Anatomy, Bony Pelvis and Lower Limb, Calf Common Peroneal (Fibular) Nerve


Article Author:
Jonathan Hardin


Article Editor:
Shruti Devendra


Editors In Chief:
Sherri Murrell


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
12/6/2018 5:32:35 PM

Introduction

The common peroneal nerve, also known as the common fibular nerve,  is a major nerve that innervates the lower extremity. As one of the two major branches off the sciatic nerve, it receives fibers from the posterior divisions of L4 through S2. Specifically, it originates from the sciatic nerve and separates from it proximal to the popliteal fossa and courses its way along the posterolateral aspect of the leg deep to the long head of the biceps femoris and through the popliteal fossa before passing behind the proximal fibular head. Just inferior and lateral to the fibular head, at the fibular neck, it divides into two nerves–the superficial and deep fibular nerves. The superficial fibular nerve courses anterolaterally between the fibularis longus muscle and extensor digitorum longus muscle within the lateral compartment. As it moves distally, it terminates within the lateral compartment before reaching the ankle and foot. The deep fibular nerve courses anteriorly and runs adjacent to the anterior tibial artery between the extensor digitorum longus muscle and the tibialis anterior muscle. As the deep fibular nerve travels distally, it runs within the anterior compartment of the leg between two muscles. These muscles include the extensor hallucis longus muscle and the tibialis anterior muscle. As the nerve approaches the foot just anterior to the talus, it divides into medial and lateral branches. The medial branch travels alongside the dorsalis pedis artery and terminates in between the first two metatarsals. The lateral branch travels alongside the lateral tarsal artery and terminates near the fifth metatarsal.[1]

Structure and Function

The common fibular nerve ultimately is responsible for innervating the muscles that compose the anterior and lateral muscular compartments of the lower extremity. The anterior muscular compartment of the lower extremity consists of the tibialis anterior muscle, the extensor hallucis longus muscle, and the extensor digitorum longus muscle. This compartment is responsible primarily for dorsiflexion of the foot. The lateral muscular compartment of the lower extremity consists of the fibularis longis muscle and the fibularis brevis muscle. This compartment is responsible primarily for the eversion of the foot.

In addition to carrying motor fibers, the common fibular nerve carries afferent cutaneous sensory fibers from the lower extremity that ultimately travel proximally to the spinal cord. The majority of anterior sensation of the leg is carried by the superficial fibular nerve; however, the deep fibular nerve carries some as well. Specifically, the superficial fibular nerve carries sensory fibers from the anterolateral aspect of the lower extremity that extends from midway down the leg to the majority of the dorsal aspect of the foot and toes. The deep fibular nerve carries sensory fibers from between the first and second toes. These nerves also carry some posterolateral sensation, albeit minimal. The common fibular nerve is responsible for sensation inferolaterally to the knee via the lateral sural cutaneous nerve, which is a small cutaneous branch off the common fibular nerve. The superficial fibular nerve is responsible for some lateral leg sensation just below where the sensation from the lateral sural cutaneous nerve ends.[1]

Physiologic Variants

As in most parts of the human anatomy, the course and surrounding anatomy of the common fibular nerve has several variants that should be noted, especially for surgeons who may have to decompress the nerve. These variants may also result in an increase or decrease in the likelihood of compressed nerves. In a study comparing the anatomy in cadavers and the anatomy in surgically decompressed nerves, there were found to be a few major variants. The first one includes fibrous tissue that forms a band-like structure underneath the superficial head of the peroneus longus. The next variant also includes fibrous tissue forming a band-like structure; however, this tissue is located on the superficial surface of the deep head of a muscle known as the peroneus longus. The last variant noted includes two muscles and their uncommon junction and origin. Usually, the soleus muscle and the fibularis longis muscle originate separately on the fibular head; however, in some people, they originate together at the fibular head and separate as they move distally.[2]

Clinical Significance

The common fibular nerve is a frequently discussed subject compared to other neuromuscular complaints due to its frequency of injury and its classic clinical presentation. Because of its location, it is fairly vulnerable to injury. It travels across the lateral aspect of the knee over the neck of the fibula where its only protection is skin and subcutaneous fat and fascia. Thus, various trauma to the lateral knee often results in damage to the common fibular nerve. For example, if a football player is tackled from the side the result may be a fibular neck fracture and common fibular nerve injury. The patient would most likely present with knee pain, loss of foot dorsiflexion, loss of ankle eversion, and loss of sensation down the lateral leg and dorsum of the foot. Because of the patient’s inability to dorsiflex the foot, they will also likely present with “foot drop.” This occurs during the swinging phase of the gait cycle. Because there is a loss of dorsiflexion, the toes will drag on the ground rather than clearing the ground as in a normal gait. In many cases, the patient will compensate for their foot-dragging by exaggerating hip abduction to allow for increased clearance of their foot.

Another frequent mechanism of injury to the common fibular nerve is through compression of the nerve as it crosses the fibular head and neck or distal to them. This may occur after a splint or cast is placed incorrectly or too tight, or in the case of compartment syndrome after a trauma or burn. These examples would present similarly: the compressed nerve would initially cause paresthesias, followed by loss of sensation and weakness and ultimately resulting in loss of dorsiflexion of the foot and loss of ankle eversion if left untreated. It should be noted that, in these cases, there might also be vascular compromise, so distal pulses should be examined.

There are also clinical presentations that may mimic an injury to the common fibular nerve but are actually due to proximal injuries at the level of the sciatic nerve. One common example is in the case of piriformis syndrome. In some cases, or in anatomical variants, the sciatic nerve, which carries fibers for the common fibular nerve, may become entrapped within the piriformis muscle. A tight piriformis may then cause similar symptoms to the classic common fibular nerve injury: loss of dorsiflexion, loss of foot eversion, and loss of sensation to the anterolateral aspect of the leg and dorsum of the foot. However, in addition to these symptoms, the patient might also experience symptoms proximal to the knee similar to the classic presentation of sciatica. Thus, it is important to differentiate between sciatica, piriformis syndrome, or just simply an injury to the common fibular nerve in order to formulate a proper treatment plan.[3]


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Anatomy, Bony Pelvis and Lower Limb, Calf Common Peroneal (Fibular) Nerve - Questions

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A lesion of which nerve can cause foot drop?



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A 34-year-old male who was recently in a cycling accident presents with a chief complaint of frequently tripping while walking. On gait examination, he takes short steps and flexes his right hip much more than his left hip so that his right toes do not drag on the ground. What nerve is most likely injured?



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A 67-year-old female presents to the emergency department with a chief complaint of right foot drop and right lower extremity pain after falling down several steps. On physical exam, she is unable to both dorsiflex and evert her right foot. She also has loss of sensation on the dorsum of her right foot. Where is the injury of the damaged nerve located?



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A 17-year-old female presents to the emergency department with a chief complaint of left knee pain after being kicked hard during a soccer game. She also notices that she is unable to lift her toes up, which is causing her to significantly drag her left foot. On physical exam, the patient is unable to dorsiflex or evert her left foot, and she has lost sensation on the dorsum of her left foot. An x-ray is done, which shows a fracture of the left fibular neck. Which of the following nerves was most likely injured?

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A 47-year-old male who works in construction presents to the emergency department after falling from a ladder and landing on some broken glass. His vitals are stable, and he is in no acute distress; however, he is complaining of right leg pain. You notice that there is a piece of glass stuck in the upper lateral margin of the patient's right popliteal fossa. An injury here is most likely to damage which nerve?

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A 65-year-old female presents with a chief complaint of left knee pain and states that she has been noticing that her left foot sometimes drags while she is walking. When asked to show where her pain is located, she rubs her hands along the lateral side of the neck of her left fibula. Which nerve is she most directly palpating?

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A man backed into a whirling blade and suffered complete severance of the tendon of his biceps femoris muscle just above the lateral condyle of the femur. What is the one adjacent structure most likely to be involved?



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A 37-year-old male presents to the emergency department with a deep, 10 cm laceration to the posterior aspect of his right thigh. He is unable to dorsiflex and evert his right foot and has decreased strength in flexing his right knee. What muscle is most likely injured?



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Anatomy, Bony Pelvis and Lower Limb, Calf Common Peroneal (Fibular) Nerve - References

References

Dellon AL,Ebmer J,Swier P, Anatomic variations related to decompression of the common peroneal nerve at the fibular head. Annals of plastic surgery. 2002 Jan     [PubMed]
D’Abarno A,Bhimji SS, Anatomy, Lower Limb, Leg, Lateral Compartments null. 2018 Jan     [PubMed]
van Zantvoort APM,Setz MJM,Hoogeveen AR,Scheltinga MRM, Common Peroneal Nerve Entrapment in the Differential Diagnosis of Chronic Exertional Compartment Syndrome of the Lateral Lower Leg: A Report of 5 Cases. Orthopaedic journal of sports medicine. 2018 Aug     [PubMed]

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