Physiotherapy Theory and Practice, 28(7):552–561, 2012

Copyright © Informa Healthcare USA, Inc.

ISSN: 0959-3985 print/1532-5040 online
DOI: 10.3109/09593985.2011.653709

CASE REPORT

Physical therapy management of entrapment of the

superficial peroneal nerve in the lower leg: A case
report
Sudarshan Anandkumar, PT
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Coventry University – International School of Physiotherapy, Gokula Education Foundation, M.S.R Nagar,
MSRIT Post, Bangalore, Karnataka 54, India

ABSTRACT
This case report describes a 40-year-old male who presented with complaints of pain in the left lower lateral one-
third of the leg. Tenderness was elicited 9.7 cm above the lateral malleoli with a positive Tinel's sign at the same
site causing radiating pain into the foot (visual analog scale (VAS) score of 6.3 cm). Physical diagnosis for entrap-
ment of the superficial peroneal nerve at the site of the peroneal tunnel was entertained based on clinical exam-
ination and three positive provocation tests. Conventionally, treatment for this type of entrapment has been
surgical decompression by splitting the crural fascia, with successful outcomes. This is potentially a first-time
For personal use only.

report describing physical therapy management of entrapment mechanical interface with pain modalities, soft tis-
sue mobilization, and neural mobilization. Reduction of pain was noted in this patient (VAS score of 0 cm by the
sixth session) with complete pain resolution maintained at a six-month follow-up.

BACKGROUND of the foot; the dorsum of the first, second, and

Peripheral nerves frequently are described as
entrapped by mechanical interfaces. Examples
include the median nerve at the carpal tunnel and
the ulnar nerve at the cubital tunnel (Arle and
Zager, 2000). The most common entrapment mono-
neuropathy described in the lower extremity is the
common peroneal nerve around the fibular head
and neck (Aprile et al, 2005). Entrapment of the
superficial peroneal nerve is rare and was first
described by Henry (1945) as “Mononeuralgia in
the superficial peroneal nerve.” The superficial pero-
neal nerve is an extension of the common peroneal
nerve. It supplies the peroneus longus and brevis,
pierces the crural fascia at the level of the middle
and distal thirds of the leg, and continues subcu-
taneously as the cutaneous dorsalis medialis and the
cutaneous dorsalis intermedius nerve supplying the
skin of the anterolateral side of the leg; the dorsum
Accepted for publication 5 November 2011
Address correspondence to Sudarshan Anandkumar, Coventry
University – International School of Physiotherapy, Gokula Education
Foundation, M.S.R Nagar, MSRIT Post, Bangalore, Karnataka 54,
India. E-mail: anandkumar.sudarshan@gmail.com
third toes; and the medial side of the fourth toe
(Pecina, Krmpotic-Nemanic, and Markiewitz,
2001) (Figures 1 and 2).
The entrapment sites of the superficial peroneal
nerve are shown in Figure 2 and could be either
behind the level of the peroneus tunnel/fascial
tunnel (before the exit through deep fascia with the
fascia compressing the nerve) or at the site of exit
from the peroneal tunnel/fascial tunnel (due to a
narrow tunnel) (Styf and Morberg, 1997). Even
though only a few cases of superficial peroneal
nerve entrapment have been reported, varied causes
have been described. They include lipoma (Banerjee
and Koons, 1981), healing fracture site (Mino and
Hughes, 1984), tight boots (Lindenbaum, 1979),
dynamic compression in the fascial tunnel (Styf and
Körner, 1986), and anorexia nervosa (Sevinç,
Kalaci, Doğramaci, and Yanat, 2008). Other possibi-
lities of entrapment include direct compression from
fascial defect (Garfin, Mubarak, and Owen, 1977)
(i.e. where an increase in the intramuscular pressure
causes muscle herniation through the fascia, thus
impinging the nerve) and ankle sprains (Kernohan,
Levack, and Wilson, 1985) (i.e. common injury
mechanism with the foot in plantar flexion and

552

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For personal use only.
FIGURE 1 Shaded area showing the sensory distribution of
the superficial peroneal nerve, 203 × 304 mm (300 × 300 DPI).
inversion where the peroneal nerve, which is being
tethered proximally, gets pulled in the distal direction
taut against the fascial opening/fascial borders
causing a potential injury).
Based on the clinical presentation of superficial
peroneal nerve entrapment, there are other conditions
which may mimic its appearance. The differential di-
agnosis for it includes L5 radiculopathy (Banerjee
Physiotherapy Theory and Practice
Physiotherapy Theory and Practice 553
FIGURE 2 Course of the superficial peroneal nerve with sites
of potential entrapment: 1. common peroneal nerve, 2. super-
ficial peroneal nerve, 3. deep peroneal nerve, 4. intermediate
dorsal cutaneous nerve, 5. medial dorsal cutaneous nerve,
6. site of entrapment before the fascial tunnel, 7. lateral malleo-
lus, and 8. site of entrapment at the fascial tunnel, 203 ×
304 mm (300 × 300 DPI).
and Koons, 1981; Kopell and Thompson, 1963),
pseudoradicular pain syndrome (Styf and Morberg,
1997), prior trauma resulting in anatomical defects
(Kopell and Thompson, 1963; Mackey, Colbert, and
Chater 1977), and chronic or exertional lateral com-
partment syndrome (Garfin, Mubarak, and Owen,
1977; Styf, 1989).
In most of the studies, the treatment for entrapment
has been surgical decompression by splitting the fascia
(Kernohan, Levack, and Wilson, 1985; Lowdon,
1985; McAuliffe, Fiddian, and Browett, 1985;
Rubin, Menche, and Pitman, 1991; Sridhara and
Izzo, 1985; Styf and Morberg, 1997). Hence, studies
have described entrapment of the superficial peroneal
nerve being treated successfully surgically. This case
report speculates a potentially first-time description
of successful conservative management of superficial
peroneal nerve entrapment utilizing manual therapy
principles.
 554 Sudarshan Anandkumar
CASE DESCRIPTION AND CLINICAL
FINDINGS
A 40-year-old male, sales executive, presented with
complaints of difficulty in pushing down on the accel-
erator and brake while driving his car. He also reported
difficulty in walking and sitting for more than an hour
due to pulling intermittent pain for the past six
months. The onset of pain was gradual in the lower
one-third of the left lateral aspect of fibula extending
up to the second and third toes (Figure 3). His occu-
pational demands were five to 6 h of deskwork per day
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(six days a week) followed by 2–3 h of light activities
such as standing, walking, and talking to clients. The
patient described himself as being very physically
active taking a walk 30–35 min five days a week in
the morning. Other activities included tennis, bad-
minton, and swimming.
The patient reported that his pain increased in its
intensity day by day and plateaued approximately
after three months of its onset. Rest relieved the pain
within 50 s, indicating a mild irritability, and his
24 h pattern of symptoms varied from day to day.
For personal use only.
The visual analog scale (VAS) and lower extremity
functional scale (LEFS) were used as outcome
measures. The VAS is a valid and reliable tool to
assess pain intensity (Bijur, Silver, and Gallagher,
2001; Price, McGrath, Rafii, and Buckingham,
1983), where on a 10-cm line, “0” indicates “no
pain” and “10” indicates “worst imaginable pain.”
The minimal clinically important difference of the
VAS was established by Kelly (2001) to be a change
of 12 mm (95% confidence interval (CI) 9.15 mm).
The patient rated his current pain intensity at 6.3 cm
on the VAS.
The LEFS, which has good test–retest reliability
(Binkley, Stratford, Lott, and Riddle, 1999), was
used to evaluate functional impairment. The scores
FIGURE 3 Symptom distribution represented in black as
marked by the patient and the site of Tinel's sign and spot ten-
derness on palpation depicted in red color (circled above),
304 × 203 mm (300 × 300 DPI).
of the LEFS range from 0 (minimum) to 80
(maximum) with the minimal clinically important
difference and minimal detectable change being 9
scale points (Binkley, Stratford, Lott, and Riddle,
1999). The scale has 20 activities, where each activity
needs to be graded by the patient from “0”, indicating
extreme difficulty or unable to perform the activity, to
“4”, indicating no difficulty (Appendix 1). On initial
evaluation, a score of 59 points in the LEFS was
obtained and reassessment was documented on a
weekly basis.
The patient did not report any pain at night or while
sleeping. There was no history of bladder or bowel
dysfunction, weakness, or any pain from the spine.
The patient was not taking any medication at the
time of evaluation or prior to it and said that he had
no prior history of dysfunction or pain at the calf or
shin. His prior laboratory studies and past medical
history for screening a systemic cause for his lateral
leg pain were ruled out.
On observation, the resting calcaneal stance pos-
ition was 6° of eversion bilaterally when measured
with a standard goniometer (Sobel et al, 1999) with
the navicular height being 5.6 cm in weight bearing
(Menhz et al, 2003). The Feiss line (Cook, 2007)
drawn indicated a grade 1 flat foot with the navicular
tuberosity falling up to one-third of the distance
between the line and the floor. Gait analysis was
unremarkable.
On palpation, spot tenderness was elicited 9.7 cm
above the lateral malleoli with a positive Tinel's sign
at the same site (Figure 3) causing radiating pain
into the foot. Though tenderness was elicited over
the common peroneal nerve at the fibular head, it
was localized with no radiating symptoms. There was
an absence of sensory abnormality and muscle weak-
ness with unremarkable lower extremity reflex
testing. Dorsalis pedis artery and posterior tibial
artery pulses were present and an ankle brachial
pressure index (ABPI) value of 1.15 was obtained.
The ABPI is calculated by dividing the measure-
ments of systolic ankle blood pressure (dorsalis
pedis/posterior tibial artery) and brachial artery systo-
lic blood pressure (Al-Qaisi, Nott, King, and Kad-
doura, 2009). It is a clinical screening tool which is
considered to be quick, simple, reproducible, and
non-invasive (Al-Qaisi, Nott, King, and Kaddoura,
2009; Bhasin and Scott, 2007; Kurtoğlu et al, 2009)
and was used to rule out symptoms due to peripheral
vascular problems in the patient. The patient was
placed in the supine position for 5 min, following
which blood pressure measurements were taken. The
first measurement was taken for both the arms (right
side followed by the left side) and the higher value
obtained was used as the denominator. Next, the
Copyright © Informa Healthcare USA, Inc.

blood pressures of both the legs were taken (right side
followed by the left side) and the higher value was used
as the numerator. The diagnostic criteria for periph-
eral vascular disease (American Diabetes Association,
2003) are given in Appendix 2.
Radiographs of the knee and ankle–foot complex
were normal and the spine, hip, and knee were ruled
out clinically as the sources for the pain. Resisted iso-
metrics to the peroneal muscle group in the form of
dorsiflexion and eversion elicited pain in the lateral
compartment with no radiating symptoms into the
foot. The straight leg raise (SLR) test did not elicit
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symptoms. However, when the sensitizing component
of plantar flexion and inversion were added, the
patient's symptoms were reproduced. To differentiate
the cause of pain from nerve tension and muscle/fascia
origin, the knee was flexed maintaining the com-
ponents of plantar flexion and inversion. The patient's
pain persisted with the same radiating pain into
the foot.
EVALUATION AND DIAGNOSIS
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Styf and Morberg (1997) suggested three provocation
tests for evaluating patients with a suspicion of super-
ficial peroneal nerve entrapment to aid in diagnosis.
They are as follows: (1) resisted dorsiflexion and
eversion with pressure applied over the peroneal
tunnel (which corresponds to the nerve's passage/
pathway through the fascia); (2) passive plantar
flexion and inversion of the ankle with no pressure
application over the nerve's passage/pathway; and
(3) gentle percussion over the nerve while keeping
it in a passively stretched position of plantar flexion
and inversion.
Eliciting the evertor muscle activity by the first pro-
vocation test of resisted dorsiflexion and eversion
increases pressure within the crural fascia. This
increased pressure can stress the superficial peroneal
nerve if it is compromised in the interface. Passive
plantar flexion and inversion stretch and pull the per-
oneal nerve in the distal direction. If its mobility is
compromised in the mechanical interface, then it
can stress the nerve and thus it forms the basis for
the second provocation test. The third provocation
test is done with the aim of finding the region of dys-
function along the passage of the nerve.
The diagnosis of superficial peroneal nerve entrap-
ment is essentially clinical and the tests suggested by
Styf and Morberg (1997) do not indicate the exact
site of entrapment (i.e. before the fascial/peroneal
tunnel or at the fascial/peroneal tunnel). Correlating
the evaluation with the given clinical picture, suspi-
cion was directed toward the superficial peroneal
Physiotherapy Theory and Practice
Physiotherapy Theory and Practice 555
nerve. Furthermore, the fact that Tinel's sign was
elicited 9.7 cm above the lateral malleoli (Figure 3)
indicated that it could be the approximate interface
and potential site of impairment/dysfunction.
The cause of fascial defect was not suspected as
there was an absence of soft tissue bulge at the site
of tenderness and pain, but could not be entirely
ruled out. Furthermore, the negative history of
trauma ruled out the suspicion of fracture or ankle
sprain as the precipitating cause.
It was speculated that soft tissue dysfunction of the
crural fascia was potentially narrowing the fascial
tunnel, creating an entrapment and adverse neural
tension of the superficial peroneal nerve and causing
mechanical compression to the nerve at or near the
point where the nerve pierces the fascia to travel
within the subcutaneous tissue.
INTERVENTION
Based on the above potential diagnosis, intervention
consisted of soft tissue mobilization, neural mobiliz-
ation, and pain modalities. The patient was seen two
times in a week for three weeks. The treatment
sequence was as given below.
Week 1 (first and second sessions)
The patient was placed in the right-side lying position
with a pillow comfortably placed between the legs.
The left knee was flexed to 35 − 40°. Initially, a hot
pack was administered for 15 min with the aim of
warming up the tissue. Following this, treatment con-
sisted of soft tissue mobilization to the lateral compart-
ment of the leg, especially in the lower one-third in the
form of sweeping cross-fiber, compression broadening
(Figure 4), deep transverse friction, and deep longi-
tudinal stripping (Figure 5) with the aim of reducing
FIGURE 4 Arrow mark indicating the direction of the com-
pression broadening technique, 304 × 203 mm (300 × 300
DPI).
 556 Sudarshan Anandkumar
FIGURE 5 Arrow mark indicating the direction of the deep
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longitudinal stripping technique, 304 × 203 mm (300 × 300
DPI).
the tension in the fascia, increasing its pliability, and
breaking cross-linking bonds of fibrous tissue and ad-
hesions (Cantu and Grodin, 1992; Chamberlain,
1982; Cyriax, 1977; Lowe, 2009; Melham et al,
1998; Schleip, 2003; Stasinopoulos and Johnson,
2004).
The sweeping cross-fiber technique was performed
with a sweeping motion involving flexion of the thumb
toward the palm with the wrist going into ulnar devi-
For personal use only.
ation during the sweep. Strokes were given diagonal
to the fibers being treated with the primary pressure
point being under the thumb. Compression broaden-
ing was done with a perpendicular force applied to the
fibers with the palm of the hand. A broadening action
was then performed as shown in Figure 4. The tech-
nique of deep transverse friction was performed with
both the thumbs applying a transverse force all along
the fibers in the lateral one-third of the leg. The
method of deep longitudinal stripping was performed
in a slow manner with deep pressure from both the
thumbs applied in a longitudinal direction
(Figure 5). Each technique was administered for five
minutes with a break of less than a minute between
the techniques. All the three techniques elicited pain
at the tender spot approximately 9.7 cm above the
lateral malleoli.
Following this, passive neural mobilization in the
form of “sliders” and “tensioners” emphasizing the
peroneal tract was performed. “Sliders” are tech-
niques which involve elongation of the nerve bed at
one joint and simultaneous reduction in the nerve
bed at another joint followed by a reverse combination
(Butler, 2000; Coppieters, Stappaerts, Wouters, and
Janssens, 2003). “Tensioners” are techniques which
involve elongation of the nerve bed (Butler, 2000;
Coppieters, Stappaerts, Wouters, and Janssens,
2003) where the stress is simultaneously applied
both proximally and distally. Sliders result in a larger
excursion of the nerve along with a smaller change
in strain when compared with tensioners (Coppieters
FIGURE 6 Flexion of the knee along with simultaneous dor-
siflexion and eversion of the foot, 304 × 203 mm (300 × 300
DPI).
FIGURE 7 Extension of the knee along with simultaneous
plantar flexion and inversion of the foot, 304 × 203 mm
(300 × 300 DPI).
and Butler, 2008). Both techniques were performed
with the patient in the supine lying position. In the
slider technique, the knee was initially flexed with sim-
ultaneous plantar flexion and inversion of the foot to
slide the peroneal tract. Following this, the knee was
extended with simultaneous dorsiflexion and eversion
of the foot. In the tensioner technique, the knee was
initially flexed with simultaneous dorsiflexion and
eversion of the foot. Following this, the knee was ex-
tended with simultaneous plantar flexion and inver-
sion of the foot with the aim of tensing the peroneal
tract. Both these techniques were administered pas-
sively with 10 repetitions and three sets with a break
of 1 min between each set.
As a home program, the patient was asked to do bi-
cycling for 10 min with the aim of providing general-
ized active neural mobilization to the extremity. In
addition, he was advised to do an active tensioner
and a slider emphasizing the peroneal tract with 10
repetitions and three sets once a day. The technique
of active tensioner (Figures 6 and 7) and slider
(Figures 8 and 9) was the same as passive neural
mobilization described earlier. However, the differ-
ence was that the patient performed them actively
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FIGURE 8 Flexion of the knee along with simultaneous
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plantar flexion and inversion of the foot, 304 × 203 mm
(300 × 300 DPI)
For personal use only.
FIGURE 9 Extension of the knee along with simultaneous
dorsiflexion and eversion of the foot, 304 × 203 mm (300 ×
300 DPI).
FIGURE 10 Graph showing the progression of the VAS
scores, 304 × 203 mm (300 × 300 DPI).
first in the supine lying position and then in the stand-
ing position.
The patient was advised to ice his leg if he felt any
soreness. The minimal clinically important difference
Physiotherapy Theory and Practice
Physiotherapy Theory and Practice 557
FIGURE 11 Graph showing the progression of the LEFS
scores, 304 × 203 mm (300 × 300 DPI).
was obtained in the VAS (Kelly, 2001) (Figure 10)
with a difference of more than 12 mm where it
reduced from 6.3 cm to 4.0 cm at the beginning of
the second session. The minimal detectable change
and minimal clinically important difference were
obtained in the LEFS when the score increased from
59 points to 72 points at the end of the first-week
follow-up (Figure 11).
Week 2 (third and fourth sessions)
Examination revealed the absence of radiating pain
into the foot. However, tenderness of a lesser intensity
was present at the left lateral lower one-third of the leg
around 9.7 cm above the lateral malleoli. Passive
plantar flexion and inversion elicited pain at the
same region. As the patient was starting to feel
better, a line of management that was the same as
that followed in Week 1 was carried out. The VAS
score further dropped to 1.2 cm at the beginning of
the fourth treatment session. The patient obtained
80 points in the LEFS at the end of the second-week
follow-up (Figure 11), indicating 100% maximal
function in the scale (calculated as the LEFS score/
80 × 100).
Week 3 (fifth and sixth sessions)
Examination revealed a notable reduction in tender-
ness. Neural mobilization was administered actively
and passively. The patient was asked to swim and
was also advised to do neural mobilization exercise
in the pool with 10 repetitions and three sets. The
VAS score dropped to 0.4 cm at the beginning of the
 558 Sudarshan Anandkumar
fifth session and the patient was completely pain free
by the sixth session. A review was done once a
week for a month and a follow-up six months after
the review revealed that the patient was completely
pain free.
DISCUSSION
This case report demonstrates the diagnosis and treat-
ment of a patient with potential entrapment of the
superficial peroneal nerve. The SLR test has a sensi-
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tivity of 0.91 (95% CI – 0.82, 0.94) (Deville et al,
2000) and thus a negative result helped in ruling out
a disc herniation. The patient's pain was reproduced
when the sensitizing components of plantar flexion
and inversion tensioning the peroneal tract were
added to the SLR test. The clinical finding during
the examination of persisting pain when the knee
was flexed while maintaining the components of
plantar flexion and inversion indicated that the
source of dysfunction could be either from the fascia
or from the muscle. Furthermore, the presence of
three positive provocation tests (Styf and Morberg,
For personal use only.
1997) made the author hypothesize the possibility of
superficial peroneal nerve entrapment.
Electromyography studies (anterior tibial and pero-
neal muscle group), nerve conduction velocity exam-
ination (Levin, Stevens, and Daube, 1986), and
compartment pressure testing (Styf, 1989) add diag-
nostic value to the presence of this condition.
However, there are case reports (Lowdon, 1985;
Yang, Gala, and McGillicuddy, 2006) where electro-
neurophysiological studies have been non-diagnostic
in the presence of a nerve entrapment. It was
planned that the patient would be sent for an
electro-diagnostic examination if the therapy provided
proved to be ineffective.
Taking into consideration the surgical release pro-
cedures (Kernohan, Levack, and Wilson, 1985;
Lowdon, 1985; McAuliffe, Fiddian, and Browett,
1985; Sevinç, Kalaci, Doğramaci, and Yanat, 2008;
Yang, Gala, and McGillicuddy, 2006), which have
been done to release the entrapment and relieve symp-
toms exhibited by the patient ranging from 8 cm to
11 cm above the lateral malleoli, it was speculated
that the site where Tinel's sign was elicited (9.7 cm
above the lateral malleoli) could possibly be indicative
of an entrapment problem. The exact site of entrap-
ment (either before the fascial tunnel or at the fascial
tunnel) could not be determined due to the limitation
of physical examination and serves as a potential draw-
back of this case report.
The anatomical variations of the superficial pero-
neal nerve, which have been described in the
literature, are another point to be considered (Blair
and Botte, 1994). Variations according to the course
of the nerve are categorized as Type A, Type B, or
Type C. Type A is the most common (72%), where
the superficial peroneal nerve penetrates the crural
fascia approximately 12 cm above the lateral malleoli
and then divides into a medial and intermediate
dorsal cutaneous branch. In Type B (16%), the
medial and intermediate dorsal cutaneous nerves
branch separately from the main trunk in the calf. A
point to be noted is that the intermediate branch
emerges posterior to the fibula and then runs antero-
inferiorly on it, thus making it a potential vulnerable
site for injuries due to its proximity to the bone (as
in a fracture). In Type C (12%), the medial and inter-
mediate dorsal cutaneous nerves branch in the same
way as in Type B with the difference being that the
intermediate branch runs along the anterior border
of the fibula after piercing the fascia just anterior to
the fibula. Furthermore, Lowdon (1985) identified
that a long course of the nerve through the fascia
could be a contributing factor to dysfunction and
pain. Hence, in this patient, it is unknown if the ana-
tomical variations/anatomical anomalies had a poten-
tial role to play in causing his symptoms.
Taking into consideration the above factors, it was
hypothesized that dysfunction and pain could have
resulted from the mechanical compression and
entrapment of the perineurium and individual fasci-
cles (Millesi, Zöch, and Reihsner, 1995; Sebastian,
2010) with the possibility of the surrounding interface
being fibrotic or dysfunctional. Plantar flexion and
inversion stretch the superficial peroneal nerve at the
fascial tunnel (Kernohan, Levack, and Wilson,
1985) and hence repetitive movement could have
possibly caused scarring of the fascia or the nerve.
Some causes for the generation of pain in this
patient could have been due to mechanosensitivity
(attributed to the release of neuropeptides by nervi
nervorum) or the presence of mechanosensitive
abnormal impulse-generating sites (Saur, Bove, Aver-
back, and Reeh, 1999) and neural ischemia due to lack
of mobility in the nerve encouraging adhesions of the
surrounding tissues caused by fibrosis of the perineur-
ium (Chen and Devor, 1998).
The treatment for this patient was purely based on a
working hypothesis. A moist hot pack was initially
placed at the lateral one-third of the leg with the objec-
tive of reducing fascial tension and increasing the elas-
ticity of the superficial connective tissue (Lowe, 2009).
As it was hypothesized that the entrapment site could
be at/before the fascial tunnel, treatment in the form of
soft tissue mobilization using techniques of sweeping
cross-fiber, compression broadening, deep transverse
friction, and deep longitudinal stripping was primarily
Copyright © Informa Healthcare USA, Inc.

directed toward this interface with the aim of improv-
ing pliability in the fascia. Soft tissue mobilization was
done at the site of potential entrapment with the aim
of breaking cross-bonds of adhesions and fibrous
tissue (Cantu and Grodin, 1992; Chamberlain,
1982; Cyriax, 1977; Lowe, 2009; Melham et al,
1998; Schleip, 2003; Stasinopoulos and Johnson,
2004), which was suspected to be between the super-
ficial peroneal nerve and crural fascia.
Neural mobilization exercises in the form of sliders
and tensioners were added following this primarily to
improve the mobility of the nerve with respect to its
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interface in addition to increasing nerve vascularity,
dispersing noxious fluid, reducing adhesions, and
improving axoplasmic flow (Butler, 2000; Butler,
Shacklock, and Slater, 1994; Coppieters, Stappaerts,
Wouters, and Janssens, 2003; Gifford, 1998; Kitter-
ingham, 1996; Rozmaryn et al, 1998; Scrimshaw
and Maher, 2001; Shacklock, 1995; Shacklock,
2005). Sliders were done in this patient with the aim
of improving nerve gliding ability and removing
inflammatory products (Coppieters and Butler,
2008). Tensioners were done from the first session
itself as pain was not acute and was aimed at reducing
For personal use only.
circulatory compromise and intraneural swelling
(Coppieters and Butler, 2008).
Reduction in the patient's pain after the first
treatment session provided an indication that the
source of problem was being addressed. One possible
mechanical reason attributed to the improved positive
outcome with a reduction in pain could have been due
to the reduced tension of the crural fascia, which was
achieved first by soft tissue mobilization over the inter-
face (Sebastian, 2005) where the superficial peroneal
nerve exits (site of entrapment either before the
fascial tunnel or at the fascial tunnel). Once the inter-
face was addressed with soft tissue mobilization, it was
followed by neural mobilization in the form of sliders
and tensioners, which could have improved the
mobility of the nerve with regard to its mechanical
interface (Sebastian, 2005).
CONCLUSION
This case report describes the physical therapy diag-
nosis and management of a patient with superficial
peroneal nerve entrapment of six-month duration.
It is inferred from this case that manual therapy can
be considered as a conservative option before
surgery. More research is needed to compare the
effectiveness of manual therapy with that of surgery
in terms of functional outcomes. Although the
exact cause is unknown in this patient, superficial
peroneal nerve entrapment should be kept in mind
Physiotherapy Theory and Practice
Physiotherapy Theory and Practice 559
for patients presenting with lateral compartment
pain and could be considered as a differential
diagnostic option.
Acknowledgment
The author thanks Dr Deepak Sebastian, PT, MHS,
MTC, DPT, PhD, OCS, FAAOMPT, for his assist-
ance in preparing this manuscript.
Declaration of interest: The author reports no
declarations of interest.
REFERENCES
Al-Qaisi M, Nott DM, King DH, Kaddoura S 2009 Ankle brachial
pressure index (ABPI): An update for practitioners. Journal of
Vascular Health and Risk Management 5: 833–841
American Diabetes Association 2003 Peripheral arterial disease in
people with diabetes. Diabetes Care 26: 3333–3341
Aprile I, Caliandro P, La Torre G, Tonali P, Foschini M, Mondelli
M, Bertolini C, Piazzini DB, Padua L 2005 Multicenter study of
peroneal mononeuropathy: Clinical, neurophysiologic, and
quality of life assessment. Journal of the Peripheral Nervous
System 10: 259–268
Arle JE, Zager EL 2000 Surgical treatment of common entrapment
neuropathies in the upper limbs. Muscle and Nerve 23: 1160–1174
Banerjee T, Koons DD 1981 Superficial peroneal nerve entrap-
ment: Report of two cases. Journal of Neurosurgery 55: 991–992
Bhasin N, Scott DJ 2007 Ankle Brachial Pressure Index: Identifying
cardiovascular risk and improving diagnostic accuracy. Journal
of the Royal Society of Medicine 100: 4–5
Bijur PE, Silver W, Gallagher EJ 2001 Reliability of the visual analog
scale for measurement of acute pain. Academic Emergency
Medicine 8: 1153–1157
Binkley JM, Stratford PW, Lott SA, Riddle DL 1999 The lower
extremity functional scale (LEFS): Scale development, measure-
ment properties, and clinical application. North American
Orthopaedic Rehabilitation Research Network. Physical
Therapy 79: 371–383
Blair JM, Botte MJ 1994 Surgical anatomy of the superficial pero-
neal nerve in the ankle and foot. Clinical Orthopaedics and
Related Research 305: 229–238
Butler DS 2000 The Sensitive Nervous System, Australia, NOI-
group publications
Butler DS, Shacklock MO, Slater H 1994 Treatment of altered
nervous system mechanics. In: Boyling J and Palastanga N (eds)
Grieves Modern Manual Therapy: The Vertebral Column, 2nd
edn. pp 693–703. Edinburgh, UK, Livingston Churchill
Cantu RI, Grodin AJ 1992 Myofascial Manipulation: Theory and
Clinical Application, 2nd edn. Sprinfield, MO, Aspen
Chamberlain GL 1982 Cyriax's friction massage: A review. Journal
of Orthopaedics and Sports Physical Therapy 4: 16–22
Chen Y, Devor M 1998 Ectopic mechanosensitivity in injured
sensory axons arises from the site of spontaneous electrogenesis.
European Journal of Pain 2: 165–178
Cook CE 2007 Orthopedic Manual Therapy – An Evidence Based
Approach. Upper Saddle River, NJ, Pearson Prentice Hall
Coppieters MW, Butler DS 2008 Do “sliders” slide and “ten-
sioners” tension? An analysis of neurodynamic techniques and
considerations regarding their application. Manual Therapy
13: 213–221
 560 Sudarshan Anandkumar
Coppieters MW, Stappaerts KH, Wouters LL, Janssens K 2003
The immediate effects of a cervical lateral glide treatment
technique in patients with neurogenic cervicobrachial pain.
Journal of Orthopaedics and Sports Physical Therapy 33:
369–378
Cyriax J 1977 Deep massage. Physiotherapy 63: 60–61
Deville W, van der Windt D, Dzaferagic A, Bezemer P, Bouter L
2000 The test of Laségue. Systematic review of the accuracy in
diagnosing herniated discs. Spine 25: 1140–1147
Garfin S, Mubarak SJ, Owen CA 1977 Exertional anterolateral-
compartment syndrome: Case report with fascial defect,
muscle herniation, and superficial peroneal-nerve entrapment.
Journal of Bone and Joint Surgery 59: 404–405
Gifford L 1998 Neurodynamics In: Pitt – Brooke J, Reid H, Lock-
Physiother Theory Pract Downloaded from informahealthcare.com by University of Connecticut on 10/11/14
wood J, Kerr K (eds) Rehabilitation of Movement, pp 159–195.
London, U, WB Saunders Company Ltd
Henry AK 1945 Extensile Exposure, p 163. Edinburgh and
London, E & S Livingstone
Kelly AM 2001 The minimum clinically significant difference in
visual analogue scale pain score does not differ with severity of
pain. Emergency Medicine Journal 18: 205–207
Kernohan J, Levack B, Wilson JN 1985 Entrapment of the super-
ficial peroneal nerve: Three case reports. Journal of Bone and
Joint Surgery 67: 60–61
Kitteringham C 1996 The effect of straight leg raise exercises after
lumbar decompression surgery – A pilot study. Physiotherapy
82: 115–123
Kopell HP, Thompson WA 1963 Entrapment Neuropathies. Balti-
For personal use only.
more, Williams and Wilkins
Kurtoğlu M, Dolay K, Karamustafaoğlu B, Yanar H, Kuzkaya M
2009 The role of the ankle brachial pressure index in the diagno-
sis of peripheral arterial injury. Ulus Travma Acil Cerrahi Derg
15: 448–452
Levin KH, Stevens JC, Daube JR 1986 Superficial peroneal nerve
conduction studies for electromyographic diagnosis. Muscle
and Nerve 9: 322–326
Lindenbaum BL 1979 Ski boot compression syndrome. Clinical
Orthopaedics and Related Research 140: 109–110
Lowdon IM 1985 Superficial peroneal nerve entrapment. A case
report. Journal of Bone and Joint Surgery 67: 58–59
Lowe WW 2009 Orthopedic Massage-Theory and Technique, 2nd
edn. pp 43–62. Missouri, Mosby-Elsevier
Mackey D, Colbert DS, Chater EH 1977 Musculo-cutaneous
nerve entrapment. Irish Journal of Medicine Sciences 146:
100–102
McAuliffe TB, Fiddian NJ, Browett JP 1985 Entrapment neuropa-
thy of the superficial peroneal nerve. A bilateral case. Journal of
Bone and Joint Surgery 67: 62–66
Melham TJ, Sevier TL, Malnofski MJ, Wilson JK, Helfst RH Jr
1998 Chronic ankle pain and fibrosis successfully treated with
a new noninvasive augmented soft tissue mobilization technique
(ASTM): A case report. Medicine and Science in Sports and
Exercise 30: 801–804
Menhz HB, Tiedemann A, Kwan MM, Latt MD, Sherrington C,
Lord SR 2003 Reliability of clinical tests of foot and ankle
characteristics in older people. Journal of the American Podiatric
Medical Association 93: 380–387
Millesi H, Zöch G, Reihsner R 1995 Mechanical properties of per-
ipheral nerves. Clinical Orthopaedics and Related Research 314:
76–83
Mino DE, Hughes EC Jr 1984 Bony entrapment of the superficial
peroneal nerve. Clinical Orthopaedics and Related Research
185: 203–206
Pecina M, Krmpotic-Nemanic J, Markiewitz AD 2001 Tunnel Syn-
dromes – Peripheral Nerve Compression Syndromes, 3rd edn.
pp 245–247. Florida, CRC Press
Price DD, McGrath PA, Rafii A, Buckingham B 1983 The vali-
dation of visual analogue scales as ratio scale measures for
chronic and experimental pain. Pain 17: 45–56
Rozmaryn LM, Dovelle S, Rothman ER, Gorman K, Olvey KM,
Bartko JJ 1998 Nerve and tendon gliding exercises and the con-
servative management of carpal tunnel syndrome. Journal of
Hand Therapy 11: 171–179
Rubin M, Menche D, Pitman M 1991 Entrapment of an accessory
superficial peroneal sensory nerve. Canadian Journal of Neuro-
logical Sciences 18: 342–343
Saur SK, Bove GM, Averback B, Reeh PW 1999 Rat peripheral
nerve components release calcitonin generelated peptide and
prostaglandin E2 in response to noxious stimuli: Evidence that
nervi nervorum are nociceptors. Neuroscience 92: 319–325
Schleip R 2003 Fascial plasticity – A new neurobiological expla-
nation. Journal of Bodywork and Movement Therapies 7: 11–19.
Scrimshaw S, Maher C 2001 Randomized controlled trial of neural
mobilization after spinal surgery. Spine 26: 2647–2652
Sebastian D 2010 Triangular interval syndrome: A differential diag-
nosis for upper extremity radicular pain. Physiotherapy: Theory
and Practice 26: 113–119
Sebastian D 2005 Effects of neural interface mobilization on periph-
eral nerve mobility and pain – A single case design. Journal of
Manual and Manipulative Therapy 13: 185
Sevinç TT, Kalaci A, Doğramaci Y, Yanat AN 2008 Bilateral super-
ficial peroneal nerve entrapment secondary to anorexia nervosa:
A case report. Journal of Brachial Plexus and Peripheral Nerve
Injury 3: 12
Shacklock MO 1995 Neurodynamics. Physiotherapy 81: 9–16
Shacklock MO 2005 Clinical Neurodynamics: A New System of
Neuromusculoskeletal treatment. Oxford, UK, Butterworth
Heinemann
Sobel E, Levitz SJ, Caselli MA, Tran M, Lepore F, Lilja E, Sinaie
M, Wain E 1999 Reevaluation of the relaxed calcaneal stance
position. Reliability and normal values in children and adults.
Journal of the American Podiatric Medical Association 89:
258–264
Sridhara CR, Izzo KL 1985 Terminal sensory branches of the super-
ficial peroneal nerve: An entrapment syndrome. Archives of
Physical Medicine and Rehabilitation 66: 789–791
Stasinopoulos D, Johnson MI 2004 Cyriax physiotherapy for tennis
elbow/lateral epicondylitis. British Journal of Sports Medicine
38: 675–677
Styf JR 1989 Entrapment of the superficial peroneal nerve. Diagno-
sis and results of decompression. Journal of Bone and Joint
Surgery 71: 131–135
Styf JR, Körner LM 1986 Chronic compartment syndrome of the
leg. Journal of Bone and Joint Surgery 68: 1338–1347
Styf JR, Morberg P 1997 The superficial peroneal tunnel syndrome.
Results of treatment by decompression. Journal of Bone and
Joint Surgery 79: 801–803
Yang LJ, Gala VC, McGillicuddy JE 2006 Superficial peroneal
nerve syndrome: An unusual nerve entrapment. Journal of
Neurosurgery 104: 820–823
Copyright © Informa Healthcare USA, Inc.
 Physiotherapy Theory and Practice 561

APPENDIX 1. Lower extremity functional scale.

Unable to perform activity Quite a bit of Moderate A little bit of No

Activities or extreme difficulty difficulty difficulty difficulty difficulty

Any of your usual work 0 1 2 3 4

housework or school activities
Your usual hobbies recreational 0 1 2 3 4
or sporting activities
Getting into or out of the bath 0 1 2 3 4
Walking between rooms 0 1 2 3 4
Putting on your shoes or socks 0 1 2 3 4
Squatting 0 1 2 3 4
Physiother Theory Pract Downloaded from informahealthcare.com by University of Connecticut on 10/11/14

Lifting an object, like a bag of 0 1 2 3 4

groceries from the floor
Performing light activities around 0 1 2 3 4
your home
Performing heavy activities 0 1 2 3 4
around your home
Getting into or out of a car 0 1 2 3 4
Walking 2 blocks (about 1/6th 0 1 2 3 4
mile or about 250 m)
Walking 1 mile (1.6 km) 0 1 2 3 4
Going up or down 10 steps (about 0 1 2 3 4
1 flight of stairs)
Standing for 1 h 0 1 2 3 4
Sitting for 1 h 0 1 2 3 4
For personal use only.

Running on even ground 0 1 2 3 4

Running on uneven ground 0 1 2 3 4
Making sharp turns while running 0 1 2 3 4
fast
Hopping 0 1 2 3 4
Rolling over in bed 0 1 2 3 4

APPENDIX 2. Values of the ABPI for the diagnostic criteria of

peripheral vascular disease.

Normal 0.91–1.30

Mild obstruction/disease 0.70–0.90

Moderate obstruction/disease 0.40–0.69
Severe obstruction/disease <0.40
Poorly compressible >1.30

Physiotherapy Theory and Practice