A thorough history and physical exam to assess the status and function of the common peroneal nerve is always required. In patients with a peroneal nerve injury, clinical presentation varies based on the location and severity of the injury and the presence of anatomic variations. The most common presentation of a common peroneal nerve injury is a weakness of ankle dorsiflexion and the classic resultant foot drop or catching the toes while ambulating.[8] Foot drop can develop acutely or over days to weeks, depending on the etiology. It can also be complete or partial in severity. There may also be accompanying numbness or paresthesia present along the lateral leg, dorsal foot and/or the first toe web space. Pain may also be present in traumatic cases but is not always present.[8]

The clinician directs the clinical physical examination by the patient’s reported symptoms and requires an understanding of the relevant anatomy and possible underlying etiology. For example, in cases of suspected chronic peroneal nerve palsy with resultant foot drop, the clinician should consider as a primary documented part of the examination focusing on gait assessment as it may provide significant clues to the etiology of the symptoms.[8] For example, a patient with weakened or paralyzed dorsiflexors may ambulate with a high steppage gait to prevent dragging their toes on the ground due to nerve injury. Furthermore, numbness or dysesthesia in the upper lateral leg indicates a lesion proximal to the fibular head, which may involve the sciatic nerve or lumbosacral nerve roots. In contrast, if there is a decreased or abnormal sensation in the lower lateral leg and dorsum of the foot, the superficial peroneal nerve may be involved. If there is also altered sensation in the dorsal aspect of the first web space of the foot, the deep peroneal nerve may also be involved.[8]

In the setting of traumatic injuries to the knee, including knee dislocations, the initial examination testing is done to rule out an acute neurovascular injury that could potentially compromise the lower extremity. Knee dislocations can notoriously compromise the neurovascular structures passing from the thigh and knee to the lower limb and if not addressed urgently can lead to acute compartment syndrome (ACS) which can result in long-term compromise to the lower limb requiring operative amputation.[12][13]

To test for the motor involvement of the superficial peroneal nerve and deep peroneal nerve, one must assess foot eversion (SPN) and foot/toe dorsiflexion (DPN). A finding of weakness of both foot eversion as well as foot/toe dorsiflexion, suggests a lesion involving the common peroneal nerve.[8] Proximal lesions, for example, secondary to traumatic knee dislocations, will often present with varying degrees of numbness in both superficial peroneal nerve and deep peroneal nerve distributions. On motor examination testing, a careful and detailed examination detecting the presence or absence of dorsiflexion of the ankle and/or great toe past neutral is imperative.  The subtle distinction is important in differentiating the ability to actively dorsiflex the great toe from a maximally plantarflexed position to a near-neutral position.  Such findings do not rule out deep peroneal nerve injury.

Tinel sign is also a reliable clinical sign to localize the area of nerve irritation or entrapment. The examiner performs the Tinel test by tapping along the course of the nerve – particularly around the fibular neck. If tingling or paresthesia is elicited distally to the point of compression by tapping, it denotes a positive Tinel sign.[8]

When the history and physical examination is indicative of a potential injury to the common peroneal nerve, plain radiography should be part of the initial workup. Because of the proximity of the common peroneal nerve to the fibular neck as well as its superficial location, it is particularly susceptible to direct trauma injury as well as entrapment by soft and bony tissue. In addition to plain radiography, CT scans can be used to evaluate further osseous abnormalities, and MRI/ultrasound can be used to assess soft-tissue sources or masses.[4] The former should be considered in the setting of tibial plateau fractures while the latter (i.e., MRI) is prudent in cases of traumatic knee dislocations.

Electrodiagnostic studies, including nerve conduction velocity (NCV) tests and electromyography tests (EMG), can be used to diagnose peroneal nerve palsy. These tests help in the evaluation of the motor and sensory axons of the peroneal nerve and its branches. They are also helpful in the localization of the nerve injury. These tests are useful in patients presenting with new-onset of peroneal nerve symptoms such as foot drop without a traumatic mechanism in addition to evaluating patients in the postoperative setting of a known traumatic peroneal nerve injury to plan long-term management as well as to provide patient.

There are operative and non-operative options for the treatment of common peroneal nerve injuries. Non-operative treatments include ankle-foot orthoses and physical therapy. An ankle-foot orthotic (AFO) may be used for foot drop when surgery is not warranted or during surgical recovery. The specific purpose of an ankle-foot orthotic is to provide toe dorsiflexion during the swing phase, medial or lateral stability at the ankle during stance and, if necessary, some push off stimulation during the late stance phase. There have been advancements in ankle-foot orthotics in recent years, including carbon fiber that provides even more energy for push-off during the stance phase as well as being lighter and more comfortable to use for patients. Physical therapy for common peroneal nerve injury includes a program of stretching, strengthening, mobilization, manipulation, and proprioceptive and balancing exercises. It may also include icing, ankle bracing and/or taping.

Surgical indications for common peroneal nerve injuries include a rapidly deteriorating lesion and no signs of improvement within three months and open injuries with suspected nerve laceration.[4] Open lacerations should undergo exploration and surgical repair within 72 hours.[4]

Critical elements pertinent to the differential diagnosis of CPN injury entail discerning the following:

• Chronicity of the injury
  • Acute, subacute, or chronic
• Injury location
  • CPN injury can occur proximally about the hip (e.g., acetabular fracture, posterior hip dislocation), at the knee/fibular head/neck, or more distally in the SPN or DPN distributions
• Underlying etiology
  • Traumatic injuries (fracture/dislocations)
  • Atraumatic mechanisms
    • Systemic or inflammatory conditions (e.g., diabetes mellitus)
  • Iatrogenic causes
  • External (splint/cast) or internal (anatomic) sources of compression

Other clinical entities/pathologies that can mimic these types of presentations can include, but are not limited to:

• Peroneal tendon pathology
• Other compressive neuropathies
  • Tarsal tunnel syndrome
  • Anterior tarsal tunnel syndrome
  • Nonspecific tendinitis affecting lower limb muscles/tendons
• Chronic ankle pain

Prognosis depends on etiology. While some transient common peroneal nerve neuropathies often improve or resolve over time with nonsurgical measures, common peroneal nerve palsy following traumatic knee dislocations results in inferior outcomes with poor prognosis for the long-term recovery of nerve function.[14] Surgical intervention and tendon transfers are often necessary for refractory common peroneal nerve palsy, dictated by follow-up physical examination and serial EMG/NCS testing.  

Prognosis has been described extensively in patients who experience common peroneal nerve injury following total knee arthroplasty. In one particular study, 62% of patients had a maximal neurologic recovery, and 38% had complete recovery at 12 months.[15] In another large case series study including 318 operatively-managed peroneal nerve lesions associated with various mechanisms, 84% of patients who underwent end-to-end suture repair received good recovery by 24 months.[4] In patients who required grafts, those with grafts less than 6 cm, had a 75% recovery of function. Longer grafts were associated with worse outcomes.[4]

Common peroneal nerve injuries typically receive treatment with conservative modalities, including splinting and physical therapy. In patients with foot drop, the clinician must ensure the physical therapist and rehabilitation care team are ensuring that the risks of a fixed equinus contracture are mitigated by performing passive stretching exercises to ensure the ankle can achieve at least passive dorsiflexion to a neutral position.[8]

It is the physician's responsibility to provide patient education on the treatment options available for common peroneal nerve injuries, including the prognosis and complications that go along with each. In turn, patients should follow their individualized treatment plans for the best results. Patients should also maintain regular contact and follow up with their physician to ensure appropriate care. 

• The most common presentation with common peroneal nerve injury or palsy is acute foot drop, although symptoms may be progressive and can include sensory loss or pain.
• Weakness in foot eversion may occur if the superficial peroneal nerve component is involved.
• Weakness in dorsiflexion of the foot and great toe extension suggests deep peroneal nerve involvement.
• The pattern of sensory loss suggests either superficial or deep peroneal nerve involvement or both.
• The prognosis for common peroneal nerve injury is good following end-to-end suture repair as well as grafting.

Patients with common peroneal nerve injury/palsy experience a wide range of prognosis along a spectrum depending on the underlying etiology. For example, in the setting of knee dislocations with presenting foot drop and peroneal nerve palsy, outcomes across the board are poor in general in regards to the return of native function.

To adequately treat patients with common peroneal nerve injuries, specialists including neurologists and orthopedic surgeons must coordinate and work closely with primary care physicians, nurse practitioners, physician assistants, and physical therapists to ensure appropriate management and outcomes. 

The key to the management of common peroneal nerve is early recognition and appropriate referral to the specialist. The emergency department physician should be able to recognize common peroneal nerve injury and consult with the orthopedic surgeon. For those managed with non-surgical methods, the nurse has to educate the patient about foot drop and the potential to cause more injury to the tissues. The physical therapist should educate the patient on ambulation, ankle bracing, and the use of an assistive device. The patient requires monitoring for recovery, which in many cases, may take weeks or months. A wound care nurse should follow patients with open wounds until complete healing has occurred. Post-surgical pain control can benefit from pharmacist involvement, assisting with agent selection as well as minimizing opioid use. communication between all these disciplines is paramount so that everyone on the interprofessional team has the full clinical picture and can make decisions based on the current status.

Peroneal nerve injuries require an interprofessional team approach, including physicians, specialists, specialty-trained nurses, physical therapists, and pharmacists, all collaborating across disciplines to achieve optimal patient results. [Level 5]