J Surg. 2013;37(6):1438–45.CrossRefPubMedGoogle Scholar
  36. 36.
    Mashiah A, Soroker D, Pasik S, Mashiah T. Phenol lumbar sympathetic block in diabetic lower limb ischemia. J Cardiovasc Risk. 1995;2(5):467–9.CrossRefPubMedGoogle Scholar
  37. 37.
    Bhattarai BK, Rahman TR, Biswas BK, Sah BP, Agarwal B. Fluoroscopy guided chemical lumbar for lower limb ischemic ulcers. J Nepal Med Assoc. 2006;45(163):295–9.Google Scholar
  38. 38.
    Cross FW, Cotton LT. Chemical lumbar sympathectomy for ischemia rest pain: a randomised, prospective controlled clinical trial. Am J Surg. 1985;150:341–5.CrossRefPubMedGoogle Scholar
  39. 39.
    Barnes RW, Baker WH, Shank G, Maixner W, Hayes AC, Lin R, Clarke W. Value of concomitant sympathectomy in aortoiliac reconstruction results of a prospective, randomised study. Arch Surg. 1977;112:1325–30.CrossRefPubMedGoogle Scholar
  40. 40.
    Fify T, Quin RO. Phenol sympathectomy in the treatment of intermittent claudication: a controlled clinical trial. Br J Surg. 1975;62:68–71.CrossRefGoogle Scholar
  41. 41.
    Alexander JP. Chemical lumbar sympathectomy in patient with severe lower limb ischemia. Ulster Med J. 1994;63:137–43.PubMedPubMedCentralGoogle Scholar
  42. 42.
    Oliver S, Royo J, Perez C, Eshevaria J, Clemente M. Radiofrequency Lumbar Sympathectomy in the treatment of hypertensive leg ulcers. Eur J Pain Suppl. 2011;5(1):01–10.Google Scholar
  43. 43.
    Sunni A, Hamid A, Dunning J. Is sympathectomy of benefit in critical leg ischemia not amendable to revascularisation? Interact Cardio Vasc Thorac Surg. 2005;4:478–83.CrossRefGoogle Scholar
  44. 44.
    Nesargikar P, Ajit MK, Eyers PS, Nichols BJ, Chester JF. Lumbar chemical sympathectomy in peripheral vascular disease: does it still have role? Int J Surg. 2009;7(2):145–9.Google Scholar
  45. 45.
    Flotte CT. Evaluation of lumbar sympathectomy. Am J Cardiol. 1959;4:644–8.CrossRefPubMedGoogle Scholar
  46. 46.
    Abdurahman AF, Rutherford RB. Lumbar sympathectomy, indications and technique. In: Rutherford RB, editor. Vascular surgery. Philadelphia: Elsevier Saunders; 2005. p. 1223–35.Google Scholar
  47. 47.
    Mick S. Role of sympathetic nervous system in pain. Anaesthesia and intensive care medicine. 2005;6(2):52–5.Google Scholar
  48. 48.
    Olin JW. Thromboangiitis obliterans (Buerger’s disease). In: Rutherford RB, editor. Vascular surgery. Philadelphia: Elsevier Saunders; 2005. p. 404–18.Google Scholar
  49. 49.
    Tseng MY, Tseng JH. Endoscopic extra peritoneal lumbar sympathectomy for plantar hyperhidrosis: case report. J Clin Neurosci. 2001;8:555–6.CrossRefPubMedGoogle Scholar
  50. 50.
    Ates A, Yekeler I, Ceviz M, Pac M, Basoglu A, et al. One of the most frequent vascular diseases in north eastern of turkey: thromboangitis obliterans or Berger’s disease (experience with 344 cases). Int J Cardiol. 2006;111:147–53.CrossRefPubMedGoogle Scholar
  51. 51.
    Sanni A, Hamid A, Dunning J. Is sympathectomy of benefit in critical leg ischaemia not amenable to revascularisation? Interact Cardiovasc Thorac Surg. 2005;4:478–48.CrossRefPubMedGoogle Scholar
  52. 52.
    Baker DM, Lamerton AJ. Operative lumbar sympathectomy for severe lower limb ischaemia: still a valuable option. Ann R Coll Surg Engl. 1994;76:50–3.PubMedPubMedCentralGoogle Scholar
  53. 53.
    Perez-Burkhardt JL, Gonzalez-Fajardo JA, Martin JF, Carpintero Mediavlla LA, Mateo Gutierrez AM. Lumbar sympathectomy as isolated technique for the treatment of lower limb chronic ischemia. J Cardiovasc Surg. 1999;40:7–13.Google Scholar
  54. 54.
    Sherif R, Hatem H, Mohamed A, Mamdouh EM. Endoscopic versus open lumbar sympathectomy. Eur J Surg. 2009;28(1):13–20.Google Scholar

Copyright information

© Springer India 2016

Authors and Affiliations

  1. 1.Pain and Palliative Care Division, Department of AnaesthesiaInstitute of Medical Sciences, Banaras Hindu UniversityVaranasiIndia
  2. 2.Department of AnaesthesiologySanjay Gandhi Postgraduate Institute of Medical SciencesLucknowIndia
  3. 3.Department of MedicineRML Institute of Medical SciencesNew DelhiIndia

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