What is the treatment for a peroneal nerve injury?

Treatment for Peroneal Nerve Injury

The treatment for peroneal nerve injury should focus on early recognition, appropriate padding to prevent pressure on the nerve at the fibular head, and surgical intervention when conservative management fails to show improvement after 4-6 months. 1

Prevention and Early Management

• Specific padding to prevent pressure of hard surfaces against the peroneal nerve at the fibular head should be used to decrease the risk of peroneal neuropathy 1
• Avoid prolonged pressure on the peroneal nerve at the fibular head during positioning for procedures 1, 2
• Perform a simple postoperative assessment of extremity nerve function for early recognition of peripheral neuropathies 1
• Avoid inappropriate use of padding (e.g., padding too tight) as this may paradoxically increase the risk of neuropathy 1, 2

Conservative Treatment

• For mild peroneal nerve injuries, conservative management should be initiated with the following components:
  • Functional treatment focusing on proprioception, muscle response time, and muscle strength 1
  • Supervised exercises targeting proprioception, strength, coordination, and function to lead to faster recovery 1
  • Use of a brace and immediate functional treatment to speed up return to work or activities 1
  • Regular monitoring for signs of recovery within the first 4-6 months post-injury 3, 4

Surgical Intervention

• If spontaneous recovery has not occurred within 4-6 months after injury, surgical intervention should be considered 3, 5
• Surgical options should be selected based on the nature of the injury:
  • Neurolysis for nerve compression with continuity (89% recovery rate to useful function) 3, 4
  • Direct end-to-end suture repair for clean lacerations (82% recovery to Grade 3 or better) 3, 4
  • Nerve grafting for gap injuries (success rates vary by graft length: 75% for grafts <5.5cm, 35% for 6-12cm, and only 14% for 13-20cm) 3, 5
  • Nerve transfers as an alternative to grafting in select cases (62.9% success rate) 5
  • Posterior tibial tendon transfer for persistent functional deficits (81.5-84.2% success rate) 5

Prognostic Factors

• Better outcomes are associated with:
  • Shorter preoperative interval between injury and surgical intervention 5, 4
  • Shorter graft length when an interposed graft is used 3, 5
  • Nerve continuity 5
  • Younger patient age 5
  • Early detection and intervention 1, 6

Rehabilitation and Follow-up

• Early electrodiagnostic studies are helpful to localize and provide indications of the severity of the injury 6
• Regular assessment of peroneal nerve function should be conducted in all patients with risk factors, including those with ankle sprains 6
• Rehabilitation should focus on proprioception, strength, coordination, and functional exercises 1
• Complete recovery may take up to 4 months for mild cases with conservative management 6
• For surgical cases, follow-up should continue for at least 24 months to monitor recovery 3, 4

Common Pitfalls and Caveats

• Delayed diagnosis is common and can lead to poorer outcomes; always assess peroneal nerve function in patients with relevant injuries 6
• Inappropriate padding can increase rather than decrease the risk of neuropathy 1, 2
• Nerve grafts longer than 12cm have poor outcomes (only 14% recovery to Grade 3 or better) 3, 5
• Functional recovery after surgical intervention may take up to 48 months, with neurolysis and direct suture having better outcomes than nerve grafting 4