What is the treatment for peroneal nerve palsy?

Treatment of Peroneal Nerve Palsy

The treatment of peroneal nerve palsy should begin with conservative management for at least 2 months, followed by surgical decompression if no improvement occurs, as operative treatment has shown 97% improvement compared to only 33% with continued non-operative management. 1

Initial Assessment and Conservative Management

Clinical Evaluation

• Assess for foot drop (inability to dorsiflex the ankle)
• Evaluate sensation over the dorsum of the foot and lateral lower leg
• Check for weakness in eversion of the foot
• Determine the cause (compression, trauma, metabolic, etc.)
• Consider electrodiagnostic testing and MRI to confirm diagnosis and identify site of compression 2

Conservative Treatment (First 2 Months)

1. Ankle-Foot Orthosis (AFO)

   • Provides immediate functional improvement
   • Prevents equinus contracture
   • Improves gait mechanics 3

2. Physical Therapy

   • Neurodynamic mobilization techniques
   • Manual therapy including soft tissue work of psoas and hamstring muscles
   • Spinal and fibular head manipulation 2
   • Range of motion exercises to prevent contractures
   • Strengthening exercises for remaining functional muscles

3. Pain Management

   • For neuropathic pain, consider:
     • Gabapentin or pregabalin (first-line options)
     • Duloxetine for persistent pain 4

Surgical Management

Indications for Surgery

• No improvement after 2 months of conservative treatment
• Progressive neurological deficit
• Severe functional disability 1

Surgical Options

1. Nerve Decompression

   • Indicated for compression at fibular head
   • Releases fibrous bands and epineurial fibrosis
   • 97% success rate in restoring function 1

2. Tendon Transfer

   • For chronic cases without recovery
   • Posterior tibial tendon transfer can restore ankle dorsiflexion 3

3. Nerve Repair or Grafting

   • For transection injuries
   • Direct repair if possible
   • Autologous nerve grafting for larger defects

4. Neurotization

   • For high common peroneal nerve injuries
   • Transfer of nerves to soleus and lateral gastrocnemius to anterior tibial nerve
   • Best results when performed within 8 months of injury 5

Follow-up and Monitoring

• Regular neurological examinations to assess recovery
• Monitor for improvement in muscle strength and sensation
• Assess functional improvement in gait pattern
• Consider repeat electrodiagnostic studies to document recovery

Special Considerations

• Bilateral peroneal nerve palsy is rare but can occur with prolonged immobility or sitting 6
• Adolescents may develop peroneal nerve palsy from prolonged sitting in certain positions 6
• Injection injuries in the gluteal region can cause high common peroneal nerve palsy 5

Treatment Algorithm

1. Weeks 0-8: Conservative management with AFO, physical therapy, and pain management
2. Week 8: Reassess progress
   • If improving: Continue conservative management
   • If no improvement: Consider surgical decompression
3. 3-6 months post-injury: If no recovery despite decompression, consider tendon transfer
4. Long-term: Continue strengthening exercises and monitor for functional improvement

The evidence strongly supports early surgical intervention if conservative management fails to produce improvement within 2 months, as this significantly improves outcomes compared to prolonged non-operative treatment 1.