Peripheral nerve entrapments of the lower leg, ankle, and foot

Magnetic Resonance Neurography of the Foot and Ankle

Peripheral neuropathies of the foot and ankle can be challenging to diagnose clinically due to concomitant traumatic and nontraumatic or degenerative orthopedic conditions. Although clinical history, physical examination, and electrodiagnostic testing comprised of nerve conduction velocities and electromyography are used primarily for the identification and classification of peripheral nerve disorders, MR neurography (MRN) can be used to visualize the peripheral nerves as well as the skeletal muscles of the foot and ankle for primary neurogenic pathology and skeletal muscle denervation effect. Proper knowledge of the anatomy and pathophysiology of peripheral nerves is important for an MRN interpretation.

Diagnostic Approach to Lower Limb Entrapment Neuropathies: A Narrative Literature Review

Entrapment neuropathies of the lower limb are a misunderstood and underdiagnosed group of disorders, characterized by pain and dysesthesia, muscular weakness, and specific provoking movements on physical examination. The most frequent of these syndromes encountered in clinical practice are fibular nerve entrapment, proximal tibial neuropathy, sural nerve neuropathy, deep gluteal syndrome or sciatic nerve entrapment, and lateral femoral cutaneous nerve entrapment, also known as meralgia paresthetica. These are commonly mistaken for lumbar plexopathies, radiculopathies, and musculotendinous diseases, which appear even more frequently and have overlapping clinical presentations. A comprehensive anamnesis, physical examination, and electrodiagnostic studies should help clarify the diagnosis. If the diagnosis is still unclear or a secondary cause of entrapment is suspected, magnetic resonance neurography, MRI, or ultrasonography should be conducted to clarify the etiology, rule out other diseases, and confirm the diagnosis. The aim of this narrative review was to help clinicians gain familiarity with this disease, with an increase in diagnostic confidence, leading to early diagnosis of nerve damage and prevention of muscle atrophy. We reviewed the epidemiology, anatomy, pathophysiology, etiology, clinical presentation, and EDX technique and interpretation of the entrapment neuropathies of the lower limb, using articles published from 1970 to 2022 included in the Pubmed, MEDLINE, Cochrane Library, Google Scholar, EMBASE, Web of Science, and Scopus databases.

Magnetic Resonance Neurography of the Foot and Ankle

Peripheral neuropathies of the foot and ankle can be challenging to diagnose clinically due to concomitant traumatic and nontraumatic or degenerative orthopedic conditions. Although clinical history, physical examination, and electrodiagnostic testing comprised of nerve conduction velocities and electromyography are used primarily for the identification and classification of peripheral nerve disorders, MR neurography (MRN) can be used to visualize the peripheral nerves as well as the skeletal muscles of the foot and ankle for primary neurogenic pathology and skeletal muscle denervation effect. Proper knowledge of the anatomy and pathophysiology of peripheral nerves is important for an MRN interpretation.

Nerve decompression surgery suppresses TNF-ɑ expression and T cell infiltration in a rat sciatic nerve chronic constriction injury model

Decompression surgery (DS) is a standard treatment for chronic nerve compression injuries; however, the mechanisms underlying its effects remain unclear. Here, we investigated the effects of DS on messenger RNA (mRNA) expression of tumor necrosis factor-α (TNF-α) and T cell recruitment in a rat sciatic nerve (SN) chronic constriction injury (CCI) model. Male Wistar rats were subjected to CCI to establish a model of SN injury (CCI group). DS, in which all ligatures were removed, was performed 3 days after CCI surgery (CCI + dec group). Mechanical sensitivity was assessed using the von Frey test 3, 7, and 14 days after the CCI surgery. Gene expression of Tnfa, Cd3, Cxcl10, and immunolocalization of TNF-α and the pan T cell marker, CD3, was evaluated using quantitative polymerase chain reaction (qPCR) and immunohistochemistry, respectively. In addition, the effects of TNF-α on Cxcl10 expression and CXCL10 protein production were evaluated using qPCR and enzyme-linked immunosorbent assay in SN cell culture. Rats that received DS had significantly higher withdrawal threshold levels than those in the CCI group. In addition, Tnfa, Cd3, and Cxcl10 mRNA expression increased following CCI. DS suppressed this elevated expression, with the CCI + dec group showing significantly reduced expression levels compared to the CCI group. Furthermore, TNF-α induced Cxcl10 expression and CXCL10 protein production in SN cell culture. Therefore, DS reduced TNF-α expression and T cell recruitment in the rat SN CCI model. These observations may partly explain the mechanism underlying the therapeutic effects of DS.

An update on imaging of tarsal tunnel syndrome

Tarsal tunnel syndrome (TTS) is an entrapment neuropathy of the tibial nerve (TN) within the tarsal tunnel (TT) at the level of the tibio-talar and/or talo-calcaneal joints. Making a diagnosis of TTS can be challenging, especially when symptoms overlap with other conditions and electrophysiological studies lack specificity. Imaging, in particular MRI, can help identify causative factors in individuals with suspected TTS and help aid surgical management. In this article, we review the anatomy of the TT, the diagnosis of TTS, aetiological factors implicated in TTS and imaging findings, with an emphasis on MRI.

Cross-Cultural adaptation and validation of the Exercise-Induced Leg Pain questionnaire for Spanish speaking patients

OBJECTIVES

To cross-culturally adapt and validate a Spanish version of the Exercise-Induced Leg Pain questionnaire.

DESIGN

Clinical measurement study.

PARTICIPANTS

The validity and reliability of the adapted version were assessed in four groups of 40 patients with exercise-induced leg pain, 40 physically active healthy individuals (control group), 40 athletes with other leg conditions and 40 athletes, military personnel and candidates with no history of injury (risk group).

MAIN MEASURE

Exercise-Induced Leg Pain questionnaire.

REFERENCE MEASURES

Spanish version of the Short-Form 36 and Schepsis postsurgical classification scale.

RESULTS

In patients with exercise-induced leg pain, the mean age was 24.9 (± 6.7) years and the mean score of the questionnaire was 62.8 (± 10.9). The standard error of measurement and minimum detectable change threshold were 1.67 and 4.63 points, respectively. Excellent internal consistency (Cronbach's α = 0.942) and test-retest reliability (intraclass correlation coefficient = 0.995) were found. The exploratory and confirmatory factor analyses indicated that a one-factor solution explained 66.84% of the variance. For construct validity, 87.5% of the previously stated hypotheses were fulfilled between the total score of the questionnaire and Short-Form 36 dimensions. Concurrent validity, assessed by the Schepsis scale, was almost perfect (r = 0.92, p < 0.001). The predictive validity of the questionnaire was demonstrated using the receiving operating curve (area of 0.992; 95% CI: 0.983-1, p < 0.001).

CONCLUSION

The Spanish version of the Exercise-Induced Leg Pain questionnaire resulted in a reliable and valid instrument to assess patients with exercise-induced leg pain.

Anatomical study and branching point of neurovascular structures at the medial side of the ankle

Nerve entrapment and blood circulation impairment associated with the medial side of the ankle are not uncommon. The purpose of this study was to describe the anatomical basis of neurovascular structures of the medial ankle which comprised the number, origin, branching pattern, and branching point. Forty feet of fresh cadavers were examined by using 2 reference lines: the malleolar-calcaneal (MC) and navicular-calcaneal (NC) axes. We recorded number, origin, length of the 2 axes, the locations and widths of neurovascular structures on MC and NC axes, the branching point of neurovascular structures, and the branching pattern of neurovascular structures was recorded and was separated into 5 types. The posterior tibial nerve (PTN) bifurcated to plantar and calcaneal nerves and branched proximally to the tarsal tunnel (TT). The posterior tibial artery bifurcated to plantar and calcaneal arteries and branched inferiorly to PTN and within the TT. The calcaneal nerves and arteries had more variation of number and origin. The most common branching point of calcaneal nerves and arteries is within the TT, except the medial calcaneal nerve. It branched proximally to the TT. The anatomical knowledge from this study is important for the diagnosis and treatment of clinicians.

Peroneal Nerve Palsy due to Bulky Osteochondroma from the Fibular Head: A Rare Case and Literature Review

Common peroneal neuropathy is the most common compressive neuropathy in the lower extremities. The anatomical relationship of the fibular head with the peroneal nerve explains entrapment in this location. We report the case of a 14-year-old boy admitted with a left foot drop. The diagnosis was an osteochondroma of the proximal fibula compressing the common peroneal nerve. The patient underwent surgical decompression of the nerve and resection of the exostosis. Three months postoperatively, there was a complete recovery of the deficits. The association of osteochondroma and peroneal nerve palsy is rare. Early diagnosis is required in order to adjust the management and improve the results. It is worth to underscore that surgical resection is proven to be the appropriate treatment method ensuring high success rates.

Chronic Lower Leg Pain in Athletes: Overview of Presentation and Management

BACKGROUND

Athletes with chronic lower leg pain present a diagnostic challenge for clinicians due to the differential diagnoses that must be considered.

PURPOSE/QUESTIONS

We aimed to review the literature for studies on the diagnosis and management of chronic lower leg pain in athletes.

METHODS

A literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The PubMed, Scopus, and Cochrane library databases were searched, and articles that examined chronic lower leg pain in athletes were considered for review. Two independent reviewers conducted the search utilizing pertinent Boolean operations.

RESULTS

Following two independent database searches, 275 articles were considered for initial review. After the inclusion and exclusion criteria were applied, 88 were included in the final review. These studies show that the most common causes of lower leg pain in athletes include medial tibial stress syndrome, chronic exertional compartment syndrome, tibial stress fractures, nerve entrapments, lower leg tendinopathies, and popliteal artery entrapment syndrome. Less frequently encountered causes include saphenous nerve entrapment and tendinopathy of the popliteus. Conservative management is the mainstay of care for the majority of cases of chronic lower leg pain; however, surgical intervention may be necessary.

CONCLUSIONS

Multiple conditions may result in lower leg pain in athletes. A focused clinical history and physical examination supplemented with appropriate imaging studies can guide clinicians in diagnosis and management. We provide a table to aid in the differential diagnosis of chronic leg pain in the athlete.

Fascial entrapment neuropathy

Entrapment neuropathies are debilitating clinical conditions, creating significant morbidity in the upper and lower extremities in terms of pain, sensory abnormalities, and motor weakness, becoming a challenge to diagnose and treat. Because entrapments can have multiple origins, a misinterpretation of anatomy during examination can lead to incorrect diagnosis and treatment. This review addresses understanding of the anatomy of fascia that can play an important role in this syndrome. There is a specific microenvironment around the nerve composed of connective tissues that include deep fascia, intermuscular septa, epineurium, and perineurium. The microenvironmental modifications can be translated into change in mobility with consequence decreasing of the independency of the nerve from the surrounding structures lading to entrapments and "internal stretch lesion." The entrapments reported in this article reinforce the importance of fascia tissue in generating common symptoms that pose more difficult diagnostic challenges and may often be confused with more common clinical conditions. Clin. Anat. 32:883-890, 2019. © 2019 Wiley Periodicals, Inc.

Superficial course of the medial plantar nerve: case report

The medial and lateral plantar nerves are branched from the tibial nerve and move to the tip of the toes. A variation of medial plantar nerve was found on the left side of a 78-year-old Korean male cadaver. The tibial nerve was divided into the lateral and medial plantar nerves beneath the plantar flexor. The medial plantar nerve passed deep to plantar aponeurosis and superficial to the flexor digitorum brevis. It gave off a common plantar digital nerve and then divided into three proper plantar digital nerves near the metatarsal bases. In this article, we report a superficial course of the medial plantar nerve and describe its unique morphology and discuss the clinical significance of this variation.

Muscle Fiber Type Changes in Lumbrical Muscles at Early Stages of Chronic Nerve Compression

Chronic nerve compression (CNC) neuropathy is a common disease in the clinic and provokes paraesthesia, or numbness at early stage. The changes in muscle fiber composition and motor nerve terminal morphology in distal muscles were studied in this study. A well-established CNC model was used to assess the changes in the muscles. Behaviors were measured by von Frey filament test. The myosin heavy chain isoforms and neuromuscular junctions (NMJs) were stained by immunofluorescence to show the muscle fiber types composition and motor nerve terminals morphologic changes in the flexor digitorum longus (FDL) and lumbrical muscle. The fiber cross-sectional areas of different muscle fiber types were measured. The small-fiber degeneration of cutaneous nerve fibers was examined by detecting the protein gene product 9.5 (PGP9.5) with immunofluorescence. At 2nd month after compression, the proportion of type I and type II B fibers was markedly decreased, and that of type II A fibers was increased in the lumbrical muscle. There was no significant change in composition of muscle fiber types in FDL and NMJ morphology of FDL and lumbrical muscles. Intra-epidermal nerve fibre density (IENFD) declined at 2nd month after the compression. Our study reveals the morphological changes of the FDL and lumbrical muscle at an early stage of CNC. These findings may be helpful to understand muscle damage and pathophysiological development of the nerve compression, and provide new evidence for early treatment of CNC.

Lower extremity regional anesthesia: essentials of our current understanding

The advent of ultrasound guidance has led to a renewed interest in regional anesthesia of the lower limb. In keeping with the American Society of Regional Anesthesia and Pain Medicine's ongoing commitment to provide intensive evidence-based education, this article presents a complete update of the 2005 comprehensive review on lower extremity peripheral nerve blocks. The current review article strives to (1) summarize the pertinent anatomy of the lumbar and sacral plexuses, (2) discuss the optimal approaches and techniques for lower limb regional anesthesia, (3) present evidence to guide the selection of pharmacological agents and adjuvants, (4) describe potential complications associated with lower extremity nerve blocks, and (5) identify informational gaps pertaining to outcomes, which warrant further investigation.

Guiding Treatment for Foot Pain

In the electrodiagnostic (EDX) approach of the patient who presents with foot pain, numbness, and/or tingling, it is important to consider a broad differential diagnosis of both neuropathic and nonneuropathic conditions, including focal and systemic causes. This article assists the electromyographer in the selection and utilization of the most appropriate EDX studies for evaluation. The EDX findings and impression can then help guide potential treatment options for the patient with foot pain and other symptoms. Moreover, this discussion demonstrates the added value that EDX evaluation of the foot provides to the comprehensive assessment of foot pain.

Back Pain with Leg Pain

PURPOSE OF REVIEW

The clinical diagnostic dilemma of low back pain that is associated with lower limb pain is very common. In relation to back pain that radiates to the leg, the International Association for the Study of Pain (IASP) states: "Pain in the lower limb should be described specifically as either referred pain or radicular pain. In cases of doubt no implication should be made and the pain should be described as pain in the lower limb."

RECENT FINDINGS

Bogduks' editorial in the journal PAIN (2009) helps us to differentiate and define the terms somatic referred pain, radicular pain, and radiculopathy. In addition, there are other pathologies distal to the nerve root that could be relevant to patients with back pain and leg pain such as plexus and peripheral nerve involvement. Hence, the diagnosis of back pain with leg pain can still be challenging. In this article, we present a patient with back and leg pain. The patient appears to have a radicular pain syndrome, but has no neurological impairment and shows signs of myofascial involvement. Is there a single diagnosis or indeed two overlapping syndromes? The scope of our article encompasses the common diagnostic possibilities for this type of patient. A discussion of treatment is beyond the scope of this article and depends on the final diagnosis/diagnoses made.

A novel chronic nerve compression model in the rat

Current animal models of chronic peripheral nerve compression are mainly silicone tube models. However, the cross section of the rat sciatic nerve is not a perfect circle, and there are differences in the diameter of the sciatic nerve due to individual differences. The use of a silicone tube with a uniform internal diameter may not provide a reliable and consistent model. We have established a chronic sciatic nerve compression model that can induce demyelination of the sciatic nerve and lead to atrophy of skeletal muscle. In 3-week-old pups and adult rats, the sciatic nerve of the right hind limb was exposed, and a piece of surgical latex glove was gently placed under the nerve. N-butyl-cyanoacrylate was then placed over the nerve, and after it had set, another piece of glove latex was placed on top of the target area and allowed to adhere to the first piece to form a sandwich-like complex. Thus, a chronic sciatic nerve compression model was produced. Control pups with latex or N-butyl-cyanoacrylate were also prepared. Functional changes to nerves were assessed using the hot plate test and electromyography. Immunofluorescence and electron microscopy analyses of the nerves were performed to quantify the degree of neuropathological change. Masson staining was conducted to assess the degree of fibrosis in the gastrocnemius and intrinsic paw muscles. The pup group rats subjected to nerve compression displayed thermal hypoesthesia and a gradual decrease in nerve conduction velocity at 2 weeks after surgery. Neuropathological studies demonstrated that the model caused nerve demyelination and axonal irregularities and triggered collagen deposition in the epineurium and perineurium of the affected nerve at 8 weeks after surgery. The degree of fibrosis in the gastrocnemius and intrinsic paw muscles was significantly increased at 20 weeks after surgery. In conclusion, our novel model can reproduce the functional and histological changes of chronic nerve compression injury that occurs in humans and it will be a useful new tool for investigating the mechanisms underlying chronic nerve compression.

Isolated atrophy of the abductor digiti quinti in patients with rheumatoid arthritis

OBJECTIVE

We aim to discuss the association of isolated atrophy of the abductor digiti quinti muscle in patients with rheumatoid arthritis as well as review the anatomy and imaging findings of this condition on MRI.

MATERIALS AND METHODS

A consecutive series of 55 patients diagnosed with rheumatoid arthritis according to the 2010 ACR/EULAR classification criteria were recruited. MRI of the clinically dominant feet was performed using a 1.5-T scanner.

RESULTS

The study population was predominantly female (94.5%), and the age range was 31-79 years (mean 57.5 ± 11). A total of 55 ankles were examined by MRI, and 20 patients (36.3%), all females, showed abductor digiti quinti denervation signs. Seven patients demonstrated severe fatty atrophy of the abductor digiti quinti, corresponding to Goutallier grade 4, 2 patients showed moderate fatty atrophy (Goutallier grade 3), and the remaining 11 patients showed less than 50% fatty atrophy, corresponding to a Goutallier grade 2. Substantial agreement was found for both intra- and interobserver agreement regarding the Goutallier grading system.

CONCLUSION

Prevalence of signs of abductor digiti quinti denervation on MRI was high in the studied population, suggesting that rheumatoid arthritis may be associated with inferior calcaneal nerve compression.

Ultrasound-guided therapeutic injections for neural pathology about the foot and ankle: a 4 year retrospective review

OBJECTIVE

To describe a 4-year clinical experience with ultrasound-guided therapeutic perineural injections of peripheral nerves about the foot and ankle.

MATERIALS AND METHODS

Retrospective analysis of foot and ankle perineural injections performed between January 2012 and August 2016. Demographics, clinical indications, presence of structural pathology, immediate and interval pain relief, as well as complications were recorded.

RESULTS

Fifty-nine therapeutic injections were performed among 46 patients, accounting for multiple injections in a single visit or multiple visits [mean age = 43 years (range 18-75), 31 female (67%) and 15 male (33%)]. Most commonly, perineural injections involved the hallux branch of the medial plantar nerve (n = 17, 22%). Least commonly, perineural injections involved the saphenous nerve (n = 3, 4%). Other injections in our series include sural (10), superficial (11) and deep (7) peroneal, medial (5) and lateral (3) plantar nerves, and the posterior tibial nerve (3). Ultrasound evaluation revealed structural abnormality associated with the nerve in 30 cases (51%)-most commonly thickening with perineural scarring (n = 14). Of 45 injections with complete documentation, immediate relief of symptoms was reported in 43 (96%) cases. Interval symptom relief was achieved in 23 injections [short term (n = 12), intermediate (n = 6), and long term (n = 5)] out of 38 for which follow-up was available (61%). Complications are rare, occurring in only one case.

CONCLUSION

Ultrasound-guided perineural injections about the foot and ankle are safe and provide lasting symptomatic relief for many indications. Concomitant sonographic evaluation identifies structural abnormalities that may contribute to neuropathic symptoms, allowing targeting of injection or clinical therapy.

Subclinical Peroneal Neuropathy: A Common, Unrecognized, and Preventable Finding Associated With a Recent History of Falling in Hospitalized Patients

PURPOSE

Identification of modifiable risk factors for falling is paramount in reducing the incidence and morbidity of falling. Peroneal neuropathy with an overt foot drop is a known risk factor for falling, but research into subclinical peroneal neuropathy (SCPN) resulting from compression at the fibular head is lacking. The purpose of our study was to determine the prevalence of SCPN in hospitalized patients and establish whether it is associated with a recent history of falling.

METHODS

We conducted a cross-sectional study of 100 medical inpatients at a large academic tertiary care hospital in St Louis, Missouri. General medical inpatients deemed at moderate to high risk for falling were enrolled in the summer of 2013. Patients were examined for findings that suggest peroneal neuropathy, fall risk, and a history of falling. Multivariate logistic regression was used to correlate SCPN with fall risk and a history of falls in the past year.

RESULTS

The mean patient age was 53 years (SD = 13 years), and 59 patients (59%) were female. Thirty-one patients had examination findings consistent with SCPN. After accounting for various confounding variables within a multivariate logistic regression model, patients with SCPN were 4.7 times (95% CI, 1.4-15.9) more likely to report having fallen 1 or more times in the past year.

CONCLUSIONS

Subclinical peroneal neuropathy is common in medical inpatients and is associated with a recent history of falling. Preventing or identifying SCPN in hospitalized patients provides an opportunity to modify activity and therapy, potentially reducing risk.

Entrapment Neuropathies of the Foot and Ankle

Posterior tarsal tunnel syndrome is the result of compression of the posterior tibial nerve. Anterior tarsal tunnel syndrome (entrapment of the deep peroneal nerve) typically presents with pain radiating to the first dorsal web space. Distal tarsal tunnel syndrome results from entrapment of the first branch of the lateral plantar nerve and is often misdiagnosed initially as plantar fasciitis. Medial plantar nerve compression is seen most often in running athletes, typically with pain radiating to the medial arch. Morton neuroma is often seen in athletes who place their metatarsal arches repetitively in excessive hyperextension.

Ultrasound-Guided Peripheral Nerve Injection Techniques

OBJECTIVE

Peripheral nerves are well seen using ultrasound (US) imaging, making US an ideal modality for image-guided nerve injections. This article provides a technical guide for common upper and lower extremity peripheral nerve injections, including the median, ulnar, and radial nerves in the upper extremity and the lateral femoral cutaneous, sciatic, common peroneal, tibial, and sural nerves in the lower extremity.

CONCLUSION

US is an effective modality for use in common upper and lower extremity peripheral nerve injections. With correct technique, peripheral nerve injections can be performed safely and are useful for both diagnostic evaluation of and therapy for peripheral neuropathy.

Entrapment of the deep peroneal nerve and anterior tibial vessels by a spiral tibial fracture causing partial non-union: a case report

We report a case of entrapment of the deep peroneal nerve as well as the anterior tibial artery and vein by a spiral distal tibial shaft fracture, causing partial non-union. The authors describe the utility of MRI in making the diagnosis of this post-traumatic complication, which may potentially result in a permanent neurovascular deficit and adverse functional outcome if left undetected. The importance of recognizing the distinct possibility of entrapment and injury to the deep peroneal nerve as well as the anterior tibial vessels, when managing a fracture involving the distal third of the tibial shaft is emphasized. Absence of clinical symptoms or signs of neurovascular entrapment should not deter one from performing the relevant investigations to exclude this complication, in particular when surgical fixation is being contemplated, or in the presence of a non-healing fracture.

Peroneal Nerve Palsy: Evaluation and Management

Peroneal nerve palsy is the most common entrapment neuropathy of the lower extremity. Numerous etiologies have been identified; however, compression remains the most common cause. Although injury to the nerve may occur anywhere along its course from the sciatic origin to the terminal branches in the foot and ankle, the most common site of compressive pathology is at the level of the fibular head. The most common presentation is acute complete or partial foot drop. Associated numbness in the foot or leg may be present, as well. Neurodiagnostic studies may be helpful for identifying the site of a lesion and determining the appropriate treatment and prognosis. Management varies based on the etiology or site of compression. Many patients benefit from nonsurgical measures, including activity modification, bracing, physical therapy, and medication. Surgical decompression should be considered for refractory cases and those with compressive masses, acute lacerations, or severe conduction changes. Results of surgical decompression are typically favorable. Tendon and nerve transfers can be used in the setting of failed decompression or for patients with a poor prognosis for nerve recovery.

Peroneal nerve palsy after compression stockings application

Peroneal nerve palsy can be caused by various etiology. We report unilateral peroneal nerve palsy after compression stockings application. A 64-year-old man underwent off-pump coronary bypass graft. Surgeon did not use saphenous vein for the bypass graft. Sedation was stopped after 3 h postoperative. After 16 h, for prophylaxis of deep vein thrombosis, knee-high elastic stocking was applied. After 1 h, he took off right stocking because of numbness but left stocking was kept. After 24 h postoperative, (8 h after stocking application) patient complained suddenly left foot drop. Manual muscle test revealed 0/5 of ankle dorsiflexion, ankle eversion, and toe extension. Sensory was decreased to 70% in lower half of anterolateral aspect of tibia, foot dorsum, and toes. Foot drop and sensory abnormality decreased in 3 weeks. Cardiac surgery patients already have many risk factors for peripheral neuropathy. Clinicians should be careful when applying stockings on those patients.

Normal Anatomy and Compression Areas of Nerves of the Foot and Ankle: US and MR Imaging with Anatomic Correlation

The anatomy of the nerves of the foot and ankle is complex, and familiarity with the normal anatomy and course of these nerves as well as common anatomic variants is essential for correct identification at imaging. Ultrasonography (US) and magnetic resonance (MR) imaging allow visualization of these nerves and may facilitate diagnosis of various compression syndromes, such as "jogger's heel," Baxter neuropathy, and Morton neuroma. It may be difficult to distinguish the nerves from adjacent vasculature at MR imaging, and US can help in differentiation. The authors review the normal anatomy and common variants of the nerves of the foot and ankle, with use of dissected specimens and correlative US and MR imaging findings. In addition, the authors illustrate proper probe positioning, which is essential for visualizing the nerves at US. The authors' discussion focuses on the superficial and deep peroneal, sural, saphenous, tibial, medial and lateral plantar, medial and inferior calcaneal, common digital, and medial proper plantar digital nerves.

Cross-cultural Adaptation and Validation of the Exercise-Induced Leg Pain Questionnaire for English- and Greek-Speaking Individuals

STUDY DESIGN

Clinical measurement.

OBJECTIVES

To translate the German version of the Exercise-Induced Leg Pain Questionnaire (EILP-G) to Greek and English and evaluate the psychometric properties of the Greek version.

BACKGROUND

The EILP-G was developed to evaluate the severity of symptoms and sports ability in individuals with exercise-induced leg pain (EILP). Translation of the questionnaire to other languages will provide a standard outcome measure across populations.

METHODS

The EILP-G questionnaire was cross-culturally adapted to Greek and English, according to established guidelines. The validity and reliability of the Greek version were assessed in 40 patients with EILP, 40 patients with other lower extremity injuries, 40 track-and-field athletes with no history of EILP, and 40 young adults without pathology. Participants completed the questionnaire at baseline and again after 7 to 10 days.

RESULTS

The expert committee and the participants considered the questionnaire to have good face and content validity. Concurrent validity as assessed using the Schepsis score was almost perfect (rho = 0.947, P<.001). Dimensionality analysis revealed a 1-factor solution, explaining 83.8% of the total variance. Known group validity was demonstrated by significant differences between patients compared with the asymptomatic groups (P<.001). The Greek version exhibited excellent test-retest reliability (intraclass correlation coefficient = 0.995 for the EILP group) and internal consistency (Cronbach α = .942 for the EILP group). Finally, no ceiling or floor effects were found, as none of the individuals with EILP scored the maximum or minimum possible values on the questionnaire.

CONCLUSION

The Greek version, adapted from the original EILP-G, is a valid and reliable questionnaire, and its psychometric properties are comparable with the original version.

Chronic leg pain in athletes

Chronic leg pain is commonly treated by orthopaedic surgeons who take care of athletes. The sources are varied and include the more commonly encountered medial tibial stress syndrome, chronic exertional compartment syndrome, stress fracture, popliteal artery entrapment syndrome, nerve entrapment, Achilles tightness, deep vein thrombosis, and complex regional pain syndrome. Owing to overlapping physical examination findings, an assortment of imaging and other diagnostic modalities are employed to distinguish among the diagnoses to guide the appropriate management. Although most of these chronic problems are treated nonsurgically, some patients require operative intervention. For each condition listed above, the pathophysiology, diagnosis, management option, and outcomes are discussed in turn.

Entrapment of the superficial peroneal nerve: an anatomical insight

Entrapment of the superficial peroneal nerve is an uncommon neuropathy that may occur because of mechanical compression of the nerve, usually at its exit from the crural fascia. The symptoms include sensory alterations over the distribution area of the superficial peroneal nerve. Clinical examination, electrophysiologic findings, and imaging techniques can establish the diagnosis. Variations in the superficial peroneal sensory innervation over the dorsum of the foot may lead to variable results during neurologic examination and variable symptomatology in patients with nerve entrapment or lesions. Knowledge of the nerve's anatomy at the lower leg, foot, and ankle is of essential significance for the neurologist and surgeon intervening in the area.

Entrapment neuropathy about the foot and ankle: an update

Occurrences of entrapment neuropathies of the lower extremity are relatively infrequent; therefore, these conditions may be underappreciated and difficult to diagnose. Understanding the anatomy of the peripheral nerves and their potential entrapment sites is essential. A detailed physical examination and judicious use of imaging modalities are also vital when establishing a diagnosis. Once an accurate diagnosis is obtained, treatment is aimed at reducing external pressure, minimizing inflammation, correcting any causative foot and ankle deformities, and ultimately releasing any constrictive tissues.

Mimickers of lumbar radiculopathy

Orthopaedic surgeons frequently treat patients who report pain that radiates from the back into the lower extremity. Although the most common etiology is either a herniated disk or spinal stenosis, a myriad of pathologies can mimic the symptoms of radiculopathy, resulting in differences in the clinical presentation and the workup. Therefore, the clinician must be able to distinguish the signs and symptoms of lumbar radiculopathy from pathologies that may have a similar presentation. Being cognizant of these other possible conditions enables the physician to consider a breadth of alternative diagnoses when a patient presents with radiating lower extremity pain.

A rare cause of 'drop foot' in the pediatric age group: Proximal fibular osteochondroma a report of 5 cases

INTRODUCTION

The fibular nerve is the most frequent site of neural entrapment in the lower extremity and the third most common site in the body, following the median and ulnar nerves. The peroneal nerve is commonly injured upon trauma. Additionally, a dropped foot might be a symptom related to the central nervous system or spinal pathologies in pediatric patients. Entrapment of the peripheral nerve as an etiologic cause should be kept in mind and further analyzed in orthopedic surgery clinics.

PRESENTATION OF CASE

In this study, the evaluation and treatment results of five patients with no history of trauma, who underwent diagnostic procedures and treatment in various clinics (physical therapy and rehabilitation and neurosurgery), are reported. The patients underwent several treatments without diagnosis of the primary etiology. Upon initial consultation at our department, osteochondroma at the proximal fibula was detected after physical examination and radiologic assessment. During surgery, the peroneal nerve was dissected, starting from a level above the knee joint. Following nerve release, the osteochondroma was removed, including its cartilage cap. Consequently, recovery was observed in all five cases after surgery.

DISCUSSION

Many factors may cause non-traumatic neuropathies. However, due to their rare occurrence, lesions such as osteochondromas may be overlooked at non-orthopedic clinics. Nerve entrapment due to proximal fibular osteochondroma is rare. Surgical treatment planning plays a critical role in nerve entrapment cases.

CONCLUSION

Despite its frequent occurrence, a drop foot associated with peroneal nerve entrapment by an osteochondroma is not easily remembered and diagnosed. Especially in pediatric cases, inadequate clinical consultation and a lack of appropriate radiologic studies may result in a delay in diagnosing peroneal nerve lesions.