This patient had been noticing intermittent weakness in the right foot for many months. There was no back pain at all and no history of trauma could be recalled. He would notice that he was not able to pick the ankle up, or move it outward well. It actually got worse with activity, and would improve with rest. As time went on, it became more obvious, more constant, and more troublesome.
One of our physiatry colleagues diagnosed the patient with possible compression of the common peroneal nerve at the fibular head. An EMG was ordered and supported the diagnosis. There was no spinal compression or herniated disk in his back.
His physical exam was consistent with the common peroneal nerve compressed at the knee. He had a strong Tinel sign over the common peroneal nerve (the nerve that provides sensation to the entire top of the foot and provides muscle function to lift the foot and ankle, lift the toes, and move the foot outward. When we tapped on the common peroneal nerve just below the fibular head it sent shocks of electricity down to the top of the foot.
This is a textbook example of what relatively severe compression of this nerve presents. Some people will start to notice that they tend to trip more often, as they may have trouble lifting the foot over even small objects like a door threshold. Some patients will complain that they feel like they are walking strangely and their foot may feel “heavy.” Friends and family of the patient may even notice that the patient’s gait pattern has changed or the sound of their footsteps are different as the foot strikes the floor with a slap. The patient may even state that they feel “like I am walking with a flipper on their foot.”
If the compression of the nerve seems to affect mostly the sensory branches, one may not have any weakness at all, and only numbness or tingling into the top of the foot.
Some patients will have much worse symptoms and present with dense weakness and the complete lack of the ability to lift the foot that is constant. This typically indicates that the injury or compression is much more severe, and could also indicate that the nerve will take longer to recover once it is decompressed. Ideally we would like to see every patient as early as this one, where the symptoms were present, annoying, interfering with daily activities, BUT not constant.
This patient’s nerve was decompressed through an incision 1.5 to two inches just below the outside of the knee. It is an outpatient surgery. Often minimal medication for pain after surgery is required. We celebrate with him for his rapid recovery in his strength and function! We wish him luck as he goes back to the stream now to catch more fish!!! We also also want to shout out to Dr. Walter Roche MD for diagnosing his problem and sending him to us! This is a team win for sure!