Neural Hydrodissection of Common Peroneal Nerve in Collegiate and Professional Dancers Steven 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 Hydrodissected Nerves • Long thoracic • Baxter’s Nerve www.mskus.com • Dorsal Scapular • Ilioinguinal • Supraclavicular • Iliohypogastric • Posterior interosseous • Obturator • Brachial plexus • Genitofemoral • Cervical plexus • Axillary • C5-C7 nerve roots • Geniculate T HOMAS B. CLARK & STANLEY K.H. LAM • Greater occipital • Dorsal digital 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 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. 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. 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 • Lateral knee pain ipsilateral lower extremity • Difficulty with techniques • Recurrent ankle sprains • Turns • Peroneal muscle/tendon pain • Relevè • Ankle impingement • Pointe • Lower leg pain • Leaps • Hip/glute pain 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 Strength-Rehearse-Perform • 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! Pain from Procedure • 0 = No effect • 1 = A tiny bit • 2 = Uncomfortable • 3 = Ouch! • 4 = Hey, watch it! • 5 = Oh God, this is horrible! Ultrasound • Ultrasound guidance performed by sports medicine board certified physician with 14 years experience • Logiq S7 US machine using 5-12 mhz linear Matrix probe Procedure • 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% 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 Strength-Rehearse-Perform • 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! College 5 4 4.08 4 3.87 3.97 3 2 1 0 Strength Rehearsal Performance Total Pain from Procedure • 0 = No effect • 1 = A tiny bit • 2 = Uncomfortable • 3 = Ouch! • 4 = Hey, watch it! • 5 = Oh God, this is horrible! College 5 4 3 2 1 1.54 0 Pain 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 BANE SEZ: STAY SAFE!.