Peroneal Mononeuropathy

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Background

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]

Pathophysiology

Compression and entrapment neuropathies are predominantly demyelinating.

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.

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

Epidemiology

Race

No racial predilection is known.

Sex

No gender proclivity is known.

Age

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

Profession

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

Prognosis

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]

History

See the list below:

Physical

See the list below:

Causes

Peroneal neuropathies are classically associated with external compression at the level of the fibular head.

Physical Examination

Table 1. Physical Examination in Peroneal Mononeuropathy



View Table

See Table

Imaging Studies

The following imaging studies are useful in peroneal mononeuropathy.[24]

Other Tests

Nerve conduction studies and needle EMG aid in defining the location and type of lesion.

Histologic Findings

Peroneal neuropathy from intraneural ganglia of the peroneal nerve may have various patterns: outer (epifascicular) epineurial, inner (interfascicular) epineurial, and combined outer and inner epineurial.[30]

Medical Care

Most peroneal nerve lesions respond to conservative management with rest and elimination of triggering factors such as leg crossing. Physical therapy is helpful in recovery of function. A large Italian study showed good spontaneous improvement in patients with peroneal mononeuropathy and rehabilitation helped with recovery of deambulation.[31] Additionally, ankle foot orthosis (AFO) helps to stabilize the gait and prevent tripping due to the foot drop.

Surgical Care

Evaluation for surgical intervention[32] for peroneal nerve repair is rarely necessary except in the following situations:

A group from Turkey has reported good results after tibialis posterior tendon transfer for persistent foot drop after peroneal nerve repair.[33]

Another group has reported good results from patients with deep peroneal nerve injuries resulting in foot drop undergoing nerve transfer of functional fascicles of either the superficial peroneal nerve or of the tibial nerve as donor for deep peroneal-innervated muscle groups.[34]

A group from Italy has reported good motor improvement with a double tendon transfer method from the tibialis posterior to tibialis anterior, and flexor digitorum longus transfer to the extensor digitorum longus and extensor hallucis longus tendons.[35]

What is peroneal mononeuropathy?What is the pathophysiology of peroneal mononeuropathy?What is the pathophysiology of ischemic injuries and nerve transection in peroneal mononeuropathy?What is the anatomy relevant to peroneal mononeuropathy?What is the racial predilection of peroneal mononeuropathy?What is the sexual predilection of peroneal mononeuropathy?Which age groups are at highest risk for peroneal mononeuropathy?Which profession increases the risk for peroneal mononeuropathy?What is the prognosis of peroneal mononeuropathy?What are the signs and symptoms of peroneal mononeuropathy?Which physical findings are characteristic of peroneal mononeuropathy?What causes peroneal mononeuropathy?What are the nerve, sensory, and weakness findings indicative of peroneal mononeuropathy?What are the differential diagnoses for Peroneal Mononeuropathy?What is the role of imaging studies in the diagnosis of peroneal mononeuropathy?What is the role of nerve conduction studies in the diagnosis of peroneal mononeuropathy?What is the role of electromyography (EMG) in the diagnosis of peroneal mononeuropathy?Which histologic findings are characteristic of peroneal mononeuropathy?What is the initial treatment for peroneal mononeuropathy?When is evaluation for surgical intervention for peroneal nerve repair indicated?What is the efficacy of surgery for peroneal mononeuropathy?

Author

Shaheen E Lakhan, MD, PhD, MS, MEd, Adjunct Professor of Neuroscience, Virginia Tech Carilion School of Medicine

Disclosure: Nothing to disclose.

Specialty Editors

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

Disclosure: Nothing to disclose.

Chief Editor

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; Chief Strategy Officer, Discourse LLC

Disclosure: Nothing to disclose.

Additional Contributors

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

Disclosure: Received research grant from: Lundebck pharma.

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

Disclosure: Nothing to disclose.

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

Disclosure: Nothing to disclose.

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Peroneal sensory distribution: The striped area is the superficial peroneal sensory distribution. The green solid area represents the deep peroneal sensory distribution. All 3 areas shaded would be numb in a patient with a common peroneal nerve lesion.

Peroneal sensory distribution: The striped area is the superficial peroneal sensory distribution. The green solid area represents the deep peroneal sensory distribution. All 3 areas shaded would be numb in a patient with a common peroneal nerve lesion.

NerveSensoryWeakness
Common peroneal nerveLateral calf and dorsum of footAnkle dorsiflexion and eversion



Toe extension



Deep peroneal nerveArea between first and second toesAnkle dorsiflexion and partial eversion > inversion



Toe extension



Superficial peroneal nerveLateral calf and dorsum of footAnkle eversion