Nerve Entrapment (Peroneal)
As the sciatic nerve travels down the back of the thigh it splits into the peroneal and tibial nerves just above the knee. While the tibial nerve continues straight down the leg through the calf, the peroneal nerve wraps around the outside of the knee and continues down through the front of the lower leg. As the peroneal nerve wraps around the knee it passes under, through, or around several muscles, including the lateral hamstrings, soleus, and peroneal muscle group. Under normal circumstances, the peroneal nerve will move and slide along these muscles as the knee moves back and forth. However, If the peroneal nerve becomes compressed or stuck along any of these muscles if can become inflamed or injured, leading to pain on the outside of the knee. In some cases, the nerve can become damaged, and cause neurological symptoms (these would include tightness, burning, numbness, tingling, or muscle weakness) into the shin or top of the foot.
Signs and Symptoms of Peroneal Nerve Entrapment
- pain on the lateral aspect of the knee
- pain/tightness on the back of the leg above the knee
- tightness into the hamstrings
- pain or tightness is often present with walking, running, cycling, or climbing stairs
- the maybe tightness, burning, tingling, weakness, or numbness into the lower leg or top of the ankle
What Causes Peroneal Nerve Entrapment?
Peroneal Nerve Entrapment is an example of a repetitive strain injury. Unlike a traumatic injury which is caused abruptly following a trauma or accident, repetitive strain injuries (referred to as a RSI for short) are associated with very small amounts of tissue stress and damage that, if not addressed, can accumulate slowly over time and lead to pain (this is why it is often difficult to link these injuries back to a specific cause of event).
Here’s how this works….
As the knee is stressed and over-used it can lead to small scale damage in the surrounding muscles. This damage is referred to as ‘micro-trauma. Although only small this damage still needs to be repaired. The body does this by forming new tissue in and around the injured muscles. This new tissue, often referred to as scar tissue or soft tissue adhesions, is very sticky and acts to ‘glue’ the damaged tissues back together.
In some cases, this scar tissue can form in the muscles around the knee along the area(s) where the peroneal nerve is located. This will restrict the normal movement and sliding of the peroneal nerve on these muscles. When this happens the nerve can become damaged or irritated due to a stretch or traction injury (instead of sliding along the muscles the nerve will be pulled into an over-stretched position).
Why the hip and foot are important with Peroneal Nerve Entrapment
It is important to realize that many cases of peroneal nerve entrapment are actually caused by a problem at the hip or foot. If the muscles around these segments are not working properly it will affect the alignment and biomechanics of the knee. This will force the muscles around the knee to work harder during activities such as walking, running, climbing stairs, or with exercises at the gym. In many cases, this is what is causing the overload and excessive traction on the peroneal nerve in the first place. (“Do you want to know if your knee pain is linked to a problem at your hip or foot? Try a squat test, 1 leg squat test, or lunge test… click each test to find out more). If these issues are not resolved the peroneal nerve problem may not fully resolve, and will likely come back in the future.
Treatment – Resolving Peroneal Nerve Entrapment
The proper treatment of peroneal nerve entrapment must not only address problems with the peroneal nerve, but MUST also correct any biomechanical problems at the hip or foot as well (remember, these factors are often what is creating the overload at the knee and peroneal nerve in the first place).
For treatment to be effective we have found that there are certain steps that must be followed, and these steps must be performed in the right order if we are to expect the right results. Here is our approach when treating peroneal nerve entrapment in our clinic….
Step 1 – Resolve scar tissue adhesions and facilitate peroneal nerve sliding
The first step is to treat the scar tissue adhesions. As explained above, these adhesions are essentially gluing the peroneal nerve to the surrounding muscles, preventing the nerve from sliding around the knee.
Scar tissue adhesions do not resolve with stretching or traditional massage or soft tissue methods, but instead must be treated with specialized techniques. One of the most effective methods is to use a technique known as Active Release Techniques (ART). For those who are unfamiliar with this treatment method, ART is a new and highly successful hands-on treatment method that was specifically designed to identify and address scar tissue adhesions that are interfering with the normal movement of the body.
During an ART treatment, the practitioner will first shorten the muscle, tendon, ligament, or joint capsule and then apply a very specific tension with their hands as they stretch and lengthen the tissues. As the tissue lengthens the practitioner is able to assess the texture and tension of the tissue to determine if the tissue is healthy or contains scar tissue that needs further treatment. There are hundreds of specific ART protocols to treat the various muscles, tendons, ligaments, and nerves in the body, including the peroneal nerve.
Step 2 – Correct strength and flexibility
Simply treating the scar tissue adhesions will promote the normal health and sliding of the peroneal nerve, and will often result in a significant reduction in pain. In fact, it is not uncommon to see a significant improvement in just a few visits. However, although addressing the scar tissue frees the nerve and makes the muscles healthier, the muscles of the knee or leg may still be somewhat tight or weak. When this is the case-specific stretches or exercises can be incorporated into a home exercise/rehabilitation routine to help support in-office care. Initially, the focus is on correcting local muscle deficiencies (i.e., at the knee, hip, or foot).
Step 3 – Re-Train Functional Movement Patterns
The final stage with treatment is to ensure proper alignment and movement coordination of the foot, knee, hip, and trunk with functional movement patterns. This ensures movement of the hip, knee, and foot are coordinated and working together as a unit and the stress has been relieved from the peroneal nerve. This is what is required during real-life activities such as running, walking, cycling, and climbing stairs (the key functional movement patterns with respect to peroneal nerve entrapment/irritation include the squat, 1 leg squat, and lunge).
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