What is the treatment for peroneal neuropathy?

Treatment of Peroneal Neuropathy

The primary treatment for peroneal neuropathy involves specific padding to prevent pressure on the fibular head, avoidance of direct pressure on the nerve, and in refractory cases, surgical decompression may be necessary. 1

Etiology and Diagnosis

Peroneal neuropathy is the most common compressive neuropathy of the lower extremity 2. It typically presents with:

• Foot drop
• Pain in the lower extremity
• Numbness in the lateral leg and dorsum of foot
• Weakness in ankle dorsiflexion and eversion

Treatment Algorithm

1. Conservative Management (First-line)

• Protective Padding

  • Apply specific padding between the outside of the leg below the knee to prevent contact of the peroneal nerve at the fibular head with hard surfaces 3, 1
  • Avoid excessively tight or restrictive padding which may actually increase risk of neuropathy 3, 1

• Pressure Avoidance

  • Avoid prolonged pressure on the peroneal nerve at the fibular head 3
  • Avoid contact with hard surfaces or rigid supports near the fibular head 3

• Pharmacological Management

  • Gabapentin or pregabalin for neuropathic pain 1
  • Capsaicin cream for localized pain management 1

• Physical Therapy

  • Ankle-foot orthosis (AFO) for foot drop
  • Strengthening exercises for ankle dorsiflexors and evertors
  • Range of motion exercises

2. Interventional Approaches

• Percutaneous Electrical Nerve Stimulation

  • Should be considered for treatment of neuropathic pain 1

• Nerve Blocks

  • Diagnostic and potentially therapeutic

3. Surgical Management (For Refractory Cases)

• Microsurgical Decompression/Neurolysis
  • Indicated when conservative management fails
  • Studies show improvement in ankle dorsiflexion strength following neurolysis 4
  • Median postoperative Medical Research Council (MRC) score of 5 (from preoperative median of 1) 4
  • Low complication rate (infection 0.54%, wound dehiscence 0.27%, hematoma 0.54%) 4

Prognostic Factors

• Delayed treatment (>2 weeks) is associated with poorer outcomes 1
• Early recognition and treatment before development of foot drop leads to better outcomes 5
• Patients with obesity or traumatic causes may have less improvement after surgical decompression 5

Monitoring and Follow-up

• Perform regular postoperative assessment of extremity nerve function for early recognition of complications 3
• Monitor for improvement in motor function, particularly ankle dorsiflexion
• Assess pain levels using visual analog scale

Potential Pitfalls

• Inappropriate use of padding (too tight) may increase rather than decrease risk of neuropathy 3, 1
• Delayed diagnosis may lead to permanent nerve damage 2
• Failure to recognize peroneal neuropathy before foot drop develops 5

Early intervention is critical for preventing permanent nerve damage and optimizing functional outcomes in patients with peroneal neuropathy.