anatomy & injury of nerve

1. TIBIAL
NEUROPATHY
P/B :- DR NIYATI PATEL 1

2. ANATOMY
 Tibial nerve is also known as
medial popliteal nerve
ROOT VALUE:- L4,L5,S1,S2
Tibial nerve arising from
Ventral division of ventral rami
of L4,L5,S1,S2
MOTOR SUPPLY
◦ Gastrocnemius
◦ Soleus
◦ Plantaris
◦ Popliteus
◦ Tibialis posterior
◦ Flexor digitorum longus
◦ Flexor halluces longus
P/B :- DR NIYATI PATEL 2

3. P/B :- DR NIYATI PATEL 3

4. CAUSES
• Injection palsy
• Deep penetrating injury to the knee and upper half of the leg
• Dislocation of the knee
• Tarsal tunnel syndrome
• Morton’s neuroma
P/B :- DR NIYATI PATEL 4

5. • Tarsal tunnel syndrome in which the nerve
is entrapped in between the laciniate ligament
and the medial surface of the talus, distal to
the medial malleolus.
Tarsal tunnel syndrome is a compression, or
squeezing, on the posterior tibial nerve that
produces symptoms anywhere along the path
of the nerve running from the inside of the
ankle into the foot
symptoms:
1. Tingling, burning or a sensation similar to
an electrical shock
2. Numbness
3. Pain, including shooting pain
P/B :- DR NIYATI PATEL 5

6. • Morton’s neuroma
A neuroma is a thickening of nerve tissue that
may develop in various parts of the body. The
most common neuroma in the foot is a Morton’s
neuroma, which occurs between the third and
fourth toes. It is sometimes referred to as an
intermetatarsal neuroma.
Causes:- compression or irritation of the nerve
can lead to the development of a neuroma. One
of the most common offenders is wearing shoes
Symptoms – Tingling, burning or numbness,
Pain, A feeling that something is inside the ball
of the foot, A feeling that there is something in
the shoe or a sock is bunched up
P/B :- DR NIYATI PATEL 6

7. SIGNS & SYMPTOMS
Sensory
Tibial nerve palsy leads to loss of sensation
over the following areas:
• Sole of the foot
• Skin over the medial aspect of the heel
Autonomous zone of the tibial nerve is sole
of the foot except the medial border of the
foot, lateral surface of the heel and plantar
surface of the toes.
P/B :- DR NIYATI PATEL 7

8. Motor
The muscles that are paralyzed are gastrocnemius, plantaris,
soleus,
flexor hallucies longus, flexor digitorum longus, tibialis
posterior
and popliteus
Deformity
The patient will develop talipes calcaneovalgus deformity or
dorsiflexion deformity
Reflexes
The ankle jerk is lost and the plantar reflex may also be
inellicitable
P/B :- DR NIYATI PATEL 8

9. INVESTIGATION
RADIOGRAPH :- shows whether there is presence of fracture
MRI :- To delineate complete avulsion of nerve roots
SD CURVE:- abnormality in conduction can be verified. Sharp curve,
long chronaxie, low rheobase and the absence of contraction with
repetitive stimuli indicates denervation. If it is done 2-3 weeks after
injury, it shows the sign of denervation and to find out whether it is
moderate or severe injury
NCV:- To find out the severance of nerve fibers with wallerian
degeneration.
EMG:- it will help to find out reversible and irreversible nerve damage
and will help map out whether it pre ganglionic/ post ganglionic lesion
P/B :- DR NIYATI PATEL 9

10. TYPES OF INJURIES
In Neuropraxia  pain, numbness, muscle weakness, minimal muscle
wasting is present. Recovery occurs within minutes to days
In Axonotmesis  there is pain, evident muscle wasting, complete loss
of motor, sensory and sympathetic functions. Recovery time– months
(axon regeneration at 1-1.5 mm/day)
In Neurotmesis  no pain, complete loss of motor, sensory and
sympathetic functions. Recovery time – months and only with surgery
P/B :- DR NIYATI PATEL 10

11. TREATMENT
Conservative treatment consists of:
• IG stimulation
• Passive movement
• Stretching
• Care of anesthetic foot
• Orthosis: The patient may be prescribed below knee caliper with
dorsiflexion stop.
P/B :- DR NIYATI PATEL 11

12. SURGICAL TREATMENT
• Posterior transfer of tibialis
anterior along with extensor
halluces longus to the first
metatarsal to prevent its drop
• Transfer of evertor posteriorly
with arthrodesis of subtalar and
transverse tarsal joint
• Triple arthrodesis - The term
"triple" arthrodesis refers to a
fusion procedure of three joints of
the hindfoot; the subtalar joint
(talus and calcaneus), the
talonavicular joint, and the
calcaneocuboid joint.
P/B :- DR NIYATI PATEL 12

13. STRAIGHT LEG
RAISING (SLR)
P/B :- DR NIYATI PATEL 13

14. P/B :- DR NIYATI PATEL 14

15. SLR 1(BASIC) & SLR 2 (Sciatic &
tibial nerve)
P/B :- DR NIYATI PATEL 15

16. SLR 3 (Sural nerve)
P/B :- DR NIYATI PATEL 16

17. SLR 4 (Common peroneal
nerve)
P/B :- DR NIYATI PATEL 17

18. SLR 5 (Crossed- Well leg SLR)
P/B :- DR NIYATI PATEL 18