Peroneal nerve neuropathy. Common peroneal nerve Causes and types

The peroneal nerve departs from the sciatic nerve in the upper corner of the popliteal fossa or slightly higher on the thigh, is located in the lateral part of the popliteal fossa and in its lateral corner passes between the tendon of the biceps femoris and the lateral head of the gastrocnemius muscle. Next, it bends around the head of the fibula and, penetrating through the fibrous arch of the peroneus longus muscle, divides into deep and superficial branches. A little higher from the common peroneal nerve, the external cutaneous nerve of the leg departs, innervating its posterolateral surface and participating, together with the medial nerve of the leg, in the formation of the sural nerve. The superficial peroneal nerve runs down the anterolateral surface of the leg, supplying branches to the long and short peroneal muscles. At the level of the lower third of the leg, the nerve exits under the skin and forms the medial and intermediate nerves of the dorsum of the foot, which innervate the skin of the dorsum of the foot and fingers, with the exception of the space between the first and second toes and the little toe.

The deep peroneal nerve passes through the peroneus longus muscle, through the intermuscular septum and into the anterior tibial space, located next to the anterior tibial artery. On the lower leg, the nerve successively gives off muscle branches to the extensor digitorum longus muscle, the tibialis anterior muscle and the extensor pollicis longus muscle. On the dorsum of the foot, the nerve is located under the extensor ligaments and the tendon of the extensor digitorum longus; below, its terminal branches innervate the extensor digitorum brevis and the skin of the first interdigital space, capturing a small area of skin in this area on the dorsum of the foot.

Clinical assessment of peroneal nerve dysfunction requires, first of all, the exclusion of higher damage to its fibers at the level of the sciatic nerve, since these fibers, due to the peculiarities of their structure and blood supply, are most sensitive to mechanical influences in the pelvis, sciatic foramen, buttocks and hips.

Compression of the common peroneal nerve at the level of the popliteal fossa is most often observed with tumors, lipoma, Becker cyst, dystrophic changes in the biceps and gastrocnemius muscles.

Peroneal nerve tunnel syndrome. This term refers to a lesion of the common peroneal nerve in the osteofibrous canal at the level of its inflection on the outer surface of the neck of the fibula. The superficial location, weak vascularization, and tension of the nerve cause its increased sensitivity to direct (even minimal) trauma, pressure, traction, and penetrating injury. Among the causes that most often directly cause compression-ischemic damage to the nerve, it should be noted that squatting or kneeling (“occupational peroneal neuropathy”), unexpected sharp flexion with an inward rotation of the foot, the habit of sitting with crossed legs, an unsuccessfully applied plaster cast, compression by the boot rubber boot. The nerve can also be compressed when lying on its side on a hard surface of a table, bed, bench, as happens in patients in serious condition, in a coma, during a long operation under anesthesia, or while intoxicated. Vertebrogenic tunnel neuropathy occurs in patients with myofascial neurofibrosis in the canal area, with overload of the peroneal muscles of a postural nature with hyperlordosis, scoliosis, and damage to the L 5 root.

The uniqueness of the clinical picture of peroneal neuropathy lies in the predominance of the motor defect over sensory impairment. Weakness and atrophy of the extensors and external rotators of the foot develop, which hangs down, turns inward, and flops when walking. Over time, contracture develops with equinovarus foot deformity. Pain syndrome is absent or minimally expressed; paresthesia, sensory disorders are often limited to a small area on the back of the foot. In the case of incomplete damage to the nerve, palpation is accompanied by pain and paresthesia in the innervation zone. Tinel's sign is positive. With more severe damage, these signs are absent. The Achilles reflex is preserved; its revival, the appearance of pathological signs in combination with a weak expression of paresis, the unusual localization of hypoesthesia on the lower leg suggest a central pathology (tumor of the sagittal parts of the parietal region, myelopathy).

Neuropathy of the superficial peroneal nerve may result from its compression in the upper third of the leg by a fibrous cord that spans between the peroneus longus muscle and the anterior intermuscular septum. Vertebrogenic neuroosteofibrosis or trauma contributes to such damage; a certain role is played by the same factors that provoke neuropathy of the common peroneal nerve. There is hypotrophy of the peroneal muscle group, the foot turns inward, its extension is preserved. Hypoesthesia is detected on the dorsum of the foot, except for its lateral edge and the first interdigital space, pain on palpation of the upper third of the peroneus major muscle; pain is accompanied by paresthesia in the area of skin innervation.

Neuropathy of the cutaneous branch of the superficial peroneal nerve is a consequence of its entrapment at the point of exit from the fascia in the lower third of the leg at a distance of approximately 10 cm above the lateral malleolus along the anterolateral surface of the tibia. The occurrence of this pathology is facilitated by a congenital or traumatic defect of the fascia with small muscle or fatty hernias. An episode of sprain of the lateral ankle ligament immediately precedes the appearance of patient complaints of pain, paresthesia, numbness along the outer edge of the lower third of the leg and dorsum of the foot. An objective examination reveals pain at the point where the nerve exits the skin; Tinel's sign is positive.

Neuropathy of the median and intermediate cutaneous nerves of the dorsum of the foot. These nerves are the terminal branches of the superficial peroneal nerve on the dorsum of the foot. The subcutaneous tissue in this area is poorly represented, and the nerve trunks are easily injured, pressing against the tubercle of the scaphoid bone (medial nerve) or the cuboid bone (intermediate nerve), and below - to the bases of the second to fourth metatarsal bones.

This situation occurs when the foot is bruised by a falling object (even without noticeable damage to the skin and soft tissues) and especially often when wearing shoes such as clogs without heels and a back that secures the shoes on the foot (flip-flops), as well as tight shoes with tight lacing - it is important that in these cases conditions are created for local chronic pressure on the dorsum of the foot. The result is an unpleasant, burning paresthesia on the dorsum of the foot and in the area of the big toe (compression of the median nerve) or on the back of the second and third toes (compression of the intermediate nerve). Tinel's symptom is clearly presented; percussion of the point of nerve damage is accompanied by a feeling of current passing to the fingers. Symptoms intensify when putting on shoes, which are “culpable” for nerve damage, and decrease after exposure to heat and light rubbing of the sore spot. Hypesthesia or dysesthesia is limited to a small spot on the dorsum of the foot. The disease can continue for years, causing significant discomfort if its cause is not eliminated. The correct selection of shoes is decisive in the prevention and relief of painful symptoms.

Deep peroneal nerve neuropathy occurs with pathology of the anterior tibial space. The nerve is compressed at the level of the middle third of the leg, where it passes through the thickness of the peroneus longus muscle and the anterior intermuscular septum and is located between the long extensor digitorum and the anterior tibialis muscle. Neuromyodystrophy, congenital narrowness of the intermuscular space and post-traumatic fibrosis contribute to compression of the neurovascular bundle. The chronic version of neuropathy is characterized by deep aching pain in the anterior muscles of the leg, intensifying with walking and maximum extension of the foot. Pain extends to the back of the foot and into the space between the first and second toes; here, paresthesia is felt when putting pressure on the toe, performing the Tinel test. A few months later, weakness and atrophy of the extensors of the foot and fingers are detected.

Anterior tibial space syndrome is an acute, one might say, dramatic variant of compression-ischemic lesion of the deep peroneal nerve on the lower leg. The anterior tibial space is a closed fascial sheath containing the muscles - extensors of the foot and fingers, the deep peroneal nerve and the anterior tibial artery. With congenital or acquired narrowness of this space, any further increase in the volume of its contents leads to compression of the artery and nerve. Most often this happens when there is unexpected excessive load on the lower leg muscles (for example, when an untrained person runs long distances). The working muscles increase in volume, while the tibial artery that feeds the muscles and nerve is compressed and spasmed. Muscle ischemia occurs, swelling increases, and pinching and necrosis of the muscles of the anterior tibial space occur. The deep peroneal nerve is damaged due to compression and malnutrition.

The clinical picture of anterior tibial space syndrome is represented by severe pain in the muscles of the anterior surface of the leg, which appears immediately or several hours after physical overload of the legs. There is a sharp thickening and pain on palpation of the muscles of the anterior surface of the leg. There is no active extension of the foot; passive extension increases the pain. The pulse is not detected on the dorsal artery of the foot. The foot is cold to the touch. Reduced sensitivity on the dorsum of the first two fingers. After two to three weeks, the pain decreases, atrophy of the muscles of the anterior tibial space is detected. Partial restoration of foot extension is possible in half of the cases. The prognosis may be better with early decompression of the fascial sheath.

Anterior tarsal tunnel syndrome develops as a result of compression of the deep peroneal nerve on the dorsum of the foot under the inferior extensor ligament, where the nerve is located in a tight space on the tarsal bones together with the artery of the dorsum of the foot. The main causes leading to nerve damage are blunt trauma, compression by tight shoes, fibrosis of the cruciate ligament after injury, neuroosteofibrosis in the joints and ligaments of the foot, ganglia, and tenosynovitis of the extensor pollicis longus.

Patients are bothered by pain on the dorsum of the foot, radiating to the first and second toes, the extension of the toes is weakened, and atrophy of the small muscles of the foot is visible. A positive Tinel's sign specifies the level of compression of the nerve. An isolated lesion of the external muscular or internal sensory branch may be observed. In the first case, the pain is limited to the place of compression, there is paresis of the finger extensors; in the second, there are no muscle-motor disorders, the pain radiates to the first interdigital space, and a zone of hypoesthesia is identified here.

DIFFERENTIAL DIAGNOSTIC DIFFERENCES IN NEUROLOGICAL SYNDROMES,

CAUSED BY SPINE PATHOLOGY

(see at the end of the educational manual)

Electromyography (EMG)

Electromyography (EMG) is a method of recording the bioelectrical activity of muscles, which allows one to determine the state of the neuromuscular system. The electromyographic method is used in patients with various motor disorders to determine the location, extent and extent of the lesion.

Two methods of removing muscle biopotentials are used: cutaneous (global electromyography) and needle (local electromyography) electrodes.

An EMG study is carried out to clarify the topography and severity of damage to the nervous system. The use of electromyographic research allows for topical diagnosis of lesions of the root, plexus or peripheral nerve, to identify the type of lesion: single (mononeuropathy) or multiple (polyneuropathy), axonal or demyelinating; the level of nerve compression in tunnel syndromes, as well as the state of neuromuscular transmission. These data allow us to formulate a topical syndromic electromyographic diagnosis.

Normally, only type 1 electromyograms are recorded, reflecting frequent, rapid, and variable in amplitude potential oscillations. Electromyograms of the same type with a decrease in bioelectric processes (frequency, shape, duration of oscillation) are recorded in patients with myopathies, central pyramidal paresis and radiculoneuritis. Radicular damage is indicated by the hypersynchronous nature of the EMG curve, the appearance of unstable fibrillation potentials and fasciculations during tonic tests.

The main form of disturbances in bioelectrical processes developing in the neuromotor apparatus with lesions of the nervous system is characterized by type 2 electromyograms, reflecting more or less slowed down potential fluctuations. Electromyograms of the 2nd type predominate with neuronal and neural localization of the process.

Peculiar changes characterize electromyograms of the 3rd type, recorded during extrapyramidal changes in tone and hyperkinesis.

Complete “bioelectric silence” - type 4 electromyograms - is observed in flaccid muscle paralysis in the event of the death of all or most of the motor neurons innervating them. Computer processing of myograms is possible.

Electroneuromyography

A complex method based on the use of electrical stimulation of a peripheral nerve followed by the study of evoked potentials of the innervated muscle (stimulation electromyography) and nerve (stimulation electroneurography).

Evoked potentials of a muscle. M-response is the total synchronous discharge of motor units of a muscle during its electrical stimulation. Normally, when recorded using a surface bipolar electrode, the M-response has two phases (negative and positive), duration from 15 to 25 ms, maximum amplitude up to 7-15 mV. With denervation, neural damage, the M-response becomes polyphasic, its duration increases, the maximum amplitude decreases, the latent period lengthens, and the threshold of irritation increases.

H-response is a monosynaptic reflex response of a muscle upon electrical stimulation of sensory nerve fibers of the largest diameter using a subthreshold stimulus for motor axons.

The ratio of the maximum amplitudes of the H- and M-responses characterizes the level of reflex excitability of the alpha motor neurons of a given muscle and normally ranges from 0.25 to 0.75.

The P-wave is a potential similar in latency period and duration to the H-reflex, but unlike it, it persists with stimulation supramaximal for the M-response.

The recurrent action potential (RP) of a nerve is the total response of the nerve trunk to its electrical stimulation.

During denervation, the shape of the potential changes (it lengthens, becomes polyphasic), the amplitude decreases, and the latent period and threshold of stimulation increase.

Determination of impulse conduction velocity (ICV) along the peripheral nerve. Stimulation of the nerve at two points allows you to determine the time of passage of the impulse between them. Knowing the distance between the points, you can calculate the speed of impulse transmission along the nerve using the formula:

where S is the distance between the proximal and distal points of stimulation (mm), T is the difference in the latent periods of M-responses for motor fibers, and nerve AP for sensory fibers (ms). The normal SPI value for motor fibers of peripheral nerves of the extremities ranges from 49 to 65 m/s, for sensory fibers – from 55 to 68 m/s.

Rhythmic peripheral nerve stimulation. It is performed to identify disorders of neuromuscular conduction and myasthenic reaction. The study of neuromuscular conduction using rhythmic stimulation can be combined with pharmacological tests (proserine, etc.).

Electromyography allows you to determine changes in muscle tone and movement disorders. It can be used to characterize muscle activity and early diagnosis of lesions of the nervous and muscular systems, when clinical symptoms are not expressed. EMG studies make it possible to objectify the presence of pain syndrome and the dynamics of the process.

The purpose of electromyography:

Detection of pathology in muscle and nervous tissue, as well as the junction of muscle and nerve (neuromuscular synapse). This pathology includes herniated disc, amyotrophic lateral sclerosis, myasthenia gravis.

Determining the cause of muscle weakness, paralysis or twitching. Problems with the muscles, nerves, spinal cord, or part of the brain that may cause these changes. EMG does not reveal pathologies in the spinal cord or brain.

Purpose of electroneurography- identification of pathology from the peripheral nervous system, which includes all nerves emanating from the spinal cord and brain. Electrical nerve conduction studies are often used to diagnose carpal tunnel syndrome and Guillain-Barré syndrome.

Electromyography (EMG) is a method for studying the electrical activity of muscles at rest and during muscle contraction. There are several types of electromyography:

Interference EMG is recorded by cutaneous electrodes during voluntary muscle contractions or during passive flexion or extension of a limb.

Local EMG. Potentials are removed using concentrically coaxial electrodes immersed in the muscle.

Stimulation EMG (electro-neuromyography). The removal of biopotentials is carried out using both cutaneous and needle electrodes when the peripheral nerve is irritated.

In addition, there is the so-called external sphincter electromyography, to determine the electrical activity of the external sphincter of the bladder. Moreover, its activity can be determined using both needle electrodes and cutaneous and anal electrodes.

Electroneurography (ENG) is a method for assessing how quickly electrical signals are transmitted along nerves.

As you know, muscle activity is controlled by electrical signals emanating from the spinal cord (or brain), which are conducted by nerves. Disruption of this combined interaction of nerves and muscles leads to a pathological response of the muscle to electrical signals. Determining the electrical activity of muscles and nerves helps identify diseases that involve pathology of muscle tissue (for example, muscular dystrophy) or nervous tissue (amyotrophic lateral sclerosis or peripheral neuropathy).

To complete the examination, both of these research methods - EMG and ENG - are carried out together.

Electromyography and electroneurography also help in diagnosing post-polio syndrome, a syndrome that can develop several months to years after polio.

Preparing for research

Before performing an EMG or ENG, you should tell your doctor if you are taking any medications that affect the nervous system (for example, muscle relaxants or anticholinergics) and may alter the results of the EMG and ENG. In this case, it is necessary not to take these drugs for 3-6 days. Also tell your doctor if you are taking anticoagulants (warfarin or others). In addition, be sure to tell your doctor if you have a pacemaker (artificial heart pacemaker) implanted. It is recommended not to smoke for 3 hours before the test. In addition, for the same time you need to abstain from products containing caffeine (chocolate, coffee, tea, cola, etc.).

One of the mononeuropathies of the lower extremities, accompanied by foot drop syndrome - the inability to dorsiflex the foot and extend the toes, as well as sensory disorders of the skin of the anterolateral region of the leg and dorsum of the foot. The diagnosis is made on the basis of anamnesis, neurological examination, electromyography or electroneurography. Additionally, an ultrasound scan of the nerve and examination of the osteoarticular apparatus of the lower leg and foot are performed. Conservative treatment is carried out using a combination of medications, physiotherapy and orthopedic methods. If it fails, surgery is indicated (decompression, nerve suture, tendon transposition, etc.).

General information

Neuropathy of the peroneal nerve, or peroneal neuropathy, occupies a special position among peripheral mononeuropathies, which also include: neuropathy of the tibial nerve, neuropathy of the femoral nerve, neuropathy of the sciatic nerve, etc. Since the peroneal nerve consists of thick nerve fibers that have a larger layer of myelin sheath, then it is more susceptible to damage due to metabolic disorders and anoxia. This point is probably responsible for the fairly wide prevalence of peroneal neuropathy. According to some data, neuropathy of the peroneal nerve is observed in 60% of patients in traumatology departments who have undergone surgery and are treated with splints or plaster casts. Only in 30% of cases, neuropathy in such patients is associated with primary nerve damage.

It should also be noted that often specialists in the field of neurology have to deal with patients who have a certain history of peroneal neuropathy, including the postoperative period or time of immobilization. This complicates treatment, increases its duration and worsens the result, since the earlier therapy is started, the more effective it is.

Anatomy of the peroneal nerve

The peroneal nerve (n. peroneus) arises from the sciatic nerve at the level of the lower 1/3 of the thigh. It consists predominantly of fibers of the LIV-LV and SI-SII spinal nerves. After passing through the popliteal fossa, the peroneal nerve exits to the head of the bone of the same name, where its common trunk is divided into deep and superficial branches. The deep peroneal nerve passes into the anterior part of the leg, descends, passes to the dorsum of the foot and divides into internal and external branches. It innervates the muscles responsible for extension (dorsal flexion) of the foot and toes, pronation (raising the outer edge) of the foot.

The superficial peroneal nerve runs along the anterolateral surface of the leg, where it gives off a motor branch to the peroneal muscles, which are responsible for pronation of the foot with its simultaneous plantar flexion. In the area of the medial 1/3 of the tibia, the superficial branch of n. peroneus passes under the skin and is divided into 2 dorsal cutaneous nerves - the intermediate and medial. The first innervates the skin of the lower 1/3 of the leg, the dorsum of the foot and the III-IV, IV-V interdigital spaces. The second is responsible for the sensitivity of the medial edge of the foot, the back of the first toe and the II-III interdigital space.

Anatomically determined areas of greatest vulnerability of the peroneal nerve are: the place of its passage in the area of the head of the fibula and the place where the nerve exits the foot.

Causes of peroneal nerve neuropathy

There are several groups of triggers that can initiate the development of peroneal neuropathy: nerve injury; compression of the nerve by the surrounding musculoskeletal structures; vascular disorders leading to nerve ischemia; infectious and toxic lesions. Neuropathy of the peroneal nerve of traumatic origin is possible with knee bruises and other injuries of the knee joint, tibia fracture, isolated fracture of the fibula, dislocation, tendon damage or sprain of the ankle joint, iatrogenic damage to the nerve during reposition of the leg bones, operations on the knee joint or ankle.

Compressive neuropathy (so-called tunnel syndrome) n. peroneus most often develops at the level of its passage at the head of the fibula - superior tunnel syndrome. It may be associated with professional activities, for example, among berry pickers, parquet floor workers and other people whose work involves long periods of squatting. Such neuropathy is possible after prolonged sitting with legs crossed. When the peroneal nerve is compressed where it exits the foot, inferior tunnel syndrome develops. It may be caused by wearing excessively tight shoes. Often the cause of peroneal compression neuropathy is compression of the nerve during immobilization. In addition, compression n. peroneus may have a secondary vertebrogenic nature, that is, develop in connection with changes in the musculoskeletal system and reflex muscular-tonic disorders caused by diseases and curvatures of the spine (osteochondrosis, scoliosis, spondyloarthrosis). Iatrogenic compression-ischemic neuropathy of the peroneal nerve is possible after its compression due to incorrect position of the leg during various surgical interventions.

More rare causes of peroneal neuropathy include systemic diseases accompanied by proliferation of connective tissue (deforming osteoarthritis, scleroderma, gout, rheumatoid arthritis, polymyositis), metabolic disorders (dysproteinemia, diabetes mellitus), severe infections, intoxication (including alcoholism, drug addiction ), local tumor processes.

Symptoms of peroneal nerve neuropathy

Clinical manifestations of peroneal neuropathy are determined by the type and location of the lesion. Acute nerve injury is accompanied by a sharp, almost immediate appearance of symptoms of its damage. Chronic injury, dysmetabolic and compression-ischemic disorders are characterized by a gradual increase in the clinical picture.

Damage to the common trunk of the peroneal nerve is manifested by a disorder in the extension of the foot and its toes. As a result, the foot hangs down in a plantarflexed position and is slightly internally rotated. Because of this, when walking, moving the leg forward, the patient is forced to bend it strongly at the knee joint so as not to catch the toe on the floor. When lowering the leg to the floor, the patient first stands on his toes, then rests on the lateral plantar edge, and then lowers the heel. This gait resembles that of a rooster or a horse and has corresponding names. Difficult or impossible: raising the lateral edge of the sole, standing on the heels and walking on them. Motor disturbances are combined with sensory disorders extending to the anterolateral surface of the lower leg and dorsum of the foot. There may be pain on the outer surface of the lower leg and foot, which increases with squats. Over time, atrophy of the muscles of the anterolateral region of the leg occurs, which is clearly visible when compared with a healthy leg.

Neuropathy of the peroneal nerve with damage to the deep branch is manifested by less pronounced foot drop, reduced extension strength of the foot and toes, sensory disorders on the dorsum of the foot and in the 1st interdigital space. The long course of neuropathy is accompanied by atrophy of small muscles on the dorsum of the foot, which is manifested by retraction of the interosseous spaces.

Peroneal nerve neuropathy involving the superficial branch is characterized by sensory disturbances and pain on the lateral aspect of the lower leg and the medial aspect of the dorsum of the foot. Upon examination, a weakening of the pronation of the foot is detected. Extension of the fingers and toes is preserved.

Diagnosis of peroneal nerve neuropathy

The diagnostic algorithm for peroneal neuropathy is based on the collection of anamnestic data that may indicate the genesis of the disease, and a thorough examination of the motor function and sensory sphere of the peripheral nerves of the affected limb. Special functional tests are performed to evaluate the muscle strength of various muscles of the lower leg and foot. Surface sensitivity analysis is carried out using a special needle. Additionally, electromyography and electroneurography are used, which make it possible to determine the level of nerve damage based on the speed of action potentials. Recently, nerve ultrasound has been used to study the structure of the nerve trunk and structures located next to it.

Traumatic neuropathy requires consultation

MUSCULAR BRANCHES OF THE SACRA PLEXUS(rami musculares plexus sacralis) - innervate the piriformis, internal obturator muscles, twin muscles, quadratus femoris.

SUPERIOR GLUTAL NERVE(nervus gluteus superior) - exits the pelvic cavity through the supragiriform foramen and innervates the gluteus medius and minimus and the muscle that strains the lata fascia of the thigh.

INNER GLUTAL NERVE(nervus gluteus inferior) - exits through the infrapiriform foramen and innervates the gluteus maximus muscle.

GENITAL NERVE(nervus pudendus) - goes around the back of the sciatic spine and through the lesser sciatic foramen exits to the perineum. Gives rise to the inferior rectal nerves (innervate the skin around the anus and its external sphincter), perineal nerves (innervate the muscles of the perineum and the skin of the scrotum/labia majora), dorsal nerve of the penis (clitoris).

POSTERIOR CUTANEOUS NERVE OF THE FEMOR(nervus cutaneus femoris posterior) - exits through the infrapiriform foramen and innervates the skin of the posterior thigh and proximal part of the leg. Gives the inferior branches of the buttocks and perineal nerves to the skin of these areas.

Sciatica NERVE(nervus ischiadicus) is the largest nerve of the human body. It leaves the infrapiriform foramen and descends between the muscles of the posterior thigh into the popliteal fossa, where it divides into the common peroneal and tibial nerves. On the thigh it innervates the posterior group of muscles and the posterior part of the adductor magnus muscle.

COMMON PERONEAL NERVE(nervus fibularis communis) - can arise from the sciatic nerve at various levels. Between the neck of the fibula and the peroneus longus muscle it divides into superficial and deep branches. Also gives rise to the lateral calf cutaneous nerve.

SUPERFICIAL PERONEAL NERVE(nervus fibularis superficialis) - descends between the peroneal muscles and the long extensor digitorum. Gives muscle branches to the long and short peroneal muscles, the medial cutaneous dorsal nerve (innervates the skin of the dorsum of the foot, the medial side of the big toe, as well as the sides of the II and III fingers facing each other), the intermediate dorsal cutaneous nerve. The latter breaks up into the dorsal digital nerves of the foot and innervates the skin of the sides of the third, fourth and fifth fingers facing each other.

DEEP PERONEAL NERVE(nervus fibularis profundus) - passes under the long peroneal muscle and is directed to the back of the foot. Gives muscle branches to the tibialis anterior, extensor pollicis brevis and longus, and extensor digitorum brevis and longus. The terminal cutaneous branch innervates the skin of the first interdigital space.

TIBIAL NERVE(nervus tibialis) - in the neurovascular bundle in the popliteal fossa, it occupies a superficial position (“NEVA”), enters the knee-popliteal canal, exits from under the medial edge of the Achilles tendon, bends around the medial malleolus and at the sole is divided into medial and lateral plantar nerves . Gives muscle branches to all muscles of the posterior group of the leg and cutaneous branches: medial cutaneous nerve of the calf, medial calcaneal branches.

MEDIAL PLANT NERVE(nervus plantaris medialis) - lies in the medial groove of the plantar, innervates the flexor digitorum brevis, the abductor pollicis muscle, the medial head of the flexor pollicis brevis muscle, the I and II lumbrical muscles, as well as the common plantar digital nerves, which split into their own plantar digital nerves the skin of three and a half toes on the medial side of the foot.

LATERAL PLANT NERVE(nervus plantaris lateralis) - lies in the lateral groove of the sole, at the base of the fifth metatarsal bone it is divided into superficial and deep branches. The first innervates the skin of the plantar surface of one and a half toes on the lateral side of the foot, the deep branch innervates all the muscles of the little toe, III-IV lumbrical muscles, all interosseous muscles, the adductor pollicis muscle, the lateral head of the flexor pollicis brevis, and the quadratus plantar muscle.

Peroneal nerve neuritis is a disease that is an inflammatory process that occurs due to mechanical, chemical or endogenous damage to nerve fibers.

Anatomy of the peroneal nerve

The peroneal nerve originates from the sacral plexus. Nerve fibers are part of the sciatic nerve; at the level of the knee joint, the nerve bundle is divided into two: the tibial and peroneal nerves, which connect in the lower third of the leg into the sural nerve.

The peroneal nerve consists of several trunks and innervates the extensor muscles, the muscles that allow external rotation of the foot, and the muscles of the toes.

Causes

Due to the peculiarities of the anatomical structure, the peroneal nerve has increased vulnerability and suffers from injuries to the lower extremities more often than the tibial nerve: the nerve trunk runs almost along the surface of the bone and is practically not covered by muscle bundles.

Neuritis of the peroneal nerve can be caused by injury, hypothermia, or prolonged exposure of the limb in an uncomfortable position. In addition, inflammation can be triggered by:

Acute infectious diseases of microbial and viral nature: herpes, influenza, sore throat, typhoid fever.
Chronic infections, including sexually transmitted ones: for example, syphilis or tuberculosis leads to nerve damage.
Spinal diseases accompanied by degenerative changes or leading to narrowing of the spinal canal.
Complications after nerve trunk injuries.
Lower tunnel syndrome.
Violation blood supply nerve: ischemia, thrombophlebitis, damage to arteries or veins.
Long-term diseases leading to metabolic disorders: sugar diabetes both types, hepatitis of infectious and non-infectious origin, gout, osteoporosis.
Toxic nerve damage from alcohol, drugs, arsenic or heavy metal salts.
Hitting the barrel ischial nerve when performing an intramuscular injection into the buttock.
Incorrect position legs in cases where the patient is forced to remain motionless for a long time.

Often, damage to the peroneal nerve occurs in professional athletes who receive excessive physical stress on their legs and are often injured.

Symptoms

The severity of symptoms depends on the localization of the pathological process; symptoms are divided into two groups: impaired mobility and changes in the sensitivity of the limb. The following symptoms will indicate deep compression of the nerve:

Loss of pain, touch and temperature sensitivity surfaces of the foot from the side and front, as well as from the back of the foot, in the area of the toes. The disorders affect the first, second and part of the third finger.
Pain in the area of the lateral surface of the leg and foot, it intensifies with movement and flexion of the limb.
Difficulties with extension toes, up to complete limitation of mobility.
Weakness or the inability to raise the outer edge of the foot, it is impossible to abduct the leg at the outer side of the shin.
Inability to stand on heels or walk on them.
"Cock" gait: the leg is excessively bent at the knee and hip joint, the leg is first on the toes, and only then on the heel, forced lameness occurs, and the ability to move normally is lost.
The foot that sags and turns inward, the fingers are bent, the patient cannot return the limb to the anatomically normal position and straighten the fingers.
Atphrophia leg muscles, their mass decreases compared to a healthy limb, and trophic ulcers can form.
Change colors skin in the affected area: on the lateral surface of the leg and the back of the foot, the skin turns pale, as the neuritis develops, acquiring a purple or bluish color, sometimes darkening of areas of the skin is observed.

With superficial nerve damage, the symptoms are somewhat different:

Arises discomfort, a burning sensation and pain on the back of the foot and fingers, as well as in the lower part of the leg, the sensitivity of these areas changes slightly.
Observed weakness when moving the foot and toes, difficulty in extending movements of the toes, the first and second toes are especially affected.
Foot sags slightly, the fingers do not bend.
Atrophic the phenomena affect the lower leg only slightly; in this case, the small muscles of the foot and toes are mostly affected by degenerative changes.
When comparing the affected leg with the healthy one, it becomes noticeable sinking interdigital spaces, especially between the first and second fingers.

If the motor branch of the nerve is not affected, only sensory symptoms will be observed, without changes in the structure of the muscle fibers.

Diagnostics

The diagnosis is established by a neurologist based on a clinical examination:

Conducted survey- an anamnesis of life and illness is collected to determine when the symptoms first appeared. Based on the nature of the complaints, the cause can be determined: post-traumatic neuritis usually develops soon after injury, all symptoms in this case arise abruptly within a few days. If the cause of neuritis is a chronic disease, the symptoms will increase gradually.
In progress diagnostic examination: a comparison is made between the healthy and the diseased leg, the degree of muscle atrophy and the condition of the affected limb are calculated. The specialist pays attention to the position of the foot, toes, skin color and the condition of the spaces between the toes.
The patient will be required to perform some exercises which will help the specialist understand which part of the nerve is captured: the patient is asked to abduct the foot, straighten the toes, raise the toe and stand on the heel. The extent of nerve damage can be judged by the range of movements performed.
To determine sensitivity disorders, skin tests are performed. tests: they do dermatography of different areas of the skin, piercing the surface with a medical needle. To determine temperature sensitivity, a warm and cold water test is used.
If neuritis was provoked by injury, it is prescribed X-ray study.
It is used to determine the condition of muscles and nerve bundles. electromyography.

Once the diagnosis is made, treatment must begin immediately.

Drug treatment

Treatment of neuritis is aimed at eliminating the cause of the disease, and depending on it, will vary.

Inflammation of an infectious nature can be controlled with antibiotics and antiviral agents. Preference is given to broad-spectrum drugs; sulfonamides are used as adjuncts.

If a serious disease is identified during the examination, therapy is aimed at eliminating or correcting it: diabetics are prescribed insulin and similar drugs; if cancer is detected, chemotherapy or radio wave irradiation is used; specialized drugs are used to treat tuberculosis.

If the inflammation is caused by an incorrect position of the limb, for example, due to a too tight bandage or improper application of a cast, the cause is eliminated. In some cases, changing the plaster brace is enough to eliminate the symptoms.

Before starting the course, you must familiarize yourself with all possible contraindications and side effects of the drugs, carefully follow the dosage and regimen of taking medications. The duration of the course depends on the patient’s condition and is determined by the attending physician.

In order to alleviate the patient's condition, symptomatic treatment is used:

Anti-inflammatory non-steroidal drugs. Used both in the form of tablets and in the form of ointments and creams, they effectively relieve inflammation, relieve pain and swelling. The choice of form depends on the severity of the disorder: if inflammation is accompanied by pain and cannot be relieved by other means, a series of injections is performed. The dose of the drug is gradually reduced, then the patient is transferred to tablet forms, and then to local agents.
Drugs that improve blood supply. Prescribed in order to saturate the cells with oxygen and glucose and prevent atrophic phenomena, a number of Actovegin and Solcoseryl, which effectively affect the cells of nerves and blood vessels, prevent atrophic phenomena, and contribute to the speedy restoration of nutrition of neurons and muscle fiber cells.
Antioxidants- remove free radicals and inflammatory products from cells, help nerve cells fight hypoxia.
Vitamins Group B- to improve nerve conduction and prevent complications of neuropathy.

The combination of drugs is prescribed by a specialist; self-medication is strictly contraindicated.

Procedures

In order for the therapy to be effective, a combination of various procedures is used:

Physiotherapeutic exposure using amplimuls, magnetic therapy - procedures help relieve symptoms of inflammation, improve the condition of tissues and nerve fibers.
To maintain muscle condition - stimulation dynamic currents - this prevents atrophy and maintains skeletal muscles in working condition.
Electrophoresis. Used to transport medications directly to the treatment site. The combination of drugs depends on the cause of the disease and is selected by the attending physician.
For recovery sensitivity and limb mobility - acupuncture and massage - a combination of various methods gives positive results and helps to quickly restore the functions of the limb after the acute phase of inflammation has passed.
Orthopedic structures to restore the foot anatomically correct position, wearing an orthosis also helps to correct the gait.
Treatment is recommended for rehabilitation physical training, a set of exercises is selected individually for the patient, attention is focused on returning muscles to mobility and restoring all movements in full.

Surgical intervention is resorted to if conservative treatment is ineffective.

Surgery

The operation is applied if:

Violated integrity nerve bundles over a significant area. If there is significant nerve injury, medications will not work, nor will any other conservative methods. The operation in this case is aimed at restoring the nerve.
If the nerve has been compressed, surgery may save limb patient. The surgeon cuts or removes the formations that led to the onset of neuropathy.

During the rehabilitation period, therapy is aimed at restoring the conduction of impulses and returning the limb to the maximum possible extent of mobility.

Possible complications

If left untreated, the disease is protracted and can lead to a wide range of complications:

Pain of a chronic nature, worsening the patient’s quality of life.
Restricted leg mobility, “rooster” gait - will lead to impairment posture, lameness and, ultimately, the inability to move independently.
Dabetic gangrene, which threatens death or amputation of a limb.
Trophic ulcers, muscle atrophy - in this case it will be problematic to restore mobility.

Infectious neuritis without treatment is dangerous for the development of polyneuropathy, as well as septic damage to the body.

In order to prevent complications, it is necessary to consult a doctor immediately after the first violations are noticed.

The nervous system is the most complex complex in the human body. It consists of the brain and spinal cord, as well as numerous branches. The latter provide an instant exchange of impulses throughout the body. Disruption of one nerve has virtually no effect on the functioning of the entire network. However, it may lead to deterioration in the performance of certain parts of the body.

Neuropathy is a disease characterized by non-inflammatory damage to the nerves. Its development can be facilitated by degenerative processes, trauma or compression. The main target of the pathological process is usually the lower extremities.

The so-called neuropathy of the legs is divided into the following types:

pathology of the peroneal nerve;
tibial nerve;
sensory.

Each form of the disease is of great interest to doctors. Among all peripheral pathologies, neuropathy of the peroneal nerve occupies a special place. This is what will be discussed further in the article.

Description of the disease

Peroneal nerve neuropathy is a pathological disorder accompanied by foot drop syndrome. In the specialized literature you can find another name for this disease - peroneal neuropathy.

Since the peroneal nerve consists of thick fibers with an impressive layer of myelin sheath, it is more susceptible to metabolic disorders. Most likely, it is this moment that determines the widespread prevalence of the disease. According to available information, manifestations of the pathological process are observed in 60% of patients in trauma departments, and only in 30% of cases is it associated with primary nerve damage.

Next, we will consider the anatomical features of the structure described in the article. This is necessary to understand for what reasons neuropathy of the peroneal nerve develops (ICD-10 assigned the disease code G57.8).

Anatomical certificate

The peroneal nerve arises from the sciatic nerve at the level of the lower third of the thigh. Its structure is represented by various fibers. At the level of the popliteal fossa, these elements are separated into the common peroneal nerve. It spirals around the head of the bone of the same name. At this point, the nerve lies on the surface and is covered only by skin, which is why any external factors can put pressure on it.

The peroneal nerve then divides into two branches: superficial and deep. These elements are named due to their direction. The superficial branch is responsible for the innervation of muscle structures, rotation of the foot and sensitivity of its dorsum. The deep peroneal nerve provides finger extension as well as the sensation of pain and touch in this area.

Compression of one or another branch is accompanied by impaired sensitivity in various areas of the foot and the inability to straighten the phalanges. Therefore, the symptoms of neuropathy may vary depending on which part of the structure is damaged. In some cases, knowledge of its anatomical features allows one to determine the extent of the pathological process before consulting a doctor.

Main causes of the disease

The development of the pathological process can be caused by many factors. Among them, doctors highlight the following:

Compression of the nerve along any route. This is the so-called tunnel neuropathy of the peroneal nerve. It is divided into two groups. Upper syndrome develops against the background of pressure on structures within the vascular bundle. The disease is most often diagnosed in people whose work involves long periods of sitting in an uncomfortable position. These are berry pickers, parquet layers, seamstresses. The lower one develops as a result of compression of the deep peroneal nerve in the area of its exit to the foot. This clinical picture is typical for people who prefer uncomfortable shoes.
Impaired blood supply to the limb.
Incorrect position of the legs due to a lengthy operation or serious condition of the patient, accompanied by immobilization.
Entry into nerve fibers during intramuscular injection in the gluteal region.
Severe infectious diseases.
Injuries (tibia fracture, foot dislocation, tendon damage, ligament sprain). As a result of severe bruising, swelling occurs. It leads to compression of the nerve and deterioration of impulse conduction. A distinctive feature of this form of the disease is that only one limb is affected. Otherwise it is called post-traumatic neuropathy of the peroneal nerve.
Oncological lesions with metastasis.
Toxic pathologies (diabetes mellitus, renal failure).
Systemic diseases characterized by proliferation of connective tissue (osteoarthritis, gout, rheumatoid arthritis).

All causes of the development of the pathological process can be classified into five areas: trauma, compression, vascular disorders, infectious and toxic lesions. Regardless of which particular group of triggers neuropathy of the peroneal nerve belongs to, the ICD-10 code for this disease is the same - G57.8.

What symptoms are accompanied by the disease?

Clinical manifestations of the disease depend on the degree of neglect of the pathological process and the location of the nerve damage. All symptoms can be divided into main and accompanying ones. The first group includes sensory impairment in the affected limb. Associated symptoms may vary in each individual case. However, most often patients complain of:

swelling in the legs;
periodic feeling of “goosebumps”;
spasms and cramps;
discomfort when walking.

It was noted a little higher that the clinical picture of the disease also depends on the location of the nerve damage. For example, damage to the common trunk is manifested by a violation of the process of extension of the foot. Because of this, it begins to hang down. When walking, the patient is forced to constantly bend his leg at the knee so as not to catch his foot on the floor. When lowering it, he first stands on his toes, then transfers his weight to the lateral plantar edge and only then lowers his heel. This manner of movement resembles that of a rooster or a horse, which is why it bears similar names.

Movement disorders are combined with Patients often note the appearance of pain on the outer surface of the lower leg, which only intensifies when squatting. Over time, the affected area develops. This sign of the disease is clearly visible, especially when compared with a healthy limb.

What are the symptoms of peroneal nerve neuropathy when the deep branch is affected? In this case, the foot drop is less pronounced. However, sensory and motor impairments are also present. If the disease is not treated, it is complicated by atrophy of small muscles.

Neuropathy of the peroneal nerve when the superficial branch is affected is accompanied by impaired sensitivity and severe pain in the lower part of the leg. During examination, patients are often diagnosed with decreased pronation of the foot.

Diagnostic methods

Timely detection of the pathological process and elimination of the underlying disease - these two factors are the key to successful therapy. How is neuropathy diagnosed?

First, the doctor collects the patient's medical history. During this procedure, he studies his disease record and conducts a survey to clarify the information. Then the doctor moves on to instrumental diagnostic methods. Certain tests are performed to evaluate muscle strength, and skin sensitivity is analyzed using a special needle. Additionally, electromyography and electroneurography are used. These procedures allow us to determine the extent of nerve damage. An equally informative examination method is ultrasound, during which the doctor can examine damaged structures.

Peroneal nerve neuropathy always requires differential diagnosis with other disorders that have similar clinical manifestations. These include peroneal muscular atrophy syndrome and cerebral tumors.

In particularly serious cases, consultation with specialists is required. For example, a traumatologist. Based on the results of the tests already received, the doctor may prescribe an x-ray of the bones or knee joint.

Peroneal nerve neuropathy: ICD

To understand the essence of the doctor’s diagnosis, you need to familiarize yourself with a special code system. They are recorded in The system is built very simply. First comes the designation with a Latin letter, which defines the group of diseases. This is followed by a numerical code indicating a specific ailment. Sometimes you can find another symbol. It carries information about the type of disease.

Many patients are interested in what the ICD code is for peroneal nerve neuropathy. It should be noted that the described illness does not have a designation as such. Category G57 includes mononeuropathies of the lower extremities. If we delve deeper into the study of pathologies belonging to this class, our disease will not be found there. However, it can include code G57.8, which refers to other mononeuralgia of the lower limb.

Knowing what the International Classification of Diseases is, you can get any information on the issue of diagnosis. This also applies to a disease such as neuropathy of the peroneal nerve. ICD-10 assigned it code G57.8.

Principles of therapy

The treatment tactics for this pathology are determined by its cause. Sometimes it is enough to replace the plaster cast that is compressing the nerve. If uncomfortable shoes are the trigger, new shoes can also be a solution to the problem.

Patients often consult a doctor with a whole “bouquet” of concomitant diseases. Diabetes mellitus, oncology or renal failure - these disorders can cause such an illness as peroneal nerve neuropathy. Treatment in this case comes down to eliminating the underlying disease. The remaining measures will be of an indirect nature.

Drug therapy

The main medications used in the treatment of neuropathy are the following:

Non-steroidal anti-inflammatory drugs (Diclofenac, Nimesulide, Xefocam). They help reduce swelling and pain, and remove symptoms of inflammation. NSAIDs are most often prescribed for the diagnosis of peroneal nerve axonal neuropathy.
B vitamins.
Antioxidants (Berlition, Tiogamma).
Means for improving the conduction of impulses along the nerve (“Proserin”, “Neuromidin”).
Preparations for restoring blood circulation in the affected area (“Caviton”, “Trental”).

This list contains only a few medications. In each specific case, the choice of drugs depends on the clinical picture of the disease and previous ailments.

Physiotherapeutic procedures

Various physiotherapeutic measures have proven themselves in the treatment of neuropathy. The following procedures are usually recommended to patients:

magnetic therapy;
electrical stimulation;
massage;
reflexology;

Massage is particularly effective for neuropathy of the peroneal nerve. But performing this procedure at home is unacceptable. Massage must be performed by a qualified specialist. Otherwise, you can not only pause the treatment process, but also harm your health.

Surgical intervention

If conservative therapy shows ineffectiveness for several weeks, the doctor decides to perform surgery. It is usually prescribed in case of traumatic damage to nerve fibers. Depending on the clinical picture and general condition of the patient, nerve decompression, neurolysis or plastic surgery may be performed.

After surgery, a long recovery period is required. At this time, the patient should limit physical activity and engage in exercise therapy. It is necessary to examine the affected limb every day for cracks and wounds. If they are detected, the leg should be provided with complete rest. For this purpose, special crutches are used, and wounds are treated with antiseptic agents. The doctor gives other recommendations on an individual basis.

Consequences

What outcome awaits patients diagnosed with peroneal nerve neuropathy? Treatment of the disease largely determines the prognosis for recovery. If you start therapy in a timely manner and follow all the doctor’s recommendations, you can hope for a positive result. The complicated course of the disease and delayed treatment aggravate the situation. In this case, patients often lose their ability to work.

Let's summarize

Peroneal nerve neuropathy is a serious condition. It may be based on vascular disorders, intoxication and toxic lesions. However, the main reason for the development of the pathological process is still considered to be injuries of various origins.

Its main manifestations are associated with impaired motor activity of the limb, and treatment tactics are largely determined by the factors that contributed to the development of the disease. The doctor may prescribe medication or physical therapy. In rare cases, surgery is required.