Combat Boot Palsy: Case Reports

LTC Paul F. Gafens, MC, USA*

MAJ Mohammad A. Saeed, Me, USA **

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T here are numerous foot problems thought to be caused
or aggravated by the wearing of combat boots, partic-
ularly in young soldiers. Most of the problems are either
dermatologic or musculoskeletal in nature and can usually
be remedied rather quickly with appropriate care. How-
ever, occasionally patients present with vague foot pain or
numbness that does not respond to the usual modes of
therapy . The purpose of this paper is to describe the au -
thors' experience with a somewhat unusual cause of foot
symptoms, namely superficial peroneal nerve palsy, which
we believe can be caused or aggravated by the wearing of
combat boots.

Report of Cases
Case 1. This 19 year old male soldier was seen originally on
the Neurology Service with a three-month history of numbness of
the dorsum of the left foot. He denied any leg or back symptoms.
There was no muscle weakness and the reflexes were normal on
clinical examination . There was a slight decrease in light touch on
the dorsum of the left foot as compared with the right, but no
sharp demarcation of the sensory deficit. The soldier was referred
to the Physical Medicine Service for electrodiagnostic studies.
Needle electromyographic evaluation of the left leg was negative
for any signs of radiculopathy or common peroneal nerve palsy.
The latency of the right superficial peroneal nerve with the stimu-
lation site at 14 em from the recording electrodes was 3.5 msec
(N < 4.0 msec), while the left superficial peroneal nerve re-
sponse was absent. The patient was given a profile to avoid wear-
ing of combat boots. The patient's symptoms slowly improved
and, at a folIowup visit several months later, he had no numbness
or parasthesis of the foot and his left superficial peroneal nerve la-
tency was now normal at 3.6 msec.
Case 2. This 20 year old infantry soldier presented to the
Physical Medicine Service with a one and one-half-year history of
moderate pain on the dorsum of the left foot made worse by
walking long distances or runn ing. The patient's symptoms were Fig. 1. Photograph 01 patient described in Case 2 showing callus forma-
totalIy confined to the foot. On clinical examination , this soldier tion on ankle and area 01 hyperesthesia.
demonstrated normal strength and normal reflexes. There was
hyperesthesia on the dorsum of the foot in the distribution of the
superficial peroneal nerve , with an obvious calIus on the dorsum
of the ankle (Fig. 1). On electrodiagnostic testing, the left superfi-
cial peroneal nerve response was absent , while the right was a found, but the patient did report continued improvement follow-
normal 3.3 msec. The patient was given a profile against wearing ing surgery with a gradual lessening of his symptoms.
combat boots and showed some partial improvement over the Case 3. The patient was a 21 year old female soldier who pre-
next few weeks. However, since he still had some symptoms, a sented to the Physical Medicine Service with a nine-week history
trial injection of one per cent Xylocaine around the superficial pe- of paresthesias on the dorsum of the left foot , particularly in the
roneal nerve was given, with good temporary relief of the dysesthe- third, fourth , and fifth toe areas . There were no leg or back symp-
sia. A neurosurgical consultation resulted in surgical exploration of toms. On physical examination, muscle strength and reflexes were
the nerve . At operation, no definite neuroma or entrapment was normal. There was a positive Tinel sign on tapping the dorsum of
the left ankle. There was a slight sensory deficit to pin prick over
the dorsum of the left foot. Electrodiagnostic studies showed an
From the Physical Medicine Service, Madigan Army Medical Center, absent superficial peroneal nerve response on the left foot, with a
Tacoma, Wash . 98431. normal response of 3.7 msec on the right foot. The patient was
'Chief. Physical Medicine Service. given a profile against wearing combat boots and her symptoms
•• Assistant Chief, Physical Medicine Service. resolved in a matter of a few weeks.

Military Medicine, Vol. 147, August 1982 664

Combat Boot Palsy: Case Reports
I vague and are difficult for the patient to localize with any
~uperficial Psroneat
Medial Dorsal
lnterrnediate?" Cutaneous
Dorsal
Cutaneous
Fig. 2. Diagram showing anatomy of the sensory branches 01 me super-
flclal peroneal nerve.
Discussion
The superficial peroneal nerve branches from the com-
mon peroneal nerve as it passes between the fibula and the
peroneus longus muscle . It then passes between the pero-
neus longus and brevis muscles, supplying both, and then
becomes subcutaneous by piercing the deep fascia near the
distal third of the leg,? Normally, after piercing the fascia,
the nerve divides into two sensory branches, the intermedi-
ate dorsal cutaneous branch and the medial dorsal cutane-
ous branch (Fig. 2).s This division usually occurs about
10.5 em above the lateral mallelolus,! and the nerves run
distally to supply all the skin of the dorsum of the foot, ex-
cept for an area on the lateral portion of the foot supplied
by the sural nerve and the adjacent sides of the great toe
and the second toe supplied' by the deep peroneal nerve."
These branches of the superficial peroneal are quite easily
subjected to pressure trauma on the dorsum and dorso-
lateral aspect of the ankle and foot. This is particularly
true for the intermediate dorsal cutaneous branch." Symp-
toms relating to problems with this nerve are often quite
665
precision. There is frequently not a definite sensory deficit
on clinical testing. Occasionally, the diagnosis of superfi-
cial peroneal nerve palsy can be suspected when palpation
or percussion of the nerve reduplicates the symptoms.
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Sometimes the symptoms can be relieved, at least tempo-
rarily, by infiltration of a local anesthetic around the
superficial peroneal nerve or one of its branches. The phy-
sician must be careful not to confuse this entity with foot
symptoms secondary to L, radiculopathy or common pero-
neal nerve problems. A careful history, physical evalua-
tion , and electrodiagnostic studies should be helpful in this
differential.
In evaluating problems relating to the superficial pero-
neal nerve, the physician was limited to strictly clinical
skills until 1970, when Oi Benedetto] described a method
which, by electrically stimulating the superficial peroneal
nerve, obtained a sensory response that could be recorded
with standard electrodiagnostic equipment . The present au-
thors have employed a modification of this technique over
a period of years in evaluating suspected problems of the
superficial peroneal nerve. The modified technique has re-
cently been described in detail in the literature by Izzo et af.3
Over a two-year period, we have encountered 12 cases
of superficial peroneal nerve palsy . Some were related to
ankle sprains and the wearing of casts but, in six of these
cases, the wearing of combat boots appeared to be the ma-
jor etiologic factor in the problem. In five of these six cases,
the authors were able to document the involvement of the
superficial peroneal nerve with electrodiagnostic studies,
while in the other case the diagnosis was made on a strictly
clinical basis. In this case, the patient stopped wearing com-
bat boots after the initial visit and , by the time he returned
for his scheduled electro diagnostic studies, he was clini-
cally symptom-free. All six patients improved partially or
completely merely by eliminating the use of combat boots
through the military medical profile system . In only one
case was surgical exploration considered necessary . One
interesting factor was that all six of these patients had been
wearing the old style combat boot. We have yet to encoun-
ter a case of superficial peroneal nerve palsy in a soldier
wearing the newer style military boot, with cut-outs to re-
lieve pressure over the dorsum of the ankle and foot (Fig. 3).
Fig. 3. The old style combat boot (right) and the newer version (left) with
cut-outs to relieve pressure over the dorsum of the ankle and foot .
Military Medicine, Vol. 147, August 1982
666 Combat Boot Palsy: Case Reports

Summary
The unusual entity of superficial peroneal nerve palsy
caused or aggravated by wearing combat boots is discussed
and illustrated by three case reports. The value of recently
References
IDi Benedetto, M.: Sensory nerve conduction in lower extremities.
Arch . Phys . Med. Rehabil.. 51:253-258, 1970.
2Hollingshed, W. H.: Functional Anatomy of the Limbs and Back. Ed.
3, Philadelphia, W. B. Sanders Co. , 1969, pp. 319 and 336.

improved electrodiagnostic techniques in confirming the
diagnosis is emphasized . The possible advantage to the sol-
dier of the newer style combat boots, with cut-outs over
the' dorsum of the ankle and foot, in prevention of this
problem is discussed . Military physicians should be aware
of this sensory nerve dysethesia in evaluating vague foot
symptoms particularly in young soldiers.
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31zzo, K., Sridhara . C. R., Rosenholtz , H., and LeMont, H.: Sensory
conduction studies of the branches of the superficial peroneal nerve. Arch.
Phys, Med. Rehabil., 62:24-27, 1981.
4Kosinski, c.: The course , mutual relations, and distribution of the cu-
taneous nerves of the metazonal region of the leg and foot. J. Anat ., 60:
274-297 , 1926.
5LeMont, H. : The branches of the superficial peroneal nerve and their
clinical significance. J. Am . Podiatry Assoc., 65:310-3 14, 1975.

The lawyers are the cleverest men, the ministers are the most learned, and the doc-
tors are the most sensible.
Oliver Wendell Holmes

Case for Diagnosis*

T fant
his is the case of a three month old Caucasian male in-
who was found dead by his mother. He was said
to have been sick the previous day and to have had a fever,
but there was no fever present when the child was examined
in a dispensary.
Autopsy Findings: Acute tracheobronchitis and pulmo-
nary edema and congestion; cerebral congestion and conges-
tion of the leptomeninges; a small hematoma of the tricus-
pid valve; mild focal urinary cystitis, and some congestion
of the liver with minute foci of extramedullary hematopoi-
esis. The final impression was that this was consistent with
sudden infant death syndrome. There was no indication of
a traumatic death; viral cultures and results of toxicologic
studies were negative.
A tumor nodule in the testicular adnexa (Fig. 1) was an
incidental finding during microscopic examination of the
autopsy material.
Diagnosis and discussion appear on page 679.
Fig. 1. Testicular adnexa with nodule. Hand E, x15.
'Prepared by COL Gelmar S. Landry , MC, USA, Chairman, Dept. of
Pediatric Pathology, Armed Forces Institute of Pathology, Washington,
D.C. 20306.

Military Medicine , Vol. 147, August 1982