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General Rehabilitation

(Kiosk 1) A Case of Peroneal Neuropathy Following Prolonged Hospitalization

Friday, November 17, 2023
12:00 PM – 1:45 PM CT

    Primary Author(s)

  • Emily Sears

    Medical Student, OMS-IV
    AT Still University School of Osteopathic Medicine
    Denton, Texas

    • Co-Author(s)

  • Saloni Tandon, OMS-IV (she/her/hers)

    Medical Student, current PM&R applicant
    University of North Texas HSC Fort Worth Texas College of Osteopathic Medicine
    Katy, Texas

  • PC

    Patricia Colucci, DO

    Physician
    Baylor University Medical Center PM&R Program
    Dallas, Texas

  • OS

    Omar F. Selod, DO

    Doctor of Osteopathic Medicine
    n/a
    Fort Worth, Texas

Case Diagnosis: Patient presents with peroneal neuropathy and underlying lumbar radiculopathy.

Case Description: 81-year-old male with prior lumbar laminectomy presented with right-sided foot drop following prolonged hospitalization. He reported right calf cramping and ankle weakness. Examination included 0/5 right great toe extension, 0/5 ankle dorsiflexion and right 1+ patellar reflex. Magnetic Resonance Imaging (MRI) of the lumbar spine revealed severe bilateral foraminal narrowing at L5-S1, possible new left L5 nerve impingement and hemilaminectomy.

Discussion: Diagnosing peroneal neuropathy in the setting of multilevel radiculopathy is difficult. This patient’s known radiculopathy and history of laminectomy with new MRI findings further clouded the picture. The motor branch proximal to the fibular head helped localize the lesion. Demonstrated drop in velocity across the fibular head compared to the symptom-free side led us to conclude that peroneal entrapment at the fibular head coincided with lumbosacral radiculopathy.

Setting: Outpatient PM&R clinic

Assessment/Results: Nerve conduction studies (NCS) were pertinent for no response with stimulation and pickup at the right extensor digitorum brevis (EDB). After moving the pickup to tibialis anterior (TA), NCS demonstrated a drop in conduction velocity and amplitude when stimulating above versus below the fibular head. Contralaterally, there was a mild drop across the fibular head. With examination findings, NCS disparities between sides favored entrapment neuropathy.

Electromyography (EMG) suggested chronic denervation at multiple levels including TA, peroneus longus and the medial gastrocnemius. The right short head of biceps femoris demonstrated 2+ polyphasic potentials and a 1+ reduced pattern. Additional EMG findings suggested underlying polyradiculopathy. The summation of evidence demonstrated severe peroneal neuropathy with acute and chronic multilevel lumbosacral radiculopathy.

Conclusion: Teasing out isolated mononeuropathies with background polyradiculopathy requires thoughtful history taking, advanced imaging and specific muscle testing. Not one modality can determine the diagnosis. The patient was referred to physical therapy, neurosurgery and supplied ankle foot orthosis. MRI of the right knee is pending.