Lesion of L5 lumbosacral trunk or plexusDifferential diagnosis

Sciatica SOS

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Sciatic nerve lateral trunk lesion

Postpartum - L5 lesions

Acute trauma/transsection: nerve repair Therapy

Incomplete/blunt trauma: wait for spontaneous repair Compressive episode: decrease pressure.

Depending on the cause, and on the site of the lesion. Prognosis

Hackam DG, Zwimpfer TJ (1998) Congenital neuropathy of the lateral cutaneous nerve of References the calf presenting as a peroneal sensory neuropathy. Can J Neurol Sci 25: 168-170

Muckart RD (1976) Compression of common peroneal nerve by intramuscular ganglion from the superior tibio-fibular joint. J Bone Joint Surg Am 58: 241-244

Nakano KK (1978) Entrapment neuropathy from Baker's cyst. JAMA 239: 135

Petit-Lacour MC, Pico F, Rappoport N, et al (2002) Fluctuating peroneal nerve palsy caused by an intraneural cyst. J Neurol 249: 490-491

Sarrafian SK (1993) Anatomy of the foot and ankle: descriptive, topographic, functional. Lippincott, Philadelphia

Staal A, van Gijn J, Spaans F (1999) The peroneal nerves. In: Staal A, van Gijn J, Spaans F (eds) Mononeuropathies. Saunders, London Edinburg New York, pp 133-141

Tibial nerve

Genetic testing

Fig. 45. Tibial nerve anatomy. Tibial nerve originates from sciatic nerve above the knee at variable sites

Fig. 46. Tibial nerve lesions. A Tibial nerve injury to the left leg. Note, that the patient is unable to spread the toes. B Distal tibial nerve lesion: B-1 Normal, B-2 Atrophy and wrinkling of the skin of the plantar pedis. C Complete tibial nerve lesion, note the discoloration of the skin and hyperkeratosis

Fibers for the tibial nerve come from L3-S4. The nerve originates from the medial part of the sciatic nerve. It has a protected position in the thigh and popliteal fossa. In the lower leg, the tibial nerve innervates the gastrocnemius, posterior tibial, flexor digitorum longus, and flexor hallucis muscles. It passes through the tarsal tunnel (behind the medial malleolus), along with the tibial posterior artery and tendons of the posterior tibial and short flexor digitorum muscles. Here the nerve branches into the medial and lateral plantar nerves. The medial plantar nerve innervates the abductor hallucis and the short flexor digitorum brevis. The lateral plantar nerve innervates the flexor and abductor digiti minimi, the adductor hallucis and the interosseous muscles. The sensory fibers from both plantar nerves innervate the sole of the foot. Branches include the medial plantar proper digital nerve (to the great toe) and the lateral plantar proper digital nerve (to the little toe). Four terminal branches are called interdigital nerves (divide into two digital nerves after the distal ends of metatarsal bone.

In the popliteal fossa, the medial cutaneous nerve arises from the tibial nerve. This nerve unites with the lateral sural cutaneous nerve (from the peroneal nerve) to form the sural nerve. A sensory branch in the foot, the calcaneal nerve, innervates the medial part of the heel (see tarsal tunnel syndrome) (see Fig. 45).

Patients present with weakness of the plantar flexors and foot invertors, long toe flexors, and intrinsic foot muscles. Sensory loss usually involves the sole of the foot (see Fig. 46).

Anatomy

Symptoms

Proximal tibial nerve lesions

The terminal branches of the tibial nerve, the medial and lateral plantar and medial calcaneal nerves can be compressed within the tarsal tunnel. Clinical manifestations include foot and ankle pain along with paresthesias on various areas on the sole of the foot, depending on the particular terminal nerve involved.

Distal tibial and plantar nerves

Tibial nerve injury affecting foot intrinsic muscles can also result in clawing of the toes.

Signs Proximal lesions result in weakness of plantar flexion, absent inversion (supina tion), and reduced or absent flexion of the toes. Sensory disturbances occur at the sole of the foot (with or without sural nerve inclusion). Absent ankle jerk.

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