Unraveling Sural Nerve Entrapment: Diagnosis and Conservative Treatment | OEP369 - Ortho Eval Pal: Optimizing Orthopedic Evaluations and Management Skills

Episode Transcript
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Speaker 1 (00:00):
Hello everyone, and welcome to episode 369 of the
OrthoEvalPal podcast.
I'm your host, Paul Marquis,and today we're going to be
talking about sural nerveentrapment.
We're going to be discussingthe course of the sural nerve,
we'll talk about some of thesigns and symptoms of sural
nerve entrapment and then we'llgo over some treatment tips for
sural nerve entrapment.

(00:20):
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(01:26):
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on other products.
So, folks, we're back to theshow.
It has been absolutely crazy inthe world of Paul lately.

(01:48):
We're in the middle ofrevamping our website, so this
Thursday we should have our newwebsite up and published and
ready to rock.
We are also, you know,preparing for a live shoulder
course which will be giving inMay, and also preparing some
live BFR courses to complementour online BFR program.

(02:10):
So lots going on over here,along with life and everything
else that happens along with allof that stuff.
So just a little crazy here.
Hope that everything is goingwell with all of you folks and
that you're able to keepeverything in line and
straighter than I do.
So what I want to talk abouttoday is sural nerve entrapment.
Now, this is not something thatwe see very often, and the

(02:35):
reason I want to bring this upis because sometimes we can we
can mistake in lateral Achillesdiscomfort or lateral foot pain
for something other than thesural nerve entrapment.
So I want to kind of talk aboutwhat this nerve does, where it
exists and how you manage itwhen you think you're suspicious
that somebody might have it.
So you know, the sural nerve isa sensory nerve.

(02:58):
It controls sensation to the,you know, the distal third of
the lower leg, lateral side,mostly down to the lateral heel,
lateral ankle, lateral footarea.
It's derived from the sciaticnerve which splits just above
the knee going to the tibialnerve and the common peroneal

(03:18):
nerve, and then the tibial nervebranches off to the medial
sural nerve, the common peronealnerve branches off to the
lateral sural nerve and theycome back and converge again
just between the heads of thegastroc and just really below
that, near the musculotendinousjunction, and then it starts to

(03:39):
migrate off laterally just alongthe Achilles tendon down to the
posterior lateral malleolararea and then you have a small
branch that comes off of thatwhich is your lateral dorsal
cutaneous nerve, which cancontrol some sensation to the
lateral foot area.
So your cerebral nerve controlssensation, a lot of

(04:02):
proprioception, so that whenpeople have like neuropathy,
this nerve gets affected and itcan really throw their gait off.
You'll notice that they startto walk with more of a wider
base of support, almost like aone-year-old, you know, trying
to get their balance.
The feet are turned out alittle bit.
They're really wide, so theystart to lose proprioception and
that ability to know where thefoot is in space.

(04:24):
It also helps with temperaturesensation and also it can cause
pain.
So if you have pain in thatarea it does transmit that.
This nerve is very superficial,so just subcutaneous, and
that's why it is often picked asa nerve for nerve transplants
and things like that or biopsies, because it is so easy to get

(04:46):
to.
Now, what causes a sural nerveentrapment?
Well, you could have trauma tothe sural nerve, which is easy
to do.
Just a kick to the back of theleg to especially that lateral
calf area, lateral Achillesregion, can cause some trauma to
the nerve itself.
You can develop some softtissue hypertrophy, swelling in

(05:08):
that area that compresses thenerve and then you can end up
with some scar tissue aroundthat area so that the sterile
nerve doesn't glide and move aswell anymore.
We've seen, you know, injuryfrom, from surgical procedures
in that area.
I'll always remember when I wasa young therapist observing an
Achilles reconstruction and theorthopedic surgeon kind of

(05:31):
started quizzing me prettyaggressively and asked what this
particular structure was, andit was the sural nerve.
And he said, interestinglyenough, a lot of you know a lot
of those get cut because theycan look just like a plantarus
tendon and it's really difficultsometimes to identify that but

(05:52):
it's easy, apparently, to injure.
So you know how do we?
How do we treat this?
Well, first thing you want todo is you want to make sure that
you rule out a lumbar nerveroot compression of some sort.
Okay, so one of the ways youcan do that is do some, some
lower quadrant screening, dosome reflex testing.

(06:13):
A sural nerve entrapment is notgoing to cause a loss of reflex
at the Achilles or at thepatella tendon.
You will lose sensation in thesame area.
So that can make it a littlebit difficult.
The sural nerve is a sensorynerve, it's not a motor nerve.
So you do manual muscle testingthroughout the lower extremity

(06:33):
to see if there is any unusualweakness.
If you see weakness, you needto be thinking upstream a little
bit more.
The next thing you might wantto try is like a straight leg
raise test.
If it's sural nerve, you couldactually get a little stretch,
especially if you're doing aBraggers test.
So you do the straight legraise test, you dorsiflex the
foot.

(06:53):
Now the sural nerve is on a lotof tension.
But if you take the foot andplantar flex it and do the
straight leg raise, you're lesslikely to affect that sural
nerve.
And if it gives them pain, youknow.
Basically, going down the legand it's above the knee, more
likely to be a nerve rootcompression up above the knee at

(07:15):
the lumbar spine area.
So that's how you can kind oftease these out.
So what do you do to treat these?
Well, usually there'ssignificant tightness.
The calf is tight.
Maybe somebody has been reallyhitting calf strengthening
exercises.
They develop some hypertrophythere.
So getting that calf stretchedout, stretching that
gastrocnemius muscle a littlebit more on a slant board, I

(07:39):
like to warm these up.
Getting on a stationary bikeisn't going to damage the
cerebral nerve.
Um, the foot can stay in a veryneutral position.
Put the foot on the center ofthe pedal, not on the ball of
the.
Don't put the the foot on thepedal so that the pedal is on
the ball of the foot, becausethat's going to activate the
calf a lot more.
So just put that pedal to thecenter of the foot.

(07:59):
Do some biking, get that legwarmed up, I like to use a nice
hot pack over that area.
This nerve is superficial.
Um, I may get the patient kindof long sitting and maybe have
them bend the knee andstraighten the knee just a
little bit, like you know 10 to15 degrees of flexion, and then
get into extension while theyhave the hot pack on.
Also, maybe some very gentledorsiflexion, plantar flexion,

(08:23):
while the heat is there.
Ultrasound is very effective inthis area because, again, this
is very subcutaneous, it's notvery deep.
So the other thing you mightwant to do is start to work on
some soft tissue mobilization.
Now I wouldn't get in here andreally scrape this nerve up hard

(08:44):
with a Graston tool orsomething like that, but maybe
just a little light soft tissuemobilization to the gastroc
muscle and the surroundingstructures, but not to reproduce
the symptoms you knowsignificantly.
The other thing you want to dois talk about their daily
activities, their sports, theirhobbies.
Do they wear something like acowboy boot or do they wear a
high leather boot where when thetop is strapped on it causes

(09:07):
compression to that sural nerve?
A ski boot a downhill ski boot,classic for putting some
pressure on there If you'rewalking, not so much while
you're skiing downhill becauseyour pressure is a little more
forward and the knee is a littlebit bent.
So that helps with that.
Really, the best treatment forthis in regards to conservative

(09:29):
therapy is sural nerve glidingexercises.
By getting the knee into fullextension, dorsiflexing the foot
and inverting it at the sametime will help to get a little
bit of the gliding going.
So, like any other nerveflossing activity, you don't

(09:50):
want to push this so hard thatit's very painful and that the
reproduction of tingling orburning lasts a long time.
You should get it.
It should be temporary, whileyou're doing the exercise, more
when you're dorsiflexing andinverting than when you are
plantar flexing and everting.
Okay, I like to start thesefolks doing it passively at

(10:11):
first, just to give them a feel,and then I have them start to
do it at home.
I usually will have them doabout.
I usually will have them doabout, you know, five pumps,
about five times.
I might also throw in somesciatic nerve flossing while
doing this, also just to get thewhole sciatic nerve moving and
mobilized a little bit better.

(10:32):
After this the patient willstart doing it on their own and
start to, you know, increasethat nerve gliding.
You know, walking activities andactivities that improve the
myofascial mobility throughoutthe whole back, the leg, can be
very beneficial and you want tojust make sure that people are
not having more tingling, moreburning, more loss of sensation.

(10:53):
Especially if they're diabetics.
They really increase the riskof having some ulceration and
nerve injuries, skin injuries onthe outer side of the foot.
So definitely something to takea look at, keep it in the back
of your mind when you seesomebody with lateral calf,
lateral ankle and foot pain,lateral heel pain also, or loss

(11:16):
of sensation there.
Something to make sure that youkeep an eye on, because it's
not something you see very often, but it does exist.
And I hope that today's episodekind of brought just another
look at another part of thehuman body that you can kind of,
you know, look at with adifferent perspective so that

(11:37):
you don't just get into the sameold routine of oh, this is an
ankle sprain and this is whatthis should be, this is how you
should treat it.
But you need to look outside ofthe box just to make sure you
don't miss anything when you'reseeing your patients.
So, um hope you enjoyed today'sshow.
Please be patient with us as wetransition to our new website.
Lots of moving parts there, um,it's a.
It's a big job.

(11:58):
It's kept me really busy in thelast couple of weeks, but super
excited to bring it to folks sothat there's just more content,
more accessibility and hope.
It's everything.
You folks need to become moreeducated in how to do orthopedic
evaluations better.
So again, folks, be kind toeach other and take care.

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Unraveling Sural Nerve Entrapment: Diagnosis and Conservative Treatment | OEP369

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.css-14f5ked{margin:0;word-break:break-word;display:-webkit-box;-webkit-box-orient:vertical;box-orient:vertical;-webkit-line-clamp:2;overflow:hidden;}Unraveling Sural Nerve Entrapment: Diagnosis and Conservative Treatment | OEP369