Disorders of the Nerves
Lower extremity peripheral nerve entrapments can occur frequently, but they can be underrecognized and certainly misdiagnosed when the presentation is atypical. Because pain is a subjective experience, the symptoms can be vague and may be referred. Thus, the scrutinizing examiner must have a keen awareness of these syndromes in obtaining a history. A thorough knowledge of peripheral nerve anatomy is essential in establishing the diagnosis. Radiographs might reveal bony or joint abnormalities that are contributing to the problems. The presence of more proximal lesions (double-crush phenomenon) and metabolic conditions should not be overlooked. Electrodiagnostic test results may be normal, but they can be useful to find or rule-out systemic or more proximal pathologies. In some patients, modifying footwear, wearing an orthosis, or altering activity can result in relief. Use of oral and topical medications can be helpful in managing the symptoms. In certain cases, injections may be both diagnostic and therapeutic. For recalcitrant cases, surgery may be indicated and usually gives satisfactory results when the diagnosis and contributing pathology is clear. In performing surgery, the risks of poor response remain, even in the best of hands. When a patient fails nerve release, revision release and transection of damaged nerves with careful burial in surrounding deeper tissues or into bone can be helpful. For those unfortunate patients who continue to suffer intractable nerve pain, the options include further nerve transection, nerve wrap, or other nerve-containment procedures, peripheral nerve stimulation (PNS), or spinal cord stimulation (SCS)..
