COMMON PERONEAL NERVE1 Anatomy

Formed by: Axons from L4, L5, S1 & S2 roots Course of axons o Through popliteal fossa: Separates from sciatic nerve in upper fossa o Behind head & along fibula: Covered only by skin & subcutaneous tissue o Behind peroneus longus muscle (fibular tunnel): In anterior compartment of leg o Emerge from fibular tunnel: Nerve divides into superficial & deep branches o Deep peroneal nerve passes through: Anterior tarsal tunnel Divides into lateral and medial terminal branches Lateral terminal branch: Supplies Extensor digitorum brevis & Extensor hallucis brevis Medial terminal branch o Supplies adjacent sides of great & 2nd toes (92%) o Absent in 8%: Muslces supplied by Superficial peroneal nerve Branches o Common peroneal in popliteal fossa: Sensory o Superficial peroneal Motor o Peroneus brevis o Peroneus longus o Accessory deep peroneal branch: Innervates Extensor digitorum brevis Cutaneous sensory o Lower leg: Anterolateral o Foot: Dorsum, except between 1st 2 toes o Medial & Intermediate dorsal cutaneous nerves of foot o Deep peroneal Motor branches in leg o Tibialis anterior o Extensor hallucis & Extensor digitorum longus o Peroneus tertius Lateral terminal branch in foot o Extensor digitorum brevis

May also be innervated by accessory deep peroneal from superficial peroneal (28%) Cutaneous: Skin between 1st & 2nd toes

Clinical syndrome

Weakness o Foot: Dorsiflexion & Eversion of foot o Toes: Extension o Gait: Steppage Sensory loss o Lower leg: Anterolateral o Foot & Toes: Dorsum Tendon reflexes: Normal Pain & Tinel's sign: Over lateral fibular neck

Differential diagnosis

L5 root: EHL may be weaker than Anterior tibial Lumbosacral trunk or plexus Sciatic nerve: Lateral trunk

Causes

External compression o Fibular head lesion Etiologies o Especially with weight loss o Altered consciousness: Coma, Anesthesia, Sleep & Bed rest o Crossed legs o Leg braces Partial lesion: More involvement of deep peroneal than superficial peroneal axons o Distal: Superficial peroneal nerve (Sensory branches) Branches: Medial & Intermediate Dorsal cutaneous branches Clinical o Sensory loss: Medial dorsal foot up to ankle Trauma: Blunt; Traction; Fractures o Ankle: Acute plantar flexion & inversion Entrapment o Squatting (Gardners & Farmers): Lesion locations Compression between biceps tendon & lateral head of gastrocnemius + Head of the fibula

Fibular tunnel Anterior tarsal tunnel: Deep peroneal nerve o Masses Ganglia: From the superior tibiofibular joint Baker's cyst Schwannoma & Neurofibromas: Especially in popliteal fossa o Fibular tunnel: Crescentic band at origin of peroneus longus Mononeuropathy in systemic disorder o HNPP o Vasculitis o Diabetes mellitus o Leprosy Deep peroneal o Anterior compartment syndrome Raised pressure in fascial compartment Causes: Excessive exercise, Soft tissue trauma, fractures, haemorrhage, occlusion of anterior tibial artery Clinical associations: Leg swelling o Compression: Ganglia, Osteochondroma, Aneurysm o At ankle Trauma & External compression Weak: Extensor digitorum brevis Superficial peroneal o Peroneal compartment syndrome o Local trauma o Compression of sensory branch when traversing deep fascia of lower leg

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POSTERIOR TIBIAL NERVE Anatomy

Formed by: Axons from L4, L5, S1 & S2 roots Anatomy o Anterior component: Muscles of posterior thigh (except short head of biceps) o Popliteal space: Branches to popliteus; Gastrocnemius; Soleus; Plantaris

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Posterior compartment of leg: Tibialis posterior, Flexor hallucis longus; Flexor digitorum brevis Behind medial malleolus to plantar side of foot Tarsal Tunnel Anatomy: Behind mdial malleolus; Covered by flexor retinaculum Contents: Tibial nerve; Tibial artery; Tendons FHL, FDL, Tibialis posterior Distal tibial nerve branches Medial & Lateral Calcaneal: Sensory supply to heel of sole Medial Plantar nerve o Sensory: Medial 3 1/2 toes o Motor: Abductor hallucis brevis; Flexor hallucis brevis; Flexor digitorum brevis; Lumbricales Lateral Plantar nerve o Sensory: Little toe & Lateral 4th toe o Motor: Abductor digiti quinti brevis; FDB; Quadratus plantae

Tarsal Tunnel Syndrome

Anatomy: Entrapment of tibial nerve in tarsal tunnel Clinical o Pain Peri-malleolar Ankle & Sole: Burning; Worse with weight bearing & at night Tinel sign: Over tarsal tunnel Ankle dorsiflexion o Paresthesias & Sensory loss Sole of foot o Intrinsic foot muscles: Weak & Wasted o Tendon reflexes: Normal Causes o Mass in tunnel: Lipoma, Ganglia, Neoplasms o Exostosis within the tarsal tunnel o Accessory flexor digitorum longus muscle: 4% to 8% of legs o Hindfoot valgus deformity o Athletics: Heavy stress on ankle joint; Sprinting, Jumping Differential diagnosis o Sensory polyneuropathy o Orthopedic: Fasciitis; Tendonitis

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LATERAL FEMORAL CUTANEOUS NERVE

Anatomy o Direct extensions from L2 & L3 roots o Passes under inguinal ligament o Sensory distribution: Anterior lateral thigh o May anatomose with: Superior perforator & Median perforator nerves More anterior thigh sensory field Lateral Femoral Cutaneous Neuropathy: Meralgia paresthetica o Entrapment site: Inguinal ligament o General Male ? > Female Age: Mean 51 years; Range 15 to 81 years; Most frequent 4th & 5th deacde Symptom duration: 0.5 months to 20 years; Mean 3 years o Clinical Pain: Burning, tingling, Aching Sensory loss o Sharply defined region o Anterior or Lateral thigh or Both o Never involves: Patella; Knee; Lateral iliac crest Tendon reflexers: Normal Strength: Normal Bilateral: 10%; Usually asymmetric o Predisposing factors Obesity Tight pants or belt Diabetes: Occasional; Not clearly associated Pregnancy Abdominal pressure: Increased Surgery: Spine; Pelvic osotomy o NCV Side to side variation of orthodromic amplitude >2.3 fold SNAP amplitude < 3 V o Management Conservative in most cases Weight loss Eliminate tight fitting clothes

FEMORAL NERVE

Anatomy o Roots: L2, L3, L4 o Derived from: Lumbar plexus o Branches above inguinal ligament: Psoas; Iliacus o Below inguinal ligament: Divides into anterior & posterior divisions Anterior: Medial & intermediate cutaneous nerves of thigh; Sartorius & Pectineus muscle Posterior: Quadriceps femoris (Vasti & Rectus femoris); Saphenous nerve Neuropathy o General Weakness: Hip flexion; Knee extension Sensory loss: Anterior & Medial thigh; Medial leg to medial malleolus Tendon reflex: Knee reduced or absent o Lesions Compression: Surgical positioning (Lithotomy) & retraction Ischemia: Renal transplantation; Diabetes Retroperitoneal hemorrhage: Lumbar plexopathy with prominent femoral involvement Saphenous nerve: Axonal loss with increasing age