Lateral Knee Pain

Neurology

 

Back to Neurology

 

And back to neurology... But it's not that simple! There seems to be 2 areas of neurology that might be applicable to causing footdrop and the other problems that I have with my foot and gait... and I do believe that now, in 2015, both of these areas are relevant.

 

These 2 injuries are:

 

1. Lumbar Spine injury, such as a herniated disc, or spinal stenosis,

2. Peroneal Nerve injury, such as entrapment, resulting in problems like Foot Drop.

 

I can't explain why it is that now my good, left foot has feelings of numbness. This is in the same manner that my bad, right foot now also feels... they both feel as if they are covered with bandages that are tied up far too tightly around the foot! And I do in fact have more back pain than usual. Standing at the sink washing up, where I tend to stand leaning forward a minimal amount, will result in severe lower back pain. Likewise chopping up baby spinach leaves to include in soup, I also find that I am leaning very slightly forward, and lower back pain will follow. 

 

I am wondering whether this is a Lumbar Spine Injury. I have recently had a Lumbar Spine MRI scan but am yet to receive the results. I had had an earlier one, locally, in 2010, but the consultant said that he couldn't find anything that might affect my leg. I did suggest that it was Foot Drop and that I couldn't walk properly, but clearly his letter indicated that he didn't believe me... It seems to me now, however, that he may have been correct in determining that this was not a Lumbar Spine injury, but in fact was rather a Peroneal Nerve injury, but he did not investigate this route. 

 

This observation is important in determining the order in which events occurred in 2006:

1. Was it my flat feet that caused Foot Drop?

2. Foot Drop, can't walk properly.

3. Landing with bent knee, foot in plantar flexion and xxxxx rotation of the knee.

4. Anterolateral dislocation (subluxation) of the Proximal Tibiofibular joint.

5. Violent, violent, violent pain.

6. Pain at Fibular Head, initially on palpation, now mostly always.

7. Sharp, pulling pains that seem to stem from the lateral side of the proximal fibular head.

 

 

Lumbar Spine Injury

 

It did seem likely that this was a Lumbar Spine injury, that may, or may not, be related to the low bone density results I had had after my hysterectomy in 2005. But it does not show anything that may suggest lateral knee pain. Nevertheless it does show signs of osteoporosis.

 

This must be related to my back pain and tightness felt around both feet which have been noticeable during 2015 as opposed to the time of the injury, but perhaps not the 'cause'.

 

 

Peroneal Nerve Injury

 

Well, after Nerve Conduction Studies, it does seem that the nerves are OK, although I still need to wait for written confirmation and a further consultation with orthopedics.

 

I am reluctant to delete all the following links to articles about foot drop and nerve entrapment... because it seems to me that, if the nerves are functioning correctly, then the problems must arise from the muscles... which takes me back to the Proximal Tibiofibular Joint.

 

 

However, this link goes to a table that discusses all elements of the leg and foot, and might be handy for learning about muscles:

Anatomy Tables - Anterior and Lateral Leg and Foot

http://www.med.umich.edu/lrc/coursepages/m1/anatomy2010/html/musculoskeletal_system/leg_tables.html

(2011)

 

Nerve Entrapment Guide: Thigh / Leg / Foot Problems

https://www.teleemg.com/guides-info/nerve-entrapment-guide/peroneal-neuropathy/

(Website)

 

Evaluation of Foot Drop

http://www.medschool.lsuhsc.edu/neurosurgery/nervecenter/footdrop.html

(Website)

 

Foot Drop

http://emedicine.medscape.com/article/1234607-overview#a0156

(Website)

 

Foot drop is a deceptively simple name for a potentially complex problem. It can be defined as a significant weakness of ankle and toe dorsiflexion. The foot and ankle dorsiflexors include the tibialis anterior, the extensor hallucis longus, and the extensor digitorum longus. These muscles help the body clear the foot during swing phase and control plantar flexion of the foot on heel strike.

Weakness in this group of muscles results in an equinovarus deformity. This is sometimes referred to as steppage gait, because the patient tends to walk with an exaggerated flexion of the hip and knee to prevent the toes from catching on the ground during swing phase. During gait, the force of heel strike exceeds body weight, and the direction of the ground reaction vector passes behind the ankle and knee center (see the image below).

Diagram of ground reaction vector during heel strike.

This causes the foot to plantar-flex and, if uncontrolled, to slap the ground. Ordinarily, eccentric lengthening of the tibialis anterior, which controls plantar flexion, absorbs the shock of heel strike. Foot drop can result if there is injury to the dorsiflexors or to any point along the neural pathways that supply them.

Foot drop can be associated with a variety of conditions, including dorsiflexor injuries, peripheral nerve injuries, stroke, neuropathies, drug toxicities, or diabetes. The causes of foot drop may be divided into 3 general categories: neurologic, muscular, and anatomic. These causes may overlap. Treatment is variable and is directed at the specific cause (see Treatment).

 

Epidemiology

 

Peroneal neuropathy caused by compression at the fibular head is the most common compressive neuropathy in the lower extremity. Foot drop is its most notable symptom. All age groups are affected equally, but the condition is more common in males (male-to-female ratio, 2.8:1). About 90% of peroneal lesions are unilateral, and they can affect the right or the left side with equal frequency.

 

Proximal Tibiofibular Joint Injuries

http://www.wheelessonline.com/ortho/proximal_tibiofibular_joint_injuries

(Website)

 

Proximal Tibiofibular Joint Instability

http://drrobertlaprademd.com/proximal-tibiofibular-ligament-instability

(Website)

 

DESCRIPTION OF PROXIMAL TIBIOFIBULAR JOINT PAIN

The proximal tibiofibular joint is located between the lateral tibial plateau of the tibia, and the head of the fibula. Typically, the proximal tibiofibular joint is injured in a fall when the ankle is plantar-flexed, with the stress being brought through the fibula, will cause the proximal fibula to sublux (partial dislocation) out of place over the lateral aspect of the knee joint. In other circumstances, significant trauma or a motor vehicle accident can cause a disruption of the proximal tibiofibular joint. In most circumstances, it is the posterior proximal tibiofibular joint ligament that is injured. This results in the fibula rotating away from the tibia during deep squatting.

SYMPTOMS OF AN INJURED PROXIMAL TIBIOFIBULAR JOINT:

• Instability of the joint, especially during deep squatting

• Visible bony deformity

• Concurrent irritation of the common peroneal nerve, because the common peroneal nerve crosses the lateral aspect of the fibular neck within 2-3 cm of the lateral aspect of the fibular head

 

Traumatic proximal tibiofibular dislocation with neurovascular injury

http://www.ijoonline.com/article.asp?issn=0019-5413;year=2012;volume=46;issue=5;spage=585;epage=588;aulast=Veerappa

(2012)

 

Introduction

Traumatic proximal tibiofibular dislocation is often unrecognized or misdiagnosed at the initial presentation and is a potential source of chronic morbidity. [1],[2],[3],[4] The superior, anterolateral, and posteromedial dislocation, either isolated or associated with a fracture of the tibia or exceptionally with an ankle fracture, is described. Anterolateral dislocation is the most frequent variety and often associated with ligamentous injury and peroneal nerve palsy. Superior dislocation is very rare. [5] We report a case of inferolateral dislocation of the proximal tibiofibular joint, associated with popliteal artery transection and common peroneal nerve palsy. The associated vascular injury has not been previously reported. The peculiarity of the injury is that the disruption is extending down the interosseus membrane to the distal tibiofibular joint, homologous to the Essex Lopresti disruption in the forearm...

 

Discussion 

The proximal tibiofibular joint is the articulation between the fibula head and the inferior surface of the lateral condyle of the tibia. It is surrounded by a fibrous capsule and broad anterior and posterior ligaments. The joint is reinforced anteriorly by the biceps femoris tendon, inserting into the fibula head. Posteriorly, the popliteus tendon reinforces it. Additional support is gained from the fibular collateral ligament superiorly and inferiorly by the interosseous ligament. The joint is intimately associated with the common peroneal nerve, moving forward from the popliteal fossa around the fibula head. [6] The proximal tibiofibular joint is an inherently stable joint due to good ligamentous support. This is especially true when the knee is in extension, as the joint is protected by the surrounding ligaments. Typically, dislocation occurs when the knee is held in flexion and the foot is rotated and plantar flexed. [7] 

 

Peroneal Nerve Entrapment at Fibular Head (Knee), The Steadman Clinic

http://neckandback.com/conditions/peroneal-nerve-entrapment-at-fibular-head-knee/

(Website)

Peroneal Nerve Entrapment at Fibular Head (Knee)

This syndrome involves trapping of a peripheral nerve in a tunnel. These peripheral nerves are different from the nerves in the spinal canal (the radicular nerves) due to their “protective armor”, the epineurium and perineurium. This protective sheath makes the nerve less vulnerable to injury than the spinal nerves. Nonetheless, these nerves can be injured by stretch, impact and compression.

All of these entrapment syndromes are very similar in their pathology (the basic disorder that causes the problem). This pathology is compression of the nerve by a bone or tendon. The difference in each disorder is the nerve distribution (where the nerve travels and what it does) and whether this nerve contains only sensory nerves, only motor nerves or a combination of the two...

 

If the compressed nerve has strictly a pure sensory distribution, no motor weakness will be present and therefore no atrophy can occur. Atrophy only occurs when the muscle belly shrinks due to a lack of nerve supply.

However, pain inhibition can cause temporary muscle weakness in certain leg positions. This is not true muscle weakness but an actual subconscious reflex to prevent pain from occurring by subconsciously refusing to contract the muscle for fear of pain.

 

https://www.columbianeurosurgery.org/problems-and-treatments/nerve-entrapments/peroneal-neuropathy/

(Website)

This entrapment syndrome occurs when the common peroneal nerve is compressed along its course around the fibular head, a bony structure found on the lateral aspect of the leg just below the knee... Typically a single traumatic event... injures the peroneal nerve. A severe blow to the side of the knee, twisting the ankle (thus stretching the nerve), and prolonged recumbency with the knee against a hard surface are all common causes of peroneal nerve injuries in this location. These patients typically complain of pain in the lower leg, numbness on the top of the foot, and foot drop.

 

http://drrobertlaprademd.com/peroneal-nerve-entrapment

(Website)

PERONEAL NERVE ENTRAPMENT

Once it has been determined that the irritation of the common peroneal nerve is located at the fibular neck, one most commonly confirms this diagnosis on physical exam.  The common peroneal nerve can be palpated where it crosses the lateral aspect of the fibula about 2 centimeters distal to the fibular head.  In addition, about 3 to 4 cm proximal to this, it courses out from under the undersurface of the long head of the biceps femoris.  Therefore, the nerve can usually be palpated in most patients by the examiner rolling the nerve under one's fingers, where it crosses the lateral aspect of the fibular shaft. 

When one elicits a positive response to palpation or rolling of the common peroneal nerve at this location, one would anticipate that it would reproduce a "zinging"-type sensation down the lateral aspect of the leg and over the dorsum of the foot (a positive Tinel’s sign).  In most circumstances, there is no significant motor weakness, unless there has been a knee ligament dislocation or an injury to the posterolateral knee structures.  In any event, one should perform a thorough physical exam to validate that the main motor structures innervated by the common peroneal nerve are still intact.  This includes ankle dorsiflexion, EHL strength, total extension, and foot eversion strength. 

 

http://www.epainassist.com/sports-injuries/knee-injuries/peroneal-nerve-injury

 

Causes of Peroneal Nerve Injury:

• Fibular Fracture- Fracture of fibula causes knee joint injury and peroneal nerve laceration resulting in foot drop.1

 

General Symptoms Of Peroneal Nerve Injury Are:-

• Numbness or tingling on the anterior side or on top of the foot.

• Reduced sensation to touch.

• Weakness with lifting the foot in an upward direction and turning it outwards.

• Loss of function of the foot.

• Severe cases of peroneal nerve injury results in footdrop meaning the inability of a person to lift the foot up when ambulating.

• Presence of a slapping gait where the foot slaps on the ground during ambulation due to inadequate control over muscles.

• Symptoms of the peroneal nerve injury are similar to symptoms produced as a result of compression of the nerve at a level above usually at the nerve root.

 

http://drrobertlaprademd.com/images/stories/publication/anatomy-biomechanics-lateral-side-knee-surgical-implications.pdf

(2015)

Anatomy and Biomechanics of the Lateral Side of the Knee and Surgical Implications

 

Neurovascular

Structures Common Peroneal Nerve

The common peroneal nerve provides innervation to the lower extremity and is supplied by branches of L4-S2 spinal nerve roots. The common peroneal nerve emerges from a bifurcation of the sciatic nerve in the posterior aspect of the thigh, courses along the biceps femoris and around the neck of the fibula, and splits into the superficial and deep peroneal nerves. Sensory divisions of the common peroneal nerve include 2 articular branches, 1 recurrent articular nerve, and the lateral sural cutaneous nerve. Motor function of the nerve includes foot eversion and plantar flexion via innervation of the peroneus longus and peroneus brevis muscles, foot dorsiflexion and toe extension via the tibialis anterior, extensor hallucis longs, and extensor digitorum longus muscles, and intrinsic foot movements via the intrinsic muscles of the foot. During posterolateral corner procedures, a common peroneal nerve neurolysis is typically performed to minimize the risk of foot drop postoperatively due to swelling (Fig. 6). Common peroneal nerve neuropraxia has been reported due to hematoma formation at the fibular head after primary injury and is also a concern in cases where a postoperative hematoma leads to nerve compression.41