Professional Documents
Culture Documents
Sport Related Peripheral Nerve Injuries
Sport Related Peripheral Nerve Injuries
DOI 10.1007/s11332-2005-004-0012-5
REVIEW
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)
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
Ilioinguinal nerve
the anterior superior iliac spine, and emerges under the lat-
eral end of the inguinal ligament through a small tunnel
The ilioinguinal nerve receives fibers from L1-L2 spinal formed by a split in the lateral attachment of the inguinal lig-
roots and arises from the uppermost part of the lumbar ament to the anterior superior iliac spine. Once it reaches the
G. Cavaletti et al.: Sport-related peripheral nerve injuries: part 2 63
proximal anterior aspect of the thigh, it crosses the sartorius ament, lateral to the femoral artery in the lacuna musculo-
muscle and pierces the fascia lata to become superficial and rum. At the level of Scarpa’s (femoral) triangle, in the ante-
innervate the skin of the anterolateral aspect of the thigh. rior aspect of the upper thigh, it provides two branches: one,
Symptoms of lateral femoral cutaneous nerve injury the motor ramus, is devoted to the innervation of the quadri-
(meralgia paresthetica) are exclusively represented by pain ceps, sartorius and pectineus muscles; the other, the sensory
and sensory impairment over the anterior aspect of the thigh, ramus, innervates the skin of the anterior thigh. The main
exacerbated by the squatting position. trunk of the nerve, which is now exclusively sensory (saphe-
Compression and entrapment of the nerve can occur in nous nerve), continues along the medial border of the sarto-
the inguinal ligament tunnel, particularly in contact sports, rius muscle, then enters the subsartorial canal (also know as
women’s gymnastics (secondary to repeated trauma of un- the adductor canal) of Hunter, together with the femoral
even bar work) and scuba divers (due to direct trauma by the artery and vein. The canal is formed by the vastus medialis
weight belt) [4, 5]. Rarely, meralgia paresthetica has been (lateral wall) and adductor longus (medial wall) muscles, by
described in soccer players, secondary to upper thigh trau- the vastoadductor membrane (floor) and it is covered by the
ma [6]. 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-
Obturator nerve 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 obturator nerve, one of the two main terminal trunks of The femoral nerve can be injured in the abdomen or
the lumbar plexus, receives fibers from L2-L4 spinal roots along its course in the lower limb. In sports medicine the
and emerges from the medial border of the psoas muscle most common lesion affecting the femoral nerve is sec-
passing into the lesser pelvis. It goes into a fibro-osseus tun- ondary to psoas bursitis or strain of the iliopsoas, with asso-
nel (obturator tunnel) located under the pubic ramus; within ciated hematoma and muscular swelling leading to nerve
this tunnel it divides into two main branches (anterior and trunk compression [1]. Hyperextension of the hip with acute
posterior), as well a branch directed to the obturator exter- femoral nerve injury has been reported in gymnasts, football
nus muscle. The anterior motor branch innervates the ad- and basketball players and long jumpers [7].
ductor longus, brevis and gracilis muscles (occasionally al- The clinical presentation of femoral nerve injury in-
so the pectineus muscle), while the sensory fibers are di- cludes pain in the inguinal region, weakness of the quadri-
rected to the skin and fascia of the distal two-thirds of the ceps, sartorius and pectineus muscles, and reduced or absent
medial thigh. The motor posterior branch supplies the ad- knee jerk. Sensory impairment is much rarer than motor
ductor magnus and obturator externus muscles, while the signs.
sensory fibers innervate the articular capsule, cruciate liga- The saphenous nerve may be injured in the adductor
ments and synovial membrane of the knee joint. canal, as a consequence of inflammatory conditions (such as
Obturator nerve injury can lead to motor impairment in- thrombophlebitis) or, in the distal portion of the canal, which
volving the adductor muscles and sensory impairment, gen- is close to the knee joint, by bursitis. Damage during arthro-
erally associated with pain, in the medial aspect of the thigh. scopic examination has also been reported as an infrequent
The course of the obturator nerve exposes it to possible complication of the procedure. Saphenous nerve injury can
damage in the pelvis as well as within the obturator tunnel. occur as a consequence of repetitive knee flexion in cycling
During sport activities obturator injury is rare, with the ex- and rowing and of muscular hypertrophy in weight-lifters
clusion of direct trauma from pelvic fractures [1, 7]. and bodybuilders [7].
Obturator tunnel syndrome has been described secondary to The clinical presentation of a saphenous injury is typi-
inflammatory changes in the course of osteitis pubis [1], cally exercise-related, poorly localized medial leg or knee
while entrapment can be due to the presence of a fascial pain, which can be misdiagnosed as popliteal artery entrap-
band compressing the nerve at the distal exit of the canal [8]. 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.
The femoral nerve, the other terminal trunk of the lumbar Superior and inferior gluteal nerves
plexus, is formed, like the obturator nerve, by fibers arising
from L2-L4 spinal roots. It emerges from the lateral aspect These two motor nerves arise from the sacral plexus and
of the psoas muscle, passes under the iliac fascia and de- pass through the sciatic notch into the deep gluteal region
scends along the iliac muscle passing under the inguinal lig- along with the sciatic nerve, pudendal nerve and posterior
64 G. Cavaletti et al.: Sport-related peripheral nerve injuries: part 2
cutaneous nerve of the thigh. The superior nerve receives amination is usually normal, while in some cases the only
fibers from L4-S1 spinal roots, passes above the piriformis pathological results can be obtained in the NSC using long
muscle and enters the deep gluteal region to innervate the latency evoked potentials (F and H waves), which can be
gluteus medius, gluteus minimus and tensor fascia lata mus- normal at rest and delayed during the maneuvers which elic-
cles. The inferior nerve receives fibers from L5-S2 ventral it the onset of symptoms.
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]. Common peroneal nerve
diagnosis. Anterior compartmental syndrome can be mimic- popliteal fossa, where it continues distally deep to the gas-
ked in skiers, where the deep peroneal nerve is compressed trocnemius muscle. In the calf, it innervates the gastrocne-
at the ankle by improperly fitted ski boots. The deep per- mius, soleus, tibialis posterior, flexor digitorum longus and
oneal nerve may be also compressed by the crural fascia or flexor hallucis longus muscles. About at mid-leg, the tibial
where the terminal branches cross the anterior aspect of the nerve becomes superficial and passes medially to the
ankle joint subcutaneously, for instance by inadequate or ex- Achilles tendon; it runs down along the posteromedial as-
cessively high shoes. 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
Common peroneal nerve syndrome into the medial and lateral plantar nerves and into the me-
dial calcaneal branch that supplies sensation to the medial
In common peroneal syndrome, the most common clinical aspect of the heel. The tibial nerve and its branches pass in
presentation is represented by exercise-induced leg pain and distinct fascial tunnels separate from the other contents of
numbness. Pain originates in the site of compression and the tarsal tunnel, including the posterior tibial vessels and
subsequently spreads along the sensory distribution of the the tendons of the tibialis posterior, flexor digitorum
nerve, resembling in most cases an anterior compartmental longus and flexor hallucis longus. Compression of the
syndrome, with exacerbation of the symptoms occurring neural structures at this site is known as tarsal tunnel syn-
during forced inversion of the ankle. Clinical examination drome [12]. The medial plantar nerve reaches the sole of
usually evidences muscle weakness (particularly in ankle the foot by passing under the origin of the abductor hallu-
dorsiflexion and inversion), hypoesthesia and positive Tinel’s cis muscle and through a fibro-osseus space formed by the
sign at the level of the fibular neck. Foot drop is typically attachment of the flexor hallucis brevis to the calcaneus.
seen only in long lasting and severe cases. 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-
Superficial peroneal nerve syndrome trinsic foot muscles.
Injury or entrapment of the tibial nerve in the leg is rare,
Clinical signs include cramping pain and hypoesthesia over although compression by space-occupying lesions can occur
the lateral calf or dorsum of the foot, exacerbated by resist- in the popliteal fossa. Entrapment of the distal branches is,
ed ankle dorsiflexion and eversion. This syndrome has been on the contrary, rather common, particularly at the tarsal tun-
reported in runners, soccer players, jockeys, tennis players nel level (see below). The branches of the tibial nerve can be
and bodybuilders [1, 7]. 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
Deep peroneal nerve syndrome the flexor hallucis brevis to the calcaneus. The first sensory
branch of the lateral plantar nerve may be entrapped between
Symptoms are generally those of an anterior compartmental the muscular layers or when it passes in close relation to the
syndrome, due to compression of the nerve secondary to ex- plantar fascial attachment to the calcaneus, causing persis-
ercise-induced muscular hypertrophy in subjects with in- tent heel pain.
elastic compartmental fascia which leads to nerve ischemia. The interdigital nerves, which originate from both the
It is more frequent in runners and in all those sport activities medial and lateral plantar nerves, can be damaged by com-
where long-lasting running is common. The typical clinical pression (particularly in runners) against the transverse
presentation is with exercise-induced aching or cramping metatarsal ligament caused by repeated dorsiflexion of the
pain and hypoesthesia, which last much longer than exercise toes. This clinical condition (known also as Morton’s neuro-
withdrawal. Time from beginning of exercise and symptoms ma) induces foot pain radiated to the toes, numbness and hy-
onset is variable with the individuals. 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
Tibial nerve medial aspect of the great toe. A common cause is the use of
inadequate sport shoes and the typical complaint is pain and
This nerve origins from L5-S3 spinal roots and represents paresthesia over the medial aspect of the great toe when
the medial terminal trunk of the sciatic nerve at the walking.
66 G. Cavaletti et al.: Sport-related peripheral nerve injuries: part 2
Tarsal tunnel syndrome can be an underdiagnosed cause of chronic calf and ankle
pain, and it has been reported particularly in runners, soccer
Damage to the tibial nerve at the tarsal tunnel induces a typ- and tennis players [13].
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 Posterior cutaneous nerve of the thigh
clinical examination is often poorly informative, although a
positive Tinel’s sign or reduced sensation over the foot sole The posterior cutaneous nerve of the thigh arises from S1-
can be found. Forcing the heel into valgus position can evoke S3 spinal roots, passes through the sciatic notch below the
the onset of the typical pain. NCS can be helpful in sup- piriformis muscle and medially to the sciatic nerve, then
porting a diagnostic suspect. runs superficially over the back of the thigh to the knee. It
Tarsal tunnel syndrome is particularly frequent in runners provides the cutaneous innervation to the skin over the low-
[12], but it has also been described in mountain climbers and er buttock and posterior thigh, while its perineal branches in-
basketball, soccer and football players [1, 5]. It is believed nervate the skin of the perineum and genitals.
that the cause of tarsal tunnel syndrome is in most cases re- Prolonged bicycle riding may induce compression in the
peated ankle hyperextension and hyperflexion motions or re- intrapelvic course, while prolonged sitting may also cause
current ankle sprains, which cause tenosynovitis of the ten- entrapment of the nerve to the distal edge of gluteus max-
dons running into the tunnel or its fibrosis. In both cases re- imus muscle. Numbness and tingling paresthesia within the
duction of the tunnel cross-sectional area occurs, leading to territory of cutaneous innervation are the most common
compression of neural structures. In some cases, a difficult symptoms [1, 7].
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 Pudendal nerve
is associated with numbness or tingling sensation at the me-
dial malleolus and sole of the foot, while in plantar fascitis This is the main perineal nerve, arising from S2-S4 spinal
the origin of pain is most commonly located over the calca- roots. It passes through the sciatic notch and runs deep to the
neus. In plantar fascitis, Tinel’s sign and sensory impairment sacrospinous ligament into the perineal region. Its first
are not observed, but it should be remembered that these clin- branch is the inferior rectal (or hemorrhoidal) nerve, which
ical signs can also be absent in tarsal tunnel syndrome. NCS innervates the external anal sphincter and contains sensory
is normal in plantar fascitis. Achilles tendonitis should also fibers from the lower anal canal and perineal skin. The sec-
be considered, although in this case pain is generally local- ond branch (perineal nerve) supplies the perineal muscles,
ized more proximally in the leg. 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-
Sural nerve clists, where prolonged riding may result in sensory loss or
even impotence in males, in the most severe cases [1].
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 Conclusions
calf or in the popliteal fossa and then the sural nerve runs be-
tween the two heads of the gastrocnemius muscle beneath Sport-related nerve entrapment syndromes in both upper and
the crural fascia. At the distal third of the calf, the nerve lower limbs can be the cause of acute and chronic discom-
pierces the fascia and join the lesser saphenous vein lateral- fort, frequently associated with motor impairment. The
ly to the Achilles tendon, then it passes behind the lateral symptoms of many of these syndromes (in our review we
malleolus to supply the ankle joint, the posterior calf and the have considered only the most frequently reported) are ac-
lateral side of the heel and foot. tivity-related. Appropriate clinical assessment and diagnos-
The sural nerve can be compressed in its distal course, tic tests can allow an accurate diagnosis, provided that the
particularly by tight ski boots, while the crural fascia can act clinician maintains a high suspicion level toward this possi-
as a compression or a fixation point for the nerve, so that bility. The issue of nerve injury management is beyond the
athletic activities such as running may stretch the nerve at scope of this review, but it is clear that once a neural syn-
this level. Repetitive ankle inversion injuries may also lead drome has been clearly recognized, an appropriate and early
to fibrosis and nerve entrapment. Sural nerve entrapment treatment should always be started, using a step-by-step
G. Cavaletti et al.: Sport-related peripheral nerve injuries: part 2 67
strategy ranging from rest, use of splints, anti-inflammatory 6. Ulkar B, Yildiz Y, Kunduracioglu B (2003) Meralgia pares-
medications, training and technical equipment modification, thetica: a long-standing performance-limiting cause of ante-
reaching in the most severe cases also surgical exploration rior thigh pain in a soccer player. Am J Sports Med 31:787-
and intervention. 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
References 8. Bradshaw C, McCrory P (1997) Obturartory nerve entrap-
ment. Clin J Sports Med 7:217-219
1. McCrory P, Bell S (1999) Nerve entrapment syndromes as a 9. Merlo IM, Poloni TE, Alfonsi E, Messina AL, Ceroni M
cause of pain in hip, groin and buttock. Sports Med 27:261- (1997) Sciatic pain in a young sportsman. Lancet 349:846
274 10. Stewart J (1993) Focal peripheral neuropathies. Raven, New
2. Lacroix VJ (2000) A complete approach to groin pain. Phys York
Sportsmed 28:66-86 11. Kopell HP, Thompson W (1962) Peripheral nerve entrapments
3. LeBlanc KE, LeBlanc KA (2003) Groin pain in athletes. in lower extremity. N Engl J Med 266:16-19
Hernia 7:68-71 12. Jackson DL, Haglund (1992) Tarsal tunnel syndrome in run-
4. McGregor J, Moncur J (1977) Meralgia paresthetica: a sport ners. Sports Med 13:146-149
lesion in girl gymnast. Br J Sports Med 11:16-17 13. Fabre T, Montero C, Gaujard E, Gervais-Dellion F, Durandeau
5. Lorei MP, Hershman EB (1993) Peripheral nerve injuries in A (2000) Chronic calf pain in athletes due to sural nerve en-
athletes. Sports Med 16:130-147 trapment. Am J Sports Med 28:679-682