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Sonographic Tracking of The Lower Limb Peripheral Nerves
Sonographic Tracking of The Lower Limb Peripheral Nerves
Sonographic Tracking of The Lower Limb Peripheral Nerves
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FEMORAL NERVE second, third, and fourth lumbar roots. It descends
Anatomy through the psoas major muscle and exits medially
near the pelvic brim. It then courses behind the
The femoral nerve (VIDEO 1; http://links.lww.
common iliac artery and along the lateral wall of the
com/PHM/A199) arises from the ventral rami of the
lesser pelvis and enters the obturator foramen. After
second, third, and fourth lumbar roots; descends
leaving the foramen, it divides into anterior and
underneath the psoas major muscle; and emerges
posterior branches, which innervate the adductor
from it at its lower lateral border. It then passes
longus, adductor brevis, adductor magnus, obtu-
beneath the inguinal ligament and divides into the
rator externus, and gracilis muscles. It also gives
anterior and posterior branches. The anterior branch
sensory branches to the medial thigh.4
provides motor control of the pectineus and sar-
torius muscles and also gives off the intermediate
and medial cutaneous nerves, which provide sensa- Technique
tion over the anterior and medial thigh. The poste- After identifying the inguinal crease, the trans-
rior branch splits into the muscular division to ducer is placed in an oblique direction perpendicu-
supply the quadriceps muscles and the articular lar to the inguinal ligament. The pectineus muscle,
division to innervate the knee joint. The saphenous originating from the superior pubic ramus and in-
nerve also derives from the posterior branch of the serting into the femur, is seen medial and deep to
femoral nerve.3,4 the femoral vessels. From superficial to deep, the
adductor longus, brevis, and magnus muscles reside
medial to the pectineus. The anterior branch of the
Technique
obturator nerve runs in the fascial cleft between
The transducer is placed on the inguinal crease the adductor longus and brevis muscles, whereas the
in the transverse plane, where the ilioposas and posterior branch lies between the adductor brevis
pectineus muscles can be clearly recognized. To- and magnus muscles (Fig. 2).
gether with the femoral artery and vein, the femoral
nerve is located between the two muscles under-
neath the iliac fascia (Fig. 1). Moving the transducer PUDENDAL NERVE
distally, the nerve can be visualized to give off the Anatomy
saphenous nerve, nerves to the anterior compartment The pudendal nerve (VIDEO 3; http://links.lww.
of the thigh, and the anterior cutaneous branches. com/PHM/A201) arises from the second, third, and
fourth sacral roots. It runs below the piriformis
muscle, passes between the sacrotuberous and
OBTURATOR NERVE
sacrospinous ligaments at the ischial spine, and
Anatomy enters the pudendal (Alcock) canal, which is formed
The obturator nerve (VIDEO 2; http://links.lww. by the obturator internus muscle and the obtura-
com/PHM/A200) arises from the ventral rami of the tor fascia. Inside the pudendal canal, it divides into
FIGURE 1 US image (axial view) shows the femoral nerve (arrow) positioned above and between the iliopsoas
and pectineus muscles, underneath the fascia iliaca (arrow heads), next to the femoral artery (Fa) and
vein (Fv). The transducer is placed on the inguinal crease in the transverse plane.
2 Hung et al. Am. J. Phys. Med. Rehabil. & Vol. 00, No. 00, Month 2016
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FIGURE 2 US image (axial view) shows the obturator nerve within the adductor muscles. The anterior branch
(arrow) of the obturator nerve runs between the adductor longus and brevis muscles; the posterior
branch (arrowhead) lies between the adductor brevis and magnus muscles. The transducer is placed in
an oblique direction perpendicular to the inguinal ligament.
branches, including the inferior rectal nerve, the is situated medial to the pudendal artery inside the
perineal nerve, and the dorsal nerve of the penis/ interligamentous zone (Fig. 3).
clitoris. It supplies sensation over the external gen-
italia, anus, and perineum and innervates the pel-
LATERAL FEMORAL
vic muscles, including the external urethral and anal
CUTANEOUS NERVE
sphincters.5
Anatomy
Technique The lateral femoral cutaneous nerve (VIDEO 4;
The probe is placed on the gluteal fold in the http://links.lww.com/PHM/A202) is a pure sensory
transverse plane, where the ischial tuberosity, with nerve originating from the second and third lumbar
its bony surface tilting outward, is seen. Moving the nerves. It arises from the lateral edge of the psoas
transducer cranially, the ischial spine can be visu- muscle, crosses the iliacus muscle, usually passes
alized as a flat bony plane. Medial to it, a pulsating under the inguinal ligament, and exits the pelvis me-
vessel (the pudendal artery) can be seen. The artery dial and inferior to the anterior superior iliac spine.
is interposed between the two hyperechoic lines, It divides into the anterior and posterior branches.
the sacrotuberous ligament superficially, and the The anterior branch innervates the skin of the ante-
sacrospinous ligament deeply. The pudendal nerve rior and lateral aspects of the thigh but also makes
FIGURE 3 US image (axial view) shows the pudendal nerve (arrow) lying between the sacrotuberous ligament
(arrowheads) superficially and the sacrospinous ligament (void arrows) deeply. Adjacent to the nerve is
the internal pudendal artery (asterisk). The transducer is placed proximal to the gluteal fold in the
transverse plane.
Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
an anastomosis with the saphenous nerve form- SCIATIC NERVE
ing the peripatellar plexus. The posterior branch
Anatomy
courses through the fascia lata and then provides
the sensory innervation starting from the level of The sciatic nerve (VIDEOS 5 [http://links.lww.
the greater trochanter down to the middle of the com/PHM/A203] and 6 [http://links.lww.com/PHM/
thigh.6 A204]) derives from the L4Y5 and S1Y3 roots. It
exits the pelvis through the greater sciatic foramen
and runs below the piriformis muscle. It descends
along the posterior thigh, superficial to the adductor
Technique magnus muscle, until it reaches the popliteal fossa,
The transducer is placed in the transverse plane where it divides into tibial and common peroneal
medial to the anterior superior iliac spine. When the nerves.4
transducer is moved downward, the sartorius and
tensor fascia lata muscles are seen at the medial and Technique
lateral aspects, respectively. The lateral femoral cu- The transducer is placed between the ischial
taneous nerve is visualized between the abovemen- tuberosity and greater trochanter in the transverse
tioned muscles and inside the space formed by plane. The sciatic nerve is situated lateral to the
the fascia iliaca deeply and fascia lata superficially ischial tuberosity overlying the quadratus femoris,
(Fig. 4A). Tracking the nerve distally, the sonogra- a quadrilateral muscle connecting the ischial tu-
pher can visualize it dividing into several branches berosity and the intertrochanteric crest of the
to innervate the thigh (Fig. 4B). femur (Fig. 5A). It descends between and deep to the
FIGURE 4 A, US image (axial view) shows the lateral femoral cutaneous nerve (arrow) superficial to the sartorius
muscle and below the inguinal ligament. The transducer is placed in the transverse plane medial to the
anterior superior iliac spine (asterisk). B, When the transducer is moved distally, the lateral femoral
cutaneous nerve divides into several branches (arrowheads) to innervate the thigh.
4 Hung et al. Am. J. Phys. Med. Rehabil. & Vol. 00, No. 00, Month 2016
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FIGURE 5 A, US image (axial view) shows the sciatic nerve (arrow) positioned lateral to the ischiocrural tendon
(asterisk) and above the quadratus femoris (QF) muscles. The transducer is placed between the ischial
tuberosity and the greater trochanter in the transverse plane. B, The sciatic nerve (arrow) descends
between and below the lateral (biceps femoris long head [BFL] and short head [BFS]) and medial
(semitendinosus [ST] and semimembranosus [SM]) hamstring muscles and above the adductor
magnus muscle. VL, vastus medialis. C, The sciatic nerve gives off the common peroneal (arrowhead)
and tibial nerves (arrow) while it arrives at the proximal opening of the popliteal fossa. LG, lateral
gastrocnemius; MG: medial gastrocnemius; Pa, popliteal artery.
lateral (biceps femoris) and medial (semitendinosus until it arrives at the proximal opening of the
and semimembraneous) hamstring muscles and su- popliteal fossa to give off common peroneal and
perficial to the adductor magnus muscle (Fig. 5B) tibial nerves (Fig. 5C).
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SAPHENOUS NERVE Technique
Anatomy The transducer is placed in the medial aspect of
the midthigh in the transverse plane. The saphe-
The saphenous nerve (VIDEOS 7 [http://links.
nous nerve is situated in the space between the
lww.com/PHM/A205] and 8 [http://links.lww.com/
vastus medialis (laterally) and sartorius (medially)
PHM/A206]) departs from the femoral nerve as its
muscles, whereby it is accompanied by the femoral
largest cutaneous branch a few centimeters distal to
artery (Fig. 6A). The nerve gradually shifts to the post-
the inguinal ligament. It then descends with the
eromedial aspect of the distal thigh and emerges
femoral artery and vein and enters the adductor
from the fascia lata between the tendons of sarto-
canal, which is bordered by the sartorius muscle
rius and gracilis muscles, becoming a subcutaneous
anteriorly, adductor longus and magnus muscles
nerve. Below the knee, it runs along the tibia with the
posteromedially, and vastus medialis muscle laterally.
great saphenous vein (Fig. 6B).
At the distal end of the canal, it accompanies the
genicular artery and gives off the infrapatellar SURAL NERVE
branch to supply the medial knee joint and the
patellar tendon. The remaining part becomes the Anatomy
sartorial branch, which exits the adductor canal be- Lateral and medial sural cutaneous nerves
tween the sartorius and gracilis muscles. Thereafter, (VIDEO 9; http://links.lww.com/PHM/A207), the
it travels with the great saphenous vein and provides collateral branches of the common peroneal and
cutaneous sensation to the medial aspect of the leg tibial nerves, respectively, combine to form the sural
and foot.7,8 nerve at the proximal one-third of the leg by the
FIGURE 6 A, US image (axial view) shows the saphenous nerve (arrow) surrounded by vastus medialis muscle
laterally, adductor longus muscle medially, and sartorius muscle superficially and accompanied by
the femoral artery (Fa). The transducer is placed in the medial aspect of the midthigh in the transverse
plane. B, Below the knee, the saphenous nerve (arrow) runs along the tibia border with the greater
saphenous vein (GSv).
6 Hung et al. Am. J. Phys. Med. Rehabil. & Vol. 00, No. 00, Month 2016
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connection of the sural communicating branch. It second, and third sacral roots. It courses through the
courses with the small saphenous vein, down to the popliteal fossa and then runs between the soleus and
posterolateral aspect of the leg and onto the dorsal deep ankle/foot flexor muscles (tibialis posterior,
lateral foot. It provides sensation of the lower lateral flexor digitorum longus, and flexor hallucis longus).
leg and lateral parts of the heel, ankle, and foot.9 It innervates the gastrocnemius, soleus, plantaris,
and deep ankle/foot flexors. It also gives off the me-
Techniques dial sural cutaneous nerve. It passes posterior to the
The transducer is placed behind the lateral medial malleolus and then gradually bifurcates to
malleolus in the transverse place. The sural nerve is the medial and lateral plantar nerves at the tarsal
situated in the subcutaneous layer between pero- tunnel.9
neal muscles and the Achilles tendon, accompanied
by the small saphenous vein (Fig. 7A). Gradually Technique
moving the transducer upward, the nerve will be The transducer is placed behind the medial
seen between the two heads of the gastrocnemius malleolus in the transverse plane. The tibial nerve
muscle (Fig. 7B). is situated adjacent to the posterior tibial artery
and posterior to the tibialis posterior and flexor
TIBIAL NERVE
digitorum longus tendons (Fig. 8A). Moving the
Anatomy transducer distally enables the visualization of the
The tibial nerve (VIDEOS 10 [http://links.lww. tibial nerve as it divides into the medial and lat-
com/PHM/A208] and 11 [http://links.lww.com/PHM/ eral plantar nerves (Fig. 8B), penetrating the plane
A209]) arises from the sciatic nerve and contains the interposed between the abductor hallucis brevis
fibers from the fourth and fifth lumbar and the first, and quadratus plantae muscles. On the other hand,
FIGURE 7 A, US image (axial view) shows the sural nerve (arrow) in the subcutaneous layer between the peroneal
muscles and the Achilles tendon and accompanied by the small saphenous vein (SSv). The transducer is
placed behind the lateral malleolus in the transverse plane. B, Proximally, the sural nerve (arrow) is
seen between the two heads of the gastrocnemius muscles. MG, medial gastrocnemius.
Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
FIGURE 8 A, US image (axial view) shows the tibial nerve (arrow) located posterior to the tibialis posterior (TP)
and flexor digitorum longus (FDL) tendons and accompanying the posterior tibial artery (asterisk). The
transducer is placed behind the medial malleolus in the transverse plane. FHL, flexor hallucis longus.
B, Moving the transducer distally, the tibial nerve divides into the medial (arrow) and lateral (arrowhead)
plantar nerves. C, Moving the transducer proximally from the ankle level, the tibial nerve (arrow) runs
deep to the soleus muscle and superficial to the deep plantar flexor muscles. D, At the popliteal fossa,
the tibial nerve (arrow) runs next to the popliteal artery (Pa).
when the transducer is advanced proximally, the the peroneus brevis and extensor digitorum longus
tibial nerve can be seen to course underneath the muscles.11
soleus muscle and superficial to the deep plantar The deep peroneal nerve courses inferome-
flexor muscles (flexor hallucis longus, flexor digi- dially after the bifurcation and runs deep to the
torum longus, and tibialis posterior) (Fig. 8C) until extensor digitorum longus muscle and superficial
it merges with the common peroneal nerve in the to the interosseous membrane, where it inner-
popliteal fossa (Fig. 8D). vates the anterior compartment muscles (tibialis
anterior, extensor hallucis longus, and extensor
digitorum longus). Thereafter, it descends with the
PERONEAL NERVE
anterior tibial artery and gives off a motor branch
Anatomy to the extensor digitorum brevis muscle and a ter-
minal sensory branch to the interspace between the
The common peroneal nerve branches off from
first and second toes.9
the sciatic nerve and is composed by the fourth and
fifth lumbar and the first and second sacral roots.
It crosses posterior to the lateral head of the gas- Technique
trocnemius muscle and runs in the subcutaneous Common Peroneal Nerve
layer behind the fibular head. It then bifurcates The transducer is placed at the proximal pop-
into the superficial and deep peroneal nerves.10 The liteal fossa in the transverse plane to visualize the
superficial peroneal nerve first descends below the most distal part of the sciatic nerve, which gives off
peroneus longus muscle and supplies the peroneus the common peroneal nerve laterally and the tibial
longus and brevis muscles. The cutaneous branch nerve medially. The common peroneal nerve (Video 12;
of the superficial peroneal nerve then runs between http://links.lww.com/PHM/A210) passes above the
8 Hung et al. Am. J. Phys. Med. Rehabil. & Vol. 00, No. 00, Month 2016
Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
lateral head of the gastrocnemius muscle and courses Deep Peroneal Nerve
to the lateral aspect of the proximal leg (Fig. 9A and The transducer is placed at the anterior ankle
B). It then crosses the inferior portion of the fibular joint in the transverse plane. The deep peroneal nerve
head and runs under the proximal end of the (Video 13; http://links.lww.com/PHM/A211) is located
peroneus longus until it divides into the superficial lateral to the extensor hallucis longus tendon
and deep peroneal nerves (Fig. 9C). and adjacent to the dorsalis pedis artery (Fig. 10A).
FIGURE 9 A, US image (axial view) shows the common peroneal nerve (arrow) coursing between the lateral head
of the gastrocnemius and the short head of the biceps femoris (BF) muscles. The transducer is placed at
the proximal popliteal fossa in the transverse plane. B, Tracing the common peroneal nerve (arrow)
distally, the plantaris muscle is visualized under the lateral head of the gastrocnemius muscle. C, The
common peroneal nerve (arrow) then crosses the inferior portion of the fibular head to give off the
superficial and deep peroneal nerves.
Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
FIGURE 10 A, US image (axial view) shows the deep peroneal nerve (arrow) lateral to the extensor hallucis longus
tendon (arrowheads) and muscle (EHL), where it accompanies the dorsalis pedis artery (asterisk). The
transducer is placed at the anterior ankle joint in the transverse plane. TA, tibialis anterior tendon. B,
Moving the transducer proximally, the deep peroneal nerve (arrow) runs superficial to the interosseus
membrane (void arrows) and deep to the tibialis anterior, EHL, and extensor digitorum longus (EDL)
muscles, where it accompanies the anterior tibial artery (star).
Tracking proximally, the nerve runs with the ante- muscles. It then courses between the fibula and the
rior tibial artery, superficial to the interosseus peroneus longus muscle when the transducer passes
membrane, and deep to the tibialis anterior, extensor the proximal end of the peroneus brevis (Supple-
digitorum longus, and extensor hallucis longus mus- mentary Fig. 1B; http://links.lww.com/PHM/A213).
cles (Fig. 10B). It merges with the superficial pero- The nerve can be tracked until it merges with the
neal nerve slightly distal to the fibular head. deep peroneal nerve slightly distal the fibular head.
10 Hung et al. Am. J. Phys. Med. Rehabil. & Vol. 00, No. 00, Month 2016
Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
static and dynamic imaging helps evaluate the painVA description of techniques and review of lit-
nerves_ morphology and gliding as well as their erature. Pain Physician 2008;11:215Y24
actual relationship with the nearby structures. Fi- 6. Park BJ, Joeng ES, Choi JK, et al: Ultrasound-guided
nally, for the nerves that need to be tracked through lateral femoral cutaneous nerve conduction study.
Ann Rehabil Med 2015;39:47Y51
the whole limb, sonographers can navigate either
starting from the proximal or distal sites depending 7. Trescot AM, Brown MN, Karl HW: Infrapatellar sa-
phenous neuralgiaVDiagnosis and treatment. Pain
on their expertise or preference.
Physician 2013;16:E315Y24
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