Is decompression of the common peroneal nerve and burying the nerve into the muscle medically necessary for a patient with a diagnosis of tarsal tunnel syndrome (TTS) of the left lower extremity (LLE)?

Medical Necessity Assessment for Common Peroneal Nerve Decompression in Tarsal Tunnel Syndrome

Decompression of the common peroneal nerve and burying the nerve into muscle is NOT medically indicated for a patient with tarsal tunnel syndrome of the left lower extremity, as this represents treatment of an anatomically distinct and unrelated nerve compression syndrome.

Anatomical and Clinical Mismatch

The fundamental issue here is a critical anatomical disconnect between the diagnosis and the proposed intervention:

• Tarsal tunnel syndrome involves compression of the posterior tibial nerve as it traverses the tarsal tunnel behind the medial malleolus, causing pain, numbness, and tingling in the plantar aspect of the foot 1, 2

• The common peroneal nerve is an entirely separate structure that branches from the sciatic nerve and courses around the fibular head laterally, with no anatomical relationship to the tarsal tunnel 3

• The patient's surgical history documents appropriate procedures for tarsal tunnel syndrome: tibial neurolysis, medial and lateral plantar neurolysis, and tarsal tunnel release 1

Clinical Presentation Analysis

The patient's current symptoms warrant careful interpretation:

• Continuous pain on the lateral aspect of the left heel with pain upon palpation of the surgical scar suggests either incomplete resolution of the original tarsal tunnel syndrome, scar neuroma formation, or a separate lateral heel pathology 1

• This lateral heel pain does NOT indicate common peroneal nerve pathology, which would typically present with dorsal foot pain, weakness of foot dorsiflexion/eversion, or sensory deficits in the first web space 4, 2, 5, 6

• The common peroneal nerve and its deep branch (which can cause anterior tarsal tunnel syndrome) are located on the dorsum of the foot and ankle, not the lateral heel 4, 2, 5, 6

Appropriate Diagnostic Pathway

Before any additional surgical intervention, the following evaluation is essential:

• Electrodiagnostic testing (EMG/NCS) to objectively document any nerve pathology and localize the specific nerve involved 5, 6

• Dynamic ultrasound examination to assess for nerve entrapment, neuroma formation at the surgical site, or peroneal tendon pathology (which could cause lateral heel pain) 3, 7

• MRI of the ankle and foot to evaluate for structural causes of persistent symptoms, including incomplete decompression, scar tissue, or alternative diagnoses 3, 1

Alternative Explanations for Lateral Heel Pain

The lateral heel pain following tarsal tunnel surgery more likely represents:

• Scar neuroma of the sural nerve or lateral calcaneal nerve branches, which were addressed in the original surgery but may have developed painful neuromas 1

• Incomplete decompression of medial calcaneal nerve branches that can refer pain laterally 1, 2

• Peroneal tendon pathology (tendinopathy, subluxation, or tear), which commonly causes lateral heel and ankle pain 3, 7

• Lateral plantar nerve entrapment (distal tarsal tunnel syndrome), which can present with lateral heel pain 2

Common Peroneal Nerve Decompression: When Actually Indicated

Common peroneal nerve decompression would only be appropriate if the patient demonstrated:

• Foot drop or weakness of ankle dorsiflexion/eversion 3, 8

• Sensory deficits in the dorsum of the foot or first web space 4, 5, 6

• Electrodiagnostic confirmation of common peroneal nerve compression at the fibular head 5, 6

• Pain localized to the lateral knee or dorsal foot, not the lateral heel 8, 4, 2

Critical Pitfalls to Avoid

• Operating on the wrong anatomical structure based on incomplete diagnostic workup will not address the patient's symptoms and exposes them to unnecessary surgical risks 3

• Assuming all lower extremity neuropathic pain after tarsal tunnel surgery represents a new nerve compression requiring additional decompression is inappropriate without objective confirmation 1

• Failure to obtain electrodiagnostic studies before revision or additional nerve surgery represents substandard care 5, 6

Recommendation

The request for common peroneal nerve decompression with diagnosis of tarsal tunnel syndrome is NOT medically necessary. The proposed procedure addresses an anatomically unrelated nerve and would not treat tarsal tunnel syndrome or its complications. Appropriate workup including electrodiagnostic studies, advanced imaging, and potentially diagnostic nerve blocks should be completed before considering any additional surgical intervention 1, 5, 6.