Peripheral nerve surgeons can treat foot drop, which is caused by paralysis of the muscles below the knee that lift the front part of the foot, resulting in a foot that “hangs” at the ankle. A person who has foot drop may have difficulty walking and may need to wear a brace on the leg. Possible causes of foot drop include lumbar disc herniation, damage to the peroneal nerve (usually near the knee) or damage to the nerve above the knee. A foot drop can begin after an injury to the back or leg, an operation on the knee, or even activities such as squatting for prolonged periods of time or crossing the legs.
When the weakness is due to compression of the peroneal nerve, a simple operation can be performed. The peroneal nerve runs around the neck of the bone on the outside of the leg (fibula) just below the knee. It then runs under a muscle that frequently has a tight fascial edge (the peroneus longus). At the point where the nerve runs under this muscle, this tight spot can be released and pressure eliminated. Many times, this is all that is required to restore function to the foot.
At times, these procedures will not be sufficient to restore the function of the foot. In such cases, nerve transfers can sometimes be used. This procedure involves taking nerves with less important roles, or branches of a nerve that perform redundant functions, and transferring them to restore function in a more crucial nerve that is severely damaged. A nerve transfer for correcting foot drop may involve taking branches of the tibial nerve, which supplies muscles that push the foot down, and transferring them to nerves that supply muscles involved in pulling the foot up. Either the branches of the tibial nerve that innervate the muscles that flex the toes or those that contribute to flexing the calf muscles may be used as donor nerves.
After this procedure, patients will still be able to push the foot down. However, as they regain function from the nerve transfer, they also will be trained to use these muscles to pull the foot up. The brain then learns this process, and the patient is able to pull the foot up simply by thinking about pulling the foot up. This can be a difficult transfer to re-educate and may require a physical therapist to help patients learn this technique. Recovery of function after nerve transfer is a long process. Patients generally see small signs of recovery three to six months after the operation, but in most cases, return of movement takes six to 12 months.
The tarsal tunnel refers to the space formed between the inside of the ankle and the ligaments behind the heel. Inside the tarsal tunnel are the nerves and tendons that provide movement and flexibility to the foot. One of the nerves in the tarsal tunnel is the tibial nerve, which provides sensibility to the bottom of the foot. When this nerve is compressed, this condition is called tarsal tunnel syndrome. Symptoms of tarsal tunnel syndrome may include pain in the bottom of the foot, numbness, or a tingling or burning sensation that is bothersome to patients. Tarsal tunnel syndrome may be caused by systemic conditions, trauma to the ankle, or the natural shaping of the foot. Causes may include trauma to the ankle (including ankle sprains), diabetes that can cause swelling, or an enlarged ganglion cyst or bone spur that compresses the nerve. Proper diagnosis of a tarsal tunnel syndrome requires experience with the condition and a complete history and examination.
Occasionally, diagnostic treating may include electrical testing such as a lower extremity EMG or nerve conduction study. Possible treatment options may include anti-inflammatory medications or steroid injections into the nerves in the tarsal tunnel to relieve pressure and swelling. Orthotics may be recommended to reduce pressure on the foot and limit movement that could cause compression on the nerve. Depending on the severity of the condition, one of many surgical options may be recommended, including tarsal tunnel release (decompression of the nerve surgically).
Nerves of the lower extremity can be affected in the same way as upper extremity nerves. Nerves can be injured in trauma, they can be injured during surgery for other indications, they can be involved with tumors, and they can be compressed. Injured nerves can be painful, cause a lack of feeling or muscle weakness.
Meralgia paresthetica is the term for compression of a branch of the nerves that gives normal sensation to the outside of the upper thigh. This nerve is called the lateral femoral cutaneous nerve and it can be injured or compressed at any spot where it travels from the nerve roots near the spine down to the thigh region. The nerve is often pinched between the bones, the ligament which forms the groin crease, or the muscles in the area. Surgery in the groin area from hernia surgery or bone harvesting, as well as a history of massive weight loss can predispose patients to pain from this nerve compression. Pressure on this nerve causes feelings of numbness and/or burning pain along the front and outside part of the thigh, extending from the inside of the hip, the groin and the buttock areas down to the knee. Surgical exploration and decompression of this nerve can frequently improve the symptoms in patients with this condition.
Radial tunnel syndrome is the least common of the nerve compression syndromes of the arm. Pinching of the radial nerve in the forearm can cause pain to radiate along the outside of the arm, centered around the elbow. The syndrome predominantly causes pain, and rarely causes weakness in extension of the fingers. It can occur in conjunction with the condition lateral epicondylitis or “tennis elbow”. Many patients improve with rest combined with physical therapy, and unfortunately, nerve conduction tests are often unreliable in making a diagnosis. Patients with well-diagnosed radial tunnel syndrome that is not responsive to conservative treatment are often improved with surgical release of the radial nerve through a small incision on the back of the forearm just past the elbow.
Cubital tunnel syndrome is due to a pinched or compressed ulnar nerve at the elbow. Compression of this nerve causes pins and needles to be felt in the small finger and the ring finger and occasionally bending of the two fingers in the form of a claw. In moderate to severe cases, there can be weakness in the small muscles of the hand, clumsiness, and even decreased grip strength. In very severe cases of a compressed nerve at the elbow, there is atrophy or weakness in the muscles of the hand and/or forearm. This is sometimes obvious in the muscles on the back of the hand between the thumb and index finger.
The ulnar nerve at the elbow is most irritated when the elbow is bent, so keeping the elbow straight helps to relieve pressure on the nerve. This is most important when patients are sleeping. A splint is often prescribed, and the padded part of the splint is worn on the inside of the elbow to keep the arm straight.
In instances when patient fails to improve, develops weakness in the hand, and has nerve electrical studies that show slowing of the nerve at the elbow, peripheral nerve specialists frequently recommend a surgical release or decompression of the nerve. There are several techniques by which the nerve can be released. In cases where the muscles of the hand are very weak, Dr. Barbour occasionally recommends an additional procedure to increase the strength in the hand, called a supercharge nerve transfer. This nerve transfer increases the number of nerve fibers receiving the hand to prevent irreversible weakness.
Carpal tunnel syndrome is due to a compressed median nerve at the wrist. The pinched nerve causes pain on the inner part of the forearm up to the elbow, but usually not past the elbow. There is decreased feeling with pins and needles in the thumb, index, and long fingers. A classic association of carpal tunnel syndrome is waking up at night and shaking your hand to make it feel better. Conditions associated with carpal tunnel syndrome include diabetes, renal failure, trauma to the wrist including broken wrists, obesity, arthritis in the neck, and pregnancy.
Carpal tunnel is typically graded as mild, moderate, or severe by your surgeon. In moderate carpal tunnel syndrome, there is weakness of the muscles of the thumb, and in severe cases, there is atrophy or thinning of the muscles of the thumb. Mild carpal tunnel syndrome usually responds well to behavior changes and resting the area. Sometimes carpal tunnel symptoms can be caused by conditions that are temporary (such as pregnancy or recovering from broken bones or surgery) and will get better as time passes. Moderate and severe carpal tunnel are not usually improved with therapy or temporary measures such as steroid injections.
Patients with mild carpal tunnel syndrome frequently wear night splints to lower the pressure on the nerve. The splints prevent bending of the wrist at night, so the median nerve is not in a bent and compressed position. Patients with symptoms not responsive to splinting or with thumb weakness are generally considered candidates for surgery.
As part of Dr. Barbour’s practice, both traditional open approach and minimally invasive (using a smaller incision) carpal tunnel releases are performed. Some patients interested in office-based procedures may be candidates for “wide awake” surgery and carpal tunnel release with local numbing medicine alone.
John R. Barbour is a triple board-certified plastic and reconstructive surgeon and fellowship trained hand and peripheral nerve specialist. Dr. Barbour provides valuable patient education to men and women in the Washington, DC area, including Fairfax, Arlington, Alexandria and surrounding areas of Virginia. The material offers in-depth information about our procedures.
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Patient education allows men and women in the Washington, DC area, including Fairfax, Arlington, Alexandria and surrounding communities in Virginia, to make informed decisions about their procedures and care. As a triple board-certified plastic and reconstructive surgeon, Dr. Barbour provides his patients with accurate and current information. Contact Barbour Plastic Surgery to schedule a consultation.
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