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Background:  At least 128,000 patients in the United States each year suffer from foot drop. This is a debilitating condition, marked by the inability to dorsiflex and/or evert the affected ankle. Such patients are rendered to a lifetime of relying on an ankle-foot orthosis (AFO) for walking and nighttime to prevent an equinovarus contracture., Methods:  This narrative review explores the differential diagnosis of foot drop, with a particular focus on clinical presentation and recovery, whether spontaneously or through surgery., Results:  Contrary to popular belief, foot drop can be caused by more than just insult to the common peroneal nerve at the fibular head (fibular tunnel). It is a common endpoint for a diverse spectrum of nerve injuries, which may explain its relatively high prevalence. From proximal to distal, these conditions include lumbar spine nerve root damage, sciatic nerve palsy at the sciatic notch, and common peroneal nerve injury at the fibular head. Each nerve condition is marked by a unique clinical presentation, frequency, likelihood for spontaneous recovery, and cadre of peripheral nerve techniques., Conclusion:  The ideal surgical technique for treating foot drop, other than neurolysis for compression, remains elusive as traditional peripheral nerve procedures have been marred by a wide spectrum of functional results. Based on a careful understanding of why past techniques have achieved limited success, we can formulate a working set of principles to help guide surgical innovation moving forward, such as fascicular nerve transfer., Competing Interests: None declared., (Thieme. All rights reserved.)

A ganglion cyst is a benign mass consisting of high-viscosity mucinous fluid. It can originate from the sheath of a tendon, peripheral nerve, or joint capsule. Compressive neuropathy caused by a ganglion cyst is rarely reported, with the majority of documented cases involving peroneal nerve palsy. To date, cases demonstrating both peroneal and tibial nerve palsies resulting from a ganglion cyst forming on a branch of the sciatic nerve have not been reported. In this paper, we present the case of a 74-year-old man visiting an outpatient clinic complaining of left-sided foot drop and sensory loss in the lower extremity, a lack of strength in his left leg, and a decrease in sensation in the leg for the past month without any history of trauma. Ankle dorsiflexion and great toe extension strength on the left side were Grade I. Ankle plantar flexion and great toe flexion were Grade II. We suspected peroneal and tibial nerve palsy and performed a screening ultrasound, which is inexpensive and rapid. In the operative field, several cysts were discovered, originating at the site where the sciatic nerve splits into peroneal and tibial nerves. After successful surgical decompression and a series of rehabilitation procedures, the patient's neurological symptoms improved. There was no recurrence.

Objective: To study the changes in gait characteristics of stroke patients with foot drop after the combination treatment of foot drop stimulator and moving treadmill training and thus provide a basis for the improvement in a foot drop gait after stroke., Methods: Sixty patients with hemiplegia and foot drop caused by stroke were randomly divided into two groups of 30: the test group and the control group. Both groups received basic rehabilitation training. On this basis, the test group received the combination treatment of foot drop stimulator and moving treadmill training. The control group received foot drop stimulator training. Both groups received consecutive treatment for 3 weeks, five times a week, and every single time lasted for 30 minutes. Before and after the treatment, a gait watch three-dimensional gait analysis system was used to measure and record the maximum angles of flexion of the affected side's hip, knee, and ankle; the pace; the step length asymmetry; the iEMG of the tibialis anterior muscle; the functional ambulation category; and Ashworth's modified spasticity classification of the gastrocnemius., Results: After treatment, in the two groups, the maximum angles of flexion of the affected side's hip, knee, and ankle improved, the pace increased, the step length asymmetry decreased, the iEMG of the tibialis anterior muscle increased, the functional ambulation category improved, and Ashworth's modified spasticity classification of the gastrocnemius decreased, but the above changes in the test group were better than those in the control group. The difference is statistically significant ( p < 0.05)., Conclusions: The combination treatment of the foot drop stimulator and moving treadmill can significantly improve stroke patients' foot gait and promote the normalization of hip flexion, knee flexion, and ankle flexion. It can increase the pace, significantly reduce the step length asymmetry, reduce the muscle tone of the gastrocnemius, and improve walking function., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2021 Chen Peishun et al.)

Introduction/aims: Isolated injuries to the lateral cutaneous nerve of the calf (LCNC) branch of the common peroneal nerve can cause obscure chronic posterolateral knee and upper calf pain and sensory symptoms. Routine examination and electrodiagnostic testing do not detect them because the LCNC has no motor distribution and it is not interrogated by the typical peroneal nerve conduction study. There are only about 10 prior cases, thus scant physician awareness, so most LCNC injuries remain misdiagnosed or undiagnosed, hindering care., Methods: We extracted pertinent records from seven patients with unexplained posterolateral knee/calf pain, six labeled as complex regional pain syndrome, to investigate for mononeuropathies. Patients were asked to outline their skin area with abnormal responses to pin self-examination independently. Three underwent an LCNC-specific electrodiagnostic study, and two had skin-biopsy epidermal innervation measured. Cadaver dissection of the posterior knee nerves helped identify potential entrapment sites., Results: Initiating events included knee surgery (three), bracing (one), extensive kneeling (one), and other knee trauma. All pin-outlines included the published LCNC neurotome. One oftwo LCNC-specific electrodiagnostic studies revealed unilaterally absent potentials. Longitudinal, controlled skin biopsies documented profound LCNC-neurotome denervation then re-innervation contemporaneous with symptom recovery. Cadaver dissection identified the LCNC traversing through the dense fascia of the proximolateral gastrocnemius muscle insertion., Discussion: Isolated LCNC mononeuropathy can cause unexplained posterolateral knee/calf pain syndromes. This series characterizes presentations and supports patient pin-mappings as a sensitive, globally available, low-cost diagnostic aid. Improved recognition may facilitate more rapid, accurate diagnosis and, thus, optimize management and improve outcomes., (© 2021 Wiley Periodicals LLC.)

Objective: The primary objective of this study was to evaluate the correlation of large mitochondrial DNA (mtDNA) deletions in skin samples of people with HIV (PWH) with measures of neuropathy and prior exposure to therapy. We hypothesized that deletions would be associated with neuropathy. As secondary objectives, we determined the correlation of deletion burden with demographic data and neuropathy measures., Methods: In this retrospective cohort study, we measured the accumulation of large mtDNA deletions in skin biopsies from PWH recruited as part of the AIDS Clinical Trials Group (ACTG). Our cohort includes individuals with and without sensory neuropathy, as well as individuals with normal or abnormal skin biopsies. Skin biopsies, sural and peroneal nerve conduction studies, total neuropathy score, and deletion burden scores were measured, along with baseline demographic data such as age, CD4+ cell count, viral counts, and prior nucleoside reverse transcriptase inhibitor exposures., Results: Sixty-seven PWH were enrolled in the study. The mean age of the cohort (n = 67) was 44 years (SD 6.8, range 32-65 years), and 9 participants were female. The mean CD4+ T-cell count was 168 cells/mm 3 (SD 97 cells/mm 3 , range 1-416 cells/mm 3 ) and mean viral load was 51,129 copies/mL (SD 114,586 copies/mL, range 147-657,775 copies/mL). We determined that there was a correlation between the total mtDNA deletion and intraepidermal nerve fiber density (IENFD) ( r = -0.344, p = 0.04) and sural nerve amplitude ( r = -0.359, p = 0.004)., Conclusions: Both IENFD and sural nerve amplitude statistically correlate with mitochondrial mutation burden in PWH, specifically in those with HIV-associated sensory neuropathy as assessed by skin biopsy., (© 2021 American Academy of Neurology.)

Introduction/aims: Foot drop is common in chronic inflammatory demyelinating polyneuropathy (CIDP), but its prognosis is uncertain., Methods: CIDP patients with less than anti-gravity strength (<3/5 power) of ankle dorsiflexion (ADF) on Medical Research Council manual muscle testing on presentation at our center were identified by retrospective review. After initiation of standard treatment, ADF power was serially tabulated, and predictors of recovery were determined., Results: Of the 27 identified patients, ADF power at presentation was <3/5 in 48/54 legs. At 1 y after treatment, ADF power improved to >/= 3/5 in 17/27 patients in one (N = 6) or both (N = 11) legs. On multi-variate analysis, predictors of recovery of ADF power were tibialis anterior compound muscle action potential amplitude at presentation, shorter disease duration, and female gender., Discussion: Foot drop improves to anti-gravity power in most treated CIDP patients depending in part on the severity of fibular motor axon loss at onset of treatment., (© 2021 Wiley Periodicals LLC.)

Rationale: Peripheral nerve injury related to vascular complications associated with extracorporeal membrane oxygenation (ECMO) is perhaps underappreciated. Compared to the well-described central nervous system complications of ECMO, brachial plexopathy and lumbosacral plexopathy have rarely been reported. We report this case to heighten awareness of lumbosacral plexus injury due to pelvic hematoma formation after ECMO., Patient Concerns: A 53-year-old woman developed a large pelvic hematoma with significant mass effect on intrapelvic structures after receiving lifesaving venoarterial ECMO for cardiogenic shock following a cardiac arrest. During her hospital course, she developed bilateral foot drop that was attributed to critical illness. Her lack of neurological recovery after 6 months prompted referral to neuromuscular medicine for consultation., Diagnosis: The patient was retrospectively diagnosed with bilateral lumbosacral plexopathy due to the large pelvic hematoma., Intervention: Electromyography/nerve conduction study (EMG/NCS) obtained at the time of referral to neuromuscular medicine localized her neurological deficits to the bilateral lumbosacral plexus and demonstrated no volitional motor unit action potentials in her lower leg muscles., Outcomes: The patient had minimal recovery of strength at the level of the ankles but was ambulatory with solid ankle-foot orthoses due to spared proximal lower extremity strength. Unfortunately, the absence of any volitionally activated motor unit action potentials in her lower leg muscles on EMG performed 6 months after the initial injury was a poor prognostic indicator for successful reinnervation and future neurological recovery., Lessons: Neurological deficits occurring during the course of administration of ECMO require accurate localization. Neurology consultation and/or EMG/NCS may be useful if localization is not clear. Lesions localizing to the lumbosacral plexus should prompt radiographic evaluation with computed tomography of the abdomen and pelvis. Hemostasis of a retroperitoneal hematoma may be achieved with embolization. However, if neurological deficits do not improve, surgical consultation for hematoma evacuation may be warranted., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Foot drop represents a very common reason for a neurologist referral and is often first seen in emergency departments or by a general practitioner. This condition is defined as weakness of ankle dorsiflexion (mainly through tibialis anterior muscle weakness). The most common causes include lower motor neuron lesion, with L4-L5 radiculopathy and peroneal neuropathy being the most frequent ones. Classical diagnostic pathway includes a thorough medical history, detailed neurological examination, radiological studies (MRI of the lumbosacral spine), EMG and nerve conduction studies, and a battery of laboratory tests. The absence of abnormal radiological and neurophysiological findings when searching for the most common causes of foot drop, should raise a red flag and broaden the diagnostic yield for central nervous system pathology (upper motor neuron, UMN) as a possible cause of foot drop. Central causes of isolated foot drop are very rare, with less than 20 cases reported in literature so far, and seven of them being a meningioma. We present a case of a 79-year-old female patient with an isolated foot drop (with no UMN signs on the initial examination) and parasagittal meningioma. Central causes of foot drop should be suspected when foot drop is associated with UMN signs on examination (hyperreflexia of the patellar or ankle jerk and extensor plantar reflex) and when standard diagnostic work-up (MRI of the lumbar spine, EMG and NCS, standard laboratory screening for most common causes of foot drop) is negative or inconclusive. Although very rare, central lesions present a far more serious cause of foot drop and require a more urgent diagnostic work up and a potential neurosurgical referral and treatment. Keeping in mind the possible central causes of foot drop would eliminate unnecessary diagnostic work up and avoid delayed diagnosis and treatment.

Background: Several E2 (reference electrode) positions are described for fibular (peroneal) nerve conduction studies to tibialis anterior (TA)., Methods: This study compared the contribution of different E2 sites to the TA motor response, using remote referential recordings and different bipolar montages., Results: The medial knee contributes minimal electrical activity to the bipolar TA recordings, whereas tibial, ankle, and toe references resulted in very similar, moderate amplitude contributions consistent with far field potentials. These observations were very similar in controls and in patients with lower leg symptoms and signs., Conclusions: Standard montages using distal leg or foot E2 sites result in lower amplitudes with distortion arising from the E2 electrode, compared with the TA-Knee montage. Optimal measurement of the TA motor response is achieved using a medial knee reference, without compromising measures of fibular nerve conduction across the knee., (© 2020 Wiley Periodicals LLC.)

Background: Sciatic nerve injury after inadvertent intramuscular gluteal injection is a well-described entity. We have presented a case of a rare and probably underdiagnosed pathological entity, Nicolau syndrome, which can be confused with injection palsy., Case Description: We report the case of a 13-year-old boy who had presented with foot drop and urinary and fecal incontinence after an intramuscular injection of benzathine penicillin in the left gluteal region. On examination, the patient had multiple ecchymoses over the left gluteal region and back of the thigh, mild swelling of the left lower limb, and left foot drop. Meticulous examination also revealed a subtle weakness of the opposite limb. Nerve conduction studies revealed axonopathy involving multiple bilateral lower limb nerves. These unusual neurological-dermatological signs and electrophysiological findings raised the concern for an alternative pathology, which was later diagnosed as Nicolau syndrome. The patient experienced clinical and electrophysiological recovery after a course of oral steroids and physiotherapy during the next few months., Conclusions: Before diagnosing injection sciatic nerve injury, the possibility of medically treatable Nicolau syndrome should be considered. Neurosurgeons' familiarity with this pathology and a timely diagnosis is essential to plan appropriate treatment strategies., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Common peroneal neuropathy shares the same pathophysiology as carpal tunnel syndrome. However, management is often delayed because of the traditional misconception of recognizing foot drop as the defining symptom for diagnosis. The authors believe recognizing common peroneal neuropathy before foot drop can relieve pain and help improve quality of life., Methods: One hundred eighty-five patients who underwent surgical common peroneal neuropathy decompression between 2011 and 2017 were included. The mean follow-up time was 249 ± 28 days. Patients were classified into two stages of severity based on clinical presentation: pre-foot drop and overt foot drop. Demographics, presenting symptoms, clinical signs, electrodiagnostic studies and response to surgery were compared between these two groups. Multivariate regression analysis was used to identify variables that predicted outcome following surgery., Results: Overt foot drop patients presented with significantly lower preoperative motor function (percentage of patients with Medical Research Council grade ≤ 1: overt foot drop, 90 percent; pre-foot drop, 0 percent; p < 0.001). Pre-foot drop patients presented with a significantly higher preoperative pain visual analogue scale score (pre-foot drop, 6.2 ± 0.2; overt foot drop, 4.6 ± 0.3; p < 0.001) and normal electrodiagnostic studies (pre-foot drop, 31.4 percent; overt foot drop, 0.1 percent). Postoperatively, both groups of patients showed significant improvement in quality-of-life score (pre-foot drop, 2.6 ± 0.3; overt foot drop, 2.7 ± 0.3). Patients with obesity or a traumatic cause for common peroneal neuropathy were less likely to have improvements in quality of life after surgical decompression., Conclusion: Increased recognition of common peroneal neuropathy can aid early management, relieve pain, and improve quality of life., Clinical Question/level of Evidence: Risk, II.

Purpose: To explore the application value of conventional ultrasound and real-time shear wave elastography (SWE) to the tibial nerve (TN) and the common peroneal nerve (CPN) in diabetic peripheral neuropathy (DPN)., Materials and Methods: Thirty-three healthy volunteers, 33 diabetic patients without DPN, and 30 diabetic patients with DPN were enrolled in this study. The anteroposterior diameter (APD), the cross-sectional area (CSA), and the perimeter of the TN and the CPN were measured by conventional ultrasound, and the stiffness of the nerves was measured by SWE., Results: The conventional ultrasound parameters and stiffness of the TN in patients with DPN were significantly larger than those of the other two groups (P < 0.01). The conventional ultrasound parameters of the CPN were significantly higher in patients with DPN than in the other two groups (P < 0.01).The patients with DPN demonstrated a greater stiffness of the CPN compared to the control group (P < 0.05). The comparison of all parameters for the left and right TNs and CPNs among the three groups showed no significant difference. The area under the curve (AUC) of TN stiffness for the diagnosis of DPN was significantly greater than that of conventional ultrasound parameters., Conclusion: The conventional ultrasound parameters and the stiffness of the TN and the CPN were significantly higher in patients with DPN. The stiffness of the TN could better diagnose DPN than conventional ultrasound parameters. In short, conventional ultrasound and SWE of nerves are of good application value in the diagnosis of DPN., (Copyright © 2020. Published by Elsevier B.V.)

Introduction: The peripheral nerves of patients with diabetes are often pathologically swollen, which results in entrapment at places of anatomical narrowing. This results in nerve dysfunction. Surgical treatment of compression neuropathies in the lower extremities (lower extremity nerve decompression (LEND)) results in relief of symptoms and gain in peripheral nerve function, which may lead to less sensory loss (short term) and less associated detrimental effects including foot ulceration and amputations, and lower costs (long term). The aim of the DeCompression trial is to evaluate the effectiveness and (cost-)effectiveness of surgical decompression of compressed lower extremity nerves (LEND surgery) compared with patients treated with conventional (non-surgical) care., Methods and Analysis: A stratified randomised (1 to 1) controlled trial comparing LEND surgery (intervention) with conventional non-surgical care (control strategy) in subjects with diabetes with problems of neuropathy due to compression neuropathies in the lower extremity. Randomisation is stratified for participating hospital (n=11) and gender. Patients and controls have the same follow-up at 1.5, 3, 6, 9, 12, 18, 24 and 48 months. Participants (n=344) will be recruited in 12 months and enrolled in all affiliated hospitals in which they receive both the intervention or conventional non-surgical care and follow-up. Outcome assessors are blinded to group assignment., Primary Outcome: disease-specific quality of life (Norfolk Quality of Life Questionnaire-Diabetic Neuropathy)., Secondary Outcomes: health-related quality of life (EuroQoL 5-dimension 5-level (EQ-5D5L), 36-item Short Form (SF-36)), plantar sensation (Rotterdam Diabetic Foot Test Battery), incidence of ulcerations/amputations, resource use and productivity loss (Medical Cost Questionnaire, Productivity Cost Questionnaire) during follow-up. The incremental cost-effectiveness ratio will be estimated on the basis of the collected empirical data and a cost-utility model., Ethics and Dissemination: Ethics approval has been granted by the Medical Research Ethics Committee of Utrecht University Medical Center (reference: NL68312.041.19v5, protocol number: 19-335/M). Dissemination of results will be via journal articles and presentations at national and international conferences., Trial Registration Number: NetherlandsTrial Registry NL7664., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Foot drop is a potentially debilitating complication following injury to the sciatic nerve during primary total hip arthroplasty (THA). The aim of this study was to determine the incidence, risk factors and outcome of this complication within one large surgical practice., Methods: We analysed the records of 10,624 primary THAs carried out between January 1993 and November 2017 using a posterior approach. All were under the care of the senior author., Results: Overall, there were 47 cases (0.44%) of foot drop, but over time the incidence dropped from 0.6% to 0.3% ( p = 0.033). Preoperative protrusio acetabulae ( p < 0.001), female sex ( p < 0.001) and junior grade of surgeon ( p < 0.009) were all significant risk factors. In this series, dysplasia was not a risk factor. 1 year postoperatively, 25 (53.2%) had complete recovery, 12 (25.5%) had ongoing sensory deficit but normal power, and 10 (21.3%) had a residual sensory-motor deficit., Conclusion: Take home message:- In this series, protrusio acetabulae, female sex and junior grade of surgeon were significant risk factors for foot drop following primary THA.

Synaptic proteins play an important role for the regulation of synaptic plasticity. Numerous studies have identified and revealed individual synaptic protein functions using protein overexpression or deletion. In neuropathic pain nociceptive stimuli conveyed from the periphery repetitively stimulate neurons in the central nerve system, brain and spinal cord. Neuronal activities change the turnover (synthesis and degradation) rate of synaptic proteins. Thus, the analysis of synaptic protein turnover rather than just expression level change is critical for studying the role of synaptic proteins in synaptic plasticity. Here, we analyzed synaptosomal proteome in the anterior cingulate cortex (ACC) to identify protein turnover rate changes caused by peripheral nerve injury. Whereas PKCγ levels were not altered, we found that the protein's turnover rate decreased after peripheral nerve injury. Our results suggest that postsynaptic PKCγ synthesized by neuronal activities in the ACC is translocated to the postsynaptic membrane with an extended half-life.

Case Description: A 17-year-old male post anterior cruciate ligament reconstruction complained of the inability to extend his great toe immediately following surgery. Background: Neurological injuries following knee arthroscopy have been reported to occur between 0.6%-2.5%. The most commonly injured nerves are the saphenous and common fibular nerve (CFN). Great toe-drop secondary to isolated denervation of the extensor hallucis longus (EHL), has only been reported one time in the literature. This report describes a case of isolated denervation of the EHL following knee cruciate ligament reconstruction. A detailed description of the anatomy of the CFN is reviewed as well as how electroneuromyographic (EMG/NCS) testing can assist in the diagnosis, prognosis, and intervention of this type of injury. Outcomes: EHL paralysis did not functionally limit the patient from participating in a post-surgical rehabilitation regime. The patient successfully completed his ACL reconstruction rehabilitation and was released to return to sporting activities 9 months postsurgery. Twelve months post-surgery, the patient regained full great toe extension and strength. Discussion: It is important to note that physical therapists can identify the need for, refer, and in some instances perform EMG/NCS testing on patients with neuromuscular disorders. Isolated injury of the CFN branch that innervates the EHL is extremely rare. Understanding the anatomy of the CFN and its branches is critical for the physical therapist when performing an examination and interpreting the findings. It is also important to understand the potential causes and management approaches following this type of injury.

Background: Common peroneal nerve (CPN) injury following a knee dislocation is a serious problem, and an optimal treatment is yet to be established. We report a case of complete CPN palsy following a knee dislocation treated with sural nerve grafting., Case: A 19-year-old man suffered a knee injury during a hurdle race. Diagnosis in a previous hospital revealed a complex ligament injury with CPN palsy. Ten weeks following injury, he was admitted to our institution because of a lack of neurological improvement. Considering the grade 0 results obtained in the manual muscle test (MMT) of tibialis anterior (TA) and extensor hallucis longus (EHL), the patient was diagnosed with complete neurotmesis of CPN, and surgery was performed. Operative findings revealed CPN discontinuity and an extended nerve defect length of 15 cm; therefore, sural nerve grafting was performed to repair the CPN injury. One year postoperatively, a grade 1 result from MMT of TA and EHL indicated a gradual neurological recovery. Three years postoperatively, MMT of TA and EHL showed significant improvement to grade 4+ and grade 4, respectively, and he could walk and jog without a knee brace., Discussion: Nerve graft length of >6 cm has shown limited success, and their efficacy for the treatment of CPN palsy following knee dislocations is controversial. However, young patients with complete CPN lesion are more likely to recover regardless of the length of nerve injury. Therefore, in such cases, nerve grafting can be considered as one of the treatments for complete CPN lesion following knee dislocations.

Objective: To examine muscle membrane properties in neurogenic muscles using Muscle Velocity Recovery Cycles (MVRCs)., Methods: Forty-seven patients referred to Nerve Conduction Studies (NCS) and Electromyography (EMG) for peroneal nerve entrapment neuropathy were prospectively included. The patients were categorized as peroneal nerve entrapment neuropathy across knee (n = 22), L5-radiculapathy (n = 10), normal NCS/EMG (n = 9) and other disorders (n = 6) using NCS/EMG and neuroimaging results. Strength in anterior tibial muscle was measured by Medical Council Scale (MRC) and disease duration was recorded. In addition to conventional NCS/EMG, all subjects were examined with MVRCs in anterior tibial muscle. This provided parameters of muscle relative refractory period (MRRP) and early supernormality (ESN) and late supernormality (LSN). The results were compared with 29 age-matched healthy control subjects., Results: MRRP was prolonged and ESN and LSN were reduced in neurogenic muscles. MRRP, ESN and LSN correlated to MRC and incidence of spontaneous activity but not to motor unit potential parameters or disease duration., Conclusions: MVRC changes provide in vivo evidence of depolarization in intact human muscle fibres that could underlie reduced muscle excitability and hence weakness in neurogenic muscles., Significance: MVRCs appear to be a useful technique for revealing disease mechanism in a broad range of neuromuscular diseases., (Copyright © 2019 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)

Objective: To compare the clinical- and cost-effectiveness of ankle-foot orthoses (AFOs) and functional electrical stimulation (FES) over 12 months in people with Multiple Sclerosis with foot drop., Design: Multicentre, powered, non-blinded, randomized trial., Setting: Seven Multiple Sclerosis outpatient centres across Scotland., Subjects: Eighty-five treatment-naïve people with Multiple Sclerosis with persistent (>three months) foot drop., Interventions: Participants randomized to receive a custom-made, AFO ( n = 43) or FES device ( n = 42)., Outcome Measures: Assessed at 0, 3, 6 and 12 months; 5-minute self-selected walk test (primary), Timed 25 Foot Walk, oxygen cost of walking, Multiple Sclerosis Impact Scale-29, Multiple Sclerosis Walking Scale-12, Modified Fatigue Impact Scale, Euroqol five-dimension five-level questionnaire, Activities-specific Balance and Confidence Scale, Psychological Impact of Assistive Devices Score, and equipment and National Health Service staff time costs of interventions., Results: Groups were similar for age (AFO, 51.4 (11.2); FES, 50.4(10.4) years) and baseline walking speed (AFO, 0.62 (0.21); FES 0.73 (0.27) m/s). In all, 38% dropped out by 12 months (AFO, n = 21; FES, n = 11). Both groups walked faster at 12 months with device ( P < 0.001; AFO, 0.73 (0.24); FES, 0.79 (0.24) m/s) but no difference between groups. Significantly higher Psychological Impact of Assistive Devices Scores were found for FES for Competence ( P = 0.016; AFO, 0.85(1.05); FES, 1.53(1.05)), Adaptability ( P = 0.001; AFO, 0.38(0.97); FES 1.53 (0.98)) and Self-Esteem ( P = 0.006; AFO, 0.45 (0.67); FES 1 (0.68)). Effects were comparable for other measures. FES may offer value for money alternative to usual care., Conclusion: AFOs and FES have comparable effects on walking performance and patient-reported outcomes; however, high drop-outs introduces uncertainty.

Introduction: Neuropathy after total knee arthroplasty (TKA) can cause significant morbidity but is inconsistently reported., Methods: We reviewed the clinical, electrodiagnostic and perioperative features of all patients who underwent primary TKA at our institution and developed a new neuropathy within 8 weeks postoperatively., Results: Fifty-four cases were identified (incidence 0.37% [95% confidence interval, 0.28-0.49]) affecting the following nerve(s): peroneal (37), sciatic (11), ulnar (2), tibial (2), sural (1), and lumbosacral plexus (1). In all cases with follow-up data, motor recovery typically occurred within 1 year and was complete or near-complete., Conclusions: Post-TKA neuropathy is uncommon, typically does not require intervention and usually resolves within 1 year. Post-TKA neuropathy most often affects the nerves surgically at risk. Anesthesia type does not correlate with post-TKA neuropathy. An inflammatory etiology for post-TKA neuropathy is rare but should be considered in specific cases. Muscle Nerve 59:679-682, 2019., (© 2019 Wiley Periodicals, Inc.)

Foot drop is very common among people with chronic incomplete spinal cord injury (SCI) and likely stems from SCI that disturbs the corticospinal activation of the ankle dorsiflexor tibialis anterior (TA). Thus, if one can recover or increase the corticospinal excitability reduced by SCI, motor function recovery may be facilitated. Here, we hypothesized that in people suffering from weak dorsiflexion due to chronic incomplete SCI, increasing the TA motor-evoked potential (MEP) through operant up-conditioning can improve dorsiflexion during locomotion, while in people without any injuries, it would have little impact on already normal locomotion. Before and after 24 MEP conditioning or control sessions, locomotor electromyography (EMG) and kinematics were measured. This study reports the results of these locomotor assessments. In participants without SCI, locomotor EMG activity, soleus Hoffmann reflex modulation, and joint kinematics did not change, indicating that MEP up-conditioning or repeated single-pulse transcranial magnetic stimulation (i.e., control protocol) does not influence normal locomotion. In participants with SCI, MEP up-conditioning increased TA activity during the swing-to-swing stance transition phases and ankle joint motion during locomotion in the conditioned leg and increased walking speed consistently. In addition, the swing-phase TA activity and ankle joint motion also improved in the contralateral leg. The results are consistent with our hypothesis. Together with the previous operant conditioning studies in humans and rats, the present study suggests that operant conditioning can be a useful therapeutic tool for enhancing motor function recovery in people with SCI and other central nervous system disorders. NEW & NOTEWORTHY This study examined the functional impact of operant conditioning of motor-evoked potential (MEP) to transcranial magnetic stimulation that aimed to increase corticospinal excitability for the ankle dorsiflexor tibialis anterior (TA). In people with chronic incomplete spinal cord injury (SCI), MEP up-conditioning increased TA activity and improved dorsiflexion during locomotion, while in people without injuries, it had little impact on already normal locomotion. MEP conditioning may potentially be used to enhance motor function recovery after SCI.

Background: Tibialis posterior transfer (TPT) is the treatment most widely used to palliate foot drop due to dorsiflexor palsy. TPT has been extensively studied in patients with peripheral neurological causes of foot drop. In contrast, data are scarce on central foot drop, in which TPT is often blamed for causing flattening of the arches. The primary objective of this study was to assess the impact on foot alignment of TPT in patients with central foot drop. The secondary objective was to determine whether TPT combined with other surgical procedures improved gait., Hypothesis: TTP can induce flattening of the medial arch of the foot., Patients and Methods: We retrospectively identified 13 patients managed with TPT (1 foot per patient). Mean follow-up was 65 months (range, 12-108 months). The causes were stroke (n=5), head injury (n=3), spinal cord injury (n=2), cervical spondylotic myelopathy (n=1), cerebral palsy (n=1), and a brain tumour (n=1). The clinical assessment focused chiefly on forefoot alignment and footprint parameters. The following variables were collected from weight-bearing radiographs: Djian-Annonier angle, Méary-Toméno angle, lateral arch angle, and calcaneal pitch angle in the sagittal plane; talo-metatarsal angle in the transverse plane; and rearfoot valgus angle in the coronal plane., Results: Of the 13 feet, 6 had normal footprint parameters and 7 pes cavus. There were no cases of flatfoot. Pronation deformities and supination deformities were each found in 2 patients. Comparing the radiographic parameters between the two feet in each patient identified differences only for the lateral arch angle and calcaneal pitch angle, which indicated pes cavus on the operated side (operated side: 142.7° [range, 136°-156°], p=0.041; and 24° [range, 14°-33°], p=0.028, respectively)., Discussion: In contrast to the working hypothesis, we found no evidence of progression to valgus flatfoot after TPT transfer performed to treat central foot drop., Level of Evidence: IV, retrospective study with no control group., (Copyright © 2018. Published by Elsevier Masson SAS.)

Background:  Given the unsatisfactory outcomes with traditional treatments, there is growing interest in nerve transfers to reestablish ankle dorsiflexion in peroneal nerve palsy. The objective of this work was to perform a systematic review and meta-analysis of the primary literature to assess the effectiveness of nerve transfer surgery in restoring ankle dorsiflexion in patients with peroneal nerve palsy., Methods:  Methodology was registered with PROSPERO, and PRISMA guidelines were followed. MEDLINE, EMBASE, and the Cochrane Library were systematically searched. English studies investigating outcomes of nerve transfers in peroneal nerve palsy were included. Two reviewers completed screening and extraction. Methodological quality was evaluated with Newcastle-Ottawa Scale., Results:  Literature search identified 108 unique articles. Following screening, 14 full-text articles were reviewed. Four retrospective case series met inclusion criteria for meta-analysis. Overall, 41 patients underwent nerve transfer for peroneal nerve palsy. The mean age of the patients was 36.1 years, mean time to surgery was 6.3 months, and the mean follow-up period was 19.0 months. Donor nerve was either tibial ( n  = 36) or superficial peroneal branches/fascicles ( n  = 5). Recipient nerve was either deep peroneal ( n  = 24) or tibialis anterior branch ( n  = 17). Postoperative ankle dorsiflexion strength demonstrated a bimodal distribution with a mean Medical Research Council of 2.1. There were no significant differences in dorsiflexion strength between injury sites ( p  = 0.491), injury mechanisms ( p  = 0.125), donor ( p  = 0.066), or recipient nerves ( p  = 0.496). There were no significant correlations between dorsiflexion strength and patient age ( p  = 0.094) or time to surgery ( p  = 0.493)., Conclusions:  There is variability in dorsiflexion strength following nerve transfer in peroneal nerve palsy, whereby there appear to be responders and non-responders. Further studies are needed to better define appropriate patient selection and the role of nerve transfers in the management of peroneal nerve palsy., Competing Interests: None of the authors have potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Introduction: The present case report describes the workup of unilateral fibular-nerve-paresis in a female neonatal Fleckvieh calf. The calf was admitted to the Clinic for Ruminants with Ambulatory and Herd Health Services, Ludwig- Maximilians-University Munich as part of an investigation into a herd problem. The herd problem was presented as movement disorder in neonatal calves with an incidence of 10%. A physical, hematological, and musculoskeletal, as well as neurological examination was performed, and a diagnosis of a left-sided paresis of the fibular-nerve (N. fibularis) was made. Further special examinations including sonography, magnetic resonance tomography and muscle, lymph node, and nerve biopsies of the affected limb of the calf were also carried out. Advanced imaging examinations suggested the presence of inflammatory changes caudal to the left stifle joint in the region of the fibular nerve. Histopathological examination of the nerve biopsy confirmed the presence of a fibular-nerve-neuritis. Inflammatory changes in the ischiocrural-muscles were most likely injection-induced, consistent with the history of the veterinary practitioner and the examination results.

This is a case of a previously healthy 51-year-old man who sustained bilateral central hip dislocations following a sudden presentation of epileptic seizures. The patient was initially treated conservatively for a period of 9 months. On presentation, he had gross disability due to stiffness in both hips and left peroneal nerve paresis. Through minimally invasive direct anterior approaches, bilateral total hip arthroplasties were performed using tripolar head articulations. These were cemented into a biologic acetabular buttress constructed out of autologous bone graft. The femoral heads and necks were used as plugs and pressed into the acetabular defects, putting the medial acetabular walls under tension. At 24 months' follow-up, there was a good clinical outcome, and the acetabular walls remodelled bilaterally. In conclusion, in traumatic protrusio acetabuli, a functional, biologic reconstruction of the acetabular wall can be facilitated with the application of distraction osteogenesis (tension-stress) principles while using minimally invasive surgical techniques., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Tibialis posterior tendon transfer is performed when loss of dorsiflexion has to be compensated. We evaluated the circumtibial (CT), above-retinaculum transmembranous (TMAR), and under-retinaculum transmembranous (TMUR) transfer gliding resistance and foot kinematics in a cadaveric foot model during ankle range of motion (ROM)., Methods: Eight cadaveric foot-ankle distal tibia specimens were dissected free of soft tissues on the proximal end, applying an equivalent force to 50% of the stance phase to every tendon, except for the Achilles tendon. Dorsiflexion was tested with all of the tibialis posterior tendon transfer methods (CT, TMAR, and TMUR) using a tension tensile machine. A 10-repetition cycle of dorsiflexion and plantarflexion was performed for each transfer. Foot motion and the force needed to achieve dorsiflexion were recorded., Results: The CT transfer showed the highest gliding resistance ( P < .01). Regarding kinematics, all transfers decreased ankle ROM, with the CT transfer being the condition with less dorsiflexion compared with the control group (6.8 vs 15 degrees, P < .05). TMUR transfer did perform better than TMAR with regard to ankle dorsiflexion, but no difference was shown in gliding resistance. The CT produced a supination moment on the forefoot., Conclusion: The CT transfer had the highest tendon gliding resistance, achieved less dorsiflexion and had a supination moment. Clinical Relevance We suggest that the transmembranous tibialis posterior tendon transfer should be the transfer of choice. The potential bowstringing effect when performing a tibialis posterior tendon transfer subcutaneously (TMAR) could be avoided if the transfer is routed under the retinaculum, without significant compromise of the final function and even with a possible better ankle range of motion.

Rationale: Popliteal cyst developing in the sheath of a peripheral nerve or joint capsule may cause compression neuropathy. Although popliteal cyst is very common lesion, it seldom causes serious complications. Common peroneal nerve compression is rarely caused by an extraneural popliteal cyst., Patient Concerns: We presented the case of a 52-year-old female with common peroneal nerve compression caused by an extraneural popliteal cyst., Diagnoses: Electromyography showed the damage of common peroneal nerve. MRI magnetic resonance imaging showed the lump to be a popliteal cyst. She was diagnosed as peroneal nerve injury and popliteal cyst., Interventions: The patient was performed peroneal nerve decompression and popliteal cyst excision surgery. We excised the cyst completely and soluted the common peroneal nerve thoroughly. The cyst was filled with thick mucinous material., Outcomes: The pathological report showed that the excised mass was a popliteal cyst. There were no postoperative complications. Pain and hypoesthesia resolved 6 months after surgery., Lessons: In this case, compression of the common peroneal nerve was due to an extraneural popliteal cyst, a situation rarely encountered. MRI can show in better detail their size and internal contents as well as their relation with surrounding anatomic structures. Patients with nerve entrapment caused by enlarged or ruptured cysts must be microsurgically excised if symptomatic.

Background: Peroneal intraneural ganglion cysts (IGCs) are nonneoplastic lesions. They are responsible for a small number of footdrop cases, which occur after additional nerve damage. The earliest patient symptom related to IGCs is knee pain., Case Description: A 17-year-old boy developed pain in the left knee, which progressively worsened over 14 months. He did not seek any medical assistance during this time. The patient subsequently was involved in a bicycle accident, and 3 months later he was unable to raise his left foot and was referred to our clinic for footdrop. Surgery was performed, but the weakness persisted. We could not detect any functional reinnervation on electromyography 12 months after surgery., Conclusions: The most important factors in determining the prognosis of IGCs are the extent of the nerve trauma and the early diagnosis and treatment of the IGC. Detection of almost complete functional denervation on electromyography may indicate that it is too late for surgery., (Copyright © 2018 Elsevier Inc. All rights reserved.)

We report the case of a 71-year-old man complaining of swollen left limb and progressively worsening pain. He underwent surgery 12 years ago for popliteal artery aneurysm with proximal and distal ligation and venous bypass grafting. The patient was diagnosed as having left peroneal neuropathy caused by a 10.5 cm expanded aneurysmal sac compressing the peroneal nerve in the popliteal fossa. The patient underwent open repair with opening of the aneurysmal sac, removal of the thrombus, and sewing of the left genicular artery responsible for back-bleeding. Postoperative range of motion exercises and physical therapy allowed resolving foot drop 1 year after surgery., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Nerve injury due to a movable cystic mass during knee motion is a rare neuropathy, which can be diagnosed precisely using a dynamic ultrasonogram., Objective: To present a case with foot drop and common peroneal neuropathy that involved a movable cystic mass during knee flexion adjacent to the proximal tibiofibular joint., Methods: Case report., Results: A 47-year-old female was referred to our institute for a right foot drop. Common peroneal nerve (CPN) injury was confirmed by an electrophysiologic study. Upon a dynamic ultrasonographic study during knee flexion, a cystic mass was found that was not scanned on the static images. The mass displaced the lateral head of the gastrocnemius muscle and CPN. A cystic mass that was adjacent to the proximal tibiofibular joint was confirmed by magnetic resonance imaging., Conclusion: Ultrasonography is a convenient first-line diagnostic method of peripheral nerve disorder by virtue of its higher spatial resolution, cost-effectiveness, and prompt diagnosis. The real-time and dynamic scanning attributes are the discriminative merits of this imaging tool. This case report suggests that CPN compression occurred due to a movable cystic mass during knee flexion. Dynamic ultrasonographic evaluations could be helpful to diagnose pathologic musculoskeletal conditions.

Background and Purpose: Acute bilateral foot drop is rare and may be due to peripheral or central lesions. The purpose of this case report was to describe the differential diagnosis and recovery of a patient with low back pain (LBP) that awoke with bilateral foot drop., Case Description: A 39-year-old man with a history of LBP awoke with a steppage gait pattern. Spinal imaging and tapping were negative for sinister pathologies. A subsequent history taken by the physical therapist uncovered that the patient had previously taken a narcotic and slept in a kneeling position to relieve his LBP. Strength and sensory testing revealed isolated impairments in the fibular nerve distribution, and bilateral fibular palsy was suspected and later confirmed with electrophysiological studies. Surgical fibular nerve decompression was performed, and the patient underwent physical therapy., Outcomes: Five months later the patient demonstrated antigravity strength and a partial return of sensation. By 17 months, his Lower Extremity Functional Scale had improved from 17/80 to 78/80, revealing a near complete recovery., Discussion: The patient's history of LBP was a "red herring" that delayed the diagnosis and caused undue stress to the patient. This case stresses the importance of a thorough history and clinical examination.

Background: This retrospective comparative study reports the practical function in daily and sports activities after tibialis posterior tendon transfer for foot drop secondary to peroneal nerve palsy., Methods: Seventeen patients were followed for a minimum of 3 years after tibialis posterior tendon transfer for foot drop secondary to peroneal nerve palsy. Matched controls were used to evaluate the level of functional restoration. Functional evaluations included American Orthopaedic Foot & Ankle Society (AOFAS) scores, Foot and Ankle Outcome Score (FAOS), Foot and Ankle Ability Measure (FAAM) scores, and isokinetic muscle strength test. Radiographic evaluation for the changes of postoperative foot alignment included Meary angle, calcaneal pitch angle, hindfoot alignment angle, and navicular height., Results: Mean AOFAS, FAOS, and FAAM scores significantly improved from 65.1 to 86.2, 55.6 to 87.8, and 45.7 to 84.4 points at final follow-up, respectively. However, all functional evaluation scores were significantly lower as compared to the control group ( P < .001). Mean peak torque (60 degrees/sec) of ankle dorsiflexors, plantarflexors, invertors, and evertors at final follow-up were 7.1 (deficit ratio of 65.4%), 39.2, 9.8, and 7.3 Nm, respectively. These muscle strengths were significantly lower compared to the control group ( P < .001). No significant differences in radiographic measurements were found, and no patients presented with a postoperative flat foot deformity. One patient (5.9%) needed an ankle-foot orthosis for occupational activity., Conclusions: Anterior transfer of the tibialis posterior tendon appears to be an effective surgical option for paralytic foot drop secondary to peroneal nerve palsy. Although restoration of dorsiflexion strength postoperatively was about 33% of the normal ankle, function in daily activities and gait ability were satisfactorily improved. In addition, tibialis posterior tendon transfer demonstrated no definitive radiographic or clinical progression to postoperative flat foot deformity at intermediate-term follow-up., Level of Evidence: Level IV, retrospective case series.

Introduction: We studied patterns of nerve injury in pediatric common fibular (peroneal) neuropathy (CFN)., Methods: A retrospective analysis was performed on data from 53 children with CFN at a pediatric electromyography laboratory., Results: Conduction block at the fibular head was present in 35% of patients. Deep fibular axonal loss was identified in 77%, while superficial fibular axonal loss was identified in 45%. The pathophysiology was predominantly axonal in 72%, mostly demyelinating in 6%, and mixed in 22%. Predominantly demyelinating lesions at the fibular head demonstrated sparing of the superficial fibular sensory nerve (P = 0.01, Fischer exact test). Predominantly axonal lesions had a moderate correlation between superficial and deep fibular axonal loss (Spearman r = 0.52; P = 0.0001)., Conclusions: There is frequent axonal and fascicular injury in pediatric CFN, similar to adults. Deep and superficial fibular nerve involvements correlate in axonal lesions, whereas superficial fibular sensory fibers are often spared in demyelinating lesions. Muscle Nerve, 2016 Muscle Nerve 55: 693-697, 2017., (© 2016 Wiley Periodicals, Inc.)

Motor or motor-predominant neuropathies may arise from disease processes affecting the motor axon and/or its surrounding myelin. Lower motor neuron syndrome (LMNS) arises from a disease process affecting the spinal motor neuron itself. The term LMNS is more generally used, rather than motor neuronopathy, although both entities are clinically similar. Common features are muscle weakness (distal or proximal) with atrophy and hyporeflexia, but no sensory involvement. They can be acquired or hereditary. Immune-mediated neuropathies (multifocal motor neuropathy, motor-predominant chronic inflammatory demyelinating polyneuropathy) are important to identify, as effective treatments are available. Other acquired neuropathies, such as infectious, paraneoplastic and radiation-induced neuropathies are also well known. Focal LMNS is an amyotrophic lateral sclerosis (ALS)-mimicking syndrome especially affecting young adults. The main hereditary LMNSs in adulthood are Kennedy's disease, late-onset spinal muscular atrophy and distal hereditary motor neuropathies. Motor neuropathies and LMNS are all clinical entities that should be better known, despite being rare diseases. They can sometimes be difficult to differentially diagnose from other diseases, particularly from the more frequent ALS in its pure LMN form. Nevertheless, correct identification of these syndromes is important because their treatment and prognoses are definitely different., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

The low incidence of intraneural ganglion makes it difficult to diagnose and treat before it becomes serious nerve damage. This case describes a 69-year-old female, who suffered from the right drop foot and was diagnosed as a peroneal intraneural ganglion. Resection of the mass relieved the pain; however, motor function was not recovered. Early diagnosis and nerve decompression are essential for the peroneal intraneural ganglion before critical nerve symptoms.

Purpose: Identification of modifiable risk factors for falling is paramount in reducing the incidence and morbidity of falling. Peroneal neuropathy with an overt foot drop is a known risk factor for falling, but research into subclinical peroneal neuropathy (SCPN) resulting from compression at the fibular head is lacking. The purpose of our study was to determine the prevalence of SCPN in hospitalized patients and establish whether it is associated with a recent history of falling., Methods: We conducted a cross-sectional study of 100 medical inpatients at a large academic tertiary care hospital in St Louis, Missouri. General medical inpatients deemed at moderate to high risk for falling were enrolled in the summer of 2013. Patients were examined for findings that suggest peroneal neuropathy, fall risk, and a history of falling. Multivariate logistic regression was used to correlate SCPN with fall risk and a history of falls in the past year., Results: The mean patient age was 53 years (SD = 13 years), and 59 patients (59%) were female. Thirty-one patients had examination findings consistent with SCPN. After accounting for various confounding variables within a multivariate logistic regression model, patients with SCPN were 4.7 times (95% CI, 1.4-15.9) more likely to report having fallen 1 or more times in the past year., Conclusions: Subclinical peroneal neuropathy is common in medical inpatients and is associated with a recent history of falling. Preventing or identifying SCPN in hospitalized patients provides an opportunity to modify activity and therapy, potentially reducing risk., (© 2016 Annals of Family Medicine, Inc.)

The assessment of neuromuscular recovery after peripheral nerve surgery has typically been a subjective physical examination. The purpose of this report was to assess the value of gait analysis in documenting recovery quantitatively. A professional football player underwent gait analysis before and after surgery for a peroneal intraneural ganglion cyst causing a left-sided foot drop. Surface electromyography (SEMG) recording from surface electrodes and motion parameter acquisition from a computerized motion capture system consisting of 10 infrared cameras were performed simultaneously. A comparison between SEMG recordings before and after surgery showed a progression from disorganized activation in the left tibialis anterior and peroneus longus muscles to temporally appropriate activation for the phase of the gait cycle. Kinematic analysis of ankle motion planes showed resolution from a complete foot drop preoperatively to phase-appropriate dorsiflexion postoperatively. Gait analysis with dynamic SEMG and motion capture complements physical examination when assessing postoperative recovery in athletes.

Muscle strength measurement is important when evaluating the degree of impairment in patients with nerve injury. However, accurate and objective evaluation may be difficult in patients with severe pain or those who intentionally try to avoid full exertion. We investigated the usefulness of the affected-to-unaffected side electrophysiological parameter ratios as a measure of objective ankle dorsiflexion (ADF) strength in patients with unilateral fibular nerve injury (FNI). ADF strength was measured in patients with FNI via handheld dynamometer and manual muscle test (MMT). Fibular nerve compound muscle action potential (CMAP) amplitude and latency and ADF strength of the affected side were presented as ratios to the corresponding measurements of the unaffected side. We analysed the correlation of the CMAP ratio with the ADF strength ratio using a dynamometer and compared the CMAP ratios according to MMT grade. Fifty-two patients with FNI were enrolled. The mean CMAP latency ratio did not differ between MMT groups (p = 0.573). The CMAP amplitude ratio proportionally increased with the quantified ADF strength ratio via dynamometer increase (ρ = 0.790; p < 0.001), but the CMAP latency ratio and the quantified ADF strength ratio did not significantly correlate (ρ = 0.052; p = 0.713). The average CMAP amplitude ratio significantly differed between MMT groups (p < 0.001), and post hoc tests showed significant differences in all paired comparisons except of Fair and Good grades (p = 0.064). Electrophysiological parameter ratio, such as the affected-to-unaffected side CMAP amplitude ratio, might be sensitive parameters for ADF power estimation after FNI.

Tibiofemoral knee dislocations are typically a consequence of high-energy mechanisms, causing significant damage to the soft tissue and osseous structures of the knee. Concomitant neurovascular injuries such as popliteal artery and peroneal nerve injuries are also common and can have significant long-term consequences. The mechanism typically involves a traction injury to the peroneal nerve subsequent to an extreme varus moment applied to the knee. Complete nerve injuries typically hold a worse prognosis than incomplete palsies. Rates of functional recovery in the setting of a complete palsy following a knee dislocation event have been dismal. A period of observation and nonoperative treatment is initially performed, utilizing orthotic devices to assist with lower extremity deficits. Surgical treatment options include neurolysis, nerve grafting, tendon transfer, arthrodesis, and direct motor nerve transfers. Motor nerve transfers continue to be explored with initial reports showing promising results., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Introduction: The aim of this study was to demonstrate single fascicular involvement in common fibular (CF) neuropathy using high-resolution ultrasound (US)., Methods: We prospectively enrolled 40 adult patients with clinical and electrodiagnostic suspected CF neuropathy between April 2012 and December 2014. Two musculoskeletal radiologists used high-resolution US probes to prospectively and independently evaluate the CF nerve bilaterally in these patients. The presence of single fascicular involvement (increased cross-sectional area and loss of fascicular echotexture) was recorded., Results: US revealed involvement of only 1 fascicular component of the CF nerve in 7 patients. In all these patients, US revealed involvement of the anterior fascicles corresponding to fibers for the deep fibular nerve., Conclusions: High-resolution US allowed identification of single fascicular involvement in CF neuropathy. Anterior fascicular involvement was present in up to 17% of patients with suspected CF neuropathy., (© 2016 Wiley Periodicals, Inc.)

This article thoroughly describes the clinical examination and treatment of common fibular (peroneal) nerve compression. Aspects discussed include the anatomy of the nerve, cause of entrapment, symptoms associated with impairment, and a surgical approach to decompress the entrapped nerve. The standard protocol for decompression as it would apply to the common fibular nerve tunnel is illustrated., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: The diagnosis of common peroneal nerve entrapment neuropathy (CPNEN) is based on clinical symptoms and nerve conduction studies. However, nerve conduction studies may not detect abnormalities. Under the hypothesis that repetitive plantar flexion that loads the peroneal nerve (PN) at the entrapment point without lumbar loading would be a useful CPNEN provocation test, we evaluated the repetitive plantar flexion (RPF) test as an adjunct diagnostic tool for CPNEN. The study design was a retrospective analysis of prospectively collected data., Methods: Our study population consisted of 18 consecutive patients whose ipsilateral CPNEN improved significantly after PN neurolysis. Using repetitive ankle plantar flexion as a CPNEN provocation test, results were recorded as positive when it elicited numbness and/or pain in the affected area of the PN., Results: The RPF test induced symptoms on all affected sides in the course of 57.4 seconds (range, 14-120 seconds). In 3 patients it induced numbness in the affected area of the PN in the normal leg. Receiver operating characteristic analysis showed that the diagnostic sensitivity and accuracy of the test were 94.4% each. The suggested cutoff point was 110 seconds and the area under the receiver operating characteristic curve was 0.97 (95% confidence interval 0.93-1.02). The positive and the negative predictive values were 89.5% and 94.1%, respectively., Conclusions: Our simple RPF test elicited the symptoms of CPNEN and our provocation test helped to identify dynamic PN entrapment neuropathy as the origin of intermittent claudication., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: Quantitative assessment of nerve echogenicity using the MaxEntropy, RenyiEntropy and Yen methods has shown promise in the assessment of ulnar neuropathy at the elbow. The purpose of this study was to determine the clinical usefulness of quantitative echogenicity measurement when using these three automatic thresholding methods in the evaluation of patients with common fibular (CF) neuropathy., Methods: High-resolution ultrasonography (HRUS) images of the CF nerve from 45 patients with CF neuropathy were compared to 42 healthy controls., Results: With all three methods patients with CF neuropathy had significantly higher mean hypoechoic fraction than healthy controls at the level of the fibular head (FH): MaxEntropy 87.4% versus 71.9% (p<0.001), RenyiEntropy 84.7% versus 68% (p<0.001) and Yen 87.6% versus 68.2% (p<0.001). Patients with CF neuropathy could be differentiated from healthy controls at a hypoechoic fraction cut-off point of 82% (MaxEntropy), 80% (RenyiEntropy) and 80% (Yen) with a sensitivity of 82%, 82% and 84% respectively, and a specificity of 93%, 95% and 83% respectively. Similar results were found for sonographic measurements above the FH., Conclusion: Quantitative assessment of nerve echogenicity using the MaxEntropy, RenyiEntropy and Yen methods can be used to distinguish between patients with CF neuropathy and healthy controls with high sensitivity and specificity., Significance: These three proven automatic thresholding methods can be used to assess nerve echogenicity in future studies. Quantitative echogenicity assessment with HRUS shows promise for the future as a potential diagnostic tool in daily clinical practice., (Copyright © 2015 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.)

Background: The purpose of this study was to determine the clinical outcomes and objective measures of function that can be expected for patients following the Bridle procedure (modification of the posterior tibial tendon transfer) for the treatment of foot drop., Methods: Nineteen patients treated with a Bridle procedure and 10 matched controls were evaluated. The Bridle group had preoperative and 2-year postoperative radiographic foot alignment measurements and completion of the Foot and Ankle Ability Measure. At follow-up, both groups were tested for standing balance (star excursion test) and for ankle plantarflexion and dorsiflexion isokinetic strength, and the American Orthopaedic Foot & Ankle Society and Stanmore outcome measures were collected only on the Bridle patients., Results: There was no change in radiographic foot alignment from pre- to postoperative measurement. Foot and Ankle Ability Measure subscales of activities of daily living and sport, American Orthopaedic Foot & Ankle Society, and Stanmore scores were all reduced in Bridle patients as compared with controls. Single-limb standing-balance reaching distance in the anterolateral and posterolateral directions were reduced in Bridle participants as compared with controls (P < .03). Isokinetic ankle dorsiflexion and plantarflexion strength was lower in Bridle participants (2 ± 4 ft·lb, 44 ± 16 ft·lb) as compared with controls (18 ± 13 ft·lb, 65 ± 27 ft·lb, P < .02, respectively). All Bridle participants reported excellent to good outcomes and would repeat the operation. No patient wore an ankle-foot orthosis for everyday activities., Conclusion: The Bridle procedure was a successful surgery that did not restore normal strength and balance to the foot and ankle but allowed individuals with foot drop and a functional tibialis posterior muscle to have significantly improved outcomes and discontinue the use of an ankle-foot orthosis. In addition, there was no indication that loss of the normal function of the tibialis posterior muscle resulted in change in foot alignment 2 years after surgery., Level of Evidence: Level III, retrospective comparative series., (© The Author(s) 2015.)