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THE MOST FREQUENT CANALICULAR SYNDROMES OF THE LOWER LIMB

MERALGIA PARESTHETICA

FOR SCIENTIFIC AND INFORMATIONAL PURPOSES, CLICK HERE TO EXIT THIS WEBSITE AND CONNECT TO THE YOUTUBE CHANNEL OF PROFESSOR NABIL A. EBRAHEIM FROM THE UNIVERSITY OF TOLEDO, OHIO (USA) AND WATCH AN EDUCATIONAL VIDEO ON MERALGIA PARESTHETICA, IN ENGLISH.
In the box below you can read the Italian translation of the English text from the video.

THIS VIDEO IS MADE FOR EDUCATIONAL PURPOSES ONLY. PLEASE CONSULT YOUR DOCTOR BEFORE MAKING DECISIONS ABOUT CARE.

TRANSLATION FROM ENGLISH OF THE TEXT PRESENT IN THE ABOVE EDUCATIONAL VIDEO ON MERALGIA PARESTHETICA

The animated educational video by Prof. Ebraheim describes meralgia paresthetica.

Meralgia paresthetica causes a sensation of pain or burning that appears in the anterolateral part of the thigh and is usually caused by compression of the lateral femoral cutaneous nerve (LFCN). Wearing super tight jeans can cause compression of the LFCN. Usually, the patient complains of tingling, numbness, and pain, as well as altered touch sensitivity in the area of skin innervated by the LFCN (the outer part of the thigh). There will be tactile hypersensitivity in the anterolateral part of the thigh, and the patient will sometimes notice this altered sensitivity when putting their hands inside the pocket, e.g., to get the car keys.

Causes of meralgia paresthetica are tight pants, belts, corsets, obesity, weight gain, pregnancy, local trauma, and diabetes. The injury is usually caused by compression of the nerve as it passes under the inguinal ligament.

Anatomy of the LFCN: the nerve arises from branches of the L2 and L3 nerve roots. Variations in the course of the LFCN in the area of the anterior superior iliac spine (ASIS) can cause entrapment of the nerve near the iliac crest, causing meralgia paresthetica.

The LFCN can be damaged during bone graft harvesting from the anterior iliac crest, in the ilio-inguinal approach for acetabular fixation, in the application of an external pelvic fixator, in total hip replacement with the anterior approach or the Smith Peterson approach.

The LFCN usually passes under the inguinal ligament about 2 cm medially to the ASIS. Once out of the pelvis, the nerve divides and pierces the fascia, running in the lateral part of the thigh in the subcutaneous region and is located superficially to the Sartorius muscle. The course of the LFCN in the ASIS area is variable: under the ligament, over the ligament, over and under the ligament, and over the iliac crest. These variations can cause nerve entrapments near the iliac crest, causing meralgia paresthetica. Recognizing the variability and relationship of this nerve and its branches is important to avoid nerve injury. It is difficult to establish a safe zone for the nerve during surgical approaches to the acetabulum or proximal femur.

Disc herniation affecting the L2-L3 nerve roots can also cause meralgia paresthetica. Consider spinal pathology when meralgia paresthetica is present.

Signs of meralgia paresthetica include burning, tingling sensation, hypersensitivity to heat where hot water seems to burn the skin. The condition is usually diagnosed by the patient describing the symptoms in the thigh area. Some people say it is an elusive or obscure diagnosis for many doctors and may be undiagnosed or overlooked, but if marked it can lead to significant disability. Meralgia paresthetica could be confused with other disorders. Doctors may think it is a problem with the hip, groin, abdominal, or iliotibial band. This can cause misdiagnosis and may lead the patient to other unnecessary treatments.

Conservative treatment: physical therapy, anti-inflammatory drugs, weight loss, strengthening of abdominal muscles, avoiding wearing tight clothing and tight bands around the pelvis.

Steroid injection: ultrasound guidance for steroid injection is better than blind injection. The injection can be diagnostically and therapeutically helpful in diagnosis.

Surgical treatment: surgery is performed only in severe cases. Surgery is the last resort of treatment.

THIS VIDEO IS MADE FOR EDUCATIONAL PURPOSES ONLY.

PLEASE CONSULT YOUR PHYSICIAN BEFORE MAKING CARE DECISIONS.

TARSAL TUNNEL SYNDROME

FOR SCIENTIFIC AND INFORMATIONAL PURPOSES, CLICK HERE TO LEAVE THIS WEBSITE AND CONNECT TO THE YOUTUBE CHANNEL OF PROFESSOR NABIL A. EBRAHEIM FROM THE UNIVERSITY OF TOLEDO, OHIO (USA) AND WATCH AN EDUCATIONAL VIDEO ON TARSAL TUNNEL SYNDROME, IN ENGLISH.
In the box below you can read the Italian translation of the English text from the video.

THIS VIDEO IS MADE FOR EDUCATIONAL PURPOSES ONLY. PLEASE CONSULT YOUR PHYSICIAN BEFORE MAKING ANY DECISIONS ABOUT YOUR CARE.

TRANSLATION FROM ENGLISH OF THE TEXT PRESENT IN THE ABOVE EDUCATIONAL VIDEO ON TARSAL TUNNEL SYNDROME

The educational animated video by Dr. Ebraheim describes tarsal tunnel syndrome.
The tarsal tunnel is a fibro-osseous tunnel located posterior and inferior to the medial malleolus. The tunnel is covered by the flexor retinaculum, which protects the structures contained within the tunnel. The flexor retinaculum is a thick ligament that runs between the medial malleolus and the calcaneus.
The structures that pass through the tunnel include the posterior tibialis, the flexor digitorum longus, the posterior tibial artery, the tibial nerve, and the flexor hallucis longus. The tibial nerve is located between the posterior tibial artery and the flexor hallucis longus.
Tarsal tunnel syndrome is a compression neuropathy caused by compression of the posterior tibial nerve within the tarsal tunnel. Tarsal tunnel syndrome is the most common compression neuropathy in the ankle and foot. Thickening of the flexor retinaculum can cause compression of the posterior tibial nerve.
The causes in 80% of cases are related to a specific cause such as a space-occupying lesion like a lipoma or ganglion, varicose veins, muscle anomalies, history of trauma, tenosynovitis, rheumatoid arthritis, diabetes, or misaligned foot.
Symptoms of tarsal tunnel syndrome include burning, numbness, tingling, electric shock sensation typically around the ankle or on the bottom of the foot (plantar surface of the foot). Symptoms are worse with activities such as walking, standing, or running. Tarsal tunnel symptoms are relieved with rest and elevation. Pain associated with tarsal tunnel syndrome may worsen at night. There may be swelling around the ankle and foot.
The patient will have a positive compression test and a positive Tinel's sign. Tapping the nerve posterior to the medial malleolus causes radiating pain in the medial part of the ankle and may reach the foot.
Pressure inside the tarsal tunnel increases with dorsiflexion of the ankle and eversion of the foot. This can reproduce the symptoms. Pain associated with tarsal tunnel syndrome radiates proximally and distally.
The tarsal tunnel can present as part of the heel pain triad that occurs in adults. The heel pain triad includes tarsal tunnel syndrome, plantar fasciitis, and acquired flatfoot deformity.
The diagnosis is a combination of history, examination, electromyography (EMG), and nerve studies that can lead to the diagnosis (history is the most useful exam, EMG is accurate in about 80-90%). The dorsiflexion-eversion test can be useful in diagnosing tarsal tunnel. Sensory nerve conduction studies are more useful than motor studies (EMG). Radiculopathy should always be ruled out.
X-rays and CT scans can show a bony conflict or a fracture of the posteromedial process of the talus. MRI can show a space-occupying lesion such as a ganglion cyst or a lipoma.
The differential diagnosis includes peripheral neuropathy involving all nerves, not just the tibial nerve. The sural nerve and saphenous nerve are also involved and there will be an absent Achilles reflex.
Treatment includes immobilization, anti-inflammatory drugs, and steroid injections. The patient may use an orthosis if they have a valgus foot.
If conservative treatments fail after 3-6 months, surgical treatment is considered, which may include the following procedures: releasing the fascia proximal to the flexor retinaculum, cutting the flexor retinaculum, identifying the tibial nerve proximal to the tunnel and decompressing the nerve and its three branches, decompressing the entire tunnel for 5 cm proximally to the flexor retinaculum and distally to the deep fascia of the abductor hallucis, distal release of Baxter's nerve is usually performed if the patient has chronic pain in the medial plantar part of the heel (heel pain is rare in tarsal tunnel), decompressing Baxter's nerve by cutting the deep fascia of the abductor hallucis, removing the space-occupying mass.
The best results occur if symptoms have been present for less than a year. A positive outcome occurs in about 50-90% of cases. The best result occurs if the patient has a space-occupying lesion with positive neurological exam and EMG. Suboptimal results may occur due to traction neuritis from inadequate decompression and in repeat surgical treatment of the tarsal tunnel. In these situations, the patient will not respond well to surgery (always rule out Double Crush Syndrome).
Surgical revision has a less effective outcome unless the patient has inadequate nerve decompression.
When there is recurrence of tarsal tunnel syndrome, it is generally not advisable to repeat surgical treatment except in the case of inadequate nerve decompression. In general, tarsal tunnel decompression may not produce a good long-term result.

THIS VIDEO IS MADE FOR EDUCATIONAL PURPOSES ONLY.

PLEASE CONSULT YOUR PHYSICIAN BEFORE MAKING CARE DECISIONS.

PERONEAL NERVE PARALYSIS

The peroneal nerve (or external popliteal sciatic nerve) passes on the outer side of the knee where it becomes superficial and is contiguous to the neck of the fibula, the long outer bone of the leg, and is easily subject to compression.

An injury to the peroneal nerve can cause altered sensation, paresthesia (tingling) or pain in the lateral part of the leg, difficulty or inability to lift, dorsiflex, the foot and toes, so the foot tends to drop down, FOOT DROP.

The appearance of ganglion cysts can be other causes of paralysis; surgical treatment must include closure of the articular branch to avoid recurrences.

The differential diagnosis of foot drop must be made with other pathological situations that do not fall within the canalicular syndrome, as is excellently explained in Dr. Ebraheim's video.

DIFFERENTIAL DIAGNOSIS IN FOOT DROP

FOR SCIENTIFIC AND INFORMATIONAL PURPOSES, CLICK HERE TO LEAVE THIS WEBSITE AND CONNECT TO THE YOUTUBE CHANNEL OF PROFESSOR NABIL A. EBRAHEIM FROM THE UNIVERSITY OF TOLEDO, OHIO (USA) AND WATCH AN EDUCATIONAL VIDEO IN ENGLISH.
In the box below you can read the Italian translation of the English text from the video.

THIS VIDEO IS MADE FOR EDUCATIONAL PURPOSES ONLY. PLEASE CONSULT YOUR DOCTOR BEFORE MAKING ANY HEALTHCARE DECISIONS.

TRANSLATION FROM ENGLISH OF THE TEXT PRESENT IN THE ABOVE EDUCATIONAL VIDEO ON DIFFERENTIAL DIAGNOSIS IN FOOT DROP

Dr. Ebraheim's educational animated video describes the condition known as foot drop, which occurs due to an injury to the peroneal nerve. The causes and treatment of peroneal nerve injury are described. What is foot drop? The inability to lift the front part of the foot due to weakness or paralysis of the anterior tibialis muscle that lifts the foot. A common symptom of foot drop is a high-stepping gait, often characterized by exaggerated flexion of the thigh while walking. When a person with foot drop walks, the foot "slaps" the floor. Foot drop usually results from an injury to the peroneal nerve, which is susceptible to injury at any point along its course. The peroneal nerve starts from the nerve roots L4, L5, S1, and S2 and joins the tibial nerve to form the sciatic nerve. The sciatic nerve starts in the lower back and passes through the buttock and lower limb. In the lower part of the thigh, just above the back of the knee, the sciatic nerve divides into two nerves, the tibial nerve and the peroneal nerve, which innervate different parts of the lower leg.

The common peroneal nerve curves forward, around the neck of the fibula bone, dividing into the superficial and deep peroneal nerves. The deep peroneal nerve innervates the anterior tibialis muscle of the lower leg, which is responsible for dorsiflexion of the foot. Conditions that cause foot drop:

1- An L4-L5 disc herniation that compresses the L5 nerve root can cause foot drop. Plexus injury.

2- Pelvic fracture with lumbosacral plexus injury.

3- Sciatic nerve injury from hip dislocation. The peroneal part of the sciatic nerve is commonly traumatized in hip fractures/dislocations.

4- Knee injury: in case of knee dislocation, it is important to check for common peroneal nerve and popliteal artery injuries.

5- Compartment syndrome. Foot drop is a late finding. Irreversible muscle and nerve ischemia occurs in patients if fasciotomy is not performed. Fasciotomy must be performed early; 4 hours of ischemia can be tolerated, but after 8 hours the damage is often irreversible.

Treatment of peroneal nerve injury / foot drop:

• If a herniated disc in the lower back affects the nerve and causes symptoms of foot drop, then the herniated disc must be treated or removed.

• Obtain EMG and nerve studies of the patient.

• Recovery may take from 1 year to 18 months.

• Movement of the big toe is the last to recover.

• If no recovery is obtained, surgically explore the nerve for repair, grafting, or tendon transfer.

LAST MODIFIED 26 APRIL 2020

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