Nerve Disorders of the Hallux

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Nerve disorders about the hallux can generate remarkable pain and dysfunction. Whether caused by soft tissue entrapment, trauma, iatrogenic injury, or from an idiopathic basis; nerve disorders are approached by careful history and examination followed by nonoperative treatment. In cases that do not respond, meticulous surgical management can be helpful in many cases.

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Anatomy

The anatomy of the cutaneous innervation of the hallux can be confusing. The patterns of innervation can be variable and may not adhere to textbook descriptions. The plantar surface is innervated by branches of the medial plantar nerve, while the dorsum receives the terminal aspects of the superficial and deep peroneal nerves (Fig. 1). The most detailed text on anatomy of the foot describes several patterns of first web space innervation.2 Historically, confusion arose because one prominent

Nonoperative approach to neuritis

Initial evaluation and treatment of nerve disorders of the foot usually follow a similar pattern. The patient is questioned about medical comorbidities, trauma history, prior foot or ankle surgeries, and the location, severity, and character of the symptoms. Examination begins with observing the skin for any scars, prior burns, or contractures that could suggest entrapment of the cutaneous nerves. Overall alignment of the foot and the hallux is assessed. The location of tenderness is determined

Surgical treatment of nerve disorders

Surgical treatment for nerve problems follows simple guidelines whenever possible. A positive nerve block helps to confirm the diagnosis and should be a precursor to most surgical interventions. If an offending bone prominence or malalignment exists, then bony correction may help the neuritis. In cases of nerve entrapment, stenosis, or traction injury, neurolysis and decompression can relieve symptoms. Neurolysis offers little improvement, however, if the surgeon encounters minimal scar tissue

Dorsomedial cutaneous nerve

The dorsomedial cutaneous nerve (DMCN) is the terminal extension of the superficial peroneal nerve which innervates the dorsal and medial aspect of the hallux. (Fig. 2) The nerve has a variable course and intermingles with the deep peroneal nerve.2, 8, 9 The superficial peroneal nerve is purely sensory and can be compressed at the distal third of the leg as it egresses from the deep muscular fascia; such compression can result in distal sensory findings similar to DMCN pathology.

Neuritis of the

Deep peroneal nerve

The deep peroneal nerve extends along the dorsal tibia and emerges from under the superior extensor retinaculum. The patterns of innervations are variable. The nerve is primarily sensory but sends a motor branch to the extensor hallucis brevis muscle. A posterior sensory branch has also been described to the sinus tarsi region.22 The main nerve branch runs dorsally on the midfoot and terminates in the first web space. The deep peroneal nerve is at obvious risk for mechanical trauma or

The medial plantar nerve

The medial plantar nerve, a branch of the posterior tibial nerve, courses deep to the abductor hallucis muscle in the foot and branches in a variable pattern to the hallux and the medial forefoot.26, 27 This nerve lies within a complicated web of tissues on the medial aspect of the foot. Surgery for transfer of the flexor hallucis longus has been noted to cause damage to the medial plantar nerve.14, 28, 29, 30 This nerve has also been injured with metatarsal shortening.14 Iatrogenic compression

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