Sural Nerve Pain

I recently saw a patient who had pain resulting from her sural nerve. Let me go through a little about the anatomy and location of the sural nerve.

The sural nerve sits superficially below the skin's surface at the back of the calf. It is formed from the medial sural cutaneous nerve and the lateral sural cutaneous nerve.

It is usually between the medial and lateral gastrocnemius (calf) muscles, running parallel to the saphaenous vein. At the ankle, the sural nerve 'wraps' around the outer ankle near the peroneal tendons before it splits into 2 branches at the level of the 5th metatarsal.

The sural nerve is a sensory nerve, it provides sensation to the lower one third of the outer leg, outer heel and foot. It's main function is to let you feel sensation on your skin. It can also detect your foot position, temperature, pain, vibration and touch.

Since the sural nerve is positioned so superficially, it can be irritated from any muscular of fascial entrapment and sometimes from a simple outer ankle sprain. It can also be 'over stretched' from sitting too long with the foot pointed down and out or after a long driving trip. When the nerve is irritated, it can result in burning pain in the lateral shin or foot (known as sural neuritis).

A common cause of sural nerve pain is after a sprained ankle when the foot is rolled outwards quickly. This can over stretch the sural nerve causing pain over the area it covers. 

I also remember a previous patient who had very tight fitting ballet shoes with a strap over the outside ankle which compressed her sural nerve.

A lot of metal work

Another patient had irritation from her metal implants (pictured above) after orthopaedic surgery from fracturing both tibia and fibular. 

Patients may describe their pain being constantly present, made worse with activity but present even at rest. This constant pain at rest is what differentiates the symptoms of sural nerve pain from other conditions, where pain normally eases with rest.

I usually do a modified Straight Leg Raise tension test to compare both sides. The patient will tell you the affected side will worsen their symptoms. It may also be tender to touch along the path of the nerve.

Appropriate manual therapy will easily relieve and treat sural nerve pain. Mobilizing the ankle, stretching the nerve and of course treating the fascia that is putting tension on the sural nerve.