Persistent Post-Surgical Pain (PPSP)
Persistent Post-Surgical Pain (PPSP) is pain that develops after an operation and continues beyond the expected period of healing. While some discomfort is a normal part of recovery, pain that persists for three months or longer is no longer considered part of the usual healing process and may represent a recognised chronic pain condition.
Persistent Post-Surgical Pain is one of the most common long-term complications of surgery, yet it often goes unrecognised. It may occur after many different operations, including joint replacement, breast surgery, thoracic surgery, hernia repair and limb amputation. Early recognition and appropriate management can help reduce its impact on daily life and improve long-term outcomes.
This information is intended for educational purposes and should not replace professional medical advice. If you have new, severe or worsening symptoms, always seek advice from your GP or specialist healthcare team.
KEY FACTS
✔ Medical name
Persistent Post-Surgical Pain (PPSP)
✔ Also known as
Chronic Post-Surgical Pain (CPSP)
✔ What it affects
The nervous system following surgery, particularly when pain pathways remain active after normal tissue healing has occurred.
✔ Common symptoms
Persistent pain at or near the surgical site, burning pain, shooting or electric shock sensations, numbness, increased sensitivity to touch, pain with movement and reduced function.
✔ Who can be affected?
Anyone can develop PPSP after surgery, although the risk varies according to the type of operation, individual health factors and the body's response to healing.
✔ How is it diagnosed?
Diagnosis is based on the ICD-11 criteria. Pain must have developed or worsened following surgery, persist for at least three months, be related to the surgical area or affected nerve distribution, and not be better explained by another condition such as infection, cancer recurrence or a mechanical complication.
✔ Can it be treated?
Yes. Management focuses on identifying the pain mechanism, treating reversible causes where possible, improving function and reducing the impact of pain using an individualised approach.
✔ Associated conditions
Neuropathic pain
Chronic pain
Fibromyalgia
Small Fibre Neuropathy
Anxiety and depression
Sleep disturbance
Persistent opioid use
✔ When should I seek urgent medical advice?
New or rapidly worsening pain associated with fever, wound infection, increasing swelling, neurological weakness, vascular compromise or possible cancer recurrence requires urgent medical assessment.
UNDERSTANDING THE CONDITION
Most pain experienced after an operation is part of the body's normal healing process.
As tissues repair, inflammation gradually settles, nerves recover and pain slowly improves over the following days or weeks.
For some people, however, this recovery does not follow the expected pattern.
Instead of gradually resolving, pain continues long after healing has taken place.
This condition is known as Persistent Post-Surgical Pain (PPSP).
Rather than simply representing "pain that lasted longer than expected", PPSP reflects changes in the way the nervous system processes pain after surgery. In some people, the body's normal protective pain response fails to switch off completely, allowing pain to persist even after the tissues have healed.
Persistent Post-Surgical Pain is now recognised as a distinct medical condition within the International Classification of Diseases (ICD-11), reflecting the growing understanding that chronic pain after surgery is not simply an unavoidable consequence of an operation.
How Common Is Persistent Post-Surgical Pain?
Persistent pain after surgery is more common than many people realise.
Across all major surgical procedures, studies suggest that approximately 10–50% of patients experience some degree of persistent pain, while around 5–10% develop pain severe enough to have a significant impact on daily life. The risk varies considerably according to the type of surgery performed.
Operations associated with a higher risk include:
Limb amputation
Thoracotomy (chest surgery)
Breast cancer surgery (mastectomy)
Inguinal hernia repair
Total knee replacement
Cardiac surgery
Caesarean section
Importantly, these figures describe groups of patients rather than predicting what will happen to an individual. Personal risk depends on several factors, including the type of surgery, existing health conditions, pain before surgery and recovery after the operation.
COMMON SYMPTOMS
The symptoms of Persistent Post-Surgical Pain (PPSP) vary depending on the type of surgery, the tissues involved and whether nerves have been affected during the procedure.
For some people, the pain is mild and gradually improves over time. For others, it can become persistent and interfere with work, sleep, mobility and everyday activities.
Unlike normal post-operative discomfort, PPSP often has features suggesting that the nervous system itself has become sensitised.
Pain Around the Surgical Site
The most common symptom is pain that continues in the area where surgery was performed.
People may describe:
Persistent aching
Sharp or stabbing pain
Pain during movement
Pain when pressure is applied
Pain that limits normal activities
The pain may remain localised or spread into the surrounding tissues depending on the structures involved.
Neuropathic Pain Symptoms
If a nerve has been injured, stretched or trapped during surgery, the pain often develops a neuropathic pattern.
Common symptoms include:
Burning pain
Electric shock sensations
Shooting pain
Tingling or pins and needles
Numbness
Itching
Increased sensitivity to touch (allodynia)
Pain that is greater than expected from light pressure (hyperalgesia)
These symptoms often feel very different from the original post-operative pain and suggest that the nervous system has become more sensitive following surgery.
Increased Sensitivity Around the Scar
Many people notice that the surgical scar remains unusually sensitive long after it has healed.
Examples include:
Pain when clothing rubs against the scar.
Pain on gentle touch.
Tenderness around the incision.
Discomfort with stretching or movement.
This increased sensitivity reflects changes within the local nerves rather than ongoing tissue damage.
Reduced Movement and Function
Persistent pain may make people reluctant to move the affected part of the body.
Over time this can lead to:
Reduced mobility.
Muscle weakness.
Joint stiffness.
Loss of confidence in movement.
Avoidance of physical activity.
This reduction in activity may itself contribute to ongoing pain and delayed recovery.
Sleep Disturbance
Persistent pain frequently interferes with sleep.
People may find it difficult to:
Fall asleep.
Stay asleep.
Find a comfortable position.
Feel refreshed on waking.
Poor sleep can increase pain sensitivity and make recovery more difficult, creating a cycle in which pain and sleep disturbance reinforce one another.
Emotional Impact
Living with pain after an operation that was expected to improve your health can be frustrating and distressing.
Many people experience:
Anxiety.
Low mood.
Fear of movement.
Worry that something has gone wrong.
Reduced confidence returning to normal activities.
These reactions are common and represent part of the body's response to persistent pain rather than a sign that the pain is "psychological".
CAUSES, MECHANISMS AND DIAGNOSIS
Why Does It Happen?
Why Does Persistent Post-Surgical Pain Develop?
Surgery inevitably causes tissue injury.
Normally, this triggers a temporary pain response that gradually settles as healing takes place.
In Persistent Post-Surgical Pain, however, the nervous system continues to generate pain signals long after the tissues have recovered.
Understanding why this happens helps explain why some people recover completely while others develop long-term pain.
Tissue Injury Is Only the Beginning
Every operation involves some degree of tissue damage.
During healing, the body releases inflammatory chemicals that activate pain receptors and protect the injured area while repair takes place.
In most people, this process settles naturally as healing progresses.
Nerve Injury
Some operations also involve direct or indirect injury to nearby nerves.
Nerves may be:
Divided during surgery.
Stretched.
Compressed.
Trapped within scar tissue.
Irritated by surrounding inflammation.
As injured nerves heal, they may become unusually sensitive or begin generating pain signals spontaneously.
This is one reason why persistent pain often has burning or electric shock-like characteristics.
Central Sensitisation
One of the most important mechanisms behind Persistent Post-Surgical Pain is central sensitisation.
This describes changes within the spinal cord and brain that make the nervous system more responsive to pain signals.
As a result:
Pain signals become amplified.
Non-painful touch may become painful (allodynia).
Pain may spread beyond the original surgical area.
Pain persists despite normal tissue healing.
This does not mean the pain is imagined.
It reflects genuine changes in how the nervous system processes sensory information and is now recognised as one of the key mechanisms involved in the transition from acute to chronic pain.
Why Doesn't the Nervous System Reset?
One way to understand Persistent Post-Surgical Pain is to think of the nervous system as an alarm system.
Immediately after surgery, the alarm becomes more sensitive to protect the healing tissues.
Normally, as healing progresses, the alarm gradually returns to its usual level.
I
n Persistent Post-Surgical Pain, however, the alarm remains switched up even though healing has largely finished.
The result is ongoing pain despite the absence of continuing tissue injury.
Pain Is Real
People living with Persistent Post-Surgical Pain are sometimes told that "everything looks fine" because scans or surgical wounds appear normal.
While this is reassuring in terms of healing, it does not mean the pain is any less real.
Persistent pain results from measurable changes in the nervous system rather than ongoing damage to the tissues themselves.
Recognising this distinction helps explain why Persistent Post-Surgical Pain requires a different approach from the management of normal post-operative pain.
Who Is More Likely to Develop Persistent Post-Surgical Pain?
Although Persistent Post-Surgical Pain (PPSP) can affect anyone, research has identified several factors that increase the likelihood of developing persistent pain after an operation.
Having one or more risk factors does not mean you will definitely develop PPSP. Instead, these factors help clinicians identify people who may benefit from closer monitoring, better pain control and earlier intervention during recovery.
Before Surgery
Several factors present before an operation can influence how the nervous system responds to surgery.
These include:
Pain already present at or near the surgical site.
A history of chronic pain elsewhere in the body.
Fibromyalgia or other conditions associated with central sensitisation.
Anxiety, depression or significant pain-related worry.
Previous persistent pain after surgery.
Long-term opioid use before surgery.
These factors do not mean surgery should be avoided, but they may justify a more proactive pain management plan before and after the operation.
The Type of Surgery
Some operations carry a naturally higher risk because they involve major tissue injury or are performed close to important nerves.
Examples include:
Limb amputation
Thoracotomy (chest surgery)
Breast surgery (particularly mastectomy)
Inguinal hernia repair
Joint replacement surgery
Cardiac surgery
The greater the likelihood of nerve injury during an operation, the higher the potential risk of developing persistent neuropathic pain afterwards.
During Surgery
Although most surgical factors are outside the patient's control, they may also influence recovery.
These include:
The degree of tissue and nerve handling.
Whether nerves require division during the procedure.
The surgical technique used.
The duration of surgery.
The type of anaesthesia provided.
Whenever appropriate, modern surgical and anaesthetic techniques aim to minimise unnecessary tissue and nerve injury while maintaining the safety and effectiveness of the procedure.
After Surgery
Recovery during the first few weeks after an operation plays an important role in determining long-term outcomes.
Research shows that several post-operative factors increase the likelihood of persistent pain, including:
Poorly controlled acute post-operative pain.
Wound infection or delayed healing.
Ongoing inflammation.
Prolonged opioid use.
Reduced mobility.
Fear of movement.
Persistent psychological distress.
One of the strongest predictors of Persistent Post-Surgical Pain is severe pain during the early recovery period. This is why good pain management immediately after surgery is considered an important part of preventing chronic pain, rather than simply improving comfort.
How It Is Diagnosed
There is no single scan or blood test that confirms Persistent Post-Surgical Pain.
Instead, diagnosis is based on your symptoms, medical history, physical examination and the exclusion of other conditions that could explain the pain.
Internationally accepted diagnostic criteria published within the ICD-11 help ensure that Persistent Post-Surgical Pain is recognised consistently.
The Four Key Questions
Your clinician will consider several important questions:
Did the pain begin, or become significantly worse, after surgery?
Has the pain persisted beyond the expected healing period?
Is the pain located in the surgical area or the distribution of a nerve affected during surgery?
Could another condition better explain the pain?
Only after these questions have been carefully considered can Persistent Post-Surgical Pain be confidently diagnosed.
Excluding Other Causes
Before confirming Persistent Post-Surgical Pain, it is essential to exclude other conditions that may require different treatment.
Depending on the type of surgery, this may include assessment for:
Wound infection.
Delayed healing.
Surgical complications.
Hardware failure following orthopaedic surgery.
Hernia recurrence.
Cancer recurrence where relevant.
New, unrelated causes of pain.
I
dentifying these conditions early is one of the most important steps in the assessment process because Persistent Post-Surgical Pain should only be diagnosed when another explanation is unlikely.
Looking for Neuropathic Pain
Many people with Persistent Post-Surgical Pain develop symptoms suggesting that a nerve has been affected.
Your clinician may ask whether the pain feels:
Burning.
Shooting.
Electric shock-like.
Tingling.
Numb.
Unusually sensitive to touch.
They may also examine the surgical area for:
Reduced sensation.
Pain on light touch (allodynia).
Increased sensitivity to pinprick.
Areas of altered skin sensation.
Recognising these features is important because neuropathic pain often responds differently to treatment than pain arising primarily from inflammation or tissue injury.
Looking Beyond Pain Intensity
Pain severity is only one part of the assessment.
Your clinician will also consider how pain affects:
Walking and movement.
Sleep.
Work.
Daily activities.
Mood and wellbeing.
Confidence returning to normal life.
Ongoing use of pain medication, particularly opioids.
Understanding these wider effects helps guide treatment and monitor progress over time.
Why Early Assessment Matters
Although Persistent Post-Surgical Pain is formally diagnosed after three months, waiting until this point before reviewing persistent pain is not recommended.
If pain remains severe or is not following the expected recovery pattern after 6–8 weeks, early assessment may help identify patients who require closer monitoring, additional investigations or changes to their pain management plan.
HOW IS IT USUALLY MANAGED?
Management depends on the diagnosis, symptom severity, underlying mechanisms and each person's individual circumstances.
The treatment of Persistent Post-Surgical Pain (PPSP) aims to reduce pain, improve function and help people return to their normal activities. Because PPSP can develop through different mechanisms, management should be individualised rather than relying on a single treatment for everyone.
An important first step is identifying the dominant pain pattern. Some people experience predominantly inflammatory or nociceptive pain, while others develop neuropathic pain following nerve injury. Many have a combination of both. Understanding these mechanisms helps guide the most appropriate treatment approach.
Treating the Underlying Cause
Before focusing on long-term pain management, it is essential to confirm that no treatable surgical complication remains.
Depending on the type of surgery, this may include assessing for:
Infection
Delayed wound healing
Mechanical problems with implants or surgical repairs
Hernia recurrence
Neuroma formation
Cancer recurrence where relevant
Addressing these conditions promptly may resolve the pain or prevent further complications.
Managing Neuropathic Pain
Where pain has features of nerve injury, treatment often differs from that used for routine post-operative pain.
Depending on your individual circumstances, your healthcare professional may recommend medications commonly used for neuropathic pain, including:
Amitriptyline
Duloxetine
Gabapentin
Pregabalin
These medicines aim to reduce abnormal nerve signalling rather than simply masking pain. They are usually introduced gradually and reviewed regularly to assess both benefit and potential side effects.
Managing Nociceptive Pain
When pain remains predominantly inflammatory or mechanical in nature, treatment may include:
Paracetamol
Non-steroidal anti-inflammatory drugs (NSAIDs), where appropriate
Topical treatments for localised pain
The choice of treatment depends on your medical history, current medications and the type of surgery you have undergone.
Physiotherapy and Rehabilitation
Returning to normal movement is an important part of recovery.
Persistent pain often leads people to protect the affected area by moving less. While this is understandable, prolonged avoidance can contribute to muscle weakness, joint stiffness and reduced confidence in movement.
Individualised rehabilitation may include:
Gentle mobility exercises
Graded strengthening
Scar desensitisation where appropriate
Gradual return to daily activities
Functional rehabilitation
The aim is to restore movement safely while avoiding unnecessary fear of activity.
Psychological Support
Persistent pain affects both physical and emotional wellbeing.
Living with ongoing pain after surgery may lead to:
Anxiety
Low mood
Fear of movement
Reduced confidence
Difficulty returning to work or normal activities
Approaches such as Acceptance and Commitment Therapy (ACT) and cognitive behavioural strategies can help people develop practical skills to manage persistent pain and improve daily function. These approaches do not imply that the pain is psychological; rather, they recognise that persistent pain affects many aspects of life and benefits from a comprehensive approach.
Using Opioids Safely
Opioid medicines can play an important role in managing acute pain after surgery.
However, they are not recommended as a long-term treatment for Persistent Post-Surgical Pain.
If opioids are still required well beyond the expected recovery period, this should prompt a structured review rather than automatic continuation. Where appropriate, a gradual tapering plan may be recommended alongside other pain management strategies.
Complementary Approaches
Supportive non-pharmacological approaches used alongside conventional medical care are also beneficial.
Depending on individual needs, these may include:
Acupuncture
Mindfulness-based approaches
Transcutaneous Electrical Nerve Stimulation (TENS)
Manual therapy for scar-related or muscular discomfort
Current evidence suggests these approaches help individuals as part of a broader management plan.
Monitoring Progress
Recovery from Persistent Post-Surgical Pain should be reviewed regularly.
Rather than looking only at pain intensity, clinicians also assess:
Changes in pain over time
Daily function
Sleep quality
Neuropathic symptoms
Mood and psychological wellbeing
Return to work or usual activities
Medication use, including opioid reduction
Progress with rehabilitation
At Rowan Health, we believe that following the overall trend is often more informative than focusing on a single pain score. Monitoring recovery over time helps identify when treatment is working and when further assessment or referral may be needed.
LIVING WELL WITH THE CONDITION
Impact on Daily Life
Persistent Post-Surgical Pain can be difficult to understand because the operation itself may have been technically successful and the surgical wound may appear completely healed.
For many people, this can be confusing and frustrating. Friends, family or even healthcare professionals may assume that healing is complete because the scar looks normal, while the pain continues to affect everyday life.
Living with ongoing pain may make it harder to:
Walk or exercise.
Return to work.
Sleep comfortably.
Care for your family.
Enjoy hobbies and social activities.
It is important to remember that persistent pain after surgery is a recognised medical condition. It does not mean that your operation has necessarily failed, nor does it mean that the pain is "all in your head." Instead, it reflects ongoing changes within the nervous system that require appropriate assessment and management.
Although recovery varies from person to person, many people experience meaningful improvements through a combination of education, rehabilitation, appropriate medication and a personalised management plan focused on restoring function as well as reducing pain.
HOW ROWAN HEALTH SUPPORTS YOU
At Rowan Health, we assess Persistent Post-Surgical Pain according to the pattern and mechanism of the pain rather than treating every post-operative presentation in the same way.
Your assessment considers:
The type and location of the surgery
How the pain has changed since the operation
Whether symptoms suggest nerve injury, inflammation or a mixed pain pattern
The impact on movement, sleep, work and daily activities
Scar sensitivity, altered sensation and fear of movement
Current pain medication, including any continued opioid use
Possible surgical complications or other causes requiring referral
Where pain is not following the expected recovery trajectory, we do not wait passively for the three-month diagnostic threshold before acting. Your programme may include education, graded rehabilitation, scar treatment, support for sleep and stress, and selected evidence-informed integrative approaches alongside your conventional medical care. Referral back to the surgical team or to a specialist pain service is recommended when structural complications, significant neurological features or complex pain require further investigation.
Our aim is to improve function, reduce the impact of persistent pain and help you return safely to the activities that matter to you.
When to Seek Medical Advice
Persistent pain after surgery should not automatically be attributed to nerve sensitisation or chronic pain. Some symptoms may indicate a surgical complication or another condition requiring urgent assessment.
Seek prompt medical advice if you develop:
Fever, spreading redness, discharge or increasing swelling around the surgical site
Sudden severe pain that is different from your established pattern
Rapidly worsening pain associated with feeling generally unwell
New or progressive muscle weakness
Significant loss of sensation beyond the expected surgical area
A cold, pale or discoloured limb
Sudden loss of movement or circulation in the affected area
Signs of implant, mesh or hardware failure
Symptoms that may suggest cancer recurrence following oncological surgery
These symptoms require surgical, oncological or emergency assessment rather than routine management through a persistent pain pathway.
Call 999 if symptoms are severe, rapidly worsening or suggest a medical emergency.
If your symptoms are severe, rapidly worsening or causing immediate concern, contact NHS 24 on 111. In a medical emergency, call 999 or attend your nearest Accident & Emergency department.
FAQs
How long should pain normally last after surgery?
The expected recovery period depends on the type and extent of the operation. Pain should generally improve progressively as tissues heal.
Pain that remains severe, worsens or is not following the expected recovery trajectory at six to eight weeks should be reviewed. Persistent Post-Surgical Pain is formally diagnosed when qualifying pain continues for at least three months.
Does persistent pain mean that my surgery has failed?Not necessarily.
Not necessarily.
An operation may be technically successful while pain continues because nearby nerves have been affected or the nervous system has remained unusually sensitive after healing.
However, surgical complications must be excluded before the pain is classified as Persistent Post-Surgical Pain.
Why does the pain feel burning or electric?
Burning, shooting or electric-shock sensations often suggest that a nerve was injured, stretched, compressed or irritated during surgery.
Other possible features include numbness, tingling, itching and pain caused by light touch.
Why does my scar still hurt after it has healed?
The skin may look healed while the local sensory nerves remain sensitive.
Scar pain may be associated with nerve irritation, scar-tissue restriction, altered sensation or sensitisation of the nervous system.
Can Persistent Post-Surgical Pain improve?
Yes.
The outcome varies according to the cause, severity, duration and pain mechanism. Many people improve through appropriate medication, graded rehabilitation, desensitisation, education and coordinated pain management.
Earlier recognition of an unfavourable recovery pattern may allow treatment to begin before pain becomes more established.
Should I continue taking opioids?
Opioids may be appropriate for acute pain immediately after surgery, but they are not usually recommended as a long-term default treatment for Persistent Post-Surgical Pain.
Continued opioid use beyond the expected recovery period should prompt a structured medication review and, where appropriate, a gradual supported taper rather than abrupt discontinuation.
Should I avoid movement if it hurts?
Complete avoidance is rarely helpful once surgical healing is secure and complications have been excluded.
A gradual, individualised rehabilitation programme can help restore strength, reduce fear of movement and improve function. Activities should be progressed according to your operation, symptoms and medical advice.
Can pain be prevented before surgery?
Not every case can be prevented, but some risk factors can be identified before surgery.
Good acute pain control, appropriate anaesthetic planning, early recognition of neuropathic symptoms and structured follow-up may reduce risk or allow earlier intervention. The evidence for individual preventive medicines remains mixed, so prevention should not be presented as guaranteed.
How can Rowan Health help?
We assess the pain pattern, recovery trajectory, functional impact and possible contributing factors. We then develop a personalised support plan and recommend conventional investigation or specialist referral whenever symptoms suggest a surgical, neurological or structural cause.
Sources & references
Schug SA, Lavand’homme P, Barke A, Korwisi B, Rief W, Treede RD. The IASP classification of chronic pain for ICD-11: chronic postsurgical or posttraumatic pain. Pain. 2019.
Werner MU, Kongsgaard UE. Defining persistent post-surgical pain: is an update required? British Journal of Anaesthesia. 2014.
Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. The Lancet. 2006.
Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011.
Weinrib AZ, Burns LC, Mu A, et al. A case report on the treatment of complex chronic pain and opioid dependence by a multidisciplinary transitional pain service using the ACT Matrix and buprenorphine/naloxone. Journal of Pain Research. 2017.
National Institute for Health and Care Excellence. Perioperative care in adults: NICE guideline NG180. 2020.
National Institute for Health and Care Excellence. Neuropathic pain in adults: pharmacological management in non-specialist settings: CG173.
National Institute for Health and Care Excellence. Chronic pain (primary and secondary) in over 16s: NG193. 2021.
Clinical Review
Clinical content reviewed by
Rowan Health
Last reviewed:
4 August 2026
Related Resources
Related Conditions
Understanding Small Fibre Neuropathy >
Understanding Ehlers-Danlos Syndrome >
Understanding Hypermobility Spectrum Disorder >
Chronic & Complex Conditions >
Symptoms and Mechanisms
Understanding Chronic Pain (coming soon)
Central Sensitisation (coming soon)
Neuropathic Pain (coming soon)
Scar Sensitivity (coming soon)
Sleep Problems (coming soon)
Fatigue (coming soon)
Treatment and Support
What Is Integrative Medicine? >
If you found this information helpful, you may wish to share it with a family member, friend or someone else who is going through cancer treatment.Better understanding helps people feel more informed and prepared.
Share this page
Would You Like Personalised Support?
At Rowan Health, we provide a comprehensive assessment to understand why pain has persisted after surgery and to identify any underlying factors that may be contributing to your symptoms.
Following a comprehensive evaluation, we develop a personalised care plan tailored to your diagnosis, pain pattern and individual needs. Our aim is to improve symptom control, restore function and support your long-term recovery alongside your conventional medical care.