Neural Hydrodissection of Common Peroneal Nerve in Collegiate and

Professional DancersSteven J. Karageanes, DO, FAOASM

Medical Director, MercyElite Sports Medicine

No Financial Disclosures

Nerve Entrapment

•Altered transmission because of mechanical irritation from impingement of an anatomical neighbor

•Pressure-induced segmental injury to a peripheral nerve

due to anatomical structure or pathologic process

Entrapment Effects• Pain

• Numbness

• Tingling

• Weakness • Fatiguable • Leads to injury

Entrapment Mechanics• Compression

• Constriction

• Overstretching

• Edema

Nerve Entrapments• In tunnels: carpal tunnel or tarsal tunnel syndrome

• Between muscles: axillary nerve

• Around blood vessels: occipital nerve

• Across joints: superficial peroneal nerve

• Between bones: Morton’s neuroma

• External compression: boot/cast

• Fascial penetration sites: anterior cutaneous nerve

Common Peroneal Nerve• Weak foot extension, winging

• Lateral ankle pain/peroneus tendinitis

• Poor balance (pointe)

• Impingement pain back of ankle

• Limited relevè

• “That’s My Bad Leg”

Fascia

•Nerves travel through fascia on pathway to muscular innervation

•Repetitive compression or stretch -> neuroinflammatory response

-> fascial adhesions/constrictions

Neural Hydrodissection

• Using solution to free up fascia/scar tissue compressing nerve

Hydrodissection Research• Wu 2019/Evers 2018 et al: carpal tunnel/median nerve (TOPS)

• Delzell 2020: Median nerve at pronator tunnel

• Stoddard 2019: Ulnar nerve

• Watanabe 2020: Saphenous nerve

• Burke 2019: Sciatic nerve

• Mulvaney 2011: Lateral femoral cutaneous nerve

• Long thoracic

• Dorsal Scapular

• Supraclavicular

• Posterior interosseous

• Brachial plexus

• Cervical plexus

• C5-C7 nerve roots

• Greater occipital

Hydrodissected Nerves• Baxter’s Nerve

• Ilioinguinal

• Iliohypogastric

• Obturator

• Genitofemoral

• Axillary

• Geniculate

• Dorsal digital

T H OM AS B . C LARK & S T ANLE Y K . H . L AM

www.mskus.com

Dancer

• 66-91% of all injuries are in lower extremities

Incidence and Prevalence of Musculoskeletal Injury in Ballet. A Systematic Review Preston J. Smith, MD,* Brayden J. Gerrie, BS,* Kevin E. Varner, MD,* Patrick C. McCulloch, MD,* David M. Lintner, MD,* and Joshua D. Harris, MD*†Orthop J Sports Med. 2015 Jul; 3(7): 2325967115592621. Published online 2015 Jul 6. doi: 10.1177/2325967115592621

https://www.ncbi.nlm.nih.gov/pubmed/?term=Smith%20PJ%5BAuthor%5D&cauthor=true&cauthor_uid=26673541https://www.ncbi.nlm.nih.gov/pubmed/?term=Gerrie%20BJ%5BAuthor%5D&cauthor=true&cauthor_uid=26673541https://www.ncbi.nlm.nih.gov/pubmed/?term=Varner%20KE%5BAuthor%5D&cauthor=true&cauthor_uid=26673541https://www.ncbi.nlm.nih.gov/pubmed/?term=McCulloch%20PC%5BAuthor%5D&cauthor=true&cauthor_uid=26673541https://www.ncbi.nlm.nih.gov/pubmed/?term=Lintner%20DM%5BAuthor%5D&cauthor=true&cauthor_uid=26673541https://www.ncbi.nlm.nih.gov/pubmed/?term=Lintner%20DM%5BAuthor%5D&cauthor=true&cauthor_uid=26673541https://www.ncbi.nlm.nih.gov/pubmed/?term=Harris%20JD%5BAuthor%5D&cauthor=true&cauthor_uid=26673541https://dx.doi.org/10.1177%2F2325967115592621

Dancer• Peripheral nerves are prone to compression

Kennedy JG1, Baxter DE.Clin Sports Med. Nerve disorders in dancers 2008 Apr;27(2):329-34. doi: 10.1016/j.csm.2008.01.001.

https://www.ncbi.nlm.nih.gov/pubmed/?term=Kennedy%20JG%5BAuthor%5D&cauthor=true&cauthor_uid=18346547https://www.ncbi.nlm.nih.gov/pubmed/?term=Baxter%20DE%5BAuthor%5D&cauthor=true&cauthor_uid=18346547

Dancer• Pain tolerance much higher

• Pressure to push through smaller disabilities

Kennedy JG1, Baxter DE.Clin Sports Med. Nerve disorders in dancers 2008 Apr;27(2):329-34. doi: 10.1016/j.csm.2008.01.001.

https://www.ncbi.nlm.nih.gov/pubmed/?term=Kennedy%20JG%5BAuthor%5D&cauthor=true&cauthor_uid=18346547https://www.ncbi.nlm.nih.gov/pubmed/?term=Baxter%20DE%5BAuthor%5D&cauthor=true&cauthor_uid=18346547

Questions

• Can hydrodissecting the common peroneal nerve IMMEDIATELY and LONG TERM improve muscle strength in dancers?

• Will dancers feel improvement in strength? Ability to rehearse? Perform?

• Is the procedure well tolerated?

Subjects• Dancers: 20

• Total number of knees: 22

• Number of right knees: 11

• Number of left knees: 11

• Professional/college faculty: 9

• College: 13

Criteria• Subjective: Complaint in

ipsilateral lower extremity

• Recurrent ankle sprains

• Peroneal muscle/tendon pain

• Ankle impingement

• Lower leg pain

• Hip/glute pain

• Lateral knee pain

• Difficulty with techniques

• Turns

• Relevè

• Pointe

• Leaps

Criteria• Objective strength

• Ankle dorsiflexion/eversion: +3 or +4/5 (muscle breaks)

• Ankle plantar flexion/inversion: +5/5

• Fatiguability: 4 rep muscle test

• Ipsilateral side weakens

• Contralateral side does not change

Criteria• Physical exam

• No acute injury in LE

• No other muscle weakness in LE

• Tenderness along common perineal nerve at fibular head or distal biceps femoris tendon

• No sensory deficits

Questionnaire• Sent no earlier than 2 months after

procedure

• 4 questions

• Strength

• Rehearsal

• Performance

• Pain

• 0 = No effect

• 1 = A tiny bit

• 2 = I could tell

• 3 = Yeah, definitely different

• 4 = Whoa, things are easier

• 5 = Wow, this is amazing!

Strength-Rehearse-Perform

• 0 = No effect

• 1 = A tiny bit

• 2 = Uncomfortable

• 3 = Ouch!

• 4 = Hey, watch it!

• 5 = Oh God, this is horrible!

Pain from Procedure

• Ultrasound guidance performed by sports medicine board certified physician with 14 years experience

• Logiq S7 US machine using 5-12 mhz linear Matrix probe

Ultrasound

• Patient lies on contralateral side, leg on a bolster support

• Operator sits behind patient facing posterior knee

• Ultrasound machine on opposite side of table

• Operator can inject in direction towards the screen

Procedure

• Injectate: 5% dextrose/saline solution

• 27-gauge 1.5 inch needle on a 30 cc syringe

• 2 cc dextrose 50%

• 16 cc saline 0.9%

• 1 cc triamcinolone 40mg

• 1 cc lidocaine 1%

Procedure

Common Peroneal Nerve

Common Peroneal Nerve

Common Peroneal Nerve

Results

Strength• 22 dancers tested: +3/5 or +4/5 strength (operator could break muscle)

• AFTER 1 MINUTE: 22/22 tested +5/5 (operator could not break muscle)

• AFTER 1 MONTH: 20/20 tested +5/5

• AFTER 3 MONTHS: 13/14 tested +5/5

• In the one case, CPN hydrodissected at distal biceps femoris

• AFTER 6 MONTHS: 8/8 tested +5/5

Drop Foot

• Three non-dancers with DROP FOOT (0/5 or 1/5 eversion, dorsiflexion)

• ZERO out of THREE had any improvement

• Two were from L5 and post-operative

• One had excessive scarring around CPN, had surgery to release nerve

QUALITATITVE Dancer Questionnaires

• 0 = No effect

• 1 = A tiny bit

• 2 = I could tell

• 3 = Yeah, definitely different

• 4 = Whoa, things are easier

• 5 = Wow, this is amazing!

Strength-Rehearse-Perform

College

0

1

2

3

4

5

Strength Rehearsal Performance Total

3.973.8744.08

• 0 = No effect

• 1 = A tiny bit

• 2 = Uncomfortable

• 3 = Ouch!

• 4 = Hey, watch it!

• 5 = Oh God, this is horrible!

Pain from Procedure

College

0

1

2

3

4

5

Pain

1.54

Data Ranges• No responses below 3 for strength and rehearsal

• Only one response below 3 for performance (2)

• Only two responses above 2 for pain (3)

• 45% (10/22): at least one response of 5

• 27% (6/22): at least two responses of 5

Why in Dancers?

• Stretching

• Australian Ballet PTs: STOP static calf stretches

• Compression: kneeling on floor

• Weakness: weaker gastrocnemius causes increase in soleus recruitment

Strengths• All dancers highly trained/elite

• Accepted into college dance program

• Current professional dancer

• Current university dance faculty

• One operator performing all tests

• Multiple inclusion criteria for assessing nerve entrapment

Strengths• Mixed method study

• Quantitative

• Qualitative

• Functional and practical assessments

• Assessing tolerance of procedure

Weaknesses• Outcome study

• No control group

• No blinding

• Not truly quantitative

• No true measurement of muscle strength

• No EMG measurements

Weaknesses• Did not take ultrasound measurements

• Did not use hydroxychloroquine, azithromycin and zinc*

* Facebook Medical University

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