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BACK to MAYA-GAIA SITEMAP       Update 14 09 08

Documenting a minor impact in the outside right ankle that caused serious disability for over two weeks.

Keywords: sural nerve injury, lateral calcaneal, peroneal communicating branch, sural nerve entrapment, sciatic nerve, superficial peroneal nerve, medial sural cutaneous nerve, tibial nerve, common peroneal nerve

Symptom Summary: Subject is an 80 year old male, history of heart attack, low blood pressure, for past year recurrent mild foot swelling, otherwise in good health. In this case there was significant involvement with the peroneal communicating branch causing acute pain in muscles in the lower leg, calf and knee when bending leg at knee. Virtually no pain in leg while sitting with knee bent and raising foot on toes.

Narrative: I had not even noticed the impact until I discovered I was bleeding from a slight cut sustained from striking an unknown object as I swept sand off a stepping stone located at the entrance to my back door with my bare foot. After a few hours I started to experience pain in my calf and in flexing my leg at the knee. The next day I could hardly walk and had to keep the effected leg straight as any flexing at the knee caused severe pain radiating up my calf and concentrating at my knee. The pain was so severe after three days I resorted to using a cane to walk fearing I might lose my balance. The next day I decided to simply hobble along without a cane but walk very slowly and deliberately keeping my leg straightened out particularly in navigating stairs where I placed both feet on each step- rising to the next step with my good leg. After two weeks I felt I was able to walk and flex my leg without much pain so tried riding my bicycle in low gear to my office (about two miles round trip). That evening it was obvious that I had aggravated the leg nerves and was reexperiencing some pain. Two days later I am back to walking without serious pain but decided not to try riding my bike for another week. During first two weeks- able to hobble with involved leg kept straight while avoiding bending at knee. Sleep somewhat disturbed by backgound pain mainly in calf with obvious pain when deep knee bend attempted, over three weeks after incident.

There is the possibility that my wound was caused by impacting a dead branch of a small juniper bush next to my entrance and since there is some concerns over the toxicity of various juniper a long shot explanation for the severe reaction to my minor trauma could be that I may have been innoculated with a toxic juniper sap.

Update: In a closer examination of the site where my ankle injury occurred- I discovered that after two weeks, rain had washed away some of the mounds I had created by sweeping sand off the stepping stone and revealed a single assemblage of shells that had underlain the sand (many of the condo's planting areas had been covered by a bed of seashells at one time). This assemblage was formed by two fairly large half-shells that were cemented together which had been imbeded securely in the sand in such a way that a knife-edged blade with three prominent projections were presented that exactly matched the wound pattern that was created as I swept my right foot in a clockwise motion as it came in contact with the projecting blade.

This totally exonerates the juniper bush and the toxicity question. It does not totally eliminate the notion that some infection may have contributed to the severity of my symptoms. The injury seemed to have occurred at the point where the sural nerve is most superficial to the surface of the ankle but a contributing factor is that my skin has become thinner and more vulnerable in my old age to laceration and bruising which could account for the severity of reaction to what seemed a very minor and shallow cut (at the time I had not realized I was injured until I noticed very brief bleeding). On the third week after injury as the pain diminished I became aware of slightly attenuated motor function over the affected area- requiring that I concentrate to stablize my leg whenever under weight while bending at the knee.


Sural is the Latin term for the calf of the leg. There are numerous reports of injury to sural and peronial nerves on one leg causing disability to the opposite leg. The sural nerve is joined by fibers from the common peroneal nerve and runs down the calf to supply the lateral side of the foot.

Sural neuropathy: The sural nerve can be injured at the ankle by tendon sheaths and scar tissue. Sural nerve entrapment localized to its course as it passes through the superficial sural aponeurosis is described in athletes. Such entrapment results in chronic calf pain, exacerbated by physical exertion.

Tibial nerve syndromes involve the tibial nerve, which branches from the sciatic nerve, descends through the popliteal fossa, and passes deep between the heads of the gastrocnemius muscle, which it supplies. The nerve becomes superficial along the medial aspect of the ankle and passes under the flexor retinaculum into the foot. The flexor retinaculum forms the roof of the tarsal tunnel.

The medial sural cutaneous nerve originates from the tibial nerve of the sciatic, descends between the two heads of the Gastrocnemius, and, about the middle of the back of the leg, pierces the deep fascia, and unites with the anastomotic ramus of the common peroneal to form the sural nerve.

The lateral sural cutaneous nerve originates from the Common fibular nerve. One branch, the peroneal anastomotic (n. communicans fibularis), arises near the head of the fibula, crosses the lateral head of the Gastrocnemius to the middle of the leg, and joins with the medial sural cutaneous nerve to form the sural nerve.

Principles and Practice of Pain Medicine By Carol A. Warfield, Zahid H. Bajwa, page 324: sural neuropathy - calf pain, illustration: Common peroneal nerve (anterolateral aspect of the right leg) Schematic representation of its course, clinically relevant anatomic relations, and major branches. (from Peripheral Neuropathy, Saunders: 1984

Anomalous Course of the Medial Sural Cutaneous Nerve and Its Clinical Implications by Maria Lúcia Pimentel, Rodrigo Mota Pacheco Fernandes and Márcio Antônio Babinski - Department of Morphology, Biomedical Institute, Fluminense Federal University, Niterói, RJ, Brazil. ABSTRACT: The sural nerve is formed by the union of the medial sural cutaneous nerve, which is a branch of the main trunk (the tibial nerve), and the common fibular communicating branch of the lateral sural cutaneous nerve, which is a branch of the common fibular nerve. Anatomical variations in the formation of the sural nerve are common, although the topographical localization of this nerve is constant.

Conservative Treatment of Bilateral Sural Nerve Entrapment- in an Ice Hockey Player by Brian J. Toy, PhD, ATC, 1996.

Intraneural Injections for Rheumatoid Arthritis and Osteoarthritis by Paul K. Pybus. See last article in book: Intraneural Injections by Gus J. Prosch, Jr., M.D. Lecture #2 1987 see illustrations (Exhibits) # 14,15,16 showing injection points relative to nerves in leg.

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