I.

SPECIFIC NERVE INJURIES TO THE LOWER EXTREMITIES  Sensory changes posterior aspect of thigh
and entire leg and foot
A. Lateral Cutaneous Nerve of the Thigh (L2,L3)  Weakness: hamstrings, gluteus maximus,
o Subjected to injury at site where it passes between the ankle and foot muscles
two prongs of the inguinal ligament  Intact hip abductors, adductors and knee
extensors
o Meralgia Paresthetica  Gluteus maximus gait
 Compression of the lateral femoral cutaneous
nerve as it passes under inguinal ligament just E. Common Peroneal Nerve
medial to the ASIS into the thigh o Of all sciatic branches, this nerve is most liable to
 Presentation – discomfort in the lateral aspect of injury
the thigh (pain, burning, numbness, formication, o Site of injury at the level of head of fibula
dysesthesia and hyperpathia) o Splits into deep peroneal nerve which innervates
 Causes: muscles of the anterior compartment of the leg; and
 Trauma, postural abnormalities, occupations superficial peroneal nerve supplying the lateral
requiring long periods of hip flexion, compartment of the leg
increased intraabdominal pressure as in o Cause a foot drop deformity and equino varus
pregnancy, obesity (particularly sudden deformity
weight gain), wearing a tight belt or truss
 May be first symptom of a polyneuropathy or 1. Common Peroneal Nerve Syndrome
lesion of L2 or L3 or the lumbar plexus o Compression or injury of the nerve at the fibular
head and neck area where it winds
B. Obturator nerve (L2, L3, L4) o Causes:
o Primarily innervates the adductor muscles of the hip  Compression from tight bandages
however, note that the Adductor Magnus has a dual  Prolonged compression in bedridden
innervation
patients
o Injury presents with adductor weakness but no
 Fibular neck fractures
complete atrophy o Presentation:
 Foot drop
C. Femoral nerve (L2, L3, L4)
o Primarily innervates the anterior thigh muscles  Hypesthesia in lateral aspect of leg
(quads) as well as the iliacus and sartorius and dorsum of foot
o Presents with atrophy of anterior thigh and weak knee  Complete sensory loss first web space,
extension dorsum
o Sensory deficit: medial aspect of the leg and foot  Paralysis of anterior and lateral
which is supplied by the saphenous nerve compartment muscles
(continuation of the femoral nerve in the leg)  Steppage gait

D. Sciatic Nerve (L4-S3) 2. Deep Peroneal Nerve

o Muscles paralyzed: hamstring and all muscles below
the knee
o “spindle leg” atrophy, flail leg
o Clinical conditions/syndromes involving this nerve are:
piriformis syndrome, injection palsy, fat wallet palsy
o Present with weakness and atrophy of the knee
extensors, foot muscles (flail ankle), and sensory loss
below the knee except in the area supplied by the
saphenous nerve
1. Piriformis Syndrome
o Entrapment of the sciatic nerve between
piriformis muscle above and obturator internus
below
o Causes:
 Sustained piriformis muscle contraction
 Fibrotic changes in the muscle
secondary to direct trauma, as in
posterior hip dislocation
o Presentation:
o Present with foot drop deformity; steppage gait
o Sensory deficits: - between great and 2nd toe
dorsally
3. Anterior Compartment Syndrome
o Occurs as a result of an increase in pressure
within the anterior compartment of the leg which
contains the deep peroneal nerve, anterior tibial
artery and muscles of the anterior compartment
o Tissue pressures greater than 30 to 40 mm hg, if
prolonged more than 4 to 6 hours, will result in
ischemia & muscle necrosis.
o Causes:
 Anterior tibial tendinitis from running long
distances
 Direct blow on anterior aspect of leg as in
soccer or football or in an automobile
accident
 Tight cast application
o Presentation:
 Early, intense, unremitting pain in anterior
aspect of leg
  Signs of vascular insufficiency o Compression by a Baker’s cyst of the tibial nerve
 Absence of dorsalis pedis pulse (may also involve Common Peroneal & Sural
 Hypesthesia or anesthesia on dorsal aspect nerve)
of first web space o Effusion of semimembranous bursa producing a
 Weakness/paralysis tibialis anterior, EDL, popliteal tumor
EHL, and peroneus tertius o Proliferation of synovial tissue in patients with RA
o Treatment: o Synoviomas of the knee joint
 Prompt fasciotomy to relieve the pressure o Aneurysm of the popliteal artery
o Presentation:
4. Superficial peroneal nerve  Incomplete knee flexion due to the tumor
o Present with loss of eversion
 Pain behind the knee or calf on
o In longstanding cases, equinovarus
dorsiflexion of the foot
F. Tibial nerve  Weakness of the gastrocnemius, tibialis
o Innervates all muscles of the posterior compartment posterior, FHL, FDC and intrinsic foot
muscles (except EDB)
o Injury present with:
 Sensory loss entire plantar surface of foot
 Loss of plantarflexion and toe flexion
 Atrophy of gastrocsoleus, muscles of foot  Depending on size of tumor or mass,
 Calcaneal gait the common peroneal and sural
 Impaired push off nerves may be affected resulting in
 Inversion impaired because of paralysis of the paralysis of entire foot and ankle
posterior tibialis but tibialis anterior still intact
 Sensory loss over sole of the foot F. Superior Gluteal Nerve
 Nerve involved in tarsal tunnel syndrome o Paralysis of gluteus medius and gluteus minimus
o Present with gluteus medius gait and (+)
1. Tarsal Tunnel Syndrome Trendelenburg test
o Compression of posterior tibial nerve or its  Pelvis drops towards the unsupported side
branches as it passes through the flexor  Excessive lateral list - thorax is thrust laterally to
retinaculum behind the medial malleolus of the keep the COG over the stance leg
ankle joint
o At the tunnel, the posterior tibial nerve divides G. Inferior Gluteal Nerve
into the calcaneal nerve, medial and lateral o Have paralysis and atrophy of gluteus maximus
plantar nerves o Present with gluteus maximus gait
o Causes:  Thorax is thrust posteriorly at heel strike to
 Tenosynovitis of the tendons within the maintain hip extension of the stance leg
tunnel (FHL, FDL, TP) due to local trauma  Characterized by backward lurching of the trunk
 or systemic disease (RA, other CTD)
 Venous distension or engorgement within H. Sural Nerve
tunnel from chronic venous insufficiency o Supplies lateral aspect of leg and thigh
 Distortion of the canal as in pes
planus, pes valgus or trauma of foot
o Presentation:
 Pain radiating into foot and increasing with
activity
 Increased pain with walking, passive flexion,
and extension of ankle joint
 Decreased sensation in sole of foot medially
or laterally or both
 Skin at heel intact sensation
because calcaneal branch runs
above the retinaculum
 (+) Tinel’s sign on tapping behind the
malleolus
 Weakness and atrophy of intrinsic foot
muscles
 Hammer-toe deformity

2. Popliteal Fossa Entrapment