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Sonographic Tracking of the Lower Limb Peripheral Nerves

Article in American Journal of Physical Medicine & Rehabilitation · March 2016

DOI: 10.1097/PHM.0000000000000463

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Authors:
Chen-Yu Hung, MD
Ming-Yen Hsiao, MD
Ultrasound
Levent Ö zçakar, MD
Ke-Vin Chang, MD, PhD
Chueh-Hung Wu, MD
Tyng-Guey Wang, MD
Wen-Shiang Chen, MD, PhD
EDUCATION & ADMINISTRATION
Affiliations:
From the Department of Physical
Medicine and Rehabilitation and
Community and Geriatric Research Sonographic Tracking of the Lower
Center, Bei-Hu Branch, Taipei, Taiwan
(C-YH, K-VC); Department of Physical
Medicine and Rehabilitation, National
Limb Peripheral Nerves
Taiwan University Hospital, Bei-Hu A Pictorial Essay and Video Demonstration
Branch, Taipei, Taiwan (K-VC);
Department of Physical Medicine and
Rehabilitation, Hacettepe University ABSTRACT
Medical School, Ankara, Turkey (LÖ);
and Department of Physical Medicine Hung C-Y, Hsiao M-Y, Ö zçakar L, Chang K-V, Wu C-H, Wang T-G, Chen W-S:
and Rehabilitation, National Taiwan Sonographic tracking of the lower limb peripheral nerves: a pictorial essay and
University Hospital and National
Taiwan University College of video demonstration. Am J Phys Med Rehabil 2016;00:00Y00.
Medicine, Taipei, Taiwan Compared with the upper limbs, sonographic tracking of peripheral nerves in
(M-YH, C-HW, T-GW, W-SC).
the lower limbs is more challenging. The overlying muscles are larger, hindering
Correspondence: visualization of the deeply embedded nerves by using a linear transducer. The
All correspondence and requests for use of a curvilinear transducerVproviding an extended view with better penetra-
reprints should be addressed to: tion for the field of interestVmay be useful for scanning the nerves in the hip
Ke-Vin Chang, MD, PhD, Department
of Physical Medicine and Rehabilitation and thigh. Application of the Doppler mode helps localization of the target nerve
and Community and Geriatric Research by identifying the accompanying vessels. Aiming to demonstrate the relevant
Center, National Taiwan University tracking techniques, the present article comprises a series of ultrasound images
Hospital, Bei-Hu Branch and National
Taiwan University College of Medicine, and videos showing how to scan the nerves in the lower limb, that is, femoral,
Taipei, Taiwan. obturator, pudendal, lateral femoral cutaneous, sciatic, saphenous, sural, tibial, and
peroneal nerves.
Disclosures:
Financial disclosure statements have Key Words: Ultrasound, Nerve, Lower Extremity, Rehabilitation
been obtained, and no conflicts of
interest have been reported by the
authors or by any individuals in control
of the content of this article. U ltrasound (US) is a useful tool to evaluate musculoskeletal pathologies and
to guide relevant interventions. The advent of high-resolution transducers en-
Editor’s Note: ables direct tracking of peripheral nerves, although the investigator must have
Supplemental digital content is solid background knowledge of regional anatomy and innervation topography.
available for this article. Direct URL
citations appear in the printed text and Localization of peripheral nerves requires familiarization with the accompany-
are provided in the HTML and PDF ing arteries and veins, static and dynamic views of surrounding muscles, and
versions of this article on the journal_s recognition of osseous tunnels and prominences. During its use for muscle in-
Web site (www.ajpmr.com).
jections and nerve blocks, proficient US tracking skills can also avoid neuro-
vascular damage and provide better targeting for difficultly identified nerves with
0894-9115/16/0000-0000 electrodiagnostic studies. Similar to the authors_ previous article for the upper
American Journal of Physical limb,1 in this article, serial photos of probe placement, US images, and videos
Medicine & Rehabilitation with regard to the scanning of lower limb nerves will be demonstrated. All
Copyright * 2016 Wolters Kluwer
the images described in this article were obtained by a US scanner (HIVISION
Health, Inc. All rights reserved.
Ascendus; Hitachi, Tokyo, Japan), which was equipped with a high-frequency linear
DOI: 10.1097/PHM.0000000000000463 transducer (5Y18 MHz) and a low-frequency curvilinear transducer (3Y6 MHz).
For structures with large muscle bulk, such as the hip and thigh, a curvilinear
transducer is used for its better ability in delineating deep structures and provid-
ing a broader field of view.2

www.ajpmr.com US of Peripheral Nerves 1

Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 FEMORAL NERVE
Anatomy
The femoral nerve (VIDEO 1; http://links.lww.
com/PHM/A199) arises from the ventral rami of the
second, third, and fourth lumbar roots; descends
underneath the psoas major muscle; and emerges
from it at its lower lateral border. It then passes
beneath the inguinal ligament and divides into the
anterior and posterior branches. The anterior branch
provides motor control of the pectineus and sar-
torius muscles and also gives off the intermediate
and medial cutaneous nerves, which provide sensa-
tion over the anterior and medial thigh. The poste-
rior branch splits into the muscular division to
supply the quadriceps muscles and the articular
division to innervate the knee joint. The saphenous
nerve also derives from the posterior branch of the
femoral nerve.3,4
Technique
The transducer is placed on the inguinal crease
in the transverse plane, where the ilioposas and
pectineus muscles can be clearly recognized. To-
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
distally, the nerve can be visualized to give off the
saphenous nerve, nerves to the anterior compartment
of the thigh, and the anterior cutaneous branches.
OBTURATOR NERVE
Anatomy
The obturator nerve (VIDEO 2; http://links.lww.
com/PHM/A200) arises from the ventral rami of the
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.
Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
second, third, and fourth lumbar roots. It descends
through the psoas major muscle and exits medially
near the pelvic brim. It then courses behind the
common iliac artery and along the lateral wall of the
lesser pelvis and enters the obturator foramen. After
leaving the foramen, it divides into anterior and
posterior branches, which innervate the adductor
longus, adductor brevis, adductor magnus, obtu-
rator externus, and gracilis muscles. It also gives
sensory branches to the medial thigh.4
Technique
After identifying the inguinal crease, the trans-
ducer is placed in an oblique direction perpendicu-
lar to the inguinal ligament. The pectineus muscle,
originating from the superior pubic ramus and in-
serting into the femur, is seen medial and deep to
the femoral vessels. From superficial to deep, the
adductor longus, brevis, and magnus muscles reside
medial to the pectineus. The anterior branch of the
obturator nerve runs in the fascial cleft between
the adductor longus and brevis muscles, whereas the
posterior branch lies between the adductor brevis
and magnus muscles (Fig. 2).
PUDENDAL NERVE
Anatomy
The pudendal nerve (VIDEO 3; http://links.lww.
com/PHM/A201) arises from the second, third, and
fourth sacral roots. It runs below the piriformis
muscle, passes between the sacrotuberous and
sacrospinous ligaments at the ischial spine, and
enters the pudendal (Alcock) canal, which is formed
by the obturator internus muscle and the obtura-
tor fascia. Inside the pudendal canal, it divides into
Am. J. Phys. Med. Rehabil. & Vol. 00, No. 00, Month 2016
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
perineal nerve, and the dorsal nerve of the penis/
clitoris. It supplies sensation over the external gen-
italia, anus, and perineum and innervates the pel-
vic muscles, including the external urethral and anal
sphincters.5
Technique
The probe is placed on the gluteal fold in the
transverse plane, where the ischial tuberosity, with
its bony surface tilting outward, is seen. Moving the
transducer cranially, the ischial spine can be visu-
alized as a flat bony plane. Medial to it, a pulsating
vessel (the pudendal artery) can be seen. The artery
is interposed between the two hyperechoic lines,
the sacrotuberous ligament superficially, and the
sacrospinous ligament deeply. The pudendal nerve
is situated medial to the pudendal artery inside the
interligamentous zone (Fig. 3).
LATERAL FEMORAL
CUTANEOUS NERVE
Anatomy
The lateral femoral cutaneous nerve (VIDEO 4;
http://links.lww.com/PHM/A202) is a pure sensory
nerve originating from the second and third lumbar
nerves. It arises from the lateral edge of the psoas
muscle, crosses the iliacus muscle, usually passes
under the inguinal ligament, and exits the pelvis me-
dial and inferior to the anterior superior iliac spine.
It divides into the anterior and posterior branches.
The anterior branch innervates the skin of the ante-
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.

www.ajpmr.com US of Peripheral Nerves 3

Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 an anastomosis with the saphenous nerve form-
ing the peripatellar plexus. The posterior branch
courses through the fascia lata and then provides
the sensory innervation starting from the level of
the greater trochanter down to the middle of the
thigh.6
Technique
The transducer is placed in the transverse plane
medial to the anterior superior iliac spine. When the
transducer is moved downward, the sartorius and
tensor fascia lata muscles are seen at the medial and
lateral aspects, respectively. The lateral femoral cu-
taneous nerve is visualized between the abovemen-
tioned muscles and inside the space formed by
the fascia iliaca deeply and fascia lata superficially
(Fig. 4A). Tracking the nerve distally, the sonogra-
pher can visualize it dividing into several branches
to innervate the thigh (Fig. 4B).
SCIATIC NERVE
Anatomy
The sciatic nerve (VIDEOS 5 [http://links.lww.
com/PHM/A203] and 6 [http://links.lww.com/PHM/
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
magnus muscle, until it reaches the popliteal fossa,
where it divides into tibial and common peroneal
nerves.4
Technique
The transducer is placed between the ischial
tuberosity and greater trochanter in the transverse
plane. The sciatic nerve is situated lateral to the
ischial tuberosity overlying the quadratus femoris,
a quadrilateral muscle connecting the ischial tu-
berosity and the intertrochanteric crest of the
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).

www.ajpmr.com US of Peripheral Nerves 5

Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 SAPHENOUS NERVE
Anatomy
The saphenous nerve (VIDEOS 7 [http://links.
lww.com/PHM/A205] and 8 [http://links.lww.com/
PHM/A206]) departs from the femoral nerve as its
largest cutaneous branch a few centimeters distal to
the inguinal ligament. It then descends with the
femoral artery and vein and enters the adductor
canal, which is bordered by the sartorius muscle
anteriorly, adductor longus and magnus muscles
posteromedially, and vastus medialis muscle laterally.
At the distal end of the canal, it accompanies the
genicular artery and gives off the infrapatellar
branch to supply the medial knee joint and the
patellar tendon. The remaining part becomes the
sartorial branch, which exits the adductor canal be-
tween the sartorius and gracilis muscles. Thereafter,
it travels with the great saphenous vein and provides
cutaneous sensation to the medial aspect of the leg
and foot.7,8
Technique
The transducer is placed in the medial aspect of
the midthigh in the transverse plane. The saphe-
nous nerve is situated in the space between the
vastus medialis (laterally) and sartorius (medially)
muscles, whereby it is accompanied by the femoral
artery (Fig. 6A). The nerve gradually shifts to the post-
eromedial aspect of the distal thigh and emerges
from the fascia lata between the tendons of sarto-
rius and gracilis muscles, becoming a subcutaneous
nerve. Below the knee, it runs along the tibia with the
great saphenous vein (Fig. 6B).
SURAL NERVE
Anatomy
Lateral and medial sural cutaneous nerves
(VIDEO 9; http://links.lww.com/PHM/A207), the
collateral branches of the common peroneal and
tibial nerves, respectively, combine to form the sural
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
courses with the small saphenous vein, down to the
posterolateral aspect of the leg and onto the dorsal
lateral foot. It provides sensation of the lower lateral
leg and lateral parts of the heel, ankle, and foot.9
Techniques
The transducer is placed behind the lateral
malleolus in the transverse place. The sural nerve is
situated in the subcutaneous layer between pero-
neal muscles and the Achilles tendon, accompanied
by the small saphenous vein (Fig. 7A). Gradually
moving the transducer upward, the nerve will be
seen between the two heads of the gastrocnemius
muscle (Fig. 7B).
TIBIAL NERVE
Anatomy
The tibial nerve (VIDEOS 10 [http://links.lww.
com/PHM/A208] and 11 [http://links.lww.com/PHM/
A209]) arises from the sciatic nerve and contains the
fibers from the fourth and fifth lumbar and the first,
second, and third sacral roots. It courses through the
popliteal fossa and then runs between the soleus and
deep ankle/foot flexor muscles (tibialis posterior,
flexor digitorum longus, and flexor hallucis longus).
It innervates the gastrocnemius, soleus, plantaris,
and deep ankle/foot flexors. It also gives off the me-
dial sural cutaneous nerve. It passes posterior to the
medial malleolus and then gradually bifurcates to
the medial and lateral plantar nerves at the tarsal
tunnel.9
Technique
The transducer is placed behind the medial
malleolus in the transverse plane. The tibial nerve
is situated adjacent to the posterior tibial artery
and posterior to the tibialis posterior and flexor
digitorum longus tendons (Fig. 8A). Moving the
transducer distally enables the visualization of the
tibial nerve as it divides into the medial and lat-
eral plantar nerves (Fig. 8B), penetrating the plane
interposed between the abductor hallucis brevis
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.

www.ajpmr.com US of Peripheral Nerves 7

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
tibial nerve can be seen to course underneath the
soleus muscle and superficial to the deep plantar
flexor muscles (flexor hallucis longus, flexor digi-
torum longus, and tibialis posterior) (Fig. 8C) until
it merges with the common peroneal nerve in the
popliteal fossa (Fig. 8D).
PERONEAL NERVE
Anatomy
The common peroneal nerve branches off from
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-
trocnemius muscle and runs in the subcutaneous
layer behind the fibular head. It then bifurcates
into the superficial and deep peroneal nerves.10 The
superficial peroneal nerve first descends below the
peroneus longus muscle and supplies the peroneus
longus and brevis muscles. The cutaneous branch
of the superficial peroneal nerve then runs between
the peroneus brevis and extensor digitorum longus
muscles.11
The deep peroneal nerve courses inferome-
dially after the bifurcation and runs deep to the
extensor digitorum longus muscle and superficial
to the interosseous membrane, where it inner-
vates the anterior compartment muscles (tibialis
anterior, extensor hallucis longus, and extensor
digitorum longus). Thereafter, it descends with the
anterior tibial artery and gives off a motor branch
to the extensor digitorum brevis muscle and a ter-
minal sensory branch to the interspace between the
first and second toes.9
Technique
Common Peroneal Nerve
The transducer is placed at the proximal pop-
liteal fossa in the transverse plane to visualize the
most distal part of the sciatic nerve, which gives off
the common peroneal nerve laterally and the tibial
nerve medially. The common peroneal nerve (Video 12;
http://links.lww.com/PHM/A210) passes above the

8 Hung et al. Am. J. Phys. Med. Rehabil. & Vol. 00, No. 00, Month 2016

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lateral head of the gastrocnemius muscle and courses
to the lateral aspect of the proximal leg (Fig. 9A and
B). It then crosses the inferior portion of the fibular
head and runs under the proximal end of the
peroneus longus until it divides into the superficial
and deep peroneal nerves (Fig. 9C).
Deep Peroneal Nerve
The transducer is placed at the anterior ankle
joint in the transverse plane. The deep peroneal nerve
(Video 13; http://links.lww.com/PHM/A211) is located
lateral to the extensor hallucis longus tendon
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.

www.ajpmr.com US of Peripheral Nerves 9

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-
rior tibial artery, superficial to the interosseus
membrane, and deep to the tibialis anterior, extensor
digitorum longus, and extensor hallucis longus mus-
cles (Fig. 10B). It merges with the superficial pero-
neal nerve slightly distal to the fibular head.
muscles. It then courses between the fibula and the
peroneus longus muscle when the transducer passes
the proximal end of the peroneus brevis (Supple-
mentary Fig. 1B; http://links.lww.com/PHM/A213).
The nerve can be tracked until it merges with the
deep peroneal nerve slightly distal the fibular head.

Superficial Peroneal Nerve CONCLUSION

The transducer is placed at the anterior su-
perior aspect of the lateral malleolus. The superfi-
cial peroneal nerve (Video 14; http://links.lww.com/
PHM/A212) is bordered by extensor digitorum longus
muscle anteriorly and peroneus brevis muscle poste-
riorly (Supplementary Fig. 1A, http://links.lww.com/
PHM/A213). At this level, only the tendonious part
of peroneus longus is seen. Gradually moving the
transducer proximally, the muscle part of the peroneus
longus starts to appear and the nerve dives into
the zone between the peroneus longus and brevis
Compared with the upper extremities, tracking
the lower limb nerves is more challenging because
some of them are deeply situated and the overlying
bulky muscles further hinder penetration of the
US waves. In this regard, the use of a curvilinear
transducer can be contributory especially for the
nerves of the hip and thigh regions. Application
of Doppler mode leads to recognition of adjacent
vessels and is definitely helpful for localizing su-
perficial sensory nerves, which usually accompany
veins. Combination of short- and long-axis views or

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
nerves_ morphology and gliding as well as their
actual relationship with the nearby structures. Fi-
nally, for the nerves that need to be tracked through
the whole limb, sonographers can navigate either
starting from the proximal or distal sites depending
on their expertise or preference.
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