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This presentation contains information about the various Entrapment syndromes of Lower limb in descending order of topography. It also contains information about etiology, clinical features and management of each of these entrapment syndromes with special emphasis on electrodiagnostic confirmation.

This presentation contains information about the various Entrapment syndromes of Lower limb in descending order of topography. It also contains information about etiology, clinical features and management of each of these entrapment syndromes with special emphasis on electrodiagnostic confirmation.


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Entrapment Syndromes of Lower Limb.pptx

  1. 1. Entrapment Syndromes of Lower Limb Dr Zuber Ali Quazi Senior Resident Neurology
  2. 2. Femoral Neuropathy › Sites of compression:- – Retroperitoneal space – Deep to the Inguinal ligament. › Etiology:- – Sx (Abdominal; Pelvic; Hip) – Sustained lithotomy position. – Retroperitoneal haemorrhage. – FA Catheterization.
  3. 3. › C/F:- – Knee Extension; Instability Knee. – Hip flexion (Prox to Inguinal lig). – Sensory loss - Anterior thigh; Leg. – Pain – On Extension of thigh. – Knee reflex. › Edx:- – NCV- Routine LL; Femoral n; – EMG › Quadriceps; Iiliopsoas. › Adductor; PSM. (r/o Lumbar radiculopathy; plexopathy) Stimulation site:- Lateral to Femoral pulse, below the inguinal ligament. G1 Over Anterior thigh, halfway b/w inguinal crease & knee, G2 Over a bony prominence at knee.
  4. 4. MERALGIA PARESTHETICA Posterior to the ASIS, Across the iliac crest (4%) Anterior to ASIS and superficial to the origin of the sartorius muscle (27%) Medial to ASIS, ensheathed in the tendinous origin of the sartorius muscle (23%) Medial to origin of sartorius b/w tendon of sartorius & fascia of iliopsoas muscle deep to inguinal ligament (26%); Most medial and embedded in loose connective tissue, deep to the inguinal ligament, overlying thin fascia of iliopsoas muscle (20%)
  5. 5. Clinical features:- › Painful, burning, numb patch of skin over anterior and lateral thigh. › Atrophy › Weakness › Loss of Reflex › Etiology:- – Prolonged standing – Obese. – Tight underwear – Tight Pants, or belts. – Car seatbelts – Sx: Bone grafts, THR, Vascular bypass, Hysterectomy, Cesarean section. – Diabetes
  6. 6. Diagnosis:- Pelvic Compression Test Downward, compression force to the pelvis and maintains pressure for 45 sec. Resolution of symptoms –Positive Sp - 93.3% Sn - 95%
  7. 7. Diagnosis:- (contd..) Neurodynamic testing:- Step 1:- Examiner stabilizes the pelvis with the cranial hand and grasps the lower extremity at the knee with the caudal hand. Step 2:- The examiner then bends the knee and adducts the hip in order to tension the LCNT. Positive test = Reproduction of Symptoms.
  8. 8. › Edx:- – Routine LL study – Lateral cutaneous nerve of the thigh sensory study, (B/L studies). – Stimulating just medial to the ASIS, – Recording over Anterior thigh. › Nerve Block Test:- – 1% Lidocaine at the site where the LCNT exits the pelvis at the inguinal ligament. – Positive = If immediate symptom relief. Diagnosis:- (contd..)
  9. 9. Management:- › Non‐Surgical Interventions – NSAIDS – Avoiding compression activities. – RFA – Nerve Block. › Surgical Interventions – LCNT neurolysis and resection › KinesioTaping › Acupuncture
  10. 10. Piriformis Syndrome › Definite diagnostic pts (1) Sciatic neuropathy clinically, (2) Edx e/o sciatic neuropathy, (3) Surgical exploration showing entrapment of the sciatic nerve within a hypertrophied piriformis muscle, (4) Subsequent improvement following surgical decompression. › C/f:- – Pain more while sitting than standing; – Worsening with Flexion, Adduction, IR. – H/o trauma or – Unusual body habitus –thin – Tenderness in the mid-buttock that reproduces the symptoms.
  11. 11. Etiology:- › Acute injury with the forceful internal rotation of the hip. › Trauma to the hip or buttock area. › Piriformis muscle hypertrophy:- – Athletes. – During periods of increased weightlifting. › Sitting for prolonged periods:- – Taxi drivers. – Office workers – Bicycle riders. › Anatomic anomalies: – Bipartite piriformis muscle. – Course/branching variations with respect to the piriformis muscle.
  12. 12. Clinical Examination:- › Freiberg maneuver: pt lying supine, the examiner forcefully internally rotates the leg, stretching the piriformis. › Pace maneuver: In sitting position, pt abducts the hip against resistance, activating the piriformis. › Beatty maneuver: Lying in lateral decubitus, pt abducts the hip, activating the piriformis. › FAIR (flexion, adduction, internal rotation) maneuver: with the patient lying supine, the examiner passively flexes, adducts, and internally rotates the hip, stretching the piriformis.
  13. 13. Diagnosis:- › Edx:- – Routine Peroneal & Tibial nerve motor study; Sural sensory study. – Superficial peroneal sensory study. – H reflex latency b/w normal & FAIR positions of Hip. › EMG:- – At least TWO Peroneal nerve -innervated muscles (TA, EHL, Peroneus longus) – At least TWO Tibial nerve -innervated muscles (Medial Gastrocnemius, TP, FDL) – Short and Long heads of the Biceps Femoris – At least ONE Superior Gluteal nerve -innervated muscle (Gluteus Medius, Tensor Fascia Latae) – At least ONE Inferior Gluteal nerve-innervated muscle (Gluteus Maximus) – L5 and S1 Paraspinal muscles – At least TWO Nonsciatic, Non–L5–S1-innervated muscles (Vastus Lateralis, Iliacus, Thigh Adductors) to exclude a more widespread lesion Stimulation site: Lateral calf Recording site: b/w TA tendon & Lateral malleolus.
  14. 14. Management:- › Short-term rest. › Muscle relaxants. › NSAIDs. › Botulinum toxin. › Surgery.
  15. 15. Obturator Neuropathy › Etiology:- – Direct Trauma (e.g., Pelvic #) – THR, Pelvic operations – Compression from Tumor / Metastasis. – Lithotomy position. › C/F:- – Pain, Sensory loss - Groin / Medial Thigh. – Weakness - Adduction & IR. Craig, A. (2013), Entrapment Neuropathies of the Lower Extremity. PM&R, 5: S31-S40.
  16. 16. › NCV › EMG – Adductor grp. – Femoral n. supplied grp. – PSM
  17. 17. Saphenous Neuropathy › Etiology:- – Procedures related to Femoral artery. – Genu valgus & Internal tibial torsion. – Knee arthroscopy & Meniscectomy – Knee orthoses. – Varicose vein stripping › C/F:- – Sensory loss. – Neuropathic pain. – Medial knee pain
  18. 18. › D.D:- –Femoral Neuropathy, –L4 radiculopathy, –Lumbar Plexopathy Stimulation site;- Medial calf b/w Tibia & MG; Recording sites:-B/w Medial Malleolus & TA Mx:- Conservative/ Symptomatic
  19. 19. Fibular Tunnel syndrome › DPN – Foot & Toe drop. › SPN – Weak Foot eversion. › Etiology:- –Compression –Casts –Stockings –Gardening; Farm work (squatting, kneeling) –Mass lesions (Ganglion cysts, Tumors, Baker’s cyst) –Miscellaneous (Weight loss, Habitual leg crossing) –Iatrogenic – After Fibular osteotomies (2-27%); TKR (0.3-1.3%); Fortier LM et al. An Update on Peroneal Nerve Entrapment and Neuropathy. Orthopedic Reviews.2021;13(1).
  20. 20. Diagnosis:- › Edx:- – Peroneal motor study, › Recording: EDB › Stimulating: Ankle, Below Fibular head and Lateral popliteal fossa. – Tibial motor study. – Superficial peroneal sensory study. – Tibial and peroneal F responses. › EMG:- – At least TWO muscles by DPN – TA, EHL. – At least TWO muscles by SPN – PL, PB. – TP & at least ONE other by Tibial n. – Short head BF.
  21. 21. Superficial Peroneal Nerve Entrapment › “Mononeuralgia in the Superficial Peroneal Nerve” › Etiology:- –Sports. –External compression - Tight boots. –Trauma - Fibular shaft #, Ankle sprains a/w Ant. Talofibular lig. tear- inversion injury –Surgery – Fasciotomy, Varicose vein surgery. Rx of Ankle# –Weight loss Peroneus Longus Peroneus Brevis SPN EDL
  22. 22. › Burning pain- over the lateral calf and dorsum of the foot › ↑ Pf (eg Pressing the accelerator or brake).
  23. 23. › X-ray (To exclude stress fracture, Bone tumors) › MRI of Leg / USG:- to identify muscle hernia › Edx D.D:- • L5 radiculopathy, • Ankle joint pathology, • Anterior compartment syndrome Stimulation site:-Lateral calf; Recording site:- B/W TA tendon & Lateral Malleolus.
  24. 24. Management › Avoid Tight boots, Ballet shoe ties › Lateral shoe wedges. › Local anesthetic and steroid. › Cryoneuroablation. › RFA › Botulinum Toxin (20U). › Surgery
  25. 25. Tarsal Tunnel syndrome Floor – Medial malleolus Roof – Flexor retinalculum. Content - Tibial nerve, Tibial artery, Tibial veins, Tendons of the FHL, FDL, TP. Compression of the Posterior Tibial nerve
  26. 26. Etiology › Extrinsic causes :- –Trauma. –Poorly fitting shoes –Anatomic-biomechanical abnormalities (tarsal coalition, valgus or varus hindfoot), –Post-surgical scarring, –Pedal edema, systemic inflammatory arthropathies. › Intrinsic causes:- –Tendinopathy, tenosynovitis, perineural fibrosis, osteophytes, Hypertrophic retinaculum, –Space-occupying lesions :- enlarged or varicose veins, ganglion cyst, lipoma, neoplasm, and neuroma). m.c.
  27. 27. › C/f :- – Perimalleolar pain. – Burning pain in Ankle and Sole, ↑ Wt bearing; ↑Night. – Paresthesias & sensory loss – Sole. – Intrinsic foot muscle atrophy (Non-specific). – Tinel sign ( non specific) F>M The Dorsiflexion-eversion test:- Passively dorsiflexing and everting the ankle to end range of motion and holding for 10 seconds
  28. 28. Recommended NCV protocol:- › Routine studies – Motor = Tibial, Peroneal. – Sensory = Sural – F response = Tibial, Peroneal. – H reflex. › Special studies – Medial and Lateral Plantar Motor nerve studies. – Medial and Lateral Plantar Sensory nerve studies – Medial and Lateral Plantar mixed nerve studies. Interpretation – By Comparing Latency and Amplitude on both sides
  29. 29. Edx AHB muscle: G1 - 1 cm proximal and 1 cm inferior to navicular prominence G2 - metatarsal-phalangeal jt of the Great toe Abductor digiti quinti pedis (ADQP) muscle: G1 - Halfway b/w lateral sole of the foot and the lower margin of the Lateral Malleolus. G2 - Metatarsal-phalangeal jt of Little Toe MEDIAL AND LATERAL PLANTAR MOTOR STUDIES Stimulating the tibial nerve behind the medial malleolus.
  30. 30. Edx (contd) G1 - proximal and posterior to the medial malleolus G2 - 3–4 cm proximally Stimulation site:- proximally near the metatarsal- phalangeal jt of the Great toe. Stimulation site:- proximally near the metatarsal- phalangeal jt of Little toe. G1 - proximal and posterior to the medial malleolus G2 - 3–4 cm proximally MEDIAL AND LATERAL PLANTAR SENSORY STUDIES
  31. 31. Edx MEDIAL AND LATERAL PLANTAR MIXED NERVE STUDIES Medial ankle: G1 - Proximal & posterior to the Medial Malleolus G2 placed 3–4 cm proximally Medial sole is stimulated Lateral sole is stimulated. Recording site : Same as above
  32. 32. Recommended EMG protocol:- › AHB & ADQP (must be compared with the C/L side) › At least TWO Distal Tibial-innervated muscles but prox. to Tarsal Tunnel (MG, Soleus, TP, FDL) › At least ONE Distal Peroneal-innervated muscle (TA, EHL) Interpreting the EMG findings as Abnormal requires that:- • The abnormalities be fairly marked OR • The contralateral asymptomatic muscle is distinctly different on EMG from the symptomatic side.
  33. 33. Differential Diagnosis › Achilles tendonitis › Compartment syndrome of the Deep flexor compartment › Degenerative changes (calcaneal spurs, arthrosis of the joints of the foot). › Inflammatory conditions of the ligaments and fascia of the foot and ankle. › L5 and S1 nerve root compression › Neurogenic intermittent claudication › Plantar fasciitis › Polyneuropathy › Retrocalcaneal bursitis
  34. 34. Management › Ice over Tarsal tunnel. Analgesics, Gabanoids, TCA. › Orthotic shoes-offloading the tarsal tunnel. › Medial heel wedge. › Night splints. › Surgery (A positive Tinel sign) Prognosis:- Identifiable etiology; diagnosed early = Favorable. Without an identifiable cause & who do not respond to conservative therapy = Poor. .
  35. 35. Anterior Tarsal Tunnel Syndrome › Etiology:- – Trauma/Repetitive micro-trauma. – Ganglion cyst. – Osteophytes – Hypertrophied EHB. – Extrinsic- Tight-fitting shoes, Athletic Gear – Extreme Plantar flexion- Dancing, soccer, diving. – Traction injury - Ankle sprains. – Ankle instability › C/F:- – Sharp shooting pain, Numbness/ Tingling.(1st web space) DPN
  36. 36. Management:- › Change Footwear › Rest. › Topical Anti-inflammatory. › Oral or topical NSAIDs/ Gabapentin. › Perineural corticosteroid/anesthetic inj. › Surgery
  37. 37. Morton Neuroma › Alt names:- – Morton metatarsalgia – Interdigital neuritis – Morton entrapment – Interdigital neuralgia – Interdigital neuroma – Interdigital nerve compression syndrome – Intermetatarsal neuroma. › Compressive neuropathy of the Interdigital nerve. Transverse intermetatarsal ligament
  38. 38. Etiology › Narrow toe-box footwear, › Hyperextension of the toes in high-heeled shoes, › Inflammation of the intermetatarsal bursa, › Thickening of the transverse metatarsal ligament, › Forefoot trauma, › High impact sporting activities, › Metatarsophalangeal joint pathology, › Lipoma. F>>M Middle aged. U/L
  39. 39. › C/F:- – Plantar pain b/w Metatarsal heads – ↑ walking; wearing tight-fitting, high-heeled shoes; ↓ Rest – Burning, stabbing, or tingling with electric sensations. – “walking on a stone or marble”. – Numbness b/w toes (<50%). – With prolonged walking, Radiates - Hindfoot or leg. › “Mulder’s click.“ › Diagnosis:- USG, MRI (Dumbell shaped soft tissue lesion within the intermetatarsal space. T1-↓; T2-variable).
  40. 40. Management :- › Wide, soft-soled, laced shoe with a low heel. › Budin splint. › NSAID, TCA, Gabapentin. › RFA, Cryotherapy. › Surgery.
  41. 41. References:- › Shapiro 4th edition; Electromyography and Neuromuscular disorders. › Craig, A. (2013), Entrapment Neuropathies of the Lower Extremity. PM&R, 5: S31-S40. › Fortier LM et al. An Update on Peroneal Nerve Entrapment and Neuropathy. Orthopedic Reviews.2021;13(1). › Hong CH et al. Tarsal tunnel syndrome caused by an uncommon ossicle of the talus: A case report. Medicine (Baltimore). 2018 Jun;97(25):e11008. › Kiel J, Kaiser K. Tarsal Tunnel Syndrome: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

Hinweis der Redaktion

  • L2-L4 nerve roots; emerges from the psoas muscle; descends thro’ Pelvis deep to the iliacus fascia to exit deep to the inguinal ligament, lateral to the femoral artery.
    Incidence of Femoral nerve injury during FA catheter insertion = 0.2%
  • Hip adduction; abduction, knee flexion; distal strength are preserved.
    Iliacus EMG = 2-3 fingerbreadths lateral to Femoral pulse. Involved in lesion prox to Inguinal lig.
  • L2-L3; 66.7% of cases are within 1 cm medial to the ASIS, and 80.6% are within 2 cm L2–L3 roots.
    Type B>D>C
  • Evaluated in group of 20 patients. no other clinical trials have been performed to further strengthen the findings of the test.
  • Diagnostic accuracy was ≥90% with MRN.
    Nerve block test: Relief lasts 30‐40 min after the inj.
  • No clinical trials available, only case reports describing this intervention.
    LCNT:- At 1 ‐wk post injection, 16/20 (80%) decreased symptoms; 4 pts (20%) required a second injection due to continued pain. At the 2 month follow‐up, all pts = Pain free 
    Surgery:- overall consensus on which procedure is the best has still not been reached.
    KT:- exact physiological mech are still unknown. Hypothesized to help increase lymphatic and vascular flow, decrease pain, enhance normal muscle function, increase proprioception, and help correct possible articular malalignments. Studied on group of 10 individuals.
  • Origin: Sacrum, sciatic notch, Sacrotuberous lig then runs through Greater sciatic foramen to attach to the greater trochanter.
    Action;- External rotation of Hip. Partial Hip Abductor (in flexed position)
  • FLAIR method use in Edx
    Simultaneous downward pressure of the flexed knee and passive superolateral movement of the shin, with both acetabula oriented vertically, maximize adduction and internal rotation at the flexed thigh.
    The angle 20–35°.
  • Peroneal=EDB; Tibial=AHB
    All Thigh muscles = Tibial n.(except = Short head Biceps femoris- Peroneal n.)
    EHL= four to five fingerbreadths above the ankle, just lateral to the tibialis anterior (TA) tendon.
    TA= Lateral to the tibial crest, 2/3rd the distance above the ankle.
    PL = Lateral calf, three to four fingerbreadths distal to the fibular head.
    MG = Rostral, medial posterior calf.
    TP = medial to the tibia, slightly distal to the mid-point between the ankle and knee, deep to the FDL.
    FDL = same as above but not deep.
    BF (long) = mid-point b/w lateral knee & ischial tuberosity.
    BF (short) = three to four fingerbreadths prox. to lateral knee, medial to the tendon to the long head BF.
    G Max. = upper outer quadrant of the buttock. Alt.- 1. lower inner quadrant; 2. prone position, insert upper outer quadrant.
    G Med = latera decubitus insert- lateral thigh two to three fingerbreadths distal to the iliac crest.
    VL = lateral thigh; four to five fingerbreadths proximal to the lateral knee.
    Iliacus = two to three fingerbreadths lateral to Femoral pulse below the inguinal ligament.
    PSM = two fingerbreadths from the midline spine with the needle directed slightly medially…Activation- extend the hip with the leg straight.
  • Short term rest <48hrs.
    Botulinum Class II (AAN) Level B………Fishman et al 2002=70pts, Childers et al-2002=9pts; Fishman et al-2016=56pts
    Sx indications= failed conservative therapy
  • Rare entrapment syn. L2-4 nerve roots
    Circumduction gait
  • NO separate NCV for Saphenous n.
  • (L3, L4) is largest terminal cutaneous br. of Femoral nerve, Longest nerve in body. Travels within Quadriceps muscle - subsartorial (Hunter) canal accompanying femoral artery. Exits the canal 10 cm above the knee, piercing a fascial layer where it gives off an infrapatellar br. ; supplying Knee. Descends along medial surface of the tibia and medial malleolus, Supplies Medial aspect of Leg & Medial Foot uptill 1st Metatarsal jt.
    Vulnerable pts = In the thigh; As it exits the subsartorial canal; At the level of the knee; In the lower leg.
    medial knee pain d/t Infrapatellar br injury
  • To r/o D.D, perform EMG
    Sensory study shown is Antidromic, for orthodromic= reverse the electrode.
  • Most common neuropathy of LL, 3rd mc after median & ulnar
    SPN + DPN involvement = steppage gait
  • Tibial motor = Abductor Hallucis brevis
    Routine sampling of the EDB on needle EMG is not recommended as it is so difficult to determine what is truly “abnormal.”
    H reflex
  • Among 480 pts with Chronic Leg Pain, 17 (3.5 %) – SPN entrapment.
    Skiing, Football, Soccer, Basketball, Ice hockey, Volleyball.
    SPN -pierce the fascia by way of a tunnel (the peroneal tunnel ) 3–18 cm prox. to the lateral malleolus. Then divides into IDCN (intermediate dorsal cutaneous nerve) and MDCN (medial dorsal cutaneous nerve).
    Sensation - Distal 2/3 of the lateral leg & Dorsum of the foot.
  • Holding the foot in mild Plantar Flexion & Inversion. Thumb to roll horizontally across the nerve, just anterior to the lateral malleolus-causing replication of the pain.
    Passive PF of Fourth toe br. of SPN - tenting the skin of the dorsal foot ( FOURTH TOE SIGN )
    RLS has been a/w low gr SPN neuropathy
  • NCV is more useful than EMG
    EMG Peronei..
  • Injected just anterior to Lateral Malleolus. 12-gauge intravenous catheter is used as the introducer for the 2.0-mm cryoprobe, two to three 2-min freeze cycles. Risk of frostbite injury.
  • Tibial nerve divides into three branches. 1st Medial Calcaneal Sensory Nerve - purely sensory.
    Medial and Lateral Plantar nerves -motor and sensory fibers.
  • Atrophy of Intrinsic foot muscles = L5–S1 radiculopathy, Tibial neuropathy or polyneuropathy.
    1st case of TTS -reported by Captain Keck in an army recruit who developed pain in the feet and anesthesia.
  • AHB Abductor Hallucis Brevis. Origin:- Medial process of calcaneal tuberosity, Plantar aponeurosis, Flexor retinaculum. Insertion:- Medial aspect of base of 1st phalanx of hallux.
    ADQP – Origin:- Plantar aponeurosislies. Insertion:- Fifth toe
  • Orthodromic study….usually we do antidromic study
  • Mixed nerve study, technically easier than sensory studies….It is preferred..
    Stimulator site:- At a distance of 14 cm from the recording electrodes (measure 7 cm from the recording site into the sole of the foot, then an additional 7 cm on a line drawn parallel to the web space b/w 1st & 2nd toes…and b/w 4th & 5th web space for lateral plantar nerve.
  • AHB Abductor Hallucis Brevis. Origin:- Medial process of calcaneal tuberosity, Plantar aponeurosis, Flexor retinaculum. Insertion:- Medial aspect of base of 1st phalanx of hallux.
    ADQP – Origin:- Plantar aponeurosislies. Insertion:- Fifth toe
    Increased insertional activity and occ. fibrillation potentials with large, long-duration MUAP are frequently found in normal subjects without symptoms.
    Interpreting the EMG findings as Abnormal requires that
    The abnormalities be fairly marked or
    The contralateral asymptomatic muscle is distinctly different on EMG from the symptomatic side.
  • Intersection syndrome of the FHL and FDL at the knot of Henry.
    Morton metatarsalgia

  • Medial heel wedge.-reduce traction on the nerve by inverting the heel.
    Surgery:- Failure of conservative mx, mass effect over nerve.
    Tinel sign strong predictor of surgical relief
  • Compression of DPN at inferior extensor retinaculum. Other site:- Deep to EHL tendon overlying the talonavicular jt & deep to EHB muscle overlying 1st & 2nd TM jt.
    Inferior extensor retinaculum-Roof, medial malleolus (medially), lateral malleolus (laterally), and the talonavicular jt (floor).
    Osteophytes (bony overgrowth) of the metatarsals, talus, cuboid or navicular bones.
    Hypertrophied EHB muscle in athletes. Military equipment/boots
  • Release or decompression of the extensor retinaculum and any surrounding scar tissue
  • Neuroma – misnomer. MC location 2nd and 3rd metatarsals
  • Crunching or clicking while Compressing the forefoot in the mediolateral direction while palpating the affected space = Mulder’s click
  • Sx= Common digital n. transected