Entrapment Neuropathies in the Lower

Extremity
Mohammad A. Saeed, MD, MS
Department of Rehabilitation Medicine
University of Washington, Seattle
Seattle, Washington

Shin J. Oh, MD
Department of Neurology
University of Alabama at Birmingham
Birmingham, Alabama

Surinderjit Singh, MD, MS

Department of Rehabilitation Medicine
University of Washington, Seattle
Seattle, Washington

Frank J.E. Falco, MD

Mid Atlantic Pain Institute
Wilmington, Delaware

INTRODUCTION

An entrapment neuropathy is a focal mononeuropathy caused
by mechanical impingement at a vulnerable anatomical site.
Peripheral nerves are commonly entrapped while passing
through fibrous or osseofibrous tunnels and when traveling
over a fibrous or muscular band. Nerve entrapments may result
from a number of mechanisms, including pressure, stretch an-
gulation, and friction. Many factors influence the clinical pre-
sentation of entrapment neuropathies such as age and
underlying systemic disease. Symptoms can be sensory, motor,
or mixed, depending on which fiber types are involved in the af-
fected peripheral nerves. Most clinical entrapments involve
mixed nerves so both motor and sensory complaints are
common. Sympathetic or parasympathetic dysfunction can
occur if there is involvement of autonomic fibers.
The main pathology of entrapment neuropathy is focal seg-
mental demyelination.14 Axonal degeneration of the nerve
segment distal to the site of entrapment can result from a severe.
entrapment. A variety of electrodiagnostic patterns can exist de-
pending upon whether the lesion causes focal demyelination,
secondary axonal loss, or both.
Nerve conduction studies (NCSs) can be useful in the diagnosis
of entrapment neuropathy.24 NCSs may detect evidence of focal
demyelination, which usually precedes axonal degeneration in a
compression neuropathy. Stimulation above and below the sus-
pected site of the lesion can reveal segmental slowing of the
nerve conduction velocity (NCV) as well as changes in the am-
plitude of the compound muscle action potential (CMAP) or of
the compound nerve action potential (CNAP) as seen in con-
duction block.
The goal of this workshop is to demonstrate electrodiagnostic
techniques for the evaluation of lower-extremity entrapment
neuropathies. The electrodiagnostic evaluation of posterior
tibial nerve and its branches as well as the peroneal nerve en-
trapment syndromes are particularly emphasized during the
workshop.
2 Entrapment Neuropathies in the Lower Extremity
ENTRAPMENT NEUROPATHIES OF THE PERONEAL NERVE
Common Peroneal Nerve
The peroneal nerve is subject to injury as it travels around the
head of the fibula near the lateral side of the knee. The most
common mechanism of injury to the peroneal nerve at the
fibular head is acute compression of the nerve causing a neu-
rapraxic (conduction block) lesion.5 The nerve can also be en-
trapped as it passes through the osseofibrous tunnel between
the edge of the peroneus longus muscle and the fibula. Injury
is most often traumatic in origin resulting from traction, lacera-
tion, or compression. Damage is occasionally attributable to
nerve infarction or tumor. More proximally, the peroneal divi-
sion of the sciatic nerve can be damaged by pelvic fracture, hip
fracture or dislocation, and femoral fracture.
Anatomy
The common peroneal nerve is one of the two divisions of the
sciatic nerve originating from the L4 to S1 roots with the main
contribution from the L5. A motor branch from the peroneal
division of the sciatic nerve arises in the mid thigh area supply-
ing the biceps femoris (short head) muscle. This branch is of
great importance in the electrodiagnostic evaluation because it is
crucial in defining the proximal extent of the lesion.
The peroneal nerve separates from the tibial division of the
sciatic nerve in the popliteal fossa. The common peroneal nerve
winds around the fibular head, passes deep to the peroneus
longus, and divides into the superficial and deep peroneal
nerves. The deep peroneal nerve innervates all the anterior com-
partment leg muscles [anterior tibialis, extensor digitorum
longus, extensor hallucis longus, extensor digitorum brevis
(EDB)]. The deep peroneal nerve provides cutaneous sensation
of the web space between digits 1 and 2. The superficial per-
oneal nerve is discussed in detail in a later section.
Electrophysiological Evaluation
Peroneal motor NCSs may exhibit reduced amplitude with
proximal stimulation above the fibular head (conduction block)
when recording from the EDB, or a slow NCV across the
fibular head. If the EDB is atrophied, no response may be
recorded even though the peroneal nerve itself is intact.
Recording from the anterior tibialis or peroneus brevis with
stimulation above and below the fibular head may yield useful
data in this circumstance.
In most electrodiagnostic medicine laboratories, the standard
peroneal NCS is performed with surface recording over the
EDB. Some authors prefer peroneal motor NCSs with record-
ing over the anterior tibialis, especially in patients with foot-
drop.38 This method provides additional information for the
AANEM Workshop
following reasons: (1) the EDB may be severely denervated due
to an unrelated coexistent process, e.g., local trauma or general-
ized peripheral neuropathy; (2) the EDB sometimes receives its
major peripheral innervation from an accessory peroneal nerve
that can produce misleading findings, especially with axon loss;
and (3) peroneal nerve fibers supplying the anterior tibialis and
the EDB muscle may be affected to a much different degree in-
creasing the likelihood of detecting an abnormality when both
studies are performed.
A peroneal nerve lesion at the fibular head can produce electro-
physiologic findings of focal demyelination (conduction block
or segmental slowing of the peroneal conduction velocity across
the fibular head) or axon loss.
1. In a pure neurapraxic lesion (conduction block) at the
fibular head, the peroneal motor responses following distal
stimulation at the ankle and below the fibular head, are
normal while the response obtained following stimulation
above the fibular head is of low amplitude or unelicitable.
Superficial peroneal sensory NCSs are usually normal.
Needle examination can reveal motor unit potential
dropout and rapid firing and possible sparse fibrillation po-
tentials in peroneal nerve innervated muscles distal to the
knee if there is coexisting axonal damage.
2. Axonal loss is the most frequent presentation of common
peroneal neuropathy. An NCS performed 10 or more days
after the onset of symptoms reveals a low amplitude or un-
elicitable peroneal motor response following both distal
and proximal stimulation, depending upon the degree of
degeneration of motor fibers supplying the anterior and
lateral leg compartment muscles. The superficial peroneal
sensory response is typically unelicitable. Needle examina-
tion reveals fibrillation potentials, motor unit potential
dropout, and rapid firing in peroneal-innervated muscles
below the knee. In chronic lesions, motor unit potential
amplitudes and durations can be increased.
3. A lesion can result in both axonal loss and conduction
block. The peroneal motor amplitude is low following
distal stimulation indicating that axon loss has occurred.
There is also additional dropoff in the CMAP amplitude
with stimulation proximal to the fibular head, reflecting the
presence of conduction block affecting some or all of the
surviving fibers. Superficial peroneal sensory responses are
unelicitable or low in amplitude. Needle examination can
show changes similar to those described above, depending
on the degree of axonal injury.
Peroneal Motor Nerve Conduction Study
• Set-up: Figure 1. Motor NCS for the peroneal nerve.
AANEM Workshop Entrapment Neuropathies in the Lower Extremity
• Recording: The active surface electrode is placed over the
EDB muscle. The reference electrode is placed on the fifth
toe and a ground electrode on the dorsum of the foot.
• Stimulation: Stimulation is applied 8 cm proximal to the
active recording electrode. More proximally, the nerve is
stimulated just below the fibular head and above the fibular
head in the popliteal fossa (at least 10 cm across the fibular
head).
• Measurement: Latency measurement is to the onset of the
first negative deflection. Amplitude is measured from base-
line-to-negative peak.
• Skin temperature: 31˚C.
• Normal values: Table 1
Figure 1
Short-segment Motor Nerve Conduction Study of
the Peroneal Nerve Across the Fibular Head18
• Set-up: Figure 2. Short-segment stimulation (inching)
technique of the peroneal nerve across the fibular head.
• Recording: The surface recording electrodes are placed
over the EDB muscle following the conventional belly-
tendon method.
• Stimulation: The peroneal nerve is stimulated across the
fibular head at 2-cm increments starting 4 cm distal (D4 and
D2) and ending 6 cm proximal (P2, P4, and P6) to the
fibular head prominence (P).
• Measurement: Latency measurement is to the onset of the
first negative deflection. Amplitude is measured from base-
line baseline-to-negative peak.
3
• Skin temperature: >32˚C.
• Normal values: Table 1.
Figure 2
Peroneal Nerve Conduction Study to Anterior
Tibialis and Peroneus Brevis9
• Set-up: Figure 3. Proximal motor nerve conduction of the
peroneal nerve. R1, recording electrode in the anterior tib-
ialis. R2 recording electrode in the peroneus brevis.
• Recording: For the anterior tibialis muscle, an active
surface electrode is placed at the junction of the upper third
and lower two thirds of a line between the tibial tuberosity
and the tip of the lateral malleolus of the fibula. The refer-
ence electrode is placed over the medial aspect of the tibia,
4 cm distal to the active recording electrode. For the per-
oneus brevis the active electrode is placed at the junction of
the upper two fifths and lower three fifths of a line,
between the head of the fibula and the tip of the lateral
malleolus. The reference electrode is placed 4 cm distally
on the muscle tendon.
• Stimulation: This is applied above and below the head of
the fibula with approximately 10 cm between the two
points of stimulation.
• Measurement: Latency measurement is to the onset of the
first negative deflection. Amplitude is measured from base-
line-to-negative peak.
• Skin temperature: Not controlled.
• Normal values: Table 1.
4 Entrapment Neuropathies in the Lower Extremity AANEM Workshop

TABLE 1.
Latency (ms)/ Amplitude
NCV(m/s) (mV/µV)
Onset Negative peak
Motor Nerve Conduction Study of Peroneal Nerve 24 (N=40; 20-60 yr)
Terminal latency (8 cm) 4.8 4.0
Ankle-below fibular head 41.7
Across fibular head 39.1

18
Short-segment Motor Nerve Conduction Study of Peroneal Nerve across the Fibular Head : (N=44; 25-59 yr)
Conduction time (2-cm segment) 0.94
Amplitude reduction (2-cm segment) 9. 9%

Motor Nerve Conduction Study of Proximal Peroneal Nerve9 : (N=34; 17-44 yr)
Anterior tibialis:
Latency **** 4.2
NCV 40.5
Peroneus brevis:
Latency **** 4.6
NCV 34.9

Sensory Nerve Conduction Study of Deep Peroneal Nerve22 : (N=40; 21-50 yr)
Latency (12 cm) 3.7 4.6 1.6
NCV 32.0

Sensory Nerve Conduction Study of Superficial Peroneal Nerve17 : (N=80; 20-69 yr)
Medial dorsal cutaneous nerve:
Latency (14 cm) 3.4 4.2 5.0
NCV 39.8
Intermediate dorsal cutaneous nerve:
Latency (14 cm) 4.2 4.2 4.0
NCV 40.5
Abbreviations: N — number of subjects.
NCV — nerve conduction velocity.
*Normal limits: mean ± 2 standard deviations for latency and NCV. The lowest normal range for amplitudes.
**Onset of the initial deflection of potentials.
***Peak of the negative deflection of potentials.
****For distance, see figure 3

PERONEAL NERVE AT THE ANKLE
Anterior tarsal tunnel syndrome is a rare entrapment of the deep per-
oneal nerve at the ankle. Symptoms include pain on the dorsum
of the foot and sensory deficits in the small web area between
the first and second toes. It may also cause atrophy of the EDB
muscle.
Deep peroneal sensory neuropathy is a rare neuropathy which is char-
acterized by sensory impairment over the web space as de-
scribed. Compression of this nerve is caused by local trauma or
tight shoes. This can be detected by a newly described sensory
nerve conduction technique (Lee 90;20 Ponsford 9435).
Deep Peroneal Sensory Nerve Conduction Study20

Needle electromyography (EMG) examination reveals evidence
of denervation in the EDB muscle. NCSs can show a pro-
longed distal motor latency with stimulation of the deep per-
oneal nerve proximal to the extensor retinaculum. Sensory
conduction studies of the deep peroneal nerve should be ab-
normal when the sensory branch is involved.
• Set-up: Figure 4. Sensory NCS of the deep peroneal nerve.
• Recording: The active surface electrode is placed at the in-
terspace between the first and second metatarsal heads.
The reference electrode is placed 2 to 3 cm distally on the
second toe.

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AANEM Workshop Entrapment Neuropathies in the Lower Extremity
Figure 3
Figure 4 Lee’s method (left) and Donsford’s Method (right)
• Stimulation: The nerve is stimulated antidromically at the
ankle 12 cm proximal to the active recording electrode and
just lateral to the extensor hallucis longus tendon.
• Measurement: The latency is measured from the stimulus
onset to the onset of the first negative deflection and the
negative peak. The NCV is calculated by dividing the dis-
tance by the onset latency.
• Skin temperature: >29˚C.
• Normal values: Table 3.
SUPERFICIAL PERONEAL NERVE
The superficial peroneal nerve fibers are commonly involved in
lesions of the common peroneal nerve. Focal nerve injury can
occur at the fibular head and where the nerve exits through the
fascia to become more superficial, or at the dorsal lateral aspect
of the ankle and foot.
Copyright © October 2001
5
Anatomy
The superficial peroneal nerve is a branch of the common per-
oneal nerve with root contributions from L4, L5, and S1. After
branching off from the common peroneal nerve, it passes
between the fibula and peroneus longus and brevis muscles.
After supplying both muscles, it becomes subcutaneous after
piercing the deep fascia near the distal third of the leg. After
piercing the fascia, the nerve divides into two sensory branches
— the intermediate dorsal cutaneous branch and the medial
dorsal cutaneous branch. This division usually occurs approxi-
mately 10.5 cm above the lateral malleolus. The superficial per-
oneal nerve provides cutaneous innervation to the distal
anterolateral foreleg and to most of the dorsum of the foot,
except for an area on the lateral portion of the foot which is sup-
plied by the sural nerve, and the adjacent side of the great toe
and the second toes which are supplied by the deep peroneal
nerve.
In axonal lesions of the superficial peroneal nerve close to the
fibular head, the superficial peroneal sensory response will be of
low amplitude or absent altogether. In contrast, if conduction
block (neurapraxia) occurs at the fibular head or more proxi-
mally, the superficial peroneal sensory response will be normal
since both the stimulation and recording sites are distal to the
lesion. If the nerve is entrapped at the ankle, there may be focal
slowing of the superficial peroneal nerve conduction velocity,
and/or the response can be of low amplitude or absent. The
superficial peroneal response can be unobtainable in normal
persons over the age of 60 years.
Superficial Peroneal Sensory Nerve Conduction
Study17
• Set-up: Figure 5. Sensory NCS of the superficial peroneal
nerve
• Recording: The active surface electrode is placed over the
palpable medial dorsal cutaneous or intermediate dorsal cu-
taneous branch as they cross the anterior ankle between the
malleoli. The reference electrode is placed 3 cm distal to
the active electrode.
• Stimulation: The site of stimulation is 14 cm from the
proximal recording electrode on the anterolateral aspect of
the calf.
• Measurement: Latency is measured to the onset of the neg-
ative peak or to the negative peak. NCV is calculated by di-
viding the distance by the latency to the onset.
• Skin temperature: >28˚C.
• Normal values: Table 1.
6 Entrapment Neuropathies in the Lower Extremity
Medial and intermediate dorsal cutaneous neuropathy: Individual medial
dorsal and intermediate dorsal cutaneous neuropathy can occur
with a lesion at the ankle or the dorsum of the foot. Trauma,
surgical injury, and external compression such as is caused by
tight shoes are known causes of neuropathy. Classically, an in-
dividual branch, the MDC, IDC, or the first proper digital nerve,
is involved in isolation. Thus, pain, dysesthesia, and sensory im-
pairment are confined to the small area innervated by the indi-
vidual nerve branch. Thus, clinical diagnosis depends solely on
the distribution of the sensory impairment. Often Tinel’s sign
is present at the site of the lesion. An epidermoid cyst, a gan-
glion, and an “injection” have also been reported as causes.
Surgical neurolysis has been helpful in relieving pain in cases
where a mass or fibrosis was the cause of the distal neuropathy.
Figure 5
Dr. Oh and colleagues described the antidromic and ortho-
dromic sensory nerve conduction technique of the MDC and
IDC nerves. See Figure 6. Two branches of the MDC and two
branches of the IDC were individually tested. They were able
to confirm the diagnosis by this technique in seven cases: two
with proper digital neuropathy, two with MDC neuropathy, and
three with IDC neuropathy. Among seven cases, a definite
cause for the distal SP neuropathy was found in only four: a gan-
glion in one, a burn scar in one, tight shoes in one, and trauma
in one. In three cases, no cause was found although the most
likely cause was external pressure. Though the abnormality in
six of these cases was obvious in the NCS, they had to rely on
side-to-side comparison of amplitude in one case, indicating the
need for this comparison in some cases.
Medial and Intermediate Dorsal Cutaneous Sensory
Nerve Conduction (Oh’s method)31
• Set-up: Figure 6
• Recording: Landmark sites for the recording electrodes for
the MDC and IDC in the orthodromic sensory nerve con-
duction are shown in Figure 6: the mid-point between the
Copyright © October 2001
AANEM Workshop
medial and lateral malleolus for the MDC nerve and a point
one-quarter of the distance from the lateral to the medial
malleolus for the IDC nerve. Stimulating and recording
sites for these branches were reversed for their antidromic
sensory conduction studies.
• Stimulation: The stimulating site for each branch of the
medial and intermediate dorsal cutaneous nerves was 10 cm
distal to the recording site along a line from the recording
site to the mid-portion of the first toe in the proper digital
nerve or to the interdigital space in other branches, as
shown in Figure 6.
• Measurement: Latency is measured from the onset of the
stimulus to the onset as well as the negative peak.
• Skin temperature: above 32˚C.
• Normal values: See Table 3
ENTRAPMENT NEUROPATHIES OF THE POSTERIOR TIBIAL
NERVE
Entrapment neuropathies of the posterior tibial nerve are rela-
tively rare in comparison to other peripheral nerve entrapment
syndromes.
Anatomy
The posterior tibial nerve is a continuation of the medial trunk
of the sciatic nerve as it passes through the popliteal fossa and
then deep between the two heads of the gastroenemius muscle.
In the calf, it innervates the gastroenemius, soleus, posterior tibi-
lalis, flexor digitorum, and flexor hallucis longus muscles. At the
ankle, it passes through the tarsal tunnel. Three nerves branch
from the posterior tibial nerve near or in the tarsal tunnel. In
35% to 40% of cases, the calcaneal nerve branches from the
posterior tibial nerve proximal to the tarsal tunnel (Dellon 847;
Havel 8816). The posterior tibial nerve then divides into the
medial and lateral plantar nerve, within 1 cm of the malleolar-
calcaneal axis in a majority of cases. Inferior calcaneal nerve, the
first branch of lateral plantar nerve branches from the lateral
plantar nerve within 1-2 cm below the posterior tibial division
in majority of cases (Louisia 9921; Arenson 801). While the cal-
caneal nerve is superficially located near the heel, the other three
nerves pass through the different fibromuscular tunnel beneath
the abductor hallucis muscle. The posterior tibial nerve is rarely
compressed externally since it is deeply located in the popliteal
fossa and calf.
Posterior tibial neuropathy can clinically mimic tarsal tunnel syn-
drome (TTS). A key differentiating feature is involvement of
the plantar flexor and inverter muscles which can best be tested
AANEM Workshop Entrapment Neuropathies in the Lower Extremity
by needle EMG and posterior tibial NCSs. External compres-
sion such as from a Baker’s cyst can lead to a proximal posterior
tibial entrapment neuropathy.
Figure 6
Posterior Tibial Motor Nerve Conduction Study24
• Set-up: Figure 7. Motor NCS for the posterior tibial nerve.
Figure 7
• Recording: An active electrode is placed on the belly of the
abductor hallucis muscle located at a point 1 cm inferior
and 1 cm posterior to the navicular prominence. A refer-
ence electrode is placed on the base of the great toe.
• Stimulation: At the ankle, the nerve is stimulated just
behind the medial malleolus, 10 cm proximal to the active
recording electrode. At the knee, the nerve is stimulated
just medial to the midpoint of the popliteal fossa crease.
• Measurement: Latency measurement is to the onset of the
first negative deflection. Amplitude is measured from base-
line-to-negative peak.
• Skin temperature: >31˚C.
• Normal values: Table 2.
Posterior Tibial Mixed Nerve Conduction Study22
• Set-up: Figure 8. Mayer’s method of mixed NCS of the
posterior tibial nerve.
• Recording: Surface electrodes are placed at the popliteal
fossa just medial to the midpoint of the popliteal fossa
crease.
• Stimulation: The nerve is stimulated at the ankle.
Copyright © October 2001
7
• Measurement: Latency is measured from the onset of the
stimulus to the onset of the negative deflection.
• Skin temperature: 32˚C.
• Normal values: Table 2.
TTS is the most common entrapment neuropathy of the poste-
rior tibial nerve. The nerve is entrapped within the tarsal tunnel
behind and below the medial malleolus. It is relatively rare. In
contrast to the carpal tunnel, the tarsal tunnel has a thinner
flexor retinaculum and contains vessels.
After emerging from the tarsal tunnel, the MPN and LPN enter
the upper and lower calcaneal chambers, respectively, separated
by the interfascicular septum. MPN or LPN can be entrapped
through the calcaneal chambers or by proximal or distal edge of
interfascicular septum.34
The most common cause of TTS is trauma which accounts for
one out of three cases. Some of the other possible etiologic
factors are space occupying lesion, tenosynovitis, chronic
thrombophlebitis with pressure on the nerve, chronic foot
strain, and joint hypermobility. This syndrome has also been as-
sociated with systemic disorders such as hyperlipidemia, gout,
hypothyroidism, acromegaly, and rheumatoid arthritis. As in
carpal tunnel syndrome, the cause of the majority of TTS cases
is unknown.25
Typical symptoms include burning pain and paresthesia of the
toes and sole of the foot. Classically, the symptoms are often
worse at night, increased by activity, and diminished with rest.
The most helpful diagnostic criteria are a positive Tinel’s sign at
the ankle and objective sensory loss in the territory of any of the
8 Entrapment Neuropathies in the Lower Extremity
Figure 8
terminal branches of the posterior tibial nerve. It should be
noted, however, that not all three branches are affected in all
cases. In fact, on the basis of objective sensory findings, the
medial plantar nerve is most often involved. Weakness of the
toe flexion and atrophy of the abductor hallucis muscle are rare.
Figure 9 Motor Nerve Conduction study of plantar nerves
NCSs of the plantar nerves can assist in confirming the diagno-
sis of TTS in up to 90% of cases.27,29 Motor NCSs of the poste-
rior tibial nerves are not helpful because of the low yield.
Prolonged terminal latency of the posterior tibial nerve was ob-
served in 47% of cases.24 Near-nerve sensory NCS of the
medial and lateral plantar nerves was abnormal in more than
90% of cases in one series.27 Both the medial and lateral plantar
nerves should be tested because only one may be affected in
some cases. See Figure 9.
Felsenthel and colleagues described a technique of motor nerve
conduction of the posterior tibial nerve across tarsal tunnel. See
Figure 10. It establishes both a distal latency across the abduc-
tor tunnel as well as proximal latency across the tarsal tunnel.
Abnormality could be diagnosed using decrement of the ampli-
tude across the tarsal tunnel or abnormal across tarsal tunnel
latency. See Table 3.
There are two methods for performing sensory NCSs of the
plantar nerves - one using surface recording electrodes and the
29
other, near-nerve needle electrodes.27 See Figure 11.Copyright
When © October
AANEM Workshop
using surface recording techniques, abnormalities can be ex-
pressed either as an absent sensory nerve action potential
(SNAP) or slow sensory NCV. Near-nerve needle techniques
may be preferred because in normal elderly individuals, the
SNAP may not be obtainable with surface electrode techniques.
The SNAP is usually recordable with the near-nerve technique
and an accurate maximum NCV can be calculated in most indi-
viduals. Slow NCV and abnormal temporal dispersion are two
common abnormalities observed in TTS patients using the
near-nerve technique. The medial plantar nerve is more often
involved than the lateral plantar nerve.
Saeed and Gatens described a technique for recording mixed
NCSs of the medial and lateral plantar nerves.36 See Figure 12.
Figure 10 Felsenthal’s Method
Figure 11 Sensory Nerve Conduction study of the plantar
nerves
This method records the mixed nerve action potential from the
tibial nerve with a bar electrode placed behind the medial
malleous. Electrical stimulation is applied to the plantar aspect
of this foot over the MPN or LPN, 14 cm distance to the
recording electrode. They have found the mixed nerve con-
duction studies for LPN and MPN which predominantly test
the sensory fibers to be more practical and clinically useful.
Many prefer this technique because it has the advantage of not
requiring a signal average. Galardi and colleagues (94)12 reported
an 86% sensitivity with the mixed-nerve study in 14 cases of
TTS compared with 100% with the sensory-nerve conduction
study. He recommended both tests for the work-up of TTS and
stated
that coexistence of mixed nerve and sensory nerve con-
2001
AANEM Workshop Entrapment Neuropathies in the Lower Extremity 9

TABLE 2. NORMAL VALUES (NORMAL LIMIT) OF POSTERIOR TIBIAL AND PLANTAR NERVE CONDUCTION*

Latency (ms)/ Amplitude

NCV(m/s) (mV/µV)
Onset** Negative peak***
POSTERIOR TIBIAL NERVE

Motor Nerve Conduction Study of Posterior Tibial Nerve 24: (N=40; 20-60 yr)
Terminal latency (10 cm) 5.1 5.0
NCV 40.6

Mixed Nerve Conduction Study of Posterior Tibial Nerve 22: (N=64; 10-86 yr)
10-35 yr 48.1
36-50 yr 41.4
51-86 yr 43.7

PLANTAR NERVE
29
Motor Nerve Conduction Study of Plantar Nerve : (N=20; 19-50 yr)
Medial (10cm) 5.4 3.5
Lateral (12 cm) 6.3 3.0

Mixed Nerve Conduction Study of Plantar Nerve 36 : (N=41; 20-76 yr)

Medial (14 cm) 3.7 >5
Lateral (14 cm) 3.7 >5

32
Sensory Nerve Conduction Study of Medial Calcaneal : (N=72)
Latency (10 cm) 2.0 2.8 4.0
NCV 49.0 35.0
Sensory Nerve Conduction Study of Plantar Nerve with the Surface Electrodes29 (N=20; 19-50 yr)
Medial 28.0 2.0
Lateral 22.9 1.0

Sensory Nerve Conduction Study of Interdigital Nerve with the Near-nerve Needle 29 : N=30/N=10: (20-49 yr)/(50-59 yr)
I 35.1/32.8* 30.3/28.5 2.7/1.3
I-II 32.5/28.5 28.2/23.5 2.0/0.8
II-III 30.0/25.8 26.2/26.1 1.3/0.7
III-IV 29.6/25.7 25.4/21.7 1.3/0.7
IV-V 31.8/24.1 25.7/22.4 1.0/0.7
V 30.4/24.6 25.9/21.6 0.7/0.4

Sensory Nerve Conduction Study of Medial Plantar Proper Digital Nerve4: (N=21; 20-67 yr)
33.2 28.4 2.2
Abbreviations: N — number of subjects. NCV — nerve conduction velocity.
* Normal values for 20-49 yr/Normal values for 50-59 yr.
** Onset of the initial deflection of potentials.
*** Peak of the negative deflection of potentials.

duction abnormalities, especially if asymmetric, are highly in- axonal degeneration and the nerve involved: abductor hallucis
dicative of TTS. However the authors recommended mixed muscle in the medial plantar nerve, abductor and flexor digiti
nerve action potential for presurgical diagnosis of TTS. quinti muscles in the lateral plantar nerve, and abductor digiti
quinti muscle alone in the inferior calcaneal nerve (Park 9834). It
The needle EMG may show denervation of the involved intrin- is always prudent to compare the needle EMG findings with
sic muscles of the foot, depending on the degree of secondary asymptomatic
Copyright © October 2001 foot because positive sharp waves and fibrillation
10 Entrapment Neuropathies in the Lower Extremity AANEM Workshop

TABLE 3.

Latency(ms)/NCV(m/s) Amplitude(mV/uV)
Onset Negative peak
Sensory Nerve Conduction Study of Deep Personeal Nerve (N=50: 20-59 yr) (Ponsford 94)35
NCV 20-39 yr 40 3.2
40-59 yr 35 1.0
Sensory Nerve Conduction Study of Distal Superficial Peroneal Nerve (N=37; 20-62 yr) (Oh 2001)31
Medial dorsal cutaneous nerve
1st branch (proper digital nerve)
(10 cm)
31.9/34.8# 25.4/28.5 2.0
3rd branch 34.1/35.3 27.8/29.6 2.7
(10 cm)
Intermediate dorsal cutaneous nerve
4th branch 31.7/33.02 25.3/26.9 3.0
(10 cm)
5th branch 30.9/31.4 25.6/26.6 2.7
#Antidromic technique/orthodromic technique.
Motor nerve conduction of the posterior tibial nerve across tarsal tunnel (Felsenthals Method)11
NORMAL DATA; Number of subjects: 32. Age range: 20-45 yr.
Medial Plantar Nerve Lateral Plantar Nerve
Measurement Mean +/- SD Normal Limit Mean +/- SD Normal Limit
Latency
Distal (msec) 4.5 +/- 0.7 5.9 4.5 +/- 0.7 5.9
Proximal (msec) 6.9 +/- 0.8 8.5 6.9 +/- 0.7 8.3
Across tarsal tunnel (msec) 2.4 +/- 0.4 3.2 2.4 +/- 0.4 3.2
Side to side difference 0.9 0.9
Amplitude
Distal (mV) 7.7 +/- 3.6 1.7 12.0 +/- 5.6 3.0
Proximal (mV) 6.9 =/- 3.3 2.4 10.8 +/- 5.3 3.0
Across tarsal tunnel (%) 10.3 +/- 9.5 27.6 10.2 +/- 8.5 26.5
NCV (m/sec) 49.4 +/- 5.3 38.8 50.9 +/- 5.2 40.7
INTERPRETATION: An amplitude decrement of more than 30% across the tarsal tunnel is considered abnormal. A side - to - side variation of
more than 50% of the amplitude unusual.

were observed in the intrinsic muscles of normal feet in 6-11%
of cases.13
Medial plantar neuropathy. The medial plantar nerve can be com-
pressed in isolation along its pathway distal to the tarsal tunnel,
thereby producing a medial plantar neuropathy (MPN). The
common site of compression is at the abductor tunnel (the fi-
bromuscular tunnel behind the navicular tuberosity). Reversible
medial plantar neuropathy among joggers (“jogger’s foot”) has
been described. Apparently, jogging produces repeated injury
to the medial plantar nerve at the abductor tunnel. Clinically,
these patients have burning/tingling over the medial two thirds
of the sole of the foot and tenderness over the medial plantar
nerve at its entrance to the abductor tunnel.

Sensory NCSs of the plantar nerves can assist in the diagnosis

of MPN, being selectively abnormal in the medial plantar nerve
and normal in the lateral plantar nerve.28 Absent CNAP or slow
sensory NCV with low CNAP amplitude was observed in the
medial plantar nerve in four cases.28 Terminal latency to the ab-
ductor hallucis brevis muscle was normal in these four cases.
Needle EMG examination of the abductor hallucis brevis and
flexor digitorum brevis (I-III) muscles can show denervation in
Figure 12 Mixed Nerve Conduction study of the plantar nerves this disorder.
Copyright © October 2001
AANEM Workshop Entrapment Neuropathies in the Lower Extremity
Lateral plantar neuropathy. The lateral plantar nerve can be com-
pressed in isolation along its pathway distal to the tarsal tunnel,
producing a lateral plantar neuropathy. Sensory loss is confined
to the lateral one third of the sole of the foot. Oh (99)30 reported
eight patients with this neuropathy, confirmed by abnormal
sensory NCSs confined to the lateral plantar nerve.9 Terminal
latency to the abductor digiti quinti (ADQ) muscle was normal
in five of six tested cases. Most likely this is due to the lesion
distal to branching of the inferior calcanal nerve. Needle EMG
may show signs of denervation in the ADQ muscle if the lesion
is proximal enough to involve the inferior calcaneal branch.
However, if the lesion is distal to this division, then needle
EMG abnormalities are confined to the flexor digiti quinti
brevis muscle, sparing the ADQ muscle.
Inferior calcaneal neuropathy: The inferior calcaneal nerve is the first
branch of the lateral plantar nerve innervating the abductor
digiti quinti muscle. In orthopedic and podiatric literatures, en-
trapment of this nerve has been implicated as a common and
treatable cause of anterior heel pain syndrome. This nerve is be-
lieved to be entrapped between the deep fascia of the abductor
hallucis muscle and the medial head of the quadratus plantae
muscle. Patients are usually athletes, and there is no neurologi-
cal abnormality. Section of the deep fascia is said to be effective
in relieving pain. In nine tested patients, the needle EMG and
NCS were normal (Baxter 92).2
Park and Del Toro reported a low CMAP amplitude from the
ADQ muscle and fibrillation in the ADQ muscle in a case of
isolated inferior calcaneal neuropathy (96).33
Medial plantar digital proper nerve syndrome (Joplin’s neuroma). The
medial plantar digital proper (MPDP) nerve is a terminal
sensory branch arising from the medial plantar nerve. This
nerve supplies sensation to the medial aspect of the hallux. The
nerve lies rather superficially and, therefore, may be susceptible
to injury resulting from acute trauma to the great toe or from
chronic compression, as from a tight shoe. Joplin described a
pain syndrome due to traumatic perineurial fibrosis of the nerve
(Joplin’s neuroma). The syndrome is usually characterized by
Figure 13 Sensory Nerve Conduction Study of the medial calcaneal
nerve
Copyright © October 2001
11
pain in the medial aspect of the great toe, a painful enlarged
(cord-like) nerve immediately proximal to the interphalangeal
joint, and sensory impairment over the medial aspect of the
great toe in some cases. Diagnosis of this neuropathy can be
confirmed by the sensory NCSs of the MPDP nerve (see Figure
15).4 A low CNAP amplitude and normal NCV were found in
a recently described case.4
Calcaneal neuropathy. The third branch of the posterior tibial
nerve at the ankle is the calcaneal nerve. This nerve runs su-
perficial to the flexor retinaculum innervating the heel. The cal-
caneal nerve is typically not involved in TTS since it branches
proximal to the laciniate ligament. Isolated calcaneal neuropathy
is rare. See Figure 13.
Sensory Nerve Conduction Study of the Medial
Calcaneal Nerve32
• Set-up: Figure 13. Sensory NCS of the medial calcaneal
nerve.
• Recording: The active surface electrode is placed one third
of the distance from the apex of the heel to the midpoint
between the navicular tuberosity and tip of the medial
malleolus. A reference electrode is placed at the apex of the
heel.
• Stimulation: The posterior tibial nerve is stimulated 10 cm
proximal to the active electrode.
• Measurement: Latency to the onset and negative peak of
the sensory CNAP is measured by the conventional
method. Amplitude is measured from baseline to negative
peak.
• Skin temperature: >30˚C.
• Normal values: Table 2.
Interdigital neuropathy (Morton’s neuroma). Morton’s neuroma refers
to a III-IV interdigital neuropathy. In recent years, this term has
been used to refer to any interdigital neuropathy (IDN) of the
foot. Typically, the patient complains of precisely localized pain
on the plantar aspect of the foot between the two metatarsal
heads which often radiates to the toes. Tenderness to palpation
can be present. Sensory impairment is often present involving
the affected interdigital web and toes. Repeated trauma to the
interdigital nerve is the most commonly accepted cause of this
disorder.
NCSs of the various interdigital nerves can assist in the diagno-
sis of an interdigital neuropathy. This disorder can cause a se-
lective decrease in the CNAP amplitude (“abnormal dip
phenomenon”)27 or a slow NCV of the affected interdigital
12 Entrapment Neuropathies in the Lower Extremity
nerve10 in comparison to neighboring interdigital nerves. See
Figures 14 and 15.
Figure 14 Interdigital sensory nerve conduction study of the foot
Figure 16 Sensory NCS of the Saphenous Nerve.
Figure 15 Interdigital sensory nerve conduction study of the foot
Saphenous neuropathy. The saphenous nerve is the terminal
sensory branch of the femoral nerve that supplies the cutaneous
branches to the medial aspect of the knee and lower leg.
Symptoms of saphenous neuropathy are sensory. There is radi-
ating pain over the distribution of nerve, primarily on the medial
calf and lower one-third leg until medial ankle. A Tinel sign may
be elicited anywhere along the nerve, typically at the site of en-
trapment or trauma.
The most common cause of saphenous neuropathy is a com-
plication of the removal of the adjacent sapheno7us vein during
coronary bypass surgery.19 The nerve is also vulnerable during
operations on varicose veins or local trauma and lacerations. A
rare entrapment of the saphenous nerve at the exit from
Hunter’s canal was reported.23 Diagnosis of this neuropathy can
be confirmed by the sensory NCSs of the saphenous nerve.
Saphenous Nerve Conduction Study37
• Set-up: Figure 16. Antidromic method of sensory NCS of
the saphenous nerve.
• Recording: The reference electrode is placed just anterior
to the highest prominence of the medial malleolus in the
space between the malleolus and the medial border of the
tibialis anterior tendon. The active electrode is located 3 cm
above the reference and just medial to the tibialis anterior
tendon.
Copyright © October 2001
AANEM Workshop
• Stimulation: The nerve is stimulated antidromacally 14 cm
above the active recording electroe, deep to the medial
border of the tibia. Firm pressure should be exerted on the
stimulating electrode, pushing them between the medial
gastrocnemius and the tibia.
• Measurement: Latency is measured from the stimulus
onset to the peak of the first negative deflection of re-
sponse. The amplitude measurement is conventional.
• Skin tempertature: Not controlled.
• Normal values: Table 4
An NCS of the lateral femoral cutaneous nerve can be used as
an objective diagnostic aid in this disorder. The most promi-
nent abnormality is an absence of sensory CNAP, as observed
in 58% of the reported cases.24 In 17% of the reported cases,
the sensory NCV was slow.24 The somatosensory evoked po-
tential test has also been used to detect this disorder
Lateral Femoral Cutaneous Nerve Conduction Study3
• Set-up: Figure 17. Antidromic method of sensory NCS
of the lateral femora cutaneous nerve.
• Recording: Recording electrodes are placed 12 cm directly
inferior to the anterior superiro iliac spine on the tibialis an-
terior tendon.
• Stimulation: The nerve is stimulated 1 cm medial to the an-
terior superior iliac spine with a TeflonTM-coated monopo-
AANEM Workshop Entrapment Neuropathies in the Lower Extremity
TABLE 4. NORMAL VALUES (NORMAL LIMIT) OF SAPHENOUS AND LATERAL FEMORAL CUTANEOUS NERVE*
Latency (ms)/
NCV(m/s)
Onset** Negative peak***
24
Saphenous Nerve : (N=40; 20-9 yr)
Latency
NCV
Lateral Femoral Cutaneous Nerve1 : (N=24; 19-81 yr)
Latency
Abbreviations: N — number of subjects. NCV — nerve conduction velocity.
*Normal limits: mean ± 2 standard deviations for latency and NCV.
**Onset of the initial deflection of potentials.
***Peak of the negative deflection of potentials.
lar needle electrode. A surface electrode is used as a refer-
ence electrode. Stimulation with an active surface electrode
is adequate in thin individuals.
• Measurement: Latency is measured at the peak of the neg-
ative deflection of the CNAP. Amplitudes and distance
measurements are conventional.
• Skin temperature: Not controlled.
• Normal values: Table 4.
Lateral femoral cutaneous neuropathy (Meralgia aresthetica). The lateral
femoral cutaneous nerve originates from the L2 and L3 spinal
nerves. It takes a course through the pelvis, entering the leg at
the level of the upper and lateral end of the inguinal ligament.
An NCS of the lateral femoral cutaneous nerve can be used as
an objective diagnostic aid in this disorder. The most promi-
nent abnormality is an absence of sensory CNAP, as observed
in 58% of the reported cases.24 In 17% of the reported cases, the
sensory NCV was slow.24 The somatosensory evoked potential
test has also been used to detect this disorder.
Figure 17 Sensory NCS of the lateral femoral cutaneous nerve
Copyright © October 2001
13
Amplitude
(mV/µV)
4.4 <6.0
38.3
3.0 10.0
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Figure 18 Lower extremity potentials are difficult to obtain compared with upper extremities. Above are some of the difficult to obtain sensory
and mixed nerve action potentials in a 52-year-old normal subject. Site 1 — calcaneal nerve. Site 2 — deep peroneal sensory nerve. Site 3 —
saphaneous nerve. Site 4 — medial plantar digital proper nerve. Site 5 — mixed medial plantar nerve. Site 6 — mixed lateral plantar nerve.

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25. Oh SJ. Entrapment neuropathies of the posterior tibial nerve.
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26. Oh SJ, Kim HS, Ahmad B. Electrophysiological diagnosis of inter-
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28. Oh SJ, Lee KW. Medial plantar neuropathy. Neurology
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29. Oh SJ, Sarala P, Kuba T, Elmore R. Tarsal tunnel syndrome: elec-
trophysiological study. Ann Neurol 1979;5:327-330.
30. Oh SJ, Kwon KH, Hal JS, Kim DE, Demirci M. Lateral plantar neu-
ropathy. Muscle Nerve 1999;22:1234-1238.
31. Oh SJ, Demirci M, Dajani B, Melo AC, Claussen GC. Distal sensory
nerve conduction of the superficial peroneal nerve: new method and
report of seven cases. Muscle Nerve 2001 (In Press)
32. Park TA, Del Toro DR. The medial calcaneal nerve: anatomy and
nerve conduction technique. Muscle Nerve 1995;18:32-38.
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Muscle Nerve 1996;19:106-108.
34. Park TA, Del Toro DR. Electrodiagnostic evaluation of the foot.
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E A E E A E EL E E E

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COMPARISON OF FOUR DIFFERENT NERVE CONDUCTION
TECHNIQUES OF THE SUPERFICIAL FIBULAR SENSORY NERVE
MATHEW R. SAFFARIAN, DO, NATHAN C. CONDIE, DO, ERICA A. AUSTIN, DO, KATIE E. MCCAUSLAND, DO,
MICHAEL T. ANDARY, MD, JAMES R. SYLVAIN, DO, IIAN R. MULL, MS, ERIC D. ZEMPER, PhD, and
MARY L. JANNAUSCH, MS
Department of Physical Medicine and Rehabilitation, Michigan State University, 1200 E. Michigan Avenue, Suite 520, East Lansing,
Michigan, 48912
Accepted 21 December 2016
ABSTRACT: Introduction: There are many different nerve
conduction study (NCS) techniques to study the superficial fibu-
lar sensory nerve (SFSN). We present reference distal latency
values and comparative data regarding 4 different NCS for the
SFSN. Methods: Four different NCS techniques, Spartan tech-
nique, Izzo techniques (medial and intermediate dorsal cutane-
ous branches), and Daube technique, were performed on (114)
healthy volunteers. A total of 108 subjects with 164 legs were
included. Results: The mean latency of the Spartan technique
was longest (3.9 6 0.3 ms) while the Daube technique was the
shortest (3.6 6 0.7 ms). The mean amplitude of the Daube
technique displayed the highest (15.2 6 8.2 lV) with the Spartan
technique having the lowest (8.7 6 4.2 lV). Among the absent
sensory nerve action potentials (SNAPs), the Spartan technique
was absent only twice (1.2%) and the Izzo Medial technique
was absent more than the other techniques (2.9%). Conclu-
sions: All 4 techniques were reliable methods for obtaining the
superficial fibular nerve SNAP, present in 95% of individuals.
Muscle Nerve 000:000–000, 2017
There are a variety of different nerve conduction
study (NCS) techniques to study the superficial fib-
ular sensory nerve (SFSN). The different techni-
ques differ in the placement of the active and
reference electrode as well as in the position of
stimulation. There is variability in the anatomic
location of where the SFSN exits the fascia in the
distal leg. It is unclear in the literature which tech-
nique is more reliable than others.
DiBenedetto described one of the earliest tech-
niques in 1970.1 She was the first to describe an
antidromic NCS for both the SFSN as well as the
sural nerve. DiBenedetto noted that in her labora-
tory she had difficulty obtaining the SFSN
response in 2–3% of healthy appearing individuals.
Due to the relative ease and consistency of obtain-
ing a sensory nerve action potential (SNAP) in
both children and adults, the sural sensory nerve
has been relied upon as the main sensory nerve
Additional supporting information may be found in the online version of
this article.
Abbreviations: ANOVA, analysis of vasriance; SFSN, superficial fibular
sensory nerve; SNAP, sensory nerve action potential
Key words: amplitude; Daube method; distal latency; Izzo method; nerve
conduction study; Spartan method; superficial fibular sensory nerve
Correspondence to: M. Saffarian; e-mail: saffarianmr@gmail.com
C 2017 Wiley Periodicals, Inc.
V
Published online 00 Month 2017 in Wiley Online Library (wileyonlinelibrary.
com). DOI 10.1002/mus.25543
Superficial Fibular NCS
for evaluation of peripheral neuropathies of the
lower extremity.1
Due in part to a lack of details regarding exact
electrode placement in the DiBenedetto study, a
wide range of different techniques have been
described in the literature.1–3 Nearly a decade after
DiBenedetto’s work, Izzo et al described 2 different
techniques based on the 2 main branches of the
SFSN in the lower leg, the medial and intermedi-
ate dorsal cutaneous branches. They used these 2
techniques to study the sural and saphenous senso-
ry nerves. Their data showed the saphenous NCS
to be unreliable (absent in 13% of healthy sub-
jects). The intermediate dorsal cutaneous branch
SNAP was present in 98% of subjects while the
medial dorsal cutaneous branch SNAP mimicked
that of the sural nerve, having a 100% response
rate. However, the Izzo techniques rely upon pal-
pation and visualization for electrode placement,
and the description of the area of stimulation is
vague, allowing for subjectivity and interpretation
errors in an objective study.4
In an attempt to further standardize a technique,
Daube et al. offered a more detailed explanation of
the stimulation site for the SFSN describing it as
“just anterior to the edge of the palpable shaft of
the fibula”.5 Issues remained with their technique,
including an 8.6% absent response rate, likely attrib-
utable to the more proximal location of their stimu-
lation site compared with those documented by Izzo
et al.4 and DiBenedetto.1
In the electrodiagnostic laboratory at Michigan
State University, a modified procedure has been
used that integrates aspects of the previously
described techniques, we are calling the “Spartan
technique.” This technique was developed to
account for the location of the SFSN as it exits the
fascia in the distal leg and by describing the stimu-
lation and recording sites as precisely as possible
in an effort to eliminate subjectivity. This Spartan
technique has yet to be validated and compared
with the others in the literature.
In the lower leg, the common fibular nerve
gives rise to the superficial fibular nerve distal to
the head of the fibula as it passes between the fibu-
laris longus muscle and the fibula itself.6 The
MUSCLE & NERVE Month 2017 1
nerve continues to travel distally between the fibu-
laris muscles to provide motor innervation to both
the fibularis longus and brevis muscles. In the low-
er third of the leg, the nerve becomes superficial.4
Previous studies have localized the nerve piercing
the fascia and becoming superficial 10.5 cm proxi-
mal to the lateral malleolus, but new studies have
shown that it could be anywhere from 7 to 9 cm.7
Once the nerve pierces the fascia, it divides into
the medial dorsal cutaneous and intermediate dor- FIGURE 1. The Spartan technique is demonstrated by placing
sal cutaneous sensory nerves. Both nerves travel the bar electrode on the dorsum of the foot, 4–5 cm distal to the
infra-malleolar line between the first and second metatarsals and
over the extensor retinaculum to provide sensation
stimulating 14 cm proximally to the anterior edge of the fibula.
to the dorsum foot.
The medial dorsal cutaneous branch travels just
lateral to the extensor hallucis longus tendon to and lateral malleolus along the inframalleolar line.
An Xlteck NeuroMaxV EMG System was used for
R
provide sensation to the dorsomedial aspect of the
foot and the medial aspect of the first 3 toes. The all studies with the following settings: low frequen-
intermediate cutaneous sensory branch provides cy filter of 30 HZ, high-frequency filter of 2,000 HZ,
sensation to the anterolateral aspect of the ankle, pulse duration of 0.2 ms, sweep speed of 1 ms/
just medial to the lateral malleolus, the lateral dor- division, and gain of 20 mV. The ground electrode
sum of the foot, and the lateral sides of the last 3 was placed on the anterior leg between the bar
toes.4 electrode and the stimulation site. Variables ob-
In this report, we introduce a new NCS tech- tained included distal latency (ms), amplitude
nique developed at Michigan State University (mV), and amount of stimulation current (mA)
called the Spartan technique and present compara- required to obtain a waveform. The studies were
tive data regarding the presence or absence of a carried out by 4 different electrodiagnosticians.
SNAP, distal latency, amplitude, and stimulation
strength required for 4 different NCS techniques Techniques. With the Spartan technique (Fig. 1), a
for the SFSN. line is drawn to connect the most distal portion of
the lateral malleolus to the most distal portion of
MATERIALS AND METHODS the medial malleolus (inframalleolar line). A bar
After obtaining IRB approval from Michigan State electrode was placed in the spaces between the first
University, 4 different antidromic NCS techniques, and second metatarsals 4–5 cm distal to that line.
the Spartan technique, the Izzo techniques (medial This is in the distribution of the medial dorsal cuta-
and intermediate dorsal cutaneous branches), and neous branch. The recording active electrode was
the Daube technique, were performed on 114 proximal. The stimulator was placed 14 cm proxi-
healthy volunteers. Informed consent was obtained mally and laterally along the anterior border of the
from all participants. Subjects were recruited from fibula with the stimulating cathode distal.
the local community and included hospital employ-
ees, university students, and patients in maintenance Izzo Techniques. Medial Dorsal Cutaneous Branch. The
therapy programs, among others, in an attempt to medial branch passes over the anterior ankle to
follow the recent American Association of Neuromus- the dorsum of the foot, lateral to the tendon of
cular and Electrodiagnostic Medicine Normative the extensor hallucis longus (Fig. 2).4
Data Taskforce Guidelines. Participants either had 1
or 2 legs tested, based primarily on subject prefer-
ence and time constraints.
Participants were excluded from the study if
they had a history of a neuropathy, diabetes melli-
tus, or symptoms of weakness or numbness in the
lower extremities. NCS were performed with the
subject in the supine position. A bar electrode was
placed on the foot or at the ankle, depending on
the technique being studied, with stimulation
14 cm proximal to the active electrode over the FIGURE 2. The Izzo Medial technique is demonstrated by plac-
ing a bar electrode over the medial cutaneous branch of the
SFSN. Temperature was maintained > 328C in all SFSN, just lateral to the extensor hallucis longus tendon and
subjects. The temperature measurement was stimulating 14 cm from the proximal recording electrode on the
obtained at the halfway point between the medial anterolateral aspect of the leg.

2 Superficial Fibular NCS MUSCLE & NERVE Month 2017


FIGURE 3. The Izzo Intermediate technique is demonstrated by
placing a bar electrode over the intermediate branch of the
SFSN, 1–2 cm medial to the lateral malleolus and stimulating
14 cm from the proximal recording electrode on the anterolateral
aspect of the leg.
FIGURE 4. The Daube technique is demonstrated by placing a
bar electrode over the proximal portion of the SFSN, 3 cm proxi-
mal to the bimalleolar line between the tibia and fibula and stim-
ulating 14 cm proximal to the anterior fibula.
Intermediate Dorsal Cutaneous Branch. The inter-
mediate branch is 1–2 cm medial to the lateral mal-
leolus (Fig. 3).
In both Izzo techniques, a recording bar elec-
trode is placed over the nerve with the active elec-
trode proximal at the level of the ankle. The site
for stimulation is 14 cm from the proximal record-
ing electrode on the anterolateral aspect of the leg
with the anode proximal.4
Daube Technique. A recording bar electrode is
placed 3 cm proximal to a point on the bimalleolar
line, midway between the edge of the tibia and the
tip of the lateral malleolus and overlying the inter-
mediate dorsal cutaneous branch, with the refer-
ence electrode 3 cm distal on the dorsum of the
ankle (Fig. 4). The site of stimulation is 14 cm proxi-
mal to the active recording electrode, just anterior
to the palpable edge of the shaft of the fibula.5
Table 1. ANOVA analysis.*
Spartan Izzo Medial
Latency (ms) 3.9 6 0.3 (3.2-5.0) 3.7 6 0.4 (3.1-5.3)
Amplitude (mV) 8.7 6 4.2 (1.7-21.0) 11.3 6 5.9 (1.2-30.8)
Stimulation (mA) 18.4 6 9.1 (5.0-58.0) 21.5 6 9.5 (8.1-57.4)
*Ranges in parentheses.
Superficial Fibular NCS
Statistical Analysis. A total of 6 volunteers (9 legs)
were excluded from the numerical calculations
due to inability to obtain SNAPS with all of the
techniques. These were counted as absent. A total
of 108 subjects with 164 legs were included in the
final statistical analysis. Data were collected and
maintained in an Excel spreadsheet. Analysis of
the data was performed using IBM SPSS Statistics,
Version 21. Because data were not collected on
both legs of all subjects, and 3 variables were com-
pared across the 4 techniques, we determined that
the optimal statistical analyses should be per-
formed with a linear mixed-effects model.
Because most nerve conduction data do not fol-
low a Gaussian distribution, a percentile cutoff was
used as a second set of statistical analysis. The per-
centile cutoff was set at 2.5%. The data were ana-
lyzed with both absent values included (114
subjects and 173 total legs) and with absent values
excluded (108 subjects and 164 total legs).
RESULTS
A total of 164 legs in 108 subjects were included
in the final analysis of variance (ANOVA) statistical
analysis, mean age of 38 years (613.7 years; 20–70
years). The average 6 1 standard deviation of the
distal latency, amplitude, and amount of stimulation
required to obtain a response are listed in Table 1.
A SNAP in at least 1 technique was obtained in
100% of subjects. All 4 techniques produced a mea-
surable SNAP in 95% of subjects tested.
The mean distal latency of the Spartan tech-
nique was longest (3.9 6 0.3 ms) compared with
the other techniques, while the Daube technique
was the shortest (3.6 6 0.7 ms). The Spartan tech-
nique was significantly slower (P < 0.0001) when
compared with the other 3 techniques (Supple-
mentary Table S1, which is available online). The
Izzo Medial technique distal latency was also signif-
icantly longer (P 5 0.007) when compared with the
Daube technique. There was no statistically signifi-
cant difference between the Izzo Medial and Izzo
Intermediate techniques or between the Daube
and Izzo Intermediate techniques.
The Daube technique produced the highest
mean amplitude (15.2 6 8.2 lV), and the Spartan
technique produced the smallest (8.7 6 4.2 lV).
The amplitude of the Spartan technique was signif-
icantly smaller (P < 0.0001) compared with the
Izzo Intermediate Daube
3.7 6 0.3 (3.0-4.7) 3.6 6 0.7 (2.8-5.5)
11.8 6 7.6 (1.0-40.0) 15.2 6 8.2 (1.3-37.3)
21.7 6 10.7 (5.0-54.4) 27.3 6 13.2 (9-80.0)
MUSCLE & NERVE Month 2017 3
 Table 2. Absent SNAPs.*
Subject 1 Subject 2 Subject 3 Subject 4 Subject 5 Subject 6
Age 26 89 66 79 47 56
# Legs studied 2 1 1 1 2 2
Spartan Present Present Absent Present Absent (1/2) Present
Izzo Medial Present Absent Present Absent Absent (2/2) Absent (1/2)
Izzo Intermediate Present Present Present Absent Absent (2/2) Absent (1/2)
Daube Absent (1/2) Present Present Absent Absent (2/2) Absent (1/2)

*Parentheses indicate number of absent SNAPs in subjects in which both legs were studied.

other 3 techniques (Supplementary Table S2). The
Daube technique SNAP amplitude was significantly
larger (P < 0.0001) than the other 3 techniques.
There was no statistically significant difference
between the amplitudes of the Izzo Medial and
Izzo Intermediate techniques.
The amount of stimulation required to obtain a
maximal response was lowest for the Spartan tech-
nique (18.4 6 9.1 mA), and the Daube technique
required the highest stimulation (27.3 6 13.2 mA).
The Spartan technique required significantly lower
stimulation current (P < 0.0001) compared with the
other 3 techniques (Supplementary Table S3). The
Daube technique required a significantly stronger
stimulation (P < 0.0001) when compared with the
other 3 techniques. The Izzo Medial and Izzo Inter-
mediate techniques required a lower stimulation
current to obtain a SNAP and were not statistically
different from each other.
A summary of the absent SNAPs is shown in
Table 2. At least 1 absent SNAP was seen in 6 sub-
jects (9 legs). Among the absent responses, the
Spartan technique was absent only twice (1.2%),
while the Izzo Medial technique was absent more
than the others (2.9%). The Izzo Intermediate and
Daube technique had the same rate of absent
SNAPs (2.3%).
Tables 3 and 4 show the percentile cutoff distri-
bution of the data. When absent values are included
in the data analysis, they are considered “normal”
for the Izzo Medial technique for latency, ampli-
tude, and stimulation current. Additionally, with
absent values included the high end of normal does
not change, except for the latency of the Izzo Medial
Technique. With absent SNAPs excluded, the low
end of normal is higher for all techniques in latency,
amplitude, and stimulation current.
DISCUSSION
Numbness on the dorsum of the foot is a com-
mon presenting symptom in the electrodiagnostic
lab. The most common etiologies include: L5 radic-
ulopathy, fibular neuropathy, and generalized
peripheral polyneuropathy. When testing this nerve,
an absent or very small SNAP is highly suggestive of
a diffuse neuropathy or focal entrapment of the fib-
ular nerve. If the SFSN SNAP is absent in otherwise
normal subjects, the ability to diagnose disease is
limited. Previous studies have documented difficulty
in obtaining a response, with an absent potential in
3–8% of normal healthy individuals.1,5 Document-
ing that this SNAP is present in all, or nearly all,
healthy patients will allow physicians to diagnose
nerve injury when the SFSN SNAP is absent. The
goals of this study were to: (1) introduce the Spartan
technique developed at Michigan State University as
a modification of the DiBenedetto technique, and
(2) compare the 4 main techniques used for investi-
gating the SFSN by documenting the presence or
absence of a SNAP and analyzing the distal latency,
amplitude, and amount of stimulation necessary to
obtain a response.
In all the subjects enrolled in the study, a
response on at least 1 technique was obtained in
every subject. All four techniques produced a
SNAP in 95% of subjects, thus demonstrating 4 dif-
ferent reliable methods of a SFSN SNAP.
The exact reason behind absent responses in
normal subjects is unknown. As previously stated,
previous studies have shown an absent response

Table 3. Percentile ranks with absent values included.* Table 4. Percentile ranks with absent values excluded
Izzo- Izzo- Izzo- Izzo-
Spartan Medial Intermediate Daube Spartan Medial Intermediate Daube
Latency (ms) 3.2-5.0 Absent-5.3 3.0-4.8 2.8-5.5 Latency (ms) 3.3-5.0 3.1-5.3 3.2-4.7 2.9-5.5
Amplitude (mV) 1.7-21.0 Absent-30.8 1.0-40.0 1.3-37.3 Amplitude (mV) 2.3-21.0 2.2-30.8 2.5-40.0 3.0-37.3
Stimulation (mA) 5.5-58.0 Absent-57.4 5.0-54.4 9-80.0 Stimulation (mA) 6.6-58.0 10-57.4 9.0-54.4 10.2-80.0
*Ranges indicated. Ranges indicated

4 Superficial Fibular NCS MUSCLE & NERVE Month 2017

rate of 3–8% in normal subjects. A possibility is
anatomical variation in normal subjects. Operator
error may account for the fact that some responses
were seen with the use of one technique but were
absent with another technique performed on the
same individual. Finally, undiagnosed peripheral
neuropathy may contribute to the absent SNAPs
seen in our study.
Although there were statistically significant dif-
ferences between distal latencies, amplitudes, and
stimulation current required to obtain some
results, there seems to be no clinically significant
difference between the techniques. The distal
latency tended to be the longest and the ampli-
tude the smallest with the Spartan technique. The
opposite was true for the Daube technique, which
had the shortest latency and the largest amplitude.
The Spartan SNAP was obtained at a more distal
location in the foot compared with the other tech-
niques. As the SFSN travels distally and branches
into the foot, the diameter of the nerve decreases.
This likely influences the distal latency and SNAP
amplitude. This could also help explain the results
of the Daube technique, which were obtained
more proximal than the other techniques.
The Daube technique required a stronger stimu-
lation to obtain a SNAP than the other techniques.
The anatomy of the SFSN could explain this finding
as well. A study performed by Park et al. found that
the SFSN SNAP was optimally obtained on the fibula
7–9 cm proximal to the intermalleolar line.7 A stron-
ger stimulation current may have been necessary to
penetrate the fibularis longus and brevis muscles, as
the SFSN has not yet pierced the fascia at that level.
Superficial Fibular NCS
This could be verified in future studies with the use
of ultrasound.
Some limitations of this study are worth noting.
Four different electrodiagnosticians obtained the
data. To our knowledge, the inter-rater reliability of
the four different techniques has yet to be studied.
Finally, the patient population was a convenience sam-
ple and may not represent the general population.
In conclusion, all 4 of the techniques studied
were reliable methods for obtaining the SFSN
SNAP, which was found in 95% of individuals stud-
ied. Although there were significant statistical differ-
ences, there seems to be minimal clinical difference
between the 4 techniques.
We confirm that we have read the Journal’s posi-
tion on issues involved in ethical publication and
affirm that this report is consistent with those guide-
lines. None of the authors have any conflicts of
interest to disclose. NCS, Nerve conduction study.
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4. Izzo KL, Sridhara CR, Rosenholtz H, Lemont H. Sensory conduction
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MUSCLE & NERVE Month 2017 5
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