PERIPHERAL

NERVE
INJURY
(UPPER LIMB)

Justine Ramos, PTRP, MSPT | NRAT 211

Nervous System
Functions:
• Senses changes in the body & external env’t
• Interprets these changes
• Responds to these interpretations

Parts:
CNS – brain & SC
PNS
• 12 pairs of CN & branches
• 31 pairs of spinal nerves
• Peripheral nerves
Nerve: Functions
Sensory innervation to skin & joints (dermatomes)
Motor innervation to muscles (myotomes)
Influence over BV diameter by vasomotor nerves
Sympathetic/parasympathetic secremotor to glands
• (e.g. Facial nerve: lacrimal, sublingual, submandibular)
Nerve: Structure
Myelin Sheath
Formed by Schwann cells (PNS)

Functions:
• Speed of nerve conduction
• Insulates & maintains axons

Nerve conduction directly prop. to fiber diameter

(Skeletal muscle, sensory fibers, touch, pressure, heat, cold, kinesthetic sense)
Intraneural Connective Tissue
Peripheral Nerve
Injuries
Localized nerve
injuries/mononeuropa
thies are classified by
the degree of axonal
& supporting structure
involvement

Adapted from: Burchiel, K. J. (Ed.). (2002). Surgical Management of Pain (p. b-002-44939).
Georg Thieme Verlag. https://doi.org/10.1055/b-002-44939
PNI: Types according to Etiology
Stretching/Tensile Injuries
Laceration
Compression

Burnett, M. G., & Zager, E. L. (2004). Pathophysiology of peripheral nerve injury: a brief review. Neurosurgical focus, 16(5), 1-7.
Stretching/Tensile Injuries
Most common type
PNs: inherently elastic (endoneurium)
Isolated (BPI) or in association with Fx (radial nerve injury)
Continuity retained unless force is too great
Laceration
Knife blade
Complete transections; some nerve element continuity
remains
Compression
Entrapment neuropathies
Do not involve a severance or tearing of the neural elements
Total loss of both motor & sensory function may occur

Mechanism:
• Mechanical compression
• Ischemia
Classification Seddon Sunderland Pathology
Focal demyelination; nerve
Neurapraxia 1 conduction block without
axonal degeneration
Axonal degeneration with intact
Axonotmesis 2 endoneurium; good
prognosis
Axonal degeneration;
endoneurial disruption with
Axonotmesis 3
intact perineurium; (+)
synkinesis
Axonal degeneration;
endoneurial and perineurial
Axonotmesis 4 disruption with intact
epineurium; (+) neuroma
fomation
Complete axonal degeneration;
Neurotmesis 5 disruption of all connective
tissue elements
Neural
Response
to Injury
Nerve
Conduction
Block

Segmental
Demyelination

Axonal
Degeneration
Demyelination
Myelin sheath injury with
axons remains intact

Conduction Block
Failure of an AP to propagate past an area of demyelination
along axons that are intact
Axonal Injury
Axonal Degeneration
• Begins in a “dying back”
fashion and affects the nerve in a
length dependent manner
• Starts distally and ascends
proximally

Wallerian Degeneration
At the site of a nerve lesion, the
axon degenerates distally
Nerve segment proximal to the
injury site is essentially intact with
some minor dying back at the
lesion site 1 to 2 cm
Regeneration of Peripheral Nerve
Axonal outgrowth
• Rate: 1 mm/day
• Direction: Proximal to distal

Mechanisms:
• Remyelination
• Collateral sprouting
• Regeneration from proximal site of injury

Synkinesis- i.e., crocodile tears; type 3 PNI

Quan, D., & Bird, S. J. (1999). Nerve conduction studies and electromyography in the evaluation of peripheral nerve injuries. Univ Pa Orthop J, 12, 45-51.
Aging of PN
7th decade: evidence of PN dysfxn
• Alterations in vibratory sensation
• Touch sensitivity
• Pain threshold (slight)
• Ankle jerks & PN conduction velocity
Electrodiagnosis
EMG-NCV
Rheobase & Chronaxie
Pulse Ratio
Nerve Excitability test
Strength-duration curve
Galvanic-faradic excitability test
EMG-NCV
Measurement of nerve response amplitude & conduction velocity
along the course of each nerve

2 parts:
• Nerve Conduction Study (sensory & motor)
• Needle Examination of the muscles
Quan, D., & Bird, S. J. (1999). Nerve conduction studies and electromyography in the evaluation of peripheral nerve injuries. Univ Pa Orthop J, 12, 45-51.
Clinical Manifestation
Impairment of motor Alteration in DTRs - â or loss
• Weakness or paralysis
• Onset Fasciculations or cramps
• Distribution of weakness • Sense of stiffness of heaviness
• Distal or Proximal
• Symmetrical or
Asymmetrical Sensory Abnormalities
• Sensory loss
• Paresthesias
• Dysesthesia
Sensory Ataxia & Tremor (i.e. Tabes Dorsalis)

Deformity & Trophic Changes

• Claw Hand
• Charcot Arthropathy

Autonomic Disorders
• Anhidrosis
• Orthostatic hypotension
Radiculopathy
Pathologic process affecting
the nerves at the root level
MC presents as pure sensory
sensorimotor or pure motor
complaints
• D/t larger size of the sensory
fibers, rendering them more
prone to injury
MC Etiology:
• HNP – adults <50 y/o
• Spinal Stenosis - >50 y/o

Clinical Presentation
C5 C6
C7 C8
Cervical Myotome affected 2° HNP
Plexopathy
Pathologic process typically occurring distal to the DRG & proximal to
the PN
Abnormalities can appear diffuse & will not follow any particular
dermatomal or myotomal distribution

Common etiologies include:

• Trauma (traction, transection, obstetrical injuries, compression, &
hemorrhage)
• Cancer (tumor & radiation therapy)
• Idiopathic (neuralgic amyotrophy)
Brachial Plexus Injuries
Upper Trunk Brachial Plexopathy/Erb’s Palsy/ “Stinger”
Klumpke’s Palsy/Lower Trunk Brachial Plexopathy
Thoracic Outlet Syndrome (TOS) (Lower Trunk Plexopathy)
Upper Trunk Brachial Plexopathy/Erb’s
Palsy/ “Stinger”
C5–C6 nerve roots of the upper trunk

Etiology: nerve traction or compression

or from an obstetrical injury; can be
sports related (stinger)

(+) Waiter’s Tip Deformity

Klumpke’s Palsy /Lower Trunk Brachial
Plexopathy
Involves the C8–T1 nerve roots or
lower trunk
(+) Claw hand (Intrinsic minus hand) –both UN & MN

Etiology: obstetrical traction

injury, forced adduction seen in
an MVA, falls, shoulder
dislocations, etc.

Partial claw hand – UN palsy Benediction (Papal) Sign - MN

Thoracic Outlet Syndrome (TOS) (Lower
Trunk Plexopathy)
Vascular TOS
• Can occur from a pathology resulting in
arterial or venous compromise
(subclavian artery, subclavian vein, or
axillary vein)

Neurogenic TOS
• Compression of lower trunk of the
brachial plexus between:
• Fibrous band
• First cervical rib and clavicle
(costoclavicular syndrome)
• Muscular entrapment by the scalenes
(anterior & middle scalene syndromes)
• Pectoralis minor muscle (pectoralis minor
syndrome)
Provocative Test for TOS
Median Nerve
Median Nerve Entrapment
Arm – Ligament of Struthers
2 cm bone spur 3 to 6 cm proximal to
the medial epicondyle

Connected to the epicondyle by a

ligament in 1% of the pop’n
Involvement of all median nerve
innervated muscles
• Weakness in grip strength (FDP &
FDS)
• Wrist flexion (FCR)

A dull, achy sensation can occur in

the distal forearm

Difficulty in flexing the 2nd & 3rd

digits (FDP weakness) = Active
benediction sign
(+) Papal/Benediction/Preacher’s/Bishop’s Sign
“PAMPU” = Papal: ACTIVE – Median, PASSIVE - Ulnar
Brachial pulse maybe diminished
Lacertus Fibrosis (Bicipital Aponeurosis)
Thickening of the antebrachial fascia
attaching the biceps to the ulna

Overlies the MN in the proximal

forearm

Caused by entrapment or hematoma

compression resulting from an arterial
blood gas or venipuncture

Presentation similar to LOS

Forearm – Pronator Teres Syndrome

Compression between the heads of the PT

muscle or the bridging fascial band of the
FDS muscle

Affects all median innervated muscles

except the PT

Dull ache of the proximal FA exacerbated

by forceful pronation (PT) or finger flexion
(FDS)

FA & hand muscles may become easily

fatigued
Forearm – Anterior Interosseus Nerve
Syndrome

Injury to a motor nerve branch of the

MN - pure motor syndrome (A) Normal. (B) Abnormal OK sign
Pulp to pulp contact instead of tip to tip = weakness of FDP 1 & FPL

It supplies the FPL, PQ, and FDP 1 & 2

(4P muscles)
• FPL is usually the first muscle affected

(A) Normal. (B) Inability to make a fist due

(+) (Abnormal) OK sign to problems incorporating the thumb and index finger.
Carpal Tunnel Syndrome – MC entrapment of MN (Hand)
MC nerve entrapment of the UE
Nerve can be injured in the carpal
tunnel by:
• Idiopathic process (MC)
• á canal volume from thyroid
disease, CHF, renal failure, mass
(tumor, hematoma), & pregnancy
(it usually occurs at 6 months and
resolves postpartum)
• â canal volume from a Fx,
arthritis, & rheumatoid
tenosynovitis.
• Double crush syndrome from DM,
cervical radiculopathy, & TOS
Usuallys starts with nocturnal pain,
aching & numbness, tingling, “pins &
needles” paresthesia relieved by
shaking of hands (Flick sign)

AbN sensation to the lateral 3–1/2

fingers of the hand except at the base
of the thumb

Weakness on “LOAF” muscles

(Lumbricals 1 and 2, Opponens pollicis,
Abductor pollicis brevis, & Flexor pollicus
brevis)
Leblanc, K., & Cestia, W. (2011). Carpal tunnel syndrome. American family physician, 83 8, 952-8 .
Anomalous Innervations
Martin-Gruber Anastomosis
• Fibers from the AIN
anastamose with the UN; or
nerve fibers of the proximal
MN cross over to the UN in
the forearm to innervate the
ADP, ADM, & 1st DI muscles
(MC)
• Occur in 15% to 20% of the
population
Riche-Cannieu Anastomosis
• Connection of the recurrent
branch of the MN in the
hand to the deep motor
branch of the UN
• Produces an all-ulnar
innervated hand
Ulnar Nerve
Ulnar Nerve Entrapment
Arm – Arcade of Struthers
Compression of fascial band in
the medial arm that connects the
brachialis to the triceps brachii

Involvement of all the ulnar nerve

innervated muscles
Wrist flexion may result with a
radial deviation (FCU weakness)

AbN sensations may occur in all

sensory branches of the ulnar
nerve

(+) Ulnar claw hand

A) Benediction posture (PASSIVE) - clawing of
the fourth and fifth fingers while fingers and
thumb are held slightly abducted

B) Wartenberg’ sign - abduction of the little

finger with the hand at rest

C) Froment’s sign - seen when using the

thumb and index finger to pinch an object

D) Weakness of the ulnar flexor digitorum

profundus, inability to completely flex the
distal phalanx of the fourth and fifth digits.
Forearm – Tardy Ulnar Palsy
UN injury secondary to a trauma
that results in bone overgrowth or
scar formation after distal
humeral fracture

Nerve traction can also occur

from an á carrying angle due to
a cubitus valgus deformity

May demonstrate involvement of

all the ulnar nerve innervated
muscles
Elbow – Cubital Tunnel Syndrome
MC entrapment at the elbow

CT - bordered by the medial

epicondyle & olecranon with an
overlying aponeurotic band

UN compression beneath the

proximal edge of the FCU
aponeurosis or arcuate ligament
(Osborne’s fascia)
All ulnar nerve innervated
muscles are affected except FCU

Symptoms similar to an injury at

the AOS

(+) Tinel’s sign

Hand – Guyon’s (Pisohamate)
Canal
Nerve can be injured by cycling
activities (cyclist’s palsy), wrist
ganglions, or RA

All UN innervated intrinsic muscles of

the hand are involved
Entrapment of UN at the wrist can take on several
patterns: (1) pure motor affecting only the deep
palmar motor branch, (2) pure motor affecting the
deep palmar & hypothenar motor branches, (3)
motor & sensory (proximal canal lesion), and rarely
(4) pure sensory involving only the sensory fibers to
the volar 4th & 5th fingers
UN compression at Guyon’s Canal
Radial Nerve
Arm – Axillary Crutch Palsy
Compressed with improper
axillary crutch use

Weakness in all radial nerve

innervated muscles, including
the triceps brachii

Sensation may be decreased

over the posterior arm &
forearm
Spiral Groove – Saturday Night Palsy or
Honeymooner’s Palsy
Common mechanisms described are
the arm being positioned over a sharp
ledge, such as a chair back or from a
person’s head resting on the humerus

Fracture of the humerus at SG (MC)

Weakness RN innervated muscles
below the spiral groove with triceps
brachii & anconeus spared

Weakness of:
• Elbow flexion (BR weakness)
• Supination (supinator weakness)
• Wrist drop (ECRL, ECRB, ECU
weakness)
• Finger extension (EDC weakness)

Sensory deficits may occur in the

dorsal aspect of the hand &
posterior FA
Forearm – Radial Tunnel
Syndrome
Entrapment between the
brachialis and BR

Symptoms that mimic a

resistant lateral epicondylitis
syndrome
Subdivide the anterior, proximal
forearm just distal to the elbow
crease in to 9 regions arranged
in a 3×3 grid. 3 medial regions
without course of nerve are the
control areas and expected to
be free of pain and discomfort.
Tenderness on the two
proximal regions at the
lateral column indicates
radial nerve irritation. In the
middle column, the two distal
regions overlie the route of
median nerve, and pain and
tenderness in this area indicates
a high level of median nerve
irritation.
Moradi, A., Ebrahimzadeh, M. H., & Jupiter, J. B.
(2015). Radial Tunnel Syndrome, Diagnostic and
Treatment Dilemma. The Archives of Bone and
Joint Surgery, 3(3), 156–162.
Posterior Interosseus Nerve (PIN)
Syndrome (Supinator Syndrome,
Arcade of Frohse Syndrome)

Compression of the PIN (motor

branch of RN) at the Arcade of
Frohse of the supinator – Pure
motor syndrome

Also be injured by a lipoma,

ganglion cyst, synovitis from RA,
or a Monteggia fracture
(Monteggia Fracture of the proximal 1/3 of the ulna &
D/L of RH after a FOOSH locked in full pronation)
Involves all the PIN innervated
distal extensors: EDC, EIP, ECU,
EPB, EPL, APL with sparing of
supinator, BR, triceps, ECRL,
ECRB, & anconeus

A pseudo claw-hand deformity

may be demonstrated (finger
extensor weakness)

Radial deviation is noted with

wrist extension (ECU weakness)
an sensation is spared.
Superfical Radial Nerve Neuropathy
Cheralgia Paresthetica/ Wristwatch
syndrome/ Wartenberg’s Disease

Pure sensory syndrome

Compression at the wrist from a

wristwatch, tight handcuffs,
peripheral IV placement

Sensory abnormalities including

numbness, burning, or tingling on
the dorsal radial aspect of the hand
• Discomfort may be exacerbated with
palmar & ulnar wrist flexion or forced
pronation
Neuropathies of the Shoulder Girdle & Proximal Arm
Pharmacologic Treatment: Neuropathic Pain
MOA: Reduction of neuronal hyperexcitability, peripherally or centrally

When oral medications fail, the pain may be controlled with a peripheral nerve block or with an indwelling catheter

Allen, S. (2005). Pharmacotherapy of neuropathic pain. Continuing Education in Anaesthesia Critical Care & Pain, 5(4), 134–137.
https://doi.org/10.1093/bjaceaccp/mki036
 Surgical Repair
Primary surgical techniques
used include external neurolysis,
end-to-end repair, nerve
grafting & nerve transfer

Campbell, W. W. (2008). Evaluation and management of

peripheral nerve injury. Clinical Neurophysiology, 119(9), 1951–
1965. https://doi.org/10.1016/j.clinph.2008.03.018

Grinsell, D., & Keating, C. P. (2014). Peripheral Nerve Reconstruction after

Injury: A Review of Clinical and Experimental Therapies. BioMed Research
International, 2014, 1–13. https://doi.org/10.1155/2014/698256
Nadi, M., & Midha, R. (2018). Management of Peripheral Nerve
Injuries. In Principles of Neurological Surgery (pp. 832-841.e2).
Elsevier. https://doi.org/10.1016/B978-0-323-43140-8.00061-5
Rehabilitation
Maintain PROM
TENS/EMS – for pain or retardation of denervation atrophy; improve circulation
Sensory re-education programs (sensory stimulation pinching and tapping,
brushing and icing)
Desensitization techniques – to decrease pain & allodynia (i.e. massage)
Strengthening exercise (isometric, graded weight progression, open-close chain)
Static or dynamic splinting - help protect the injured part & improve function

Campbell, W. W. (2008). Evaluation and management of peripheral nerve injury. Clinical Neurophysiology, 119(9),
1951–1965. https://doi.org/10.1016/j.clinph.2008.03.018
PERIPHERAL
NERVE
INJURY
(LOWER LIMB)
Justine Ramos, PTRP, MSPT | NRAT 211
Lumbar Plexus
Nerve fibers originating from
the ventral rami of L1, L2, L3, L4
roots form the lumbar plexus

Ventral rami then divide to form

anterior & posterior division
• Anterior division forms the
obturator nerve
• Posterior division forms the
femoral nerve & lateral femoral
cutaneous nerve
 Iliohypogastric N.
Ilioinguinal N.
Genitofemoral N.

Muscular & Cutaneous

innervation of Lumbar plexus
(Femoral & Obturator Nerve)

Lateral Femoral Cutaneous Nerve

Sacral Plexus
Nerve fibers originating from the ventral rami
of L4, L5, S1, S2, S3, S4 roots form the sacral
plexus

Ventral rami then divides to form anterior &

posterior division

SCIATIC nerve – largest branch, largest nerve

in the body
• Tibial (N.) portion originates from the anterior
division
• Common peroneal nerve originates from the
posterior division
Muscular & Cutaneous
innervation from Sacral Plexus
(Tibial & Common Peroneal
Nerves)
Lumbosacral Plexopathies
Multiple potential etiologies:
• Neuralgic amyotrophy: similar to brachial plexus pathology.
• Neoplastic versus radiation plexopathy: similar to brachial plexus
pathology.
• Retroperitoneal bleed: This can involve a hematoma formation in
the psoas muscle.
• Hip dislocation
• Obstetric injuries/cephalopelvic disproportion: Presents as a
postpartum foot drop
Lower Limb Mononeurapathy
Lateral Femoral
Cutaneous Nerve
MERALGIA PARESTHETICA
• Compression by a repeated low-grade
trauma, protuberant abdomen,
pregnancy, or tight clothing

• Diabetes, tumor, infection and rapid

weight loss can also affect the nerve in
a nonspecific manner

originate from the L2 & L3 nerve roots

from the posterior division of the lumbar plexus
Pure sensory syndrome with no muscle
involvement

Patient may report sensory complaints in

the lateral thigh
• Pain, numbness, burning, or a
• Dull ache, exacerbated with hip extension or
hyperflexion, prolonged sitting/squatting, or
driving

Sx is usually self-limited

Interventions may include

• Rehabilitation
• NSAIDs
• Cortisone injections, surgical release
• Removal of compressive clothing (e.g., wide
belt, compressive athletic clothing)
Femoral Nerve

Nerve runs through the psoas muscle à travels under the inguinal
ligament lateral to the femoral artery à through the femoral triangle to
innervate:
• Iliacus, Pectineus (1/2), Sartorius
• Quadriceps muscles (Rectus femoris, Vastus lateralis/intermedius/medialis)
• Saphenous nerve
Femoral Neuropathy (Femoral N.)
Compressive lesion in the pelvis from trauma, fracture,
retroperitoneal hematoma, tumor, inguinal ligament compression, or
cardiac catheterization

Most common cause is iatrogenic from abdominal or pelvic surgery

Involved muscles include all femoral
nerve innervated muscles

Patient may complain of weakness of

knee extension (quadriceps), knee
instability & decreased sensation over
the anterior thigh and medial leg

Hip flexion weakness is noted with

injuries occurring above the inguinal
ligament
Diabetic Amyotrophy (Femoral N.)
MC cause of a femoral neuropathy

Can be seen in polyradiculopathy

and lumbar plexopathy, which can
involve the adductors & iliopsoas

Nerve can be injured from an

abnormality of the vaso-nervorum
d/t DM

Also been noted to occur after

marked weight loss
May have involvement of all femoral
nerve innervated muscles

Patient may complain of asymmetric

thigh pain, knee extension weakness
(quadriceps) & atrophy

Loss of the patella reflex may also

occur

Interventions may include

rehabilitation & optimized control of
blood sugar
Saphenous Neuropathy
Largest & longest branch of FN

Supplies sensation to the medial aspect

of the leg, medial malleolus & medial
arch of the foot

Can be entrapped in the subsartorial

(Hunter’s) canal or between the
sartorius & gracilis

Can also be related to trauma from

knee arthroscopy & menisectomy or
vascular surgery, such as
catheterization or thrombectomy
Pure sensory syndrome with no muscle
involvement

Patient may complain of medial knee pain

(Infrapatellar branch) with abnormal sensation
radiating distally along the medial aspect of the leg
& foot

Interventions may include rehabilitation or surgical

procedure
Obturator Nerve
Originate from the L2, L3, & L4 roots

Continue on as the anterior portion of the lumbar

plexus in front of the SI joint to finally form the
obturator nerve which innervates the adductors

Nerve passes through the psoas major & obturator

foramen to innervate:
• Pectineus (1/2)
• Adductor brevis
• Adductor longus
• Adductor magnus
• Obturator externus
• Gracilis
• Cutaneous branch
Obturator Neuropathy
Can occur in conjunction with a femoral nerve injury

Compression from a pelvic fracture or hernia within the

obturator foramen

Involve all muscles innervated by the obturator nerve

• Hip adduction weakness (adductor L/M/B) or with
internal rotation

May present with a circumducting gait

Decrease in sensation along the medial aspect of the

thigh
Sciatic Nerve
Originate from the L4, L5, S1, S2, S3
roots

SN exits the pelvis through the GSF

between the lesser trochanter & ischial
tuberosity

Sciatic nerve comprised of:

• Tibial (medial portion of nerve)
• Peroneal (fibular) (lateral portion) division

It travels as one unit up to the popliteal

fossa, where it splits into its respective
divisions
Muscular & Cutaneous
innervation from Sacral Plexus
(Tibial & Common Peroneal
Nerves)
Sciatic Neuropathy
Can be injured by hip trauma, hip
replacement, injection, hematoma,
pelvic fracture, penetrating wounds, or
a gravid uterus

Piriformis syndrome
• Compressive sciatic neuropathy at the
pelvic outlet that mainly affects the
peroneal (fibular) portion of the nerve as
it runs inferior or through this muscle
• AKA Fat-Wallet Syndrome or Injection
Palsy
Involves all muscles innervated by the SN

Patient’s complaints depend on which

portion of the nerve is more involved
• Can present as weakness of knee flexion
(hamstring weakness)
• Include muscles & cutaneous innervation of
both the peroneal (fibular) and tibial nerves

Peroneal (fibular) portion is more

vulnerable to injury than the tibial
• Peroneal (fibular) portion is more fixated in
the pelvis & adheres distally to the fibular
head; it has larger fascicles with less
protective epineural tissue

Hamstring & Achilles reflexes may be

abnormal
Tibial Nerve At the distal 1/3 of the thigh, the
tibial portion of the nerve runs
Nerve fibers originate from posterior to the knee and continues
the L4, L5, S1, S2 (S3) roots distally to innervate:
• Plantaris
• Medial gastrocnemius
At the soleus, it continues on as the • Lateral gastrocnemius
posterior tibial nerve and innervates: • Popliteus
• Tibialis posterior (TP) • Soleus
• Flexor digitorum longus (FDL)
• Flexor hallucis longus (FHL)

The nerve runs under the flexor

retinaculum and divides into three
branches:
Cutaneous innervation of Sciatic Nerve (Tibial & Common Peroneal Nerve)
Tarsal Tunnel Syndrome

TN can be injured by
compression under the flexor
retinaculum/Lancinate Ligament

Involves all muscles innervated

by the TN distal to the tarsal
tunnel
Patient may complain of symptoms related
to intrinsic foot weakness.
• Perimalleolar pain, numbness, &
paresthesias may extend to the toes &
soles
• Reproduced by ankle inversion

(+) Tinel’s sign may be elicited at the

ankle

Heel sensation may be spared d/t the

calcaneal branch departing proximal to the
tunnel
Common Peroneal (Fibular) Nerve
Nerve fibers originate
In the posterior thigh, the
from the L4–S2 roots peroneal (fibular) fibers within the
SN innervate the short head of the
biceps femoris
More distally, the sciatic nerve bifurcates
above the popliteal fossa into the common
peroneal (fibular) & tibial nerve
Cutaneous innervation of Lower Leg
Common Peroneal (Fibular) Neuropathy
MC site of injury is at the fibular head

Can be injured by compression from

prolonged leg crossing, weight loss,
poor positioning during surgery,
poor cast application, prolonged
squatting position (strawberry
pickers’ palsy), & metabolic
disorders (DM)
Include all muscles supplied by the deep &
superficial branches of the common peroneal
(fibular) nerve (short head of the biceps femoris
is spared)

Patient may complain of weakness of the

dorsiflexors (TA, EDL, EHL), resulting in a foot
drop or foot slap & a steppage gait

Weakness of only the ankle DF & ankle evertors

helps to clinically differentiate a peroneal
(fibular) nerve injury from an L5 radiculopathy
• Radiculopathy will also involve the ankle
invertors

Sensory loss may be noted over the distribution

of the deep & superficial peroneal (fibular)
nerves

(+) Tinel’s sign may be noted at the fibular

head
Deep Peroneal
Neuropathy
Injury to this nerve is associated
with an anterior tarsal tunnel
syndrome

Compression, trauma, or high

heeled shoes as it passes under
the extensor retinaculum

(M-L) Tom, Harry And Very Nervous Dick Tracy

(TA, EHL, DPA, ATV, DPN, EDL, PT)
Patient may complain of foot
weakness & atrophy (EDB)

May also present with numbness &

paresthesias in the 1st & 2nd web
space

Pain may be located over the

dorsum of the foot & relieved with
motion
Superficial Peroneal
(Fibular) Neuropathy
After innervating the PL & PB the
nerve continues distally as a pure
sensory nerve

Nerve can be injured by

compression from trauma, ankle
sprain, compartment syndrome, or
a lipoma
Includes peroneal longus and
peroneal brevis if the lesion is
proximal to the ankle

Patient complains of loss of

sensation in distribution of
superficial peroneal (fibular)
nerve
Sural Nerve

Nerve fibers originate from

branches of the tibial & common
peroneal (fibular) nerves

Travels from the proximal posterior

calf à lateral malleolus

Supplies cutaneous innervation to

the lateral calf & foot
Sural Neuropathy
Pure sensory neuropathy

Nerve can be injured by

compression from tight socks, a
Baker’s cyst, or a laceration

Patient may complain of abnormal

sensations to the lateral calf & foot

(+) Tinel’s sign may be elicited

along the course of the nerve
Superior & Inferior Gluteal Nerves

INFERIOR SUPERIOR GLUTEAL N.

GLUTEAL N. Nerve fibers originate from the
L4–S1 nerve roots
Nerve fibers originate
from the L5–S2 nerve
roots In the pelvic region the nerve
passes through the sciatic notch
superior to the piriformis
In the pelvic region the
nerve supplies the Muscle to innervate:
gluteus maximus • Gluteus medius
• Gluteus minimus
• Tensor fascia lata (TFL)

These nerves are typically injured by iatrogenic causes, such as hip joint replacement,
improper intramuscular injection, or pelvic masses
Superior Gluteal Neuropathy
Presents with weakness of hip
ABD & ER
(+) Trendelenburg gait
demonstrating a pelvic tilt to the
strong side will be seen

Inferior Gluteal Neuropathy

Presents weakness of hip EXT
Sensation is spared
Trendelenburg Gait

Trendelenburg (TRUE) Gait

Pelvis drops on opp. side during stance on affected side
Compensated = trunk in line but pelvis off

Gluteus Medius Lurch

Lat. Trunk flexion over the affected limb during SLS to maintain COG over the BOS
Uncompensated = side bend over weak side