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Rate ePoster

Musculoskeletal and Sports Medicine

Preferential Injury to Proximal Deep Fibular Nerve Fibers: A Case Report

Saturday, October 25, 2025
12:00 PM - 1:30 PM MT
Location: Kiosk 2
Has Audio

    Poster Presenter(s)

  • Joshua Geller, MD

    Resident
    Vanderbilt University Medical Center PM&R Program
    Nashville, Tennessee

    • Co-Author(s)

  • KE

    Kendall Ervin, MD

    Resident Physician
    Vanderbilt University Medical Center PM&R Program
    Nashville, Tennessee

  • BH

    Barton Huddleston, MD, MD

    Assistant Professor, Electrodiagnostic Medicine, Long COVID Clinic, PM&R Acute Consult program
    Vanderbilt University Medical Center
    BRENTWOOD, Tennessee

Disclosure(s):
Joshua Geller, MD: No financial relationships to disclose
Case Diagnosis: 28 F s/p left tibial plateau fracture with foot drop but intact toe extension secondary to preferential injury to the proximal branches of the deep fibular nerve.

Case Description or Program Description: A 28 year old female with past medical history of left tibial plateau fracture while skiing s/p ORIF 2 years prior had persistent paresthesias at the left 1st toe webspace and weakness with left dorsiflexion and great toe extension but with preserved digit 2-5 extension. She underwent physical therapy with minimal benefit. She presented to PM&R EMG clinic for evaluation of foot drop.

Setting: Outpatient EMG Clinic

Assessment/Results: Physical exam showed 5/5 BLE strength except for left 3/5 dorsiflexion and 4/5 EHL extension. Sensation was impaired at the 1st toe webspace. EMG showed normal amplitude and latency of sural and tibial nerves, with decreased amplitude and increased latency to the EDB CMAP. EMG showed denervation and decreased recruitment most notable at TA and EHL, with lesser changes at peroneus brevis and EDB. Ultrasound evaluation showed signs of denervation at the proximal more than distal tibialis anterior and EHL with normal muscular echotexture of the other deep fibular innervated muscles. She underwent surgical neurolysis of the fibular nerve and was lost to follow up.

Discussion (relevance): There are multiple smaller branches of larger nerves that can be compressed or injured leading to isolated muscle denervation and weakness. While there was some overlying mild common fibular nerve injury, there was additional injury to proximal fibers of the deep fibular nerve. Ultrasound localized the injury by characterizing the degree of denervation of the affected muscles of the TA and EHL with sparing of changes of the distal deep fibular muscles.

Conclusions: Isolated injury to the smaller branches of the fibular nerve can cause relatively proximal>distal weakness and should not be mistaken for common fibular injury.