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General Rehabilitation

Persistent Phantom Limb Pain After Multiple Targeted Muscle Reinnervations: A Case Report

Thursday, October 23, 2025
12:45 PM - 2:15 PM MT
Location: Kiosk 1

    Poster Presenter(s)

  • Sarah Meeuwsen, MD

    Resident Physician
    Medical College of Wisconsin Affiliated Hospitals PM&R Program
    Milwaukee, Wisconsin

    • Co-Author(s)

  • DD

    David Del Toro, MD

    Professor & Attending Physician
    Medical College of Wisconsin Affiliated Hospitals
    Milwaukee, Wisconsin

Disclosure(s):
Sarah Meeuwsen, MD: No financial relationships to disclose
Case Diagnosis: Phantom Limb Pain after Lower Extremity Amputation

Case Description or Program Description: Patient is a 50-year-old male who sustained a right knee dislocation with subsequent popliteal artery injury and lower leg compartment syndrome after snowmobile collision in 2021. He underwent right through-knee amputation at that time, followed one month later by targeted muscle reinnervation (TMR) of the common peroneal nerve, tibial nerve, and posterior femoral cutaneous nerve. He unfortunately struggled with persistent phantom limb pain without significant residual limb pain since initial TMR surgery. He was followed by PM&R, Orthopedics, and Pain Management for collaboration in addressing his symptoms for several years. Magnetic resonance image (MRI) of his residual limb was obtained by Orthopedics in early 2024 to assess for neuroma and nerve anatomy.

Setting: Large Midwest Academic Hospital, Outpatient Physical Medicine and Rehabilitation (PM&R) Clinic

Assessment/Results: MRI revealed neuroma formation within the tibial and common peroneal divisions of the sciatic nerve and additional neuromas within the nerve transfer components of the semitendinosus and biceps femoris. He underwent neuroma resection with re-do TMR and revision above knee amputation later in 2024. Unfortunately, his phantom limb pain remains persistent.

Discussion (relevance): TMR involves rerouting a nerve whose native attachment was severed to a new target for re-innervation. While initially designed to improve myoelectric prosthetic control, it has been found to effectively decrease painful neuroma formation and markedly reduce neuropathic/phantom pain. Additional outcome data in patients with major lower extremity amputation is needed.

Conclusions: TMR after lower extremity amputation is a relatively novel approach to managing phantom limb pain. Given the successes reported for this procedure, it is also important to consider the cases where TMR has not been successful. This patient’s case is complex and involves care coordination across multiple disciplines to optimize his pain control and quality of life.