COMPRESSIVE NEUROPATHIES OF THE FOOT

AND ANKLE
DONALD E. BAXTER, MD

Subtle compressive neuropathies of the foot and ankle can cause weakness in the foot that affects athletic
performance, especially iri runners or jumpers. Detection of these syndromes requires a knowledge of the
sensory distribution and anatomic course of the peripheral nerves in the foot and ankle. Most compressive
neuropathies can be treated with standard conservative measures; however, if chronic pain causes significant
disability, surgical treatment may be indicated.
KEY WORDS: entrapment syndromes, interdigital neuroma, tarsal tunnel syndrome, treatment

Tarsal tunnel syndrome usually produces burning,
aching, and cramping sensations in the forefoot as well as
plantar pain and paresthesia. These symptoms often
are a§gravatedby activity, but night pain also may oc-
cur.!: Etiologies of tarsal tunnel syndrome include
tenosynovitis of the posterior tibial tendon, varicosities,
benign tumors, bony impingment of the medial aspect of
the talus, postural tension on the nerve from excessive
pronation of the foot, and fibrosis surrounding the pos-
terior tibial nerve behind the medial malleolus.f The im-
portance of careful examination is illustrated by the ath-
lete who came to my office with typical symptoms of
tarsal tunnel syndrome. Compression of the nerve be-
hind the medial malleolus produced pain that radiated in
a fashion typical of tarsal tunnel syndrome. However,
nerve conduction studies showed that the compression
was in the deep posterior compartment at the lower edge
of the gastrocnemius. The symptoms resolved after re-
lease of the deep posterior compartment.
Tarsal tunnel syndrome distal to the medial malleolus
can be caused by isolated compression of either the me-
dial or lateral plantar nerves or by compression of both
nerves by the superior aspect of the abductor hallucis
muscle fascia (Fig 1). Most frequently the medial plantar
nerve is compressed at the knot of Henry ("jogger's
foot'": Fig 2). Symptoms include "giving way" of the
foot, radicular pains, and instability. Careful physical
examination is essential for diagnosis of distal tarsal tun-
nel syndrome. Often the athlete has a history of ankle
sprain or hypermobility at the talonavicular joint that
causes excessive migration of the navicular OJ} the head of
the talus and stretches the medial plantar nerve at the
knot of Henry. One of our patients, a world-class run-
ner, had vague foot pain that had persisted for 3 years
and that caused his foot to give way on the second or
third lap of a fast race. Careful examination suggested a
compressive disorder in the medial foot in the area of the
From Baylor College of Medicine, Houston, TX.
Address reprint requests to Donald E. Baxter, MD, 7500 Beechnut
St, No. 175, Houston, TX 77074.
Copyright © 1994 by W. B. Saunders Company
1060-1872/94/0201-0003$05.00/0
medial plantar nerve, and release allowed the runner to
return to world competition. Etiological factors in this
athlete were instability of the talonavicular joint from a
previous lateral ankle and subtalar strain and hyperflex-
ibility of the midfoot and subtalar joints.
Treatment
Initial treatment for tarsal tunnel syndrome at the ankle
and distally is conservative, including the use of a longi-
tudinal arch support or a medial sale and heel wedge
built into the athletic shoe.f This medial wedge should
be no more than 3/16-inch thick. The longitudinal arch
support or medial wedge functionally inverts the foot,
taking some of the stretching effect away from the tibial
nerve and its branches. The longitudinal arch support
also may eliminate the knifelike pinching of the medial
plantar nerve at the knot of Henry.
If problems persist despite a decrease in activity and
support of the medial foot structures, nerve conduction
studies should be performed. I -3•s Conduction should be
tested across the tarsal tunnel at the ankle. The medial
and lateral nerves also should be tested to determine if a
distal tarsal tunnel syndrome is present. Nerve testing
also will determine if neuritis or a double-crush syn-
drome (pressure on the nerve in two places) exists.
If nerve conduction studies suggest nerve compression,
surgical release should be considered, but only after con-
servative measures have failed.
Technique
With the use of a regional anesthetic at the ankle, a small
incision no longer than 3 or 4 inches is made behind the
medial malleolus to allow release of the tibial nerve.
Release of the superior edge of the abductor muscle and
the deep fascia underneath the abductor hallucis muscle
is imperative, because this is the area in which the tibial
nerve is most commonly entrapped.
If a more distal tarsal tunnel syndrome exists at the
knot of Henry, a more isolated release of the medial plan-
tar nerve is carried out. Usually, if compression is iso-

18 Operative· Techniques in Sports Medicine, Vol 2, No 1 (January), 1994: pp 18-23


Posterior tibial n.
Medial plantar n.
Nerve to abductor digiti
quinti muscle
Distal entrapment
Lateral plantar n.
Fig 1. The tarsal tunnel. (Reprinted with permission from
Baxter DE: Functional nerve disorders in the athelete's foot,
ankle, and leg. AAOS Instruct Course lect 42:185-194,1993.)
lated, some of the fat in the area will be compressed and
cause an indention on the nerve. I do not strip the re-
maining fat from the nerve but simply decompress the
tight fascial structures from the nerve in the medial aspect
of the superior abductor hallucis muscle fascia.
Rarely, the medial plantar nerve may be entrapped as it
exits the distal abductor muscle before it migrates under-
neath the tibial sesamoid. Entrapment at this location is
difficult to diagnosis with electro diagnostic studies, and
diagnosis usually depends on clinical examination. A
more proximal lesion and double-crush syndrome (such
Posterior tibial n.
Fig 2. Medial planar nerve entrapment. (Reprinted with per-
mission from Baxter DE: Functional nerve disorders in the
athelete's foot, ankle, and leg. AAOS Instruct Course lect
42:185-194, 1993.)
COMPRESSIVE NEUROPATHIES
as a lower back disorder) should be ruled out before mak-
ing this diagnosis. If entrapment is present in this area,
release of the distal abductor muscle in the area of nerve
exit will eliminate symptoms.
ENTRAPMENT OF THE FIRST BRANCH
OF THE LATERAL PLANTAR NERVE
Another common compression syndrome is caused by
entrapment of the first branch of the lateral plantar nerve
underneath the proximal portion of abductor hallucis
muscle in the heel 6 ,7 (Fig 3). This is a mixed nerve with
both sensory and motor fibers that ultimately innervates
the abductor digiti quinti muscle. It most commonly is
entrapped where it migrates over the sharp edge of the
quadratus plantae medially and underneath the tight fas-
cia of the abductor hallucis muscle (Fig 4). Pronation of
the foot, thickening of the plantar fascia, or bony forma-
tion within the proximal portion of the flexor brevis mus-
cle can compress the nerve and cause neurogenic syxnp-
toms. Pain usually occurs on the medial aspect of the
heel at the origin of the plantar fascia and migrates prox-
imally up into the ankle and across the inferior heel into
the distal lateral aspects of the foot. Application of com-
pression produces a characteristic pain along the medial
heel structures, especially under the abductor hallucis
muscle.
Treatment
This syndrome usually responds to conservative treat-
ment, including appropriate longitudinal arch support
and heel padding, stretching of the Achilles tendon and
plantar fascia, and decreased activity." If neurogenic
pain persists despite 12 months of conservative treat-
ment, decompression of the nerve should be considered.
ENTRAPMENT OF THE DEEP
FERONEAL NERVE
The deep peroneal nerve passes deep to the superior and
inferior retinaculum and bifurcates into medial and lateral
terminal branches. Compression of the deep peroneal
Fig 3. Release of the deep fascia of the abductor hallucls
muscle. (Reprinted with permission from Baxter DE: Func-
tional nerve disorders In the athelete's foot, ankle, and leg.
AAOS Instruct Course lect 42:185-194,1993.)
19

Posterior tibial n.
Abductor Nerve to abductor digiti
hallucis m. Heel spur quinti muscle
Fig 4. Branches of the posterior tibial nerve. (Reprinted with
permission from Baxter DE: Functional nerve disorders in
the athelete's foot, ankle, and leg. AAOS Instruct Course Lect
42:185-194, 1993.)
nerve causes pain, numbness, or paresthesia in the first
web space, discomfort at the site of compression, and
often night pain. The usual site of compression is be-
neath the taut inferior extensor retinaculum, but the
nerve may be compressed anywhere along its course by
an osteophyte, a ganglion, or an accessory ossicle (Fig 5).
Local trauma is another etiological factor. 8 •9 For exam-
ple, the jogger who places his or her car key in the lace of
a running shoe risks neuroplexia of the deep peroneal
nerve, which can result in significant disability.
If neurogenic pain is located in the sinus tarsi, the in-
ferior extensor retinaculum may be compressing the lat-
eral branch of the deep peroneal nerve. This may be
mistaken for a sinus tarsi bony abutment or a subtalar
strain. Often entrapment of the lateral branch of this
nerve occurs in conjunction with a joint instability, and
Inferiorextensor
retinaculum and tendon
01extensorhallucis
longusm. pressing
on peroneal n.
Fig 5. Deep peroneal nerve compression. (Reprinted with
permission from Baxter DE: Functional nerve disorders In
the athelete's foot, ankle, and leg. AAOS Instruct Course Lect
42:185-194,1993.)
20
surgery may consist of joint stabilization, nerve release,
or both.:'
Treatment
Determining appropriate treatment depends on careful
evaluation, because there are several areas of potential
compression. If a bony exostosis is visible on lateral ra-
diograph, excision of the exostosis is indicated. If hy-
permobility of the talonavicular joint causes functional
compression, removal of the sharp dorsal edge of the
talus and release of the retinacular ligament are appro-
priate. When possible, only a portion of the retinacular
ligament should be released to avoid making the extensor
tendon mechanism unstable. If an accessory bone in the
area of the first and second metatarsal bases is causing
symptoms, removal of the bone usually will relieve them.
If the bony exostosis is at the first metatarsal-tarsal joint,
some of the bony prominence in the area of compression
should be removed along with release of the nerve.
During the recovery phase the lacing pattern of the shoe
should be altered to remove pressure from the site of
compression.
ENTRAPMENT OF THE SUPERFICIAL
PERONEAL NERVE
The superficial peroneal nerve is a branch of the common
peroneal nerve that pierces the fascia 10 to 12 cm proxi-
mal to the tip of the lateral malleolus, where it divides
into two cutaneous branches (Fig 6). Entrapment of this
nerve causes numbness and tingling over the dorsum of
the ankle and foot and pain in the distal third of the leg at
the site of compression. Entrapment of the superficial
peroneal nerve may be caused by fascial compression,
muscle herniation, exertional compartment syndrome,
local trauma, or recurrent ankle sprains. 10-12
Treatment
The most difficult part of treating superficial peroneal
nerve compression is making the diagnosis. This pain
syndrome may go undiagnosed for long periods of time,
during which the athlete is treated for ankle sprain or
other ankle disorders. I have seen athletes who have
had arthroscopic ankle procedures before this syndrome
was diagnosed.
Treatment of superficial peroneal nerve compression
usually is surgical nerve release. The nerve may be com-
pressed in a local area of muscle herniation where the
superficial nerve migrates from underneath the fascia of
the lateral compartment or it may be compressed within
a more lengthy tunnel. If significant ankle instability is
an etiological factor, ligament instability should be cor-
rected at the time of nerve release.
Usually nerve release can be performed with the use of
local anesthetic and without a tourniquet. The incision
is made no longer than is necessary to release the area of
compression. The recovery phase generally occurs in 3
to 4 weeks, and excellent results can be expected in ap-
proximatslo 85% of patients. Persistence of problems
DONALD E. BAXTER
 Achilles tendinitis, although they were slightly more
proximal than those normally found in Achilles tendinitis
(Fig 7). The pain was more of a burning type of pain in
a localized area, with some occasional radicular symp-
toms. After conservative treatment failed, local decom-
pression was performed to release the sheath of the
Achilles tendon. When the exact location of the symp-
toms was exposed, the sural nerve was found to be
bound by adhesions to the posterior aspect of the Achilles
~ tendon sheath. Release of the sural nerve and place-
-1
Superficial
peroneal n. .
\

Intermediate dorsal
cutaneous n.

Fig 6. Superficial peroneal nerve entrapment. (Reprinted

with permission from the Baxter DE: Functional nerve disor-
ders in the athelete's foot, ankle, and leg. AAOS Instruct
Course Lect 42:185-194, 1993.)

may be caused by a more proximal lesion such as radic-

ulopathy from the back or from a lateral knee disorder.
One of our patients who improved after nerve release but
who continued to have pain was found to have a herni-
ated disc that was responsible for her pain (double-crush
syndrome).

ENTRAPMENT OF THE SURAL NERVE

The sural nerve runs 1 em posterior to the peroneal ten-
don sheath and divides 2 em above the ankle. One
branch innervates the lateral foot; the other often anasto-
moses with the superficial peroneal nerve. Symptoms
of sural nerve entrapment include paresthesia in the sural
nerve distribution and numbness along the lateral aspect
of the foot; these symptoms are exacerbated by' certain
positions of the foot or specific activities. The etiologies

--
of this syndrome include displaced fractures of the calca-
neus or fifth metatarsal, osteophytes, and ganglions. 13 •14
It also may be associated with instability of the lateral
ankle ligaments.

Treatment
Treatment includes identifying the source of compression
and removing the offending pressure. One of our pa-
tients, a "half-miler," had symptoms that suggested Fig 7. Sural nerve compression.

COMPRESSIVE NEUROPATHIES 21
ment in a different position relieved symptoms and al-
lowed the athlete to return to running. Another patient,
a golfer, was referred for subtalar joint fusion because of
persistent pain after a calcenael fracture. Careful evalu-
ation localized the pain at the lateral subtalar joint. Sur-
gical exploration of this area showed a small bony spur
rubbing against the sural nerve. After removal of the
spur and anterior relocation of the sural nerve, the symp-
toms subsided, and the patient was able to resume golf-
ing.
INTERDIGITAL (MORTON'S) NEUROMA
Although the etiology of interdigital neuroma (Morton's
metatarsalagia) is not completely understood, it probably
is caused by an entrapment neuropathy involving the
common digital nerve and is predominantly character-
ized by the deposition of an amorphous eosinophilic ma-
terial followed by a slow degeneration of the nerve fibers.
Even the term neuroma is not completely accurate, be-
cause the haphazard proliferation ofaxons seen in trau-
matic neuro~as is not found. The pathological process
probably is degenerative rather than proliferative, with
repetitive trauma against the deep transverse intermeta-
tarsal ligament being the most likely cause. Acute
trauma, such as fall, crush injury, or stepping on a sharp
object, occasionally results in an interdigital neuroma.
Interdigital neuromas are approximately four times more
common in women than in men.
The most common symptom of interdigital neuroma is
pain localized to the plantar aspect of the foot between
the metatarsal heads (Fig 8). Patients usually describe
the pain as a burning sensation that radiates to the toes of
the involved interspace. Pain is increased by foot activ-
ities or when the patient puts on a tight-fitting, high-
heeled shoe. About half of patients describe some
Neurofibroma -trT\-l~"'l'
Communicating -~o---I~
branch
Lateral
pIa nta r --+---"lI~'
nerve
Medial
plantar
nerve
Tibial
nerve
22
numbness in the toes or foot, and some complain of pain
radiating up the leg or a cramping sensation in the foot
and leg. In a few patients a small, moveable mass may
be palpated on the plantar aspect of the foot.
Treatment
Conservative management consists of the use of a wide,
soft, laced shoe with a low heel to allow the foot to spread
and relieve pressure on the metatarsal head area. A soft
metatarsal support just proximal to the metatarsal region
further relieves pressure. Steroid injections occasionally
may be helpful but rarely produce long-lasting results. IS
Although most patients obtain some initial relief with
these measures, approximately 70% eventually elect to
have surgery because of persistent symptoms or a desire
for different types of footwear. IS An interdigital neu-
roma may be excised through either a dorsal or a plantar
incision. The dorsal approach has as its main advantage
the prevention of scar formation on the plantar aspect of
the fOOt. I 6
Technique
Under tourniquet control an incision is made in the dorsal
aspect of the foot, beginning in the involved web space
and continuing proximally for approximately 3 em to the
level of the metatarsal head (Fig 9). It is important to
keep the incision directly in the midline, because devia-
tion to either side may result in cutting of one of the
dorsal digital nerves, which could cause a painful neu-
roma. The incision is deepened through the soft tissue
to the level of the metatarsal heads. A retractor is placed
between the metatarsal heads to spread them apart,
which places the transverse metatarsal ligament under
significant tension. A neurological freer is used to dis-
sect out the contents of the interspace, allowing identifi-
Fig 8. Most common location of Inter-
digital neuroma (plantar and dorsal
views). (Reprinted with permission
from McElvenny RY: Morton's neu-
roma: The etiology and surgical treat-
ment of Intractable pain about the
fourth metatarsophalangeal joint
(Morton's toe). J Bone Joint Surg [Br]
25:675-679,1943.)
DONALD E. BAXTER

Fig 9. Dorsal approach to Interdigital neuroma. (Reprinted
with permission from Richardson EG: Neurogenic disorders,
In Crenshaw AH led]: Campbell's Operative Orthopaedics
led 8]. St Louis MO, Mosby Year-Book, 1992.)
cation and transection of the transverse metatarsal liga-
ment.. The retractor is removed and placed deeper be-
tween the metatarsal heads to expose the contents of the
web space. The neurological freer again is used to allow
identification of the common digital nerve in the proximal
portion of the wound. The nerve is traced distally to its
bifurcation, where a significant amount of soft tissue may
be: present around the nerve. If possible this tissue
should be removed to allow the nerve to be followed past
the bifurcation. If the adhesions are too great, all of this
material is removed with the nerve rather than taking
time to carefully dissect it out. The interspace should be
carefully explored for any accessory branches from un-
derneath the metatarsal heads. In the proximal portion
of the wound, the common digital nerve is cut proximal
to the metatarsal head, dissected out distally past the
bifurcation, and excised with as little plantar fat as pos-
sible. If a significant accessory nerve branch passes to
the common nerve either medially or laterally, the con-
sequences of cutting this nerve and allowing it to retract
under the metatarsal head must be carefully considered.
If the nerve trunk appears to be larger than 2 mm, rather
than resecting the neuroma proximal to the metatarsal
heads, the common nerve should be cut just proximal to
its bifurcation, which also is just proximal to the thicken-
ing usually observed in the nerve distal to the transverse
metatarsal ligament. The distal portion of the nerve is
removed. The cut end is sutured to the side of the meta-
tarsal 'or to one of the intrinsic muscle so that it will not
drop onto the plantar aspect of the foot. Placing the
nerve along the side of the metatarsal, off the bottom of
the foot, keeps the stump neuroma from being in a
weight bearing position. The skin is closed in a single
layer, and a compression dressing is applied.
COMPRESSIVE NEUROPATHIES
Postoperative Management
The compression dressing is removed after 18 to 24
hours, and a firm forefoot dressing is applied. Ambula-
tion is permitted in a postoperative shoe. The dressing
is worn for 3 weeks, after which active and passive range-
of-motion exercises are begun.
CONCLUSION
In the evaluation of athletes with unusual symptoms
about the foot and ankle, the possibility of a nerve disor-
der should be considered. A knowledge of the exact
anatomy of the nerves to the foot and ankle and of the
common areas of compression often will allow the phy-
sician to make the diagnosis and to correct the problem
with a simple surgical procedure that rapidly restores
function. The possibility of a more proximal cause of the
ankle and foot symptoms, such as disc herniation or knee
disorders, also should be considered. Though rare in
athletes, other possible causes of neuropathy include
metabolic conditions, reflex sympathetic dysfunction,
and nutritional deficiency.
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23