Sport Sci Health (2005) 1:61–67

DOI 10.1007/s11332-2005-004-0012-5

REVIEW

G. Cavaletti • P. Marmiroli • G. Alberti • G. Michielon • G. Tredici

Sport-related peripheral nerve injuries: part 2

Received: 31 August 2004 / Accepted: 3 March 2005

Abstract Injury in the lower limbs is extremely frequent in

most sport activities, particularly when prolonged running
and physical contact are prominent features. A major chal-
lenge is the differential diagnosis between muscle, joint and
nerve lesions, although it should always be considered that
combined lesions are quite frequent. In this part of the re-
view, the most frequent nerve entrapment and traumatic le-
sions involving the peripheral nerves in the lower limb are
discussed.
Key words Peripheral nerve injury • Mononeuropathy
Sport activity • Entrapment
Introduction
In sports medicine, peripheral nerve injuries in the lower
limbs are not uncommon. They are frequently the basis of
chronic pain (particularly in the hip, groin, ankle and foot) and
in most cases distinction between nerve-related symptoms and
other pain syndromes is difficult. In fact, all these regions
have a rather complicated anatomy and in several cases symp-
toms have a combined origin. For example, fascial pathologies
can occur with onset of a “compartmental syndrome”, leading
•
to nerve compression; chronic ligament or joint inflammation
can modify the inner structure of canals crossed by peripher-
al nerves, thus creating conditions for entrapment.
In the following sections, the features of the most com-
mon sport-related nerve injuries, which involve peripheral
nerves arising from the lumbar, sacral and pudendus plexus
are discussed in detail. The most relevant clinical features in-
volving the radicular muscle innervation, the main nerve
trunks and the reflexes are summarized in Tables 1 and 2.

Table 1 Nerve and spinal root innervation of the most commonly

tested muscles in the lower limb

Nerve innervation Spine roots Muscle

Femoral nerve L2-L4 Quadriceps

Obturator nerve L2-L4 Adductor longus
Superior gluteal nerve L4-S1 Gluteus medius
Gluteus minimus
Inferior gluteal nerve L5-S2 Gluteus maximus
Sciatic nerve L5-S2 Hamstrings
G. Cavaletti • P. Marmiroli • G. Tredici () Tibial nerve S1-S2 Gastrocnemius
Department of Neurosciences and Biomedical Technology L4, L5 Tibialis posterior
University of Milan Bicocca L5-S2 Flexor digitorum longus
Via Cadore 48, I-20048 Monza (MI), Italy S1, S2 Flexor hallucis longus
Common peroneal nerve L4, L5 Tibialis anterior
L5, S1 Extensor hallucis longus
G. Alberti • G. Michielon Superficial peroneal nerve L5, S1 Peroneus longus
Institute of Physical Exercise, Health and Sporting Activities Peroneus brevis
University of Milan, Italy
62 G. Cavaletti et al.: Sport-related peripheral nerve injuries: part 2

Table 2 Relationship between reflexes, radicular distribution and muscular innervation in the lower limb

Reflexes Site and mode of elicitation Response Muscles Peripheral nerves Spine roots

Adductor reflex Tap on the medial condyle Adduction of leg Adductors of thigh Obturator L2-L4
of femur
Knee jerk Tap on tendon of quadriceps Extension at knee Quadriceps femori Femoral (L2), L3, L4
femoris below patella
Gluteal reflex Stroking skin over Tightening Gluteus medius and Superior and L4-S1
gluteal region of buttock gluteus maximus inferior gluteal
Posterior tibial reflex Tap on tendon of tibialis Supination of foot Tibialis posterior Tibial L5
posterior behind medial malleolus
Semimembranous Tap on medial hamstring tendons Contraction of Semimembranous and Sciatic S1
and semitendinous (patient prone and knee semimembranous semitendinous
reflexes slightly flexed) and semitendinous
Biceps femori reflex Tap on lateral hamstring tendons Contraction of Biceps femoris Sciatic S1, S2
(patient prone and knee biceps femoris
slightly flexed)
Ankle jerk Tap on tendo calcaneous Plantar flexion of foot Triceps surae Tibial S1, S2
(and other flexors
of foot)

plexus. The proximal course of the ilioinguinal nerve is sim-

Iliohypogastric nerve
The iliohypogastric nerve originates from fibers from T12
and L1 spinal roots. The nerves passes through the psoas
muscles, then curves downward passing behind the lower
pole of the kidney and across the quadratus lumborum mus-
cle. Approximatively halfway between the anterior superior
iliac spine and the highest point of the iliac crest, the iliohy-
pogastric nerve pierces the abdominal wall, giving off mus-
cular branches for its muscles and then continues its course
following the line of the iliac crest until it ends with a later-
al and an anterior cutaneous branch in the proximity of the
anterior superior iliac spine. At their terminal sites, the nerve
branches innervate the skin of the upper buttock and of a
small area over the pubis, respectively.
Sport-related injuries of this nerve are rather uncommon,
but when they occur the nature is nearly always secondary to
direct trauma during collision sports [1]. The major symp-
tom is pain, but objective sensory loss can also be observed.
It is still unclear whether iliohypogastric nerve injury can oc-
cur in “footballers’ hernia”, a lower abdominal bulging, but
this possibility should always be considered and ruled out
before surgical herniorrhaphy.
ilar to that described for the iliohypogastric nerve. Close to
the anterior superior iliac spine, tiny muscular branches in-
nervate the lowermost part of the transversalis and internal
oblique muscles, while a sensory branch innervates the skin
over the iliac crest. The main trunk of the nerve enters the
inguinal canal and innervates the skin over the exit hole of
the canal and part of the external genitals.
Entrapment has been reported while the nerve crosses the
abdominal wall, leading to a clinical triad of pain in the in-
guinal region radiating to the genitals, sensory abnormalities
and tenderness on palpation 2-3 cm medial to and below the
anterior superior iliac spine [1]. A tear of the external
oblique aponeurosis (“slap-shot hernia”) has been described
in hockey players [2], and ilioinguinal nerve compression
can occur. A simple provocative test is represented by the on-
set of symptoms during ipsilateral hip extension and con-
tralateral torso rotation, mimicking the athletes’ action dur-
ing shooting [3].
Lateral femoral cutaneous nerve

Ilioinguinal nerve
The ilioinguinal nerve receives fibers from L1-L2 spinal
roots and arises from the uppermost part of the lumbar
This pure sensory nerve arises from the lumbar plexus, re-
ceiving fibers from L2-L3 spinal roots. It runs retroperi-
toneally along the inner wall of the pelvis, in the direction of
the anterior superior iliac spine, and emerges under the lat-
eral end of the inguinal ligament through a small tunnel
formed by a split in the lateral attachment of the inguinal lig-
ament to the anterior superior iliac spine. Once it reaches the
G. Cavaletti et al.: Sport-related peripheral nerve injuries: part 2
proximal anterior aspect of the thigh, it crosses the sartorius
muscle and pierces the fascia lata to become superficial and
innervate the skin of the anterolateral aspect of the thigh.
Symptoms of lateral femoral cutaneous nerve injury
(meralgia paresthetica) are exclusively represented by pain
and sensory impairment over the anterior aspect of the thigh,
exacerbated by the squatting position.
Compression and entrapment of the nerve can occur in
the inguinal ligament tunnel, particularly in contact sports,
women’s gymnastics (secondary to repeated trauma of un-
even bar work) and scuba divers (due to direct trauma by the
weight belt) [4, 5]. Rarely, meralgia paresthetica has been
described in soccer players, secondary to upper thigh trau-
ma [6].
Obturator nerve
The obturator nerve, one of the two main terminal trunks of
the lumbar plexus, receives fibers from L2-L4 spinal roots
and emerges from the medial border of the psoas muscle
passing into the lesser pelvis. It goes into a fibro-osseus tun-
nel (obturator tunnel) located under the pubic ramus; within
this tunnel it divides into two main branches (anterior and
posterior), as well a branch directed to the obturator exter-
nus muscle. The anterior motor branch innervates the ad-
ductor longus, brevis and gracilis muscles (occasionally al-
so the pectineus muscle), while the sensory fibers are di-
rected to the skin and fascia of the distal two-thirds of the
medial thigh. The motor posterior branch supplies the ad-
ductor magnus and obturator externus muscles, while the
sensory fibers innervate the articular capsule, cruciate liga-
ments and synovial membrane of the knee joint.
Obturator nerve injury can lead to motor impairment in-
volving the adductor muscles and sensory impairment, gen-
erally associated with pain, in the medial aspect of the thigh.
The course of the obturator nerve exposes it to possible
damage in the pelvis as well as within the obturator tunnel.
During sport activities obturator injury is rare, with the ex-
clusion of direct trauma from pelvic fractures [1, 7].
Obturator tunnel syndrome has been described secondary to
inflammatory changes in the course of osteitis pubis [1],
while entrapment can be due to the presence of a fascial
band compressing the nerve at the distal exit of the canal [8].
Femoral and saphenous nerves
The femoral nerve, the other terminal trunk of the lumbar
plexus, is formed, like the obturator nerve, by fibers arising
from L2-L4 spinal roots. It emerges from the lateral aspect
of the psoas muscle, passes under the iliac fascia and de-
scends along the iliac muscle passing under the inguinal lig-
63
ament, lateral to the femoral artery in the lacuna musculo-
rum. At the level of Scarpa’s (femoral) triangle, in the ante-
rior aspect of the upper thigh, it provides two branches: one,
the motor ramus, is devoted to the innervation of the quadri-
ceps, sartorius and pectineus muscles; the other, the sensory
ramus, innervates the skin of the anterior thigh. The main
trunk of the nerve, which is now exclusively sensory (saphe-
nous nerve), continues along the medial border of the sarto-
rius muscle, then enters the subsartorial canal (also know as
the adductor canal) of Hunter, together with the femoral
artery and vein. The canal is formed by the vastus medialis
(lateral wall) and adductor longus (medial wall) muscles, by
the vastoadductor membrane (floor) and it is covered by the
sartorius muscle. The saphenous nerve emerges from the
canal by piercing the fascial layer about 10 cm above the
knee. It gives off the infrapatellar branch that supplies the
skin over the knee, while the remainder of the nerve de-
scends along the medial side of the tibia to end on the me-
dial side of the foot together with the greater saphenous vein.
The femoral nerve can be injured in the abdomen or
along its course in the lower limb. In sports medicine the
most common lesion affecting the femoral nerve is sec-
ondary to psoas bursitis or strain of the iliopsoas, with asso-
ciated hematoma and muscular swelling leading to nerve
trunk compression [1]. Hyperextension of the hip with acute
femoral nerve injury has been reported in gymnasts, football
and basketball players and long jumpers [7].
The clinical presentation of femoral nerve injury in-
cludes pain in the inguinal region, weakness of the quadri-
ceps, sartorius and pectineus muscles, and reduced or absent
knee jerk. Sensory impairment is much rarer than motor
signs.
The saphenous nerve may be injured in the adductor
canal, as a consequence of inflammatory conditions (such as
thrombophlebitis) or, in the distal portion of the canal, which
is close to the knee joint, by bursitis. Damage during arthro-
scopic examination has also been reported as an infrequent
complication of the procedure. Saphenous nerve injury can
occur as a consequence of repetitive knee flexion in cycling
and rowing and of muscular hypertrophy in weight-lifters
and bodybuilders [7].
The clinical presentation of a saphenous injury is typi-
cally exercise-related, poorly localized medial leg or knee
pain, which can be misdiagnosed as popliteal artery entrap-
ment. Positive Tinel’s sign is useful in the differential diag-
nosis, particularly in cases without an overt sensory impair-
ment along the course of the nerve.
Superior and inferior gluteal nerves
These two motor nerves arise from the sacral plexus and
pass through the sciatic notch into the deep gluteal region
along with the sciatic nerve, pudendal nerve and posterior
64
cutaneous nerve of the thigh. The superior nerve receives
fibers from L4-S1 spinal roots, passes above the piriformis
muscle and enters the deep gluteal region to innervate the
gluteus medius, gluteus minimus and tensor fascia lata mus-
cles. The inferior nerve receives fibers from L5-S2 ventral
roots, passes below the piriformis muscle and innervates the
gluteus maximus muscle.
Hypertrophy of the piriformis muscle can lead to com-
pression of each of the two nerves [1].
Sciatic nerve
The sciatic nerve is the major nerve arising from the sacral
plexus, originating from L4-S3 spinal roots. The trunk of the
nerve runs in the pelvis and then exits through the sciatic
notch below the piriformis muscles (although in rare cases it
can pass over or even through the muscle). Within the deep
gluteal region, the nerve passes between the ischial tuberos-
ity and the greater trochanter of the femur, lying close to the
posterior aspect of the capsule of the hip joint, just under-
neath the gluteus maximus muscle. The sciatic nerve trunk,
where the fibers which will form its terminal branches (i.e.
the common peroneal and tibial nerves) already run in sep-
arate fascicles, passes distally in the thigh to the upper side
of the popliteal fossa, where it terminates. The sciatic nerve
innervates the hamstring muscles of the thigh.
Trauma to the sciatic nerve commonly occurs in contact
sports secondary to a fall on the buttocks compressing the
nerve against the hip capsule [1]. Other rare compression in-
juries have been reported, such as that of vascular origin, just
below the inferior margin of the piriformis muscle, due to
abnormal collateral vessels originating from the inferior
gluteal artery [9]. A particular form of entrapment can occur
also at the level of the ischial tuberosity at the site of at-
tachment of the biceps femoris muscle by either a fibrous
aponeurotic band or a fibrous edge to that muscle.
Dislocated hip can be the cause of severe sciatic nerve lesion
with a sudden onset after injury [10].
Symptoms of sciatic nerve injury include buttock pain
radiating down the extremity, associated with paresthesia.
Weakness can occur in hamstring muscles, as well as in the
distal leg muscles, which are innervated by sciatic nerve ter-
minal branches.
Piriformis syndrome is a poorly defined clinical entity
[11], but it usually describes aching or cramping pain in the
buttock or hamstring, with exacerbation of the symptoms by
hip flexion movements combined with active hip external ro-
tation or passive internal hip rotation. Local muscle spasm is
usually present in the obturator internus or piriformis mus-
cle. The rest of the neurological examination is generally
normal. In view of the few clinical data, several types of in-
strumental examinations have been proposed to clarify the
occurrence of piriformis syndrome. However, the EMG ex-
G. Cavaletti et al.: Sport-related peripheral nerve injuries: part 2
amination is usually normal, while in some cases the only
pathological results can be obtained in the NSC using long
latency evoked potentials (F and H waves), which can be
normal at rest and delayed during the maneuvers which elic-
it the onset of symptoms.
Common peroneal nerve
The lateral terminal branch of the sciatic nerve is the com-
mon peroneal nerve, which originates from L4-S2 spinal
roots. It generally originates at the proximal site of the
popliteal fossa, then descends downward and laterally
through the fossa in contact with the biceps femoris muscle
and tendon, passes behind the head of the fibula and winds
obliquely around its neck, passes below the tendineous origin
of the peroneus longus muscle and enters the peroneal tunnel
between the two heads of this muscle. Proximal to the fibu-
lar head, the lateral sural cutaneous nerve branch origins from
the main nerve trunk. As the common peroneal nerve enters
the peroneal tunnel, it divides into the deep and superficial
peroneal nerves, which are both in close contact with the pe-
riostium of the fibula and are covered at this point by the
tendineous origin of the peroneus longus. The superficial per-
oneal nerve runs between the fibula and the peroneus longus
muscle and courses lying on the anterior intermuscular sep-
tum, innervating both peroneal muscles. At the distal third of
the leg, the nerve pierces the crural fascia and splits into two
cutaneous branches which innervate the anterolateral aspect
of the leg, the dorsum of the foot and the dorsal aspect of the
great, second, third and fourth (medial side) toes. The deep
peroneal nerve pierces the anterior intermuscular septum and
travels with the anterior tibial blood vessels between the tib-
ialis anterior muscle and either the extensor digitorum longus
proximally or extensor hallucis longus muscles distally, in-
nervating all these muscles and the extensor digitorum bre-
vis. The nerve enters the foot under the cruciform ligament
and supplies the skin between the great and first toes.
Injury to the main trunk of the common peroneal nerve
at the peroneal tunnel is common, frequently secondary to
external compression or direct trauma [1, 5, 7]. Functional
anatomical changes such as repetitive exercise involving
flexion and extension of the knee (e.g. in runners, cyclists)
stretch the common peroneal nerve against the fibrous arch
of the peroneal tunnel. Traction injuries, although less com-
mon, are usually severe: they can occur with adduction in-
juries of the knee, relatively common in contact sports.
Plantar flexion or ankle inversion tense the peroneus longus
muscle; compression of both the deep and superficial per-
oneal nerves against the fibular head can occur. The com-
mon peroneal nerve, as well as its two main terminal branch-
es, can be damaged in anterior and lateral compartmental
syndromes in the leg, particularly in runners: in these cases
palpation of the muscles after exercise can be helpful in
G. Cavaletti et al.: Sport-related peripheral nerve injuries: part 2
diagnosis. Anterior compartmental syndrome can be mimic-
ked in skiers, where the deep peroneal nerve is compressed
at the ankle by improperly fitted ski boots. The deep per-
oneal nerve may be also compressed by the crural fascia or
where the terminal branches cross the anterior aspect of the
ankle joint subcutaneously, for instance by inadequate or ex-
cessively high shoes.
Common peroneal nerve syndrome
In common peroneal syndrome, the most common clinical
presentation is represented by exercise-induced leg pain and
numbness. Pain originates in the site of compression and
subsequently spreads along the sensory distribution of the
nerve, resembling in most cases an anterior compartmental
syndrome, with exacerbation of the symptoms occurring
during forced inversion of the ankle. Clinical examination
usually evidences muscle weakness (particularly in ankle
dorsiflexion and inversion), hypoesthesia and positive Tinel’s
sign at the level of the fibular neck. Foot drop is typically
seen only in long lasting and severe cases.
Superficial peroneal nerve syndrome
Clinical signs include cramping pain and hypoesthesia over
the lateral calf or dorsum of the foot, exacerbated by resist-
ed ankle dorsiflexion and eversion. This syndrome has been
reported in runners, soccer players, jockeys, tennis players
and bodybuilders [1, 7].
Deep peroneal nerve syndrome
Symptoms are generally those of an anterior compartmental
syndrome, due to compression of the nerve secondary to ex-
ercise-induced muscular hypertrophy in subjects with in-
elastic compartmental fascia which leads to nerve ischemia.
It is more frequent in runners and in all those sport activities
where long-lasting running is common. The typical clinical
presentation is with exercise-induced aching or cramping
pain and hypoesthesia, which last much longer than exercise
withdrawal. Time from beginning of exercise and symptoms
onset is variable with the individuals.
Tibial nerve
This nerve origins from L5-S3 spinal roots and represents
the medial terminal trunk of the sciatic nerve at the
65
popliteal fossa, where it continues distally deep to the gas-
trocnemius muscle. In the calf, it innervates the gastrocne-
mius, soleus, tibialis posterior, flexor digitorum longus and
flexor hallucis longus muscles. About at mid-leg, the tibial
nerve becomes superficial and passes medially to the
Achilles tendon; it runs down along the posteromedial as-
pect of the tibia and then underneath the flexor or medial
retinaculum of the ankle joint, which forms the roof of the
tarsal tunnel, while the medial border is represented by the
talus and calcaneus bones. At this level the nerve divides
into the medial and lateral plantar nerves and into the me-
dial calcaneal branch that supplies sensation to the medial
aspect of the heel. The tibial nerve and its branches pass in
distinct fascial tunnels separate from the other contents of
the tarsal tunnel, including the posterior tibial vessels and
the tendons of the tibialis posterior, flexor digitorum
longus and flexor hallucis longus. Compression of the
neural structures at this site is known as tarsal tunnel syn-
drome [12]. The medial plantar nerve reaches the sole of
the foot by passing under the origin of the abductor hallu-
cis muscle and through a fibro-osseus space formed by the
attachment of the flexor hallucis brevis to the calcaneus.
The lateral plantar nerve passes separately under the ab-
ductor hallucis and then passes between flexor digitorum
brevis and quadratus plantae. Both plantar nerves end by
forming the interdigital nerves and innervate all of the in-
trinsic foot muscles.
Injury or entrapment of the tibial nerve in the leg is rare,
although compression by space-occupying lesions can occur
in the popliteal fossa. Entrapment of the distal branches is,
on the contrary, rather common, particularly at the tarsal tun-
nel level (see below). The branches of the tibial nerve can be
entrapped also distally to the tarsal tunnel exit. The medial
plantar nerve is most frequently injured where it passes un-
der the fibrous arch of the abductor hallucis origin and
through the fibro-osseous space formed by the attachment of
the flexor hallucis brevis to the calcaneus. The first sensory
branch of the lateral plantar nerve may be entrapped between
the muscular layers or when it passes in close relation to the
plantar fascial attachment to the calcaneus, causing persis-
tent heel pain.
The interdigital nerves, which originate from both the
medial and lateral plantar nerves, can be damaged by com-
pression (particularly in runners) against the transverse
metatarsal ligament caused by repeated dorsiflexion of the
toes. This clinical condition (known also as Morton’s neuro-
ma) induces foot pain radiated to the toes, numbness and hy-
poesthesia in the toes; pain can be evoked by palpation over
the affected site of the plantar aspect of the foot. Joplin’s
neuritis occurs when the medial plantar proper digital nerve
is compressed at the first metatarsophalangeal joint or on the
medial aspect of the great toe. A common cause is the use of
inadequate sport shoes and the typical complaint is pain and
paresthesia over the medial aspect of the great toe when
walking.
66
Tarsal tunnel syndrome
Damage to the tibial nerve at the tarsal tunnel induces a typ-
ical syndrome characterized by burning, sharp pain and
paresthesia that radiate into the sole of the foot toward the
toes. The symptoms are generally intermittent and are ac-
centuated by prolonged standing, walking or running. The
clinical examination is often poorly informative, although a
positive Tinel’s sign or reduced sensation over the foot sole
can be found. Forcing the heel into valgus position can evoke
the onset of the typical pain. NCS can be helpful in sup-
porting a diagnostic suspect.
Tarsal tunnel syndrome is particularly frequent in runners
[12], but it has also been described in mountain climbers and
basketball, soccer and football players [1, 5]. It is believed
that the cause of tarsal tunnel syndrome is in most cases re-
peated ankle hyperextension and hyperflexion motions or re-
current ankle sprains, which cause tenosynovitis of the ten-
dons running into the tunnel or its fibrosis. In both cases re-
duction of the tunnel cross-sectional area occurs, leading to
compression of neural structures. In some cases, a difficult
clinical challenge may be represented by the differential di-
agnosis between tarsal tunnel syndrome and plantar fascitis.
In both cases, pain starts insidiously and then becomes sharp
and activity-related. Generally, in tarsal tunnel syndrome pain
is associated with numbness or tingling sensation at the me-
dial malleolus and sole of the foot, while in plantar fascitis
the origin of pain is most commonly located over the calca-
neus. In plantar fascitis, Tinel’s sign and sensory impairment
are not observed, but it should be remembered that these clin-
ical signs can also be absent in tarsal tunnel syndrome. NCS
is normal in plantar fascitis. Achilles tendonitis should also
be considered, although in this case pain is generally local-
ized more proximally in the leg.
Sural nerve
The sural nerve generally originates from two main branch-
es, the medial cutaneous sural nerve (from the tibial nerve)
and the lateral cutaneous sural nerve (from the common per-
oneal nerve). The two trunks join at a variable position in the
calf or in the popliteal fossa and then the sural nerve runs be-
tween the two heads of the gastrocnemius muscle beneath
the crural fascia. At the distal third of the calf, the nerve
pierces the fascia and join the lesser saphenous vein lateral-
ly to the Achilles tendon, then it passes behind the lateral
malleolus to supply the ankle joint, the posterior calf and the
lateral side of the heel and foot.
The sural nerve can be compressed in its distal course,
particularly by tight ski boots, while the crural fascia can act
as a compression or a fixation point for the nerve, so that
athletic activities such as running may stretch the nerve at
this level. Repetitive ankle inversion injuries may also lead
to fibrosis and nerve entrapment. Sural nerve entrapment
G. Cavaletti et al.: Sport-related peripheral nerve injuries: part 2
can be an underdiagnosed cause of chronic calf and ankle
pain, and it has been reported particularly in runners, soccer
and tennis players [13].
Posterior cutaneous nerve of the thigh
The posterior cutaneous nerve of the thigh arises from S1-
S3 spinal roots, passes through the sciatic notch below the
piriformis muscle and medially to the sciatic nerve, then
runs superficially over the back of the thigh to the knee. It
provides the cutaneous innervation to the skin over the low-
er buttock and posterior thigh, while its perineal branches in-
nervate the skin of the perineum and genitals.
Prolonged bicycle riding may induce compression in the
intrapelvic course, while prolonged sitting may also cause
entrapment of the nerve to the distal edge of gluteus max-
imus muscle. Numbness and tingling paresthesia within the
territory of cutaneous innervation are the most common
symptoms [1, 7].
Pudendal nerve
This is the main perineal nerve, arising from S2-S4 spinal
roots. It passes through the sciatic notch and runs deep to the
sacrospinous ligament into the perineal region. Its first
branch is the inferior rectal (or hemorrhoidal) nerve, which
innervates the external anal sphincter and contains sensory
fibers from the lower anal canal and perineal skin. The sec-
ond branch (perineal nerve) supplies the perineal muscles,
the erectile tissue of the penis, the external urethral sphincter
and the skin of the perineum and genitalia. The final branch
of the nerve is the dorsal nerve of the penis or clitoris. The
most common compression injury has been described in cy-
clists, where prolonged riding may result in sensory loss or
even impotence in males, in the most severe cases [1].
Conclusions
Sport-related nerve entrapment syndromes in both upper and
lower limbs can be the cause of acute and chronic discom-
fort, frequently associated with motor impairment. The
symptoms of many of these syndromes (in our review we
have considered only the most frequently reported) are ac-
tivity-related. Appropriate clinical assessment and diagnos-
tic tests can allow an accurate diagnosis, provided that the
clinician maintains a high suspicion level toward this possi-
bility. The issue of nerve injury management is beyond the
scope of this review, but it is clear that once a neural syn-
drome has been clearly recognized, an appropriate and early
treatment should always be started, using a step-by-step
G. Cavaletti et al.: Sport-related peripheral nerve injuries: part 2
strategy ranging from rest, use of splints, anti-inflammatory
medications, training and technical equipment modification,
reaching in the most severe cases also surgical exploration
and intervention.
References
1. McCrory P, Bell S (1999) Nerve entrapment syndromes as a
cause of pain in hip, groin and buttock. Sports Med 27:261-
274
2. Lacroix VJ (2000) A complete approach to groin pain. Phys
Sportsmed 28:66-86
3. LeBlanc KE, LeBlanc KA (2003) Groin pain in athletes.
Hernia 7:68-71
4. McGregor J, Moncur J (1977) Meralgia paresthetica: a sport
lesion in girl gymnast. Br J Sports Med 11:16-17
5. Lorei MP, Hershman EB (1993) Peripheral nerve injuries in
athletes. Sports Med 16:130-147
67
6. Ulkar B, Yildiz Y, Kunduracioglu B (2003) Meralgia pares-
thetica: a long-standing performance-limiting cause of ante-
rior thigh pain in a soccer player. Am J Sports Med 31:787-
789
7. McCrory P, Bell S, Bradshaw C (2002) Nerve entrapments of
the lower leg, ankle and foot in sports. Sports Med 32:371-
391
8. Bradshaw C, McCrory P (1997) Obturartory nerve entrap-
ment. Clin J Sports Med 7:217-219
9. Merlo IM, Poloni TE, Alfonsi E, Messina AL, Ceroni M
(1997) Sciatic pain in a young sportsman. Lancet 349:846
10. Stewart J (1993) Focal peripheral neuropathies. Raven, New
York
11. Kopell HP, Thompson W (1962) Peripheral nerve entrapments
in lower extremity. N Engl J Med 266:16-19
12. Jackson DL, Haglund (1992) Tarsal tunnel syndrome in run-
ners. Sports Med 13:146-149
13. Fabre T, Montero C, Gaujard E, Gervais-Dellion F, Durandeau
A (2000) Chronic calf pain in athletes due to sural nerve en-
trapment. Am J Sports Med 28:679-682