Neuropathy of the peroneal nerve. Common peroneal nerve Causes and varieties

The peroneal nerve departs from the sciatic 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 angle passes between the tendon of the biceps femoris and the lateral head of the gastrocnemius muscle. Further, it goes around the head of the fibula and, penetrating through the fibrous arch of the long peroneal muscle, is divided into deep and superficial branches. A little higher from the common peroneal nerve, the external cutaneous nerve of the lower leg departs, innervating its posterolateral surface and participating together with the medial nerve of the lower 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 lower 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 gap between the first and second fingers and the little finger.

The deep peroneal nerve passes through the thickness of the long peroneal muscle, through the intermuscular septum and enters the anterior tibial space, located next to the anterior tibial artery. On the lower leg, the nerve successively gives off muscle branches to the long extensor of the fingers, the anterior tibial muscle and the long extensor of the thumb. On the back of the foot, the nerve is located under the extensor ligaments and the tendon of the long extensor of the big toe, below the terminal branches it innervates the short extensor of the fingers and the skin of the first interdigital space, capturing a small area of skin in this area on the back of the foot.

Clinical assessment of dysfunction of the peroneal nerve requires, first of all, the exclusion of higher damage to its fibers at the level of the sciatic nerve, since it is these fibers, due to the peculiarities of their structure and blood supply, that 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's cyst, dystrophic changes in the biceps and gastrocnemius muscles.

Tunnel syndrome of the peroneal nerve. This term refers to the defeat of the common peroneal nerve in the bone-fibrous canal at the level of its inflection on the outer surface of the neck of the fibula. Superficial location, weak vascularization, nerve tension cause its increased sensitivity to direct (even minimal) trauma, pressure, traction, penetrating injury. Among the causes most often directly causing compression-ischemic nerve damage, it should be noted squatting or kneeling (“occupational peroneal neuropathy”), unexpected sharp flexion with a turn inside the foot, the habit of sitting cross-legged, unsuccessfully applied plaster bandage, compression of the bootleg rubber boot. The nerve can also be squeezed in the supine position on the hard surface of the table, bed, bench, as occurs in patients in serious condition, in a coma, during a long operation under anesthesia, while intoxicated. Vertebrogenic tunnel neuropathy occurs in patients with myofascial neurofibrosis in the canal zone, with postural peroneal muscle overload in hyperlordosis, scoliosis, L 5 root damage.

The peculiarity of the clinical picture of peroneal neuropathy lies in the predominance of a motor defect over sensory impairments. Weakness and atrophy of the extensors and external rotators of the foot develop, which hangs down, tucked inwards, slaps when walking. Over time, contracture develops with equinovarus deformity of the foot. Pain syndrome is absent or minimally expressed; paresthesias, sensory disorders are often limited to a small area on the back of the foot. In case of incomplete damage to the nerve, palpation is accompanied by pain, paresthesias in the zone of innervation. Tinel's symptom is positive. With more severe damage, these signs are absent. Achilles reflex preserved; its revival, the appearance of pathological signs in combination with a mild paresis, unusual localization of hypesthesia 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 be the result of its compression in the upper third of the lower leg by a fibrous cord that is thrown between the long peroneal muscle and the anterior intermuscular septum. Vertebrogenic neuroosteofibrosis or trauma contributes to such damage; a role is played by the same factors that provoke neuropathy of the common peroneal nerve. Hypotrophy of the peroneal muscle group is noted, the foot turns inward, its extension is preserved. Hypesthesia is determined on the back of the foot, except for its lateral edge and the first interdigital space, pain on palpation of the upper third of the large peroneal muscle; pains are accompanied by paresthesias in the zone of skin innervation.

Neuropathy of the cutaneous branch of the superficial peroneal nerve is a consequence of its infringement at the point of exit from the fascia in the lower third of the lower leg at a distance of about 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 ligament of the ankle immediately precedes the appearance of the patient's complaints of pain, paresthesia, numbness along the outer edge of the lower third of the lower leg and rear of the foot. An objective examination reveals soreness of the exit point of the nerve under the skin; Tinel's symptom is positive.

Neuropathy of the median and intermediate cutaneous nerves of the rear of the foot. These nerves are 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 navicular bone (medial nerve) or the cuboid bone (intermediate nerve), below - to the bases of the second or 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 a heel and a back that fixes 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 rear of the foot. As a result, unpleasant burning paresthesias appear on the back of the foot and in the area of the big toe (with compression of the median nerve) or on the back of the second and third fingers (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 are aggravated when putting on shoes, "guilty" of nerve damage, decrease after exposure to heat, light rubbing of the sore spot. Hypesthesia or dysesthesia is limited to a small patch on the dorsum of the foot. The disease can continue for years, causing considerable discomfort if its cause is not removed. Proper selection of shoes is crucial in the prevention and relief of painful symptoms.

Neuropathy of the deep peroneal nerve occurs with pathology of the anterior tibial space. The nerve is compressed at the level of the middle third of the lower leg, where it passes through the thickness of the long peroneal muscle and the anterior intermuscular septum and is located between the long extensor of the fingers and the anterior tibial muscle. Neuromyodystrophy, congenital narrowness of the intermuscular space and post-traumatic fibrosis contribute to compression of the neurovascular bundle. The chronic variant of neuropathy is characterized by deep aching pains in the anterior muscles of the lower leg, aggravated by walking and maximum extension of the foot. The pain extends to the back of the foot and into the space between the first and second toes; paresthesias are also felt here when the toe is loaded, Tinel's test is performed. A few months later, weakness, atrophy of the extensors of the foot and fingers are found.

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 - the 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 an unexpected excessive load on the muscles of the lower leg (for example, while running a long distance untrained person). The working muscles increase in volume, while the tibial artery that feeds the muscles and nerve is compressed and spasmodic. Muscle ischemia occurs, edema increases, infringement and necrosis of the muscles of the anterior tibial space occurs. The deep peroneal nerve is damaged due to compression and malnutrition.

The clinical picture of the syndrome of the anterior tibial space is represented by severe pain in the muscles of the anterior surface of the lower leg, which appears immediately or several hours after physical overload of the legs. There is a sharp compaction and pain on palpation of the muscles of the anterior surface of the leg. There is no active extension of the foot, passive aggravates the pain. There is no pulse on the dorsal artery of the foot. The foot is cold to the touch. Reduced sensitivity on the back surface 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 bones of the tarsus 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, ganglion, tendovaginitis of the long extensor of the thumb.

Patients are concerned about pain on the dorsum of the foot with irradiation to the first and second fingers, weakened extension of the fingers, visible atrophy of the small muscles of the foot. A positive Tinel's symptom specifies the level of compression of the nerve. An isolated lesion of the external muscular or internal sensitive branch can be observed. In the first case, the pain is limited to the place of compression, there is paresis of the extensor fingers; in the second, there are no musculo-motor disorders, the pain radiates to the first interdigital space, and a zone of hypesthesia is also detected here.

DIFFERENTIAL DIAGNOSTIC DIFFERENCES IN NEUROLOGICAL SYNDROMES,

DUE TO SPINE PATHOLOGY

(see at the end of the teaching aid)

Electromyography (EMG)

Electromyography (EMG) is a method of recording the bioelectrical activity of muscles, which allows you 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 muscle biopotentials are used: skin (global electromyography) and needle (local electromyography) electrodes.

An EMG study is performed to clarify the topography and severity of damage to the nervous system. The use of an electromyographic study makes it possible to make a topical diagnosis of damage to 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 electromyograms of the 1st type are recorded, reflecting frequent, fast, variable in amplitude potential fluctuations. Electromyograms of the same type with a decrease in bioelectrical processes (frequency, shape, duration of oscillations) are recorded in patients with myopathies, central pyramidal paresis and radiculoneuritis. Radicular damage is evidenced by the hypersynchronous nature of the EMG curve, the appearance of unstable potentials of fibrillations and fasciculations during tonic tests.

The main form of violations of bioelectrical processes that develop in the neuromotor apparatus with lesions of the nervous system is characterized by electromyograms of the 2nd type, reflecting more or less reduced potential fluctuations. Type 2 electromyograms predominate in neuronal and neural localization of the process.

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

Complete "bioelectric silence" - type 4 electromyograms - is noted in flaccid paralysis of the muscle 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 the peripheral nerve with subsequent study of the evoked potentials of the innervated muscle (stimulation electromyography) and nerve (stimulation electroneurography).

The evoked potentials of the muscle. M-response is the total synchronous discharge of the motor units of the muscle during its electrical stimulation. Normally, when registering with 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 a denervation, neural lesion, the M-response becomes polyphasic, its duration increases, the maximum amplitude decreases, the latent period lengthens, and the irritation threshold increases.

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

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

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

The recurrent action potential (AP) 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, the latent period and the threshold of irritation increase.

Determination of impulse conduction velocity (SPI) 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 the impulse along the nerve using the formula:

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

Rhythmic stimulation of the peripheral nerve. Produced to detect violations of neuromuscular conduction, myasthenic reaction. The study of neuromuscular conduction using rhythmic stimulation can be combined with pharmacological tests (prozerin, etc.).

Electromyography allows you to establish a change 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, the dynamics of the process.

Purpose of electromyography:

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

Determination of the cause of weakness, paralysis or muscle twitching. Disorders in the muscles, nerves, spinal cord, or part of the brain that can cause these changes. EMG does not reveal pathologies from the spinal cord or brain.

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

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

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

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

Stimulation EMG (electro-neuromyography). The assignment of biopotentials is carried out both by skin and needle electrodes when the peripheral nerve is irritated.

In addition, there is also the so-called external sphincter electromyography, to determine the electrical activity of the external sphincter of the bladder. At the same time, its activity can be determined both with the help of needle electrodes, and with the help of cutaneous and anal.

Electroneurography (ENG) is a method of assessing how quickly an electrical signal is conducted along nerves.

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

For completeness of the survey, both of these research methods - both EMG and ENG - are carried out together.

Electromyography and electroneurography also help in the diagnosis of post-poliomyelitis syndrome, a syndrome that can develop months to years after polio.

Preparation for research

Before having an EMG or ENG, you should tell your doctor if you are taking any drugs that affect the nervous system (such as muscle relaxants or anticholinergics) and may change 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). Also, be sure to tell your doctor if you have a pacemaker implanted (artificial pacemaker). It is recommended not to smoke for 3 hours before the examination. In addition, during the same time you need to refrain from products containing caffeine (chocolate, coffee, tea, cola, etc.).

One of the mononeuropathies of the lower extremities, accompanied by foot drop syndrome - the impossibility of dorsal flexion of the foot and extension of its fingers, as well as sensory disorders of the skin of the anterolateral region of the lower leg and rear of the foot. The diagnosis is made on the basis of anamnesis, neurological examination, electromyography or electroneurography data. Additionally, an ultrasound of the nerve and a study of the osteoarticular apparatus of the lower leg and foot are performed. Conservative treatment is carried out by a combination of medical, physiotherapeutic and orthopedic methods. If it fails, an operation is indicated (decompression, nerve suture, tendon transposition, etc.).

General information

Peroneal neuropathy, or peroneal neuropathy, occupies a special position among peripheral mononeuropathies, which also include: tibial neuropathy, femoral nerve neuropathy, sciatic nerve neuropathy, etc. Since the peroneal nerve consists of thick nerve fibers with a larger layer of myelin sheath, then it is more susceptible to damage in metabolic disorders and anoxia. This moment probably determines the rather widespread prevalence of peroneal neuropathy. According to some reports, peroneal nerve neuropathy is observed in 60% of patients in traumatology departments who underwent 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 amount of experience in the existence of peroneal neuropathy, including the postoperative period or the time of immobilization. This complicates the treatment, increases its duration and worsens the result, since the earlier the therapy is started, the more effective it is.

Anatomy of the peroneal nerve

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

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

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

Causes of neuropathy of the peroneal nerve

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 bruises of the knee and other injuries of the knee joint, fracture of the tibia, isolated fracture of the fibula, dislocation, damage to the tendons or sprain of the ankle joint, iatrogenic damage to the nerve during reposition of the bones of the leg, 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 flooring and other people whose work involves a long stay "squatting". Such neuropathy is possible after prolonged sitting, cross-legged. With compression of the peroneal nerve at the site of its exit to the foot, inferior tunnel syndrome develops. It can be caused by wearing overly tight shoes. Often, compression of the nerve during immobilization is the cause of peroneal neuropathy of a compression nature. In addition, compression n. peroneus may have a secondary vertebrogenic character, i.e., develop in connection with changes in the musculoskeletal system and reflex muscular-tonic disorders caused by diseases and curvature of the spine (osteochondrosis, scoliosis, spondylarthrosis). Iatrogenic compression-ischemic neuropathy of the peroneal nerve is possible after its compression due to incorrect position of the leg during various surgical interventions.

Rarer 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 neuropathy of the peroneal nerve

Clinical manifestations of peroneal neuropathy are determined by the type and topic of the lesion. Acute nerve injury is accompanied by a sharp almost simultaneous appearance of symptoms of its defeat. Chronic injury, dysmetabolic and compression-ischemic disorders are characterized by a gradual increase in the clinic.

Damage to the common trunk of the peroneal nerve is manifested by a disorder in the extension of the foot and its fingers. As a result, the foot hangs down in plantar flexion and is slightly internally rotated. Because of this, when walking, moving the leg forward, the patient is forced to strongly bend it at the knee joint so as not to hook the toe on the floor. When lowering the leg to the floor, the patient first stands on the fingers, then leans on the lateral plantar edge, and then lowers the heel. Such a gait resembles a cock or horse and bears the appropriate names. Difficult or impossible: raising the lateral edge of the sole, standing on the heels and walking on them. Movement disorders are combined with sensory disorders that extend to the anterolateral surface of the lower leg and the rear of the foot. Possible pain on the outer surface of the lower leg and foot, increasing 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 involvement of the deep branch is manifested by less pronounced drooping of the foot, decreased force of extension of the foot and toes, sensory disturbances on the dorsum of the foot and in the 1st interdigital space. The prolonged course of neuropathy is accompanied by atrophy of the small muscles on the back of the foot, which is manifested by the retraction of the interosseous spaces.

Peroneal neuropathy with lesions of the superficial branch is characterized by impaired sensory perception and pain on the lateral surface of the lower leg and the medial region of the dorsum of the foot. On examination, a weakening of the pronation of the foot is found. The extension of the fingers and foot is preserved.

Diagnosis of neuropathy of the peroneal nerve

The algorithm for diagnosing peroneal neuropathy is based on the collection of anamnestic data that may indicate the genesis of the disease, and a thorough study of the motor function and sensory sphere of the peripheral nerves of the affected limb. Special functional tests are carried out to assess 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 allow to determine the level of nerve damage by the speed of action potentials. Recently, nerve ultrasound has been used to study the structure of the nerve trunk and the structures located next to it.

Traumatic neuropathy requires consultation

MUSCULAR BRANCHES OF THE SACRAL PLEXUS(rami musculares plexus sacralis) - innervate the piriformis, obturator internus muscles, twin muscles, square thigh muscle.

SUPERIOR GLUTARY NERV(nervus gluteus superior) - exits the pelvic cavity through the epipiriform opening and innervates the middle and small gluteal muscles and the muscle that strains the wide fascia of the thigh.

LOWER CLUTCH NERV(nervus gluteus inferior) - exits through the piriformis opening and innervates the gluteus maximus muscle.

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

POSTERIOR SKINAL NERVE OF THIGH(nervus cutaneus femoris posterior) - exits through the piriform opening and innervates the skin of the back of the thigh and the proximal part of the lower leg. Gives the lower branches of the buttocks and perineal nerves to the skin of these areas.

sciatic nerve(nervus ischiadicus) is the largest nerve in the human body. It emerges from the subpiriform opening and between the muscles of the posterior thigh group descends into the popliteal fossa, where it divides into the common peroneal and tibial nerves. On the thigh, it innervates the posterior muscle group and the posterior part of the adductor magnus.

COMMON PERONEAL NERVE(nervus fibularis communis) - can depart from the sciatic nerve at various levels. Between the neck of the fibula and the long peroneal muscle, it divides into superficial and deep branches. Also gives the lateral cutaneous nerve of the calf.

SUPERFICIAL PERONEAL NERVE(nervus fibularis superficialis) - descends between the peroneal muscles and the long extensor of the fingers. It gives muscle branches to the long and short peroneal muscles, the medial cutaneous dorsal nerve (innervates the skin of the rear of the foot, the medial side of the thumb, as well as the sides of the II and III fingers facing each other), the intermediate dorsal cutaneous nerve. The latter splits into the dorsal digital nerves of the foot and innervates the skin of the sides of the III, IV and V fingers facing each other.

DEEP PERONEAL NERVE(nervus fibularis profundus) - passes under the long peroneal muscle and goes to the rear of the foot. Gives muscle branches to the anterior tibial muscle, short and long extensors of the thumb, short and long extensor of the fingers. 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, goes around the medial malleolus and divides on the sole into the medial and lateral plantar nerves . Gives muscle branches to all muscles of the posterior leg group and skin branches: medial cutaneous nerve of the calf, medial calcaneal branches.

MEDIAL PLANTAR NERVE(nervus plantaris medialis) - lies in the medial groove of the sole, innervates the short flexor of the fingers, the muscle that abducts the thumb, the medial head of the short flexor of the thumb, I and II worm-like muscles, as well as the common plantar digital nerves, which decay into their own plantar digital nerves to skin of three and a half fingers on the medial side of the foot.

LATERAL PLANTAR NERVE(nervus plantaris lateralis) - lies in the lateral groove of the sole, at the base of the fifth metatarsal bone is divided into superficial and deep branches. The first innervates the skin of the plantar surface of one and a half fingers from the lateral side of the foot, the deep branch innervates all the muscles of the little toe of the foot, III-IV vermiform muscles, all interosseous muscles, the adductor thumb muscle, the lateral head of the short flexor of the thumb, and the square muscle of the sole.

Neuritis of the peroneal nerve 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 nerve, connecting 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 outward rotation of the foot, and the muscles of the toes.

Causes

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

To neuritis of the peroneal nerve can lead to trauma, hypothermia, prolonged limb in an uncomfortable position. In addition, inflammation can be provoked by:

Acute infectious diseases of microbial and viral nature: herpes, influenza, tonsillitis, typhoid fever.
Chronic infections, including sexually transmitted ones: for example, syphilis or tuberculosis leads to nerve damage.
Diseases of the spine associated with degenerate changes or leading to narrowing of the spinal canal.
Complications after nerve injury.
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, infectious and non-infectious hepatitis, gout, osteoporosis.
toxic damage to nerves by alcohol, narcotic substances, arsenic or salts of heavy metals.
Hitting the barrel ischial nerve when performing an intramuscular injection into the buttock.
Wrong position legs in the case when 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 the legs and often get injured.

Symptoms

The severity of symptoms depends on the localization of the pathological process, the 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, tactile and temperature sensitivity the surface of the foot from the side and front, as well as from the back of the foot, in the area of the toes. Violations affect the first, second and part of the third finger.
Pain in the region of the lateral surface of the lower leg and foot, it increases with movements 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 move the leg at the outer side of the lower leg.
Inability to stand up 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, the ability to move normally is lost.
foot, which sags and turns inward, the fingers are bent, the patient cannot return the limb to the anatomically normal position and straighten the fingers.
Aphrophy lower leg muscles, their mass decreases compared to a healthy limb, trophic ulcers can form.
Change colors skin in the affected area: on the lateral surface of the lower leg and the back of the foot, the skin turns pale, as neuritis develops, acquiring a purple or cyanotic color, sometimes darkening of the skin is observed.

With superficial nerve damage, the symptoms are somewhat different:

Arises discomfort, burning sensation and pain on the back of the foot and fingers, as well as in the lower part of the lower leg, the sensitivity of these areas changes slightly.
Observed weakness with movements of the foot and fingers, difficulty in extensor movements of the toes, the first and second fingers are especially affected.
Foot sags slightly, the fingers do not bend.
atrophic phenomena affect the shin slightly, for the most part, small muscles of the foot and toes are exposed to degenerative changes in this case.
When comparing the affected leg with a 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, with no change in the structure of the muscle fibers.

Diagnostics

The diagnosis is established by a neurologist on the basis of a clinical examination:

Held survey- taking an anamnesis of life and illness, to establish when the symptoms first appeared. By the nature of the complaints, the cause can be established: post-traumatic neuritis usually develops soon after the injury, all symptoms in this case occur abruptly within a few days. If the cause of neuritis was a chronic disease, the symptoms will increase gradually.
Performed diagnostic examination: a comparison is made between a healthy and diseased leg, the degree of muscle atrophy, 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 interdigital spaces.
The patient will be required to perform certain exercises, which will help the specialist to understand which part of the nerve was captured: the patient is asked to move the foot, straighten the fingers, raise the toe and stand on the heel. According to the volume of movements performed, one can judge the degree of nerve damage.
Skin tests are performed to determine sensory disturbances. tests: do dermatography of different parts of the skin, piercing the surface with a medical needle. To determine the temperature sensitivity, a test with warm and cold water is used.
If neuritis was provoked by trauma, it is prescribed X-ray study.
Used to determine the state of muscles and nerve bundles electromyography.

Once diagnosed, treatment should begin immediately.

Medical treatment

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

Inflammation of an infectious nature is stopped by antibiotics and antiviral agents. Preference is given to broad-spectrum drugs, sulfonamides are used as adjuvants.

If a serious disease was detected during the examination, therapy is aimed at eliminating or correcting it: insulin and similar drugs are prescribed for diabetics, in case of detection of an oncological disease, they resort to chemotherapy or radio wave irradiation, 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 cast, the cause is eliminated. In some cases, a change of the plaster corset is enough to eliminate the symptoms.

Before starting the course, you must familiarize yourself with all possible contraindications and side effects of drugs, carefully observe 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 nonsteroidal drugs. Used both in the form of tablets and in the form of ointments and creams, they effectively relieve inflammation, remove pain and swelling. The choice of form depends on the severity of the violations: if the inflammation is accompanied by pain and is not stopped by other means, a number of injections are performed. The dose of the drug is gradually reduced, then the patient is transferred to tablet forms, and then to local remedies.
Drugs that improve blood supply. Prescribed in order to saturate the cells with oxygen and glucose and prevent the atrophic phenomena of the Actovegin and Solcoseryl series, which effectively affect the cells of the nerves and blood vessels, prevent atrophic phenomena, and contribute to the speedy restoration of the 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 the conduction of nerves 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:

Physiotherapy exposure with the help of amplimuls, magnetotherapy - 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. It is used to transport medicines directly to the place of therapy. The combination of funds depends on the cause of the disease and is selected by the attending physician.
Recovery sensitivity and limb mobility - acupuncture and massage - a combination of various methods gives positive results and helps to quickly restore limb function after the acute phase of inflammation has passed.
Orthopedic constructions in order to return the foot anatomically correct position, wearing an orthosis also helps to correct gait.
Treatment recommended for rehabilitation physical training, a set of exercises is selected individually for the patient, attention is focused on returning mobility to the muscles 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. With a significant nerve injury, medications will not work, just like 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.

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

Possible Complications

In the absence of treatment, the disease is protracted, this can lead to a large number of complications:

Pain chronic nature, worsening the quality of life of the patient.
Restriction of leg mobility, "cock" gait - will lead to a violation posture, lameness and, ultimately, the inability to move independently.
Dabetic gangrene, which threatens with a lethal outcome 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 were 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 instantaneous exchange of impulses throughout the body. Violation of the work of one nerve practically does not affect the functioning of the whole network. However, it can lead to a 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 limbs.

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

pathology of the peroneal nerve;
tibial nerve;
sensory.

Each of the forms of the disease is of great interest to physicians. Among all peripheral pathologies, peroneal neuropathy occupies a special place. It is about her that 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 it is associated with primary nerve damage.

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

Anatomical reference

The peroneal nerve departs from the sciatic 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 separate into the common peroneal nerve. It spirals around the head of the bone of the same name. In this place, the nerve lies on the surface and is covered only by the 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 got their name due to their direction. The superficial branch is responsible for the innervation of muscle structures, the rotation of the foot and the sensitivity of its back. The deep peroneal nerve provides extension of the fingers, as well as the sensation of pain and touch in this area.

Compression of one or another branch is accompanied by a violation of sensitivity in various areas of the foot, the inability to unbend 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 you to determine the degree of the pathological process before going to the doctor.

The main causes of the disease

The development of the pathological process can be due to many factors. Among them, physicians distinguish the following:

Compression of the nerve in any of its segments. This is the so-called tunnel neuropathy of the peroneal nerve. It is divided into two groups. The upper syndrome develops against the background of pressure on the structures in the composition of the vascular bundle. The disease is most often diagnosed in people whose work is associated with a long stay in an uncomfortable position. These are berry pickers, parquet installers, 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.
Violation of the blood supply to the limb.
Incorrect position of the legs due to a long operation or a serious condition of the patient, accompanied by immobilization.
Getting into the nerve fibers during intramuscular injection in the gluteal region.
Severe infectious diseases.
Injuries (fracture of the lower leg, dislocations of the foot, damage to the tendons, sprain). As a result of severe bruising, edema occurs. It leads to compression of the nerve and a deterioration in the conduction of impulses. A distinctive feature of this form of the disease is the defeat of only one limb. Otherwise, it is called post-traumatic peroneal neuropathy.
Oncological lesions with metastasis.
Toxic pathologies (diabetes mellitus, renal failure).
Systemic diseases characterized by proliferation of connective tissue (osteoarthritis, gout, rheumatoid arthritis).

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

What symptoms accompany the disease?

Clinical manifestations of the disease depend on the degree of neglect of the pathological process and the site of nerve damage. All symptoms can be divided into main and concomitant. The first group includes a violation of sensitivity in the affected limb. Associated features may vary in each case. However, most often patients complain about:

swelling in the legs;
periodic feeling of "goosebumps";
spasms and convulsions;
discomfort when walking.

A little higher it was noted that the clinical picture of the disease also depends on the location of the nerve damage. For example, a lesion of the common trunk is manifested by a violation of the process of extension of the foot. Because of this, she begins to hang down. When walking, the patient is forced to constantly bend the leg at the knee so as not to hook the foot on the floor. When lowering it, he first stands on his toes, then transfers the weight to the lateral plantar edge, and only then lowers the heel. This manner of movement resembles a cock or horse, and therefore 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. Such a sign of the disease is clearly distinguishable, 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 drooping of the foot is less pronounced. However, sensory and motor impairments are also present. If the disease is not treated, it is complicated by atrophy of the small muscles.

Neuropathy of the peroneal nerve with damage to the superficial branch is accompanied by impaired sensitivity and severe pain in the lower leg. During examination, patients are often diagnosed with a weakened 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 history. During this procedure, he studies his disease map and conducts a survey in order to clarify the information. Then the doctor proceeds to instrumental diagnostic methods. To assess muscle strength, certain tests are carried out, and skin sensitivity analysis is carried out using a special needle. Additionally, electromyography and electroneurography are used. These procedures allow you to determine the degree of nerve damage. Ultrasound is considered an equally informative method of examination, during which the doctor can examine the damaged structures.

Peroneal neuropathy always requires a differential diagnosis with other disorders that have similar clinical manifestations. These include the syndrome of peroneal muscular atrophy, cerebral tumors.

In especially serious cases, consultation of narrow 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 the knee joint.

Neuropathy peroneal nerve: ICD

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

Many patients are interested in what code (ICD) has peroneal neuropathy. It should be noted that the described disease does not have such a designation. Category G57 includes mononeuropathies of the lower extremities. If we delve into the study of pathologies belonging to this class, our disease will not be found there. However, code G57.8 can be attributed to it, which refers to other mononeuralgias 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 such a disease as neuropathy of the peroneal nerve. The ICD-10 assigned it the code G57.8.

Principles of therapy

The tactics of treating this pathology is determined by its cause. Sometimes it is enough to replace the plaster cast, which compresses the nerve. If uncomfortable shoes are the precipitating factor, new shoes can also be a solution.

Often patients go to the doctor with a whole "bouquet" of concomitant diseases. Diabetes mellitus, oncology or kidney failure - these disorders can be the cause of such an ailment as peroneal neuropathy. Treatment in this case is reduced to the elimination of the primary disease. The remaining measures will be of an indirect nature.

Therapy with drugs

The main medicines that are used in the treatment of neuropathy are the following:

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

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

Physiotherapy procedures

Various physical therapy interventions have proven themselves in the treatment of neuropathy. Typically, patients are recommended the following procedures:

magnetotherapy;
electrical stimulation;
massage;
reflexology;

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

Surgical intervention

If conservative therapy for several weeks shows its ineffectiveness, the doctor decides to perform the operation. It is usually prescribed in case of traumatic damage to nerve fibers. Depending on the clinical picture and the general condition of the patient, it is possible to perform nerve decompression, neurolysis or plasty.

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

Consequences

What is the outcome for patients diagnosed with peroneal 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 exacerbate the situation. In this case, patients often lose their ability to work.

Let's summarize briefly

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

Its main manifestations are associated with a violation of the 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 physiotherapy. In rare cases, surgery is required.