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Sural Nerve Impingement?

Discussion in 'General Issues and Discussion Forum' started by RobinP, Jan 20, 2010.

  1. RobinP

    RobinP Well-Known Member

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    Hi Everyone,

    I'm looking for any ideas about a case.

    23 y/o male experiencing peroneal impingement in ankles, Lt>Rt
    After 10 mins on elliptical trainer, has burning sensation at the distal end of the gastroc muscle belly, i.e. the proximal formation of the tendo achilles. Not problematic when running but is painful when playing football/soccer

    Orthotic treatment for 2 years which has reduced the lateral impingement pain, but the burning is no better

    Formerly very sporty but now attends gym for fitness only
    Sedate job

    Anatomically normal appearance feet
    Talo crural joint ROM restricted - just reaches 90 degrees with knee extended. +ve Silverskiold test
    Medially rotated STJ axis Lt>Rt
    STJ and MTJs satisfactory
    Weight bearing shows excess pronation.
    Gross examination of gait (no motion analysis equipment in clinic) shows normal foot position at initial contact. Shock absorption is normal and at midstance, there is a slightly excessive degree of pronation. Terminal stance shows strong movement into supination in preparation for push off.
    Palpation of the offending area illicits no symptoms, although I have been unable to assess this when the burning takes place
    No altered sensation along the course of the sural nerve

    Current orthotic Rx is 3/4 polyprop shell with medial heel skives bilaterally and posted to 2 deg inversion. This reduces the lateral impingement pain. However, has little effect on the burning at the proximal end of the TA

    Does anyone know whether compression of the Sural nerve at this level is likely? I know it can be easily trapped further up the leg and be a cause of medial knee pain. However, I could not illicit the symptoms in clinic and the patient does not report any loss of sensation down the lateral aspect of the foot when the burning arises. Is it something else?

    Many thanks

  2. Robin,

    A couple of Questions

    Have you tried a heel lift ?

    Does the patient have a FF Equinus ?
  3. gangrene1

    gangrene1 Active Member

    You may want to try it with a pair of heel lifts.
  4. RobinP

    RobinP Well-Known Member

    Sorry - yes, have tried heel lifts when forming original prescription. Made little difference to his symptoms and caused slippage of the heel in his footwear so left out of subsequent orthoses.

    There is no midfoot equinous present

    He does regular stretching to give improved TCJ ROM


  5. Griff

    Griff Moderator

    Hi Robin,

    What are the lower limb pulses like? Doesnt sound particularly like his symptoms are vascular/ischaemic in nature from your description above, but a while back I missed a vascular condition in a road racing cyclist (altered haemodynamics at the time not being something I generally considered in young fit athletes). Vascular syndromes can and do mimic common neuromusculoskeletal presentations - and it only takes a minute to rule them out.

    I agree with the above posts - start off with adding bilateral heel raises to his devices and see if this alters his pattern of pain. Was there any neural tension/sensitisation on testing (SLR/Slump)? What is gastroc/soleus power and control like? Basically - what makes you think symptoms are neural in origin?


    EDIT: Sorry - cross posting - only just saw you had tried heel raises already
  6. Hi Again Robin,

    Here what I would do with the info we have.

    - Ref to good physio for a nerve assessment, that will possibly lead to nerve mobilisation stretching
    - get the patient to wear heel lifts when exercising- change lace set up to stop heel slippage around 10 mm
    - sports type massage for posterior leg every week for a month
    -streching 3-4 times every day for hamstring, gastroc and soleus.
    - talocural mobilisation treatments.
    -support type socks when training.

    It sounds more like a Triceps surea overuse problem which can be made worse thru reduce nerve mobility.

    I get very similar symptoms and the above treatment program helps alot.

    Hope that helps

    Edit Ian was writing similar thought about nerve mobility as I was writing the same
  7. RobinP

    RobinP Well-Known Member

    Thanks Ian

  8. Griff

    Griff Moderator

    As always it took a particular case to change my thinking - this was a young fit chap cycling at club level and putting in some serious mileage. Got unilateral calf pain only when cycling. Not when running, not when doing anything else at all. We threw the book at him: changed his shoes/cleats, orthoses, bike set up/ergonomics, tissue normalisation, nerve glides, full physiotherapy programme for lower limb including proximal control... nothing changed.

    It was only one day when he mentioned his leg felt heavy as well when symptoms started, and then dropped in that sometimes when he got off the bike his foot felt cold and looked a bit pale that the penny dropped. (A learning experience for us in history taking one could argue). Popliteal and pedal pulses were checked and were fine. Then popped him on the bike until symptoms peaked - quick jump off and re-check and there was a marked reduction on symptomatic side.

    Not suggesting this is the case in your chap of course - just thought it was worth a mention.

    Keep us posted

  9. RobinP

    RobinP Well-Known Member

    Thanks Ian. The main thing I am likely to struggle with is seeing him immediately having stopped exercising. Might have to bring him in as a private patient and put him on the cross trainer. Gives me the chance to do some 2D gait analysis at the same time.

    I'll let you know
  10. Robin another idea, Slightly leftfield. There has been some debate about the effect of a low
    b12 levels can have on exercise induced muscle pain. I tried to look some peer reveiwed stuff but found nothing. I have a couple of patient who have been tested and found to be low in
    b12 and have had injections and amazing results. I can´t find any science to back up the claims there maybe, but something to consider if you still can´t get anywhere. It a simple blood test from a GP.

    and if too leftfield heres leftfield to listen too http://www.youtube.com/watch?v=8D56eqR-qiM
  11. RobinP

    RobinP Well-Known Member

    It is more at the musculotendinous junction and it is only occuring when on the elliptical trainer and playing football. However, I will bear it in mind and it has made me think of another patient for whom it may be a more appropriate explanation.

    That kind of music is far to energetic for the likes of me! I exercise to Val Doonican!

    Thanks Michael
  12. barry hawes

    barry hawes Active Member

    Hi Robin,

    I include chronic exertional compartment syndrome in my DDx whenever I get an athlete in who presents with burning or cramping pain in a muscle of the foot or lower leg which is relieved by rest and displays no palpable tenderness on examination. Biomechanics often irrelevant. Definitive Dx made on intracompartmental pressure test on exercise.

    Hope this helps,

    Barry Hawes
  13. Irrelevent....? If the biomechancis are increasing the load on the muscle then they are not irrelevent but very relevent.
  14. stickleyc

    stickleyc Active Member

    From a purely anatomical standpoint, a sural nerve impingement doesn't seem the most obvious answer though I am aware of case reports of sural anomalies discovered in cadavers that could lead to sural impingements. An example: http://www.neuroanatomy.org/2007/041_042.pdf

    I would agree with those above that a triceps surae overuse syndrome sounds more likely.
  15. RobinP

    RobinP Well-Known Member

    sural anomalies discovered in cadavers that could lead to sural impingements. An example: http://www.neuroanatomy.org/2007/041_042.pdf

    Good article but you are right, it is sounding more like sural nerve impingement is unlikely. I'll post when I do the test

  16. RobinP

    RobinP Well-Known Member


    Definitive Dx made on intracompartmental pressure test on exercise.

    I'm not sure what that test involves. Could you describe or give me an idea of where I might find a description.

    many thanks

  17. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Google 'compartment pressures' and 'compartment syndrome' and you will see lots of information as this is the definitive test to confirm compartment syndrome. Refer to a sports physician to have it done. Its essentially like sticking a tyre pressure gauge into the leg under local anaesthesia.

    I would agree with Barry - biomechanics is often largely irrelevant. No amount of fiddling with pieces of plastic is likely to fix the condition and release the septae. It is a surgical case.

    In saying that, I don't think this case sounds like compartment syndrome to me...

  18. RobinP

    RobinP Well-Known Member

    In saying that, I don't think this case sounds like compartment syndrome to me...

    What do you think if not a compartmental syndrome?

  19. Robin:

    This does not sound like chronic exertional compartment syndrome to me since the superficial-posterior compartment is the least likely compartment to have chronic exertional compartment syndrome (CECS). However, the consistancy of the timing of the onset of pain is a characteristic feature of CECS. Another likely diagnosis is continued scarring around a previous myotendinous junction tear of the gastrocnemius musle-Achilles tendon. This myo-tendinous junction is a natural weak spot within the gastrocnemius-Achilles tendon complex and is the source of many posterior leg injuries in running/jumping athletes.

    Medial gastrocnemius myotendinous junction tears are so common that they have been given the name of tennis leg but more commonly these tears occur in older athletes. Another alternative to consider is plantaris tendon rupture that hasn't healed completely or has residual scar tissue left in the area. It would be helpful to ask the patient if the pain came on suddenly one day or gradually developed over time since tears are generally start with one or two steps fairly suddenly into a running or jumping activity. Also, to help diagnosie myontendinous tears, I will have the patient lay prone on the examining table, dorsiflex their ankle maximally and palpate deeply at the gastrocnemius myotendinous junction since often times the defect from the tear is readily palpable when the examiner's thumb is moved across the myotendinous junction, with the area of maximum tenderness being the site of the defect and site of the tear.


    Deep tissue massage along with heel lifts or switching to shoes with higher heel height differential should help this young athlete. Another thing that will help is to tell your patient to lean farther backwards during his elliptical trainer sessions since people who lean forwards habitually on elliptical trainers may develop posterior calf pain and/or temporary numbness/tingling of the forefoot. Standing up straighter, with more weight on their heels, generally resolves this problem.

    Hope this helps.
  20. LL While it I beleive depends on what you define as Biomechanics and how far along the patient is with compartment syndrome. I would always consider treating the cause of the over loading. Stretching, massage , heel list etc as treating biomechancially. An orthotoic probably won´t have much say in the matter putting a heel lift in is treating a biomechancial loading on the Gastroc and soleus.

    So I agree that with compartment syndrome controlling stj position is not so important but saying biomechanics is irrelevant I´m not sure I can agree with. Even treating and discussing the sitting position as Kevin suggested is in my world treating biomechancially, would you agree with that?

    I will however agree that if the problem is so far along no amount of conservative treatment will have much success and a release must be considered.

    So to summarize. Early to medium stage increase in compartment pressure I believe conservative/biomechical treatment to reduce the load on muscle can have great effect.

    What do you think?
  21. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    I don't consider exertional compartment syndrome to be an issue of 'overloading' in the same way we might describe a posterior tibial tendonitis in this manner.

    So this real issue is the cause - which you have alluded to.

    IMHO this cause is overuse in the presence of low incidence anatomical variation, which may be subtly influenced by massage, acunpuncture, heel lifts, orthoses and the like. However, I am yet to see anyone actually get any meaningful lasting improvement with and of these approaches. Hence my belief that this is eventually always a surgical condition - unless suitable activity modification occurs. I saw a lot of this when treating infantrymen - who have no choice but to either have surgery or quit the army.

    Its a bit like treating bunion pain with a gel cushion. It doesn't address the cause - and I think this is where we diverge in opinion.

  22. JB1973

    JB1973 Active Member

    morning all
    i'd never heard of Silverskiold test, so i googled it ( as you do) and got this article fro japma. dont know if its of any use to some of the more learned contributors but might help folk like me who hadnt heard of it.

  23. Here the full text version of what JB mentioned

    Attached Files:

  24. HansMassage

    HansMassage Active Member

    I joined this forum because I get referrals for cases like this. When I first met the referring podiatrist and explained what I do he exclaimed "I need you, I am trained up to the knee but I know the problem is coming from higher up."
    The differential between running and football and probably the elliptical is having the head down. The head down or forward places additional stress on the distal heads of the metatarsals. The support of the planter muscles has to be matched at the attachment of the soleus and the anatomy train continues up the gastrocs.
    This young man is fortunate to have such an attentive doctor. I usually get the referral after there has been a sprain strain at T11/12 and the anatomy train which continues up the adductors to the psoas minor and through T11/12 to the lower trapizius to the upper trapizius and the skull. When that is broken at T11/12 the posture really gets ugly and correspondingly the feet.
    Hans Albert Quistorff, LMP
    Antalgic Posture Pain Specialist
  25. I was going to let this sentence go but it´s taking it to the extreme to get your point across, It a bit like saying that for every bit of callous you debride you should really be prescribing an orthotic to deal with the forces which have lead to the callous ie the cause. Extreme in my book.

    I will always try the conservative pah to +ve outcome 1st and if not succes look to the more envasive treatment plans, but maybe that just me
    Last edited by a moderator: Jan 25, 2010
  26. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    But didn't you say;

    Hey nothing wrong with following conservative treatment through to its end conclusion. However, I don't think a bunion is an 'extreme' example to get this point across.

    Many podiatrists will literally :deadhorse: with a symptomatic deformity such as a bunion or hammertoe - pads, splints, shoe modifications, insoles, orthoses, reiki, acunpuncture...you name it. And keep doing it for year after year. In my mind most of these interventions may provide some modest or temporary benefit, but ultimately the 'solution' is surgical. It always stuns me that many new patients who see me about a common complaint such as these have never been even offered a surgical option - that almost cry with relief that someone has finally offered an opportunity to 'fix' the problem.

    Sure you can live with it, but in the same way you can live with exertional compartment syndrome by not exercising so much.

    But maybe I just draw a line in the sand on conservative care a lot earlier than you? But probably not as early as Steve ;)

  27. Maybe for you and definently for Steve :D. I do agree witht the bunion comments. I always give them the steps in treatment plans give them the option to try what fits there life style etc. I deal with the other side over here more than I used to in Aust. Surg 1st then ask questions later.

    Like a professional dance instructor who had some sort of 1st MTP pain, Surg said A little op and the pain will disappear, Patient ended up with a fused 1st and was told by the "surgeon" to consider a new career when she complained. :butcher:
  28. RobinP

    RobinP Well-Known Member

    Well folks,

    Here is the update on this patient. I saw him privately(as a freebie) last weekend having resupplied him with some heel raises following the advice on this thread.

    He still experiences the burning sensation after 10-15 mins but it is less severe and is more noticeable on the Lt than on the Rt.

    As advised by Ian, I did a slump test as opposed to to just an SLR test and this showed some neural tension bilaterally but more noticeably on the Lt side.

    Pulses were fine in this instance.

    On Kevin's advice, deeply palpated the musculotendinous junction and found a defect on the Lt side so there does appear to have been some type of plantaris tendon problem although the patient can remember no particular injury.

    Had the patient run until the burning began and then palpated the problematic area which was quite lateral and there was considerable discomfort. Unfortunately, where I live, there are no practitioners who can do compartment testing.

    I have given the patient the advice of having a proper nerve test and deep tissue massage to the area along with a programme of stretching to be sorted by the physio.

    I plan to review in 6/52 and will keep you updated on progress but I expect that we will see some positive results. Many thanks for all of your advvice. What a great resource this website is.


  29. Robin:

    Thank you very much for the update on your patient. Your thoughtful attention to reporting back to us on your patient's progress greatly enhances the clinical education environment of Podiatry Arena for podiatists around the world.
  30. NewsBot

    NewsBot The Admin that posts the news.

    Fascial entrapment of the sural nerve and its clinical relevance.
    Paraskevas GK, Natsis K, Tzika M, Ioannidis O.
    Anat Cell Biol. 2014 Jun;47(2):144-7.

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