Neuropathy is a term used to describe any problem related to the nerves. Most problems in the legs are considered peripheral nerve problems meaning the CNS is not involved but in the legs themselves. Sometimes the lower back can contribute to the pain or neurologic symptoms in the leg and acts as a “double” crush. Think of nerves as a garden hose and the spigot is the spine and at the end of the hose are the toes. Any kink or “crush” of that hose/nerve will cause some damage and there can be multiple crushes, which can make things more difficult to achieve a successful treatment outcome. Diabetics are more prone to neuropathy and should be monitored regularly because if there is loss of sensation this can lead to ulcer, infection and even loss of limb. Many cases of neuropathy are often called idiopathic. This term means that there is no known cause. In most cases, this is NOT the case. Usually, there is an entrapment or compression of the nerve(s). A nerve entrapment can be easily identified by a peripheral nerve surgeon, when present in the leg. Dr. Bregman and Dr. Ricciardi have been specially trained to diagnose and treat these problems. Many times other doctors will not be able to diagnose these nerve entrapments and often, special studies such as MRI or nerve conduction studies will not identify the problems. Also, if there is a history of carpal tunnel or arm nerve problems then it is more likely to be present in the legs.
Common sites of nerve entrapments in the legs:
- Tarsal Tunnel – this is like carpal tunnel in the wrist. The nerves on the inside of the ankle become stretch and compressed. This can be aggravated by flat, or hyper-pronated feet. The medial calcaneal nerve is also present here and can be a problem.
- Common Fibular Nerve – this is a nerve behind the head of the fibula near the knee. It is prone to entrapment and can also cause lower back pain and restless leg syndrome symptoms. Cramping in legs can also be present.
- Superficial Fibular Nerve – this is a branch of the common fibular nerve that is in the anterior-lateral leg and extends over the ankle into the foot. It is often injured in sports or ankle fractures but can also be a problem in athletes.
- Tibial Nerve – this nerve starts in the back of the knee and continues behind the calf muscles and eventually turns into the tarsal tunnel. Cramping is often present in the calf area.
- Deep Peroneal Nerve – this nerve is present on the top of the foot just below the ankle and can often be a problem with shoes or if there is a spur present near it.
- Saphenous and Sural Nerves – these are purely sensory and run on the inside and outside or the leg respectively. They can be injured during any surgery or injury.
Treatment if neuropathy/entrapments:
First, the proper diagnosis of the problem is made by a combination of the history, exam, and diagnostic testing. Many times there can be hormonal imbalances or other medical issues. Blood tests will often be ordered, and also a 3mm biopsy of the skin on the leg is often needed to rule out small fiber neuropathy, which is another kind of neuropathy. Diagnostic local anesthetic blocks are used to help isolate the involved nerves. In 70% of entrapment cases, surgical decompression is the treatment of choice in the other 30% they can respond to specialized physical therapy known as nerve gliding or nerve flossing. Topical prescription creams are also used to help with pain. In some cases, prescription vitamins are also prescribed as well as other medication to help deal with the pain of neuropathy. Most of the nerve surgeries are fairly quick surgeries and the patient is back to regular activity in a few weeks. Dr. Bregman is the only physician performing endoscopic tarsal tunnel surgery and teaches other doctors on the technique.