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A competitive marathoner reports 6 months of pain over the lateral distal leg and dysesthesia over the dorsum of the foot. There is a tender fullness over the distal lateral fibula with a positive Tinel's sign. There is normal motor strength, but pain with passive plantar flexion and inversion of the ankle. The most appropriate surgical treatment is:
Review Topic
DISCUSSION:
This is a case of superficial peroneal nerve entrapment by the fascial opening in the distal leg. It is classically exacerbated by plantar flexion and inversion of the foot. Treatment involves release of the fascial opening to reduce this traction phenomenon.
Sridhara et al reported on 2 cases that were successfully treated by surgical decompression of the nerve at the bulge by fasciotomy. They described the following findings: 1) a decrease in sensation on the foot dorsum over the cutaneous distribution of the nerve with sparing of the first web space; 2) a soft tissue bulge over the anterolateral leg 10 cm above the lateral malleolus; 3) a Tinel sign over the bulge; 4) an increase in the size of the bulge either with resisted ankle dorsiflexion or weight bearing; and 5) tenderness over the bulge or distally over the terminal sensory branches of the superficial peroneal nerve.
Styf et al published a more recent series of 17 patients (19 legs) with entrapment of the superficial peroneal nerve. We performed decompression of the superficial peroneal tunnel in 14 patients and local fasciectomy in three. Fourteen patients (80%) were free from symptoms or satisfied with the result.
REFERENCES:
1.
Styf J: Entrapment of the superficial peroneal nerve: Diagnosis and results of decompression. J Bone Joint Surg [Br]. 1989;71:131-135.
2.
Sridhara CR, Izzo KL. Terminal sensory branches of the superficial peroneal nerve: An entrapment syndrome. Arch Phys Med Rehabil. 1985;66:789-791.
PMID:4062533 (Link to Abstract)
3.
Styf J, Morberg P. The superficial peroneal tunnel syndrome. Results of treatment by decompression. J Bone Joint Surg [Br]. 1997;79(5):801-3.
PMID:9331039 (Link to Abstract)
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Styf J, Morberg P. The superficial peroneal tunnel syndrome. Results of treatment by decompression. J Bone Joint Surg [Br]. 1997;79(5):801-3.
PMID:9331039 (Link to Abstract)
Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions,
Personal Observations, and Biomechanic Studies)
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Sridhara CR, Izzo KL. Terminal sensory branches of the superficial peroneal nerve: An entrapment syndrome. Arch Phys Med Rehabil. 1985;66:789-791.
PMID:4062533 (Link to Abstract)
Textbooks
- Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
- AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
- Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
- Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
- Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
- Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Undefined
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Styf J: Entrapment of the superficial peroneal nerve: Diagnosis and results of decompression. J Bone Joint Surg [Br]. 1989;71:131-135.
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