MILITARY MEDICINE, 164, 6:446, 1999

Case Report

Common Peroneal Nerve Palsy in a UH-60 Aviator

Guarantor: MAJ Mark A. McGrail, MC USA
Contributor: MAl Mark A. McGrail, MC USA

A case of common peroneal nerve palsy in a UH-60 Blackhawk onance imaging of the lumbosacral spine, the results ofwhich
U.S.Army helicopter pilot is reported. A review of the literature were normal. Electromyographic and nerve conduction velocity

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revealed several reports of common peroneal nerve palsy, al- studies demonstrated conduction amplitude block across the
though there were no published reports of this injury second- fibular head in the distribution of the left common peroneal
ary to performing flight duties in the UH-60 cockpit. A common
practice among Blackhawk pilots is to brace the "collective" nerve with evidence of acute denervation/reinnervation in the
with their left knee, subjecting the common peroneal nerve to same below-the-fibular-head distribution. These studies also
possible injury. This action should be considered as a possible showed mixed axonal components, which suggested a second-
cause of common peroneal nerve palsy in this select group of ary or primary injury superimposed on the patient's history of
aviators. similar symptoms 2 years earlier. A diagnosis of left common
peroneal nerve palsywas established.
Introduction Treatment consisted of rest, cessation of flying duties, and
physical therapy. Clinical resolution ofsensory deficits occurred
he common peroneal nerve is the most frequently injured gradually over 2 months, and preinjury levels of strength were
T peripheral nerve in the lower extremity.' It is especially vul-
attained within 3 months of presentation. Follow-up electro-
nerable to injury at the point at which it crosses the fibular myographic and nerve conduction studies at 4 months after
head.There are several reported causes ofperoneal nerve palsy, injuryrevealed significant increases in conduction amplitude at
including surgical injury, lower leg compartment syndrome, the fibular head and no evidence of an active denervating pro-
trauma to the knee, improperly applied casts, and even bungee cess to the peroneal innervated muscles.
jumping. Mechanisms consist of partial and complete transec-
tion, compression, and traction. This report details a case of Discussion
common peroneal nerve palsyresulting from an unusual injury
unique to military personnel. The common peroneal nerve is inherently at risk for injury
because of its superficial course across the fibular head. The
Case Report nerve maybe transected, compressed, or stretchedas a result of
trauma or surgery to the lower extremity.' Compressive injuryis
The patient was a 31-year-old U.S. Army aviator who pre- found with improperly appliedshort and longlegcasts, exercise-
sented with numbness and weakness ofthe leftlower leg. This induced entrapment, and severe lower leg compartment syn-
began as numbness and tingling of the dorsum of the left foot drome.v' Amore proximal neuropathy mayalsomimic common
and progressed to complete loss of sensation across the mid- peroneal nerve palsy, most remarkably a herniated nucleus
dorsum ofthe foot, the dorsal surface ofthe great toe, and the pulposus at the L4-5 level. Even bungee jumping has been
anterolateral aspect of the ankle and calf. After the onset of implicated as a cause ofcommon peroneal nerve palsy." Treat-
sensory deficits, the patient experienced gradual weakness to ment options vary with the insult but include activity restric-
dorsiflexion of the left ankle and reported that his left foot tions, nonsteroidal anti-inflammatory agents, physical therapy,
"slapped" the groundas he walked. relief from the offending agent, and surgical decompression.
His past medical history was notable for a similar episode of Thepatient presented here experienced two episodes ofcom-
left calfand foot numbness and weakness 2 years earlierthat mon peroneal nerve palsywithout apparent cause. On careful
resolved spontaneously with rest within 3 months. Physical review, the only unusual activity identified with both incidents
examination was significant for decreased strength of the left was his duty as a helicopter pilot. Thecockpit ofthe Blackhawk
extensor hallucis longus, extensor digitorum longus, anterior tib- helicopter contains a control lever called the "collective." The
ialis, and peroneus brevis and longus. He also exhibited dimin- collective is located to the leftofthe seatedpilot at the level ofthe
ishedsensation tolight touchinan L5 distribution. Ttnel's testwas leftleg. Ourpatientrelated that it wasa habit for himto rest his
positive over the common peroneal nerve at the fibular head. leftknee against the collective withthe aircraftat flight idle, on
His evaluation, performed within 2 weeks of the onset of the ground with the engine running. The second episode of
symptoms, included plainradiography as well as magnetic res- common peroneal nerve palsy occurred within 2 weeks of the
patient doubling his flying hours compared with the preceding
Department ofFamily Medicine, Eisenhower Army Medical Center, Fort Gordon, several months. The action of resting the left knee against the
GA30905.
This manuscript wasreceived for review inApril 1998. The revised manuscript was collective, a previously unreported mechanism ofcommon per-
accepted for publication in September 1998. oneal nerve palsy, subjected the common peroneal nerve to
Reprint & Copyright ©byAssociation ofMilitary Surgeons ofU.S., 1999. repetitive compression and vibration at the fibular head,leading

Military Medicine, Vol. 164, June 1999 446

Common Peroneal Nerve Palsy 447

to injury. Recovery from both incidents was associated with Acknowledgments

temporary cessation of flying duties, and the patient has re-
sumed flying without recurrence of symptoms with the behav-
Butcher for their assistance In the preparation of the manuscript.
ioral modification of avoiding resting his knee against the col-
lective. Although a survey of the literature failed to identify
similar cases, anecdotal discussions with aviators reveal this
practice to be widespread and suggest that the injury may be
more common than reported.
In conclusion, a U.S. Army helicopter pilotpresented with a
second episode of common peroneal nerve palsy as a result of
duties within the UH-60 cockpit. As a consequence of these
injuries, this pilotwas removed from flying dutiesfor a totalof6
months. Awareness of this mechanism of common peroneal
The author thanks MAl Chance Conner . Dr. Tony Jerant. and Dr. Jay
References
1. Brown RE. Stonn BW: Congenital common peroneal nerve compression. Ann
Plast Surg 1994; 33: 326-9.
2. Kirgis A. Albrecht S: Palsy of the deep peroneal nerve after proximal tibial osteot-
omy, J Bone Joint Surg Am 1992: 74: 1180-5.
3. Ninkovic M. Sucur D. Starovi c B. Markovic S: A new approach to persi stent
traumatic peroneal nerve palsy . Br J Plast Surg 1994: 47: 185-9.
4. Mitra A. Stern JD. Perrotta VJ. Moyer RA: Peroneal nerve entrapment in athletes.

Downloaded from https://academic.oup.com/milmed/article/164/6/446/4832184 by guest on 04 February 2021

nerve palsy in aviators at riskand appropriate patienteducation Ann Plast Surg 1995; 35: 366-8.
may limit the incidence ofthis injuryand reduce loss ofaviator 5. Torre PH. Williams GG. Blackwell T. Davis CP: Bungee jumper's foot drop pero-
service. neal palsy caused by bungee cord jumping. Ann Emerg Med 1993: 22: 1766-7.

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Military Medicine, Vol. 164, June 1999