Baltimore Peripheral Nerve Surgeon Eric H. Williams MD Discusses Which Nerves in the Lower Extremity That Are Most Often Affected in Patients With Nerve Compressions Related to Diabetic Neuropathy
For decades, people with diabetic neuropathy in the lower extremities have been told their condition is "progressive and irreversible." However, this is not necessarily true. If you’re suffering from pain, tingling, or numbness, you may have a nerve compression that can be surgically treated. In this informative guide, Baltimore peripheral nerve surgeon Dr. Eric H. Williams explains what nerves are most commonly affected and how surgical nerve decompression may be able to reduce your pain and improve your overall quality of life.
Key Nerves Affected in Diabetic Patients With Peripheral Neuropathy
Peripheral neuropathy is common in the setting of diabetes. This condition often affects several nerve regions in the legs and feet. Each nerve causes symptoms in a different part of the foot, but it’s not uncommon for the diabetic patients that Dr. Williams treats to suffer from multiple nerve compressions.
1. Common Peroneal Nerve
The common peroneal nerve, branching off from the main sciatic nerve, helps control how your foot and ankle move. The nerve wraps around a bone near your knee (the fibula), which means it can easily get squeezed or pinched at this spot. This nerve helps you lift your foot up when you walk and straighten your toes, while also providing feeling to the outer part of your lower leg and the top of your foot.
When you have diabetes, high blood sugar can cause this nerve to swell, much like a sponge soaking up water. The nerve has to pass through some tight spaces in your leg, and when it swells, it can get squeezed or pinched.
Signs of common peroneal nerve compression, also known as peroneal neuropathy or peroneal nerve entrapment, include:
- Trouble lifting your big toe
- A “pins and needles” sensation along the outside of your lower leg and to the top of your foot
- Difficulty lifting your whole foot when walking (foot drop)
- Stumbling or losing your balance due to weakness in the foot muscles
- Callauses or sores from altered walking patterns
- A burning sensation in the leg
2. Deep Peroneal Nerve
The deep peroneal nerve, branching from the common peroneal nerve, controls specific movements in the foot and provides vital sensory information. This nerve runs down the front of your leg and crosses under the ankle before reaching the top of your foot. It controls the muscles that help lift your toes and provides feeling between your big toe and second toe.
When diabetes affects the deep peroneal nerve, high blood sugar can make it swell and become less mobile. Because the nerve has to pass under tendons and through narrow spaces in your foot, this swelling can lead to pinching or compression, especially across the top of the foot.
Signs of deep peroneal nerve compression include:
- Burning pain across the top of your foot
- Numbness between your big toe and second toe
- Pain that gets worse when walking or wearing shoes
- Trouble moving your toes
- Changed walking pattern
- Loss of feeling in parts of your foot
3. Tibial Nerve
The tibial nerve, running behind your inner ankle bone, splits into several important branches that control different parts of your foot. These branches provide feeling to your entire sole and control the small muscles in your foot that help maintain your arch and toe position. The nerve also controls your foot's sweat glands and blood flow.
When you have diabetes, high blood sugar affects not just the main tibial nerve but all of its branches (medial plantar, lateral plantar, and calcaneal nerves). Since these nerves run through tight tunnels behind your ankle and into your foot, this swelling can lead to compression in multiple areas at once.
Tibial nerve compression can be particularly dangerous for people with diabetes because the loss of feeling combined with muscle weakness means you might not notice injuries or infections developing in your foot, which could lead to serious complications if left untreated such as ulcerations or wounds. It can also affect one’s balance due to profound numbness.
Signs of tibial nerve compression include:
- Numbness or burning pain in the sole of the foot, often worse at night
- Severe pins and needles in the sole of the foot
- Weakening and atrophy of the small muscles in your foot
- Toes that start to curl or claw
- Flattening of your foot arch
- Loss of feeling in parts of your sole (heel, arch, ball of foot and toes)
- Increased risk of unnoticed injuries or sores
Tarsal tunnel syndrome is a type of tibial nerve compression that occurs in one particular location—the tarsal tunnel, which is a narrow space behind your inner ankle bone. Think of it like carpal tunnel syndrome, but in your ankle instead of your wrist.
The Science Behind Surgical Nerve Decompression
When a nerve is compressed, pain medication can help temporarily relieve symptoms. However, medication doesn’t treat the compression itself, which means that the nerve continues to be pinched.
When compression points are surgically released, the nerve has room to accommodate the swelling caused by elevated blood sugar and the conversion of glucose to sorbitol within the nerves. This can provide significant symptom relief and prevent further nerve damage.
While nerve decompression surgery isn't appropriate for every patient with diabetic neuropathy, it offers hope for many who previously had none. The key is proper evaluation and patient selection. Some of the criteria that Dr. Williams uses to determine if a patient is a good candidate for surgical nerve decompression include:
- Good blood sugar control with an A1C of less than 8.5
- A BMI (body mass index) under 50
- Good blood flow in the extremities, with a palpable pulse
- No medical conditions that would affect the ability to tolerate surgical anesthesia
What to Expect From Diabetic Neuropathy Nerve Decompression Surgery
If Dr. Williams determines you’re a good candidate for surgical nerve decompression, he will answer your questions and let you know what to expect from the procedure based on the nerves affected, the severity of the compression, and your specific medical history. However, there are some general points to keep in mind:
- Patients with moderate nerve damage may see improvement within three months, while those with more severe damage may take up to one year to see full benefits
- Most patients can walk immediately after surgery using a crutches or walker. We expect 3-4 weeks until you are fully weight-bearing.
- Pain relief often occurs before the sensation returns.
- Balance typically improves as sensation returns.
- 80-85% of patients with positive Tinel sign (nerve tapping test) experience improvement after nerve decompression surgery. This has been shown in many published peer-reviewed surgical trials from several countries now.
To learn more about the results Dr. Williams has been able to achieve with his patients, refer to the testimonials section of our website.
Can Dr. Williams Help You? answers some of the questions we most often receive from new patients and explains how to prepare for your first visit.