Peroneal Mononeuropathy

Peroneal Mononeuropathy

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Mononeuropathies are a form of peripheral neuropathy characterized by sensory disturbances and/or motor deficits in the distribution of the affected nerve. They can occur secondary to direct trauma, compression, stretch injury, ischemia, infection, or inflammatory disease. [1] In the lower extremity, peroneal neuropathy is the most common isolated mononeuropathy and the third most common mononeuropathy overall. Peroneal mononeuropathy may result in the clinical complaint of pain and sensory disturbances in the lateral lower limb and dorsal foot, and weakness of the ankle dorsiflexors and evertors. The peroneal nerve is also known as the superficial peroneal nerve and more recently the superficial fibular nerve. [2]

Compression and entrapment neuropathies are predominantly demyelinating.

Myelin loss results in slowing of the nerve conduction through the area involved.

When acute compression occurs, this may result in a conduction block. When the compression is more chronic, only slowing across the involved segment may be seen.

When compression is severe, ischemic changes occur that cause secondary axonal damage.

Pure demyelinating lesions typically have a better capacity to recover.

The pathophysiology of ischemic injuries and nerve transection is axonal damage. When axonal damage occurs, recovery is slower and longer and may not be complete.

This results in wallerian degeneration distally, and recovery requires the nerve to regenerate and reinnervate.

This process is slower than healing from other types of injuries and may not be complete.

Nerve conduction studies and electromyography (EMG) can aid in defining the lesion location and type.

Knowledge of peroneal nerve anatomy is essential to understanding the mechanism of its injury and to localizing the site of the lesion. [3]

The peroneal nerve is a division of the sciatic nerve, which splits at or slightly above the popliteal fossa to form the tibial and common peroneal nerves.

The common peroneal nerve extends anterolaterally to wind around the neck of the fibula.

At this level, the nerve is superficial, covered only by skin and subcutaneous tissue. Here, it is predisposed to direct compression.

The nerve then dives into the peroneus longus muscle, where tethering can occur, making it susceptible to stretch injury at this level.

The nerve then divides into the superficial and deep peroneal branches.

The superficial branch supplies the foot everters and sensation to the skin of the lateral calf and dorsum of the foot.

The deep peroneal branch supplies the foot and toe dorsiflexors and has a small sensory component, which innervates only the skin of the web space between the first and second toes.

No racial predilection is known.

No gender proclivity is known.

Peroneal mononeuropathy is uncommon in children but has been reported in all age groups.

Dancers are also prone to superficial and deep peroneal nerve entrapments. [4]

Common peroneal nerve decompression is a useful procedure to improve sensation and strength as well as to decrease pain. [5]

A retrospective study evaluated electrodiagnostic prognostic factors after peroneal nerve injury in 39 subjects. Outcome was associated with compound muscle action potential responses from extensor digitorum brevis and tibialis anterior: 81% of subjects with any tibialis anterior response and 94% with any extensor digitorum brevis response had a good outcome (at least 4 of 5 ankle dorsiflexion strength) compared with those with absent responses (46% and 52%, respectively). In addition, all patients with nontraumatic compression had a good outcome. [6]

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Ankle dorsiflexion and eversion

Toe extension

Ankle dorsiflexion and partial eversion > inversion

Toe extension

Shaheen E Lakhan, MD, PhD, MS, MEd Chief of Pain Management, Carilion Clinic and Virginia Tech Carilion School of Medicine

Shaheen E Lakhan, MD, PhD, MS, MEd is a member of the following medical societies: American Academy of Neurology, American Medical Association, American Pain Society, International Association for the Study of Pain

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Glenn Lopate, MD Associate Professor, Department of Neurology, Division of Neuromuscular Diseases, Washington University in St Louis School of Medicine; Consulting Staff, Department of Neurology, Barnes-Jewish Hospital

Glenn Lopate, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, Phi Beta Kappa

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Alnylam Pharmaceuticals<br/>Received income in an amount equal to or greater than $250 from: Alnylam Pharmaceuticals; GLG.

Nicholas Lorenzo, MD, MHA, CPE Co-Founder and Former Chief Publishing Officer, eMedicine and eMedicine Health, Founding Editor-in-Chief, eMedicine Neurology; Founder and Former Chairman and CEO, Pearlsreview; Founder and CEO/CMO, PHLT Consultants; Chief Medical Officer, MeMD Inc

Nicholas Lorenzo, MD, MHA, CPE is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Association for Physician Leadership

Disclosure: Nothing to disclose.

Aashit K Shah, MD, FAAN, FANA Professor and Associate Chair of Neurology, Director, Comprehensive Epilepsy Program, Program Director, Clinical Neurophysiology Fellowship, Detroit Medical Center, Wayne State University School of Medicine

Aashit K Shah, MD, FAAN, FANA is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, American Epilepsy Society, American Neurological Association

Disclosure: Received research grant from: Lundebck pharma.

Pinky Agarwal, MD Clinical Associate Professor, Department of Neurology, University of Washington School of Medicine; Attending Neurologist, Medical Director, Booth Gardner Parkinson’s Care Center

Pinky Agarwal, MD is a member of the following medical societies: American Academy of Neurology, International Parkinson and Movement Disorder Society

Disclosure: Nothing to disclose.

Alida Griffith, MD Movement Disorders Neurologist, Booth Gardner Parkinson’s Care Center

Disclosure: Nothing to disclose.

Peroneal Mononeuropathy

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