Image Presentation

High-Resolution Sonography of
Lower Extremity Peripheral Nerves
Anatomic Correlation and Spectrum of Disease

Siegfried Peer, MD, Peter Kovacs, MD,

Christoph Harpf, MD, Gerd Bodner, MD

Objective. The value of sonography for the diagnosis of diseases of the peripheral nervous system is
only little known. This image presentation is intended to raise the awareness of sonographers and clin-
icians of the potential of sonography by giving an anatomic-sonographic correlation of lower extrem-
ity peripheral nerves and an overview of commonly encountered diseases. Methods. On 2 lower
extremity cadaver specimens, peripheral nerves were imaged in typical locations such as the tarsal tun-
nel. During sonography the nerve was injected with blue dye, and thin-slice anatomic sections were
obtained at the scan level with a chain saw. In addition, sonographic images of patients with typical
diseases are shown. Results. An excellent anatomic-sonographic correlation was obtained, which
underlines the feasibility of sonography for imaging of lower extremity peripheral nerves. Reliable
results may be obtained with sonography of typical disease processes of lower extremity peripheral
nerves. Conclusions. Recent developments in sonographic technology such as the introduction of
high-frequency linear array transducers, compound imaging, and extended field-of-view imaging
strongly improve the applicability of transcutaneous sonography for the examination of peripheral
nerve disease. Key words: sonography; anatomy; peripheral nerve.

D
Received September 18, 2001, from the
Departments of Radiology (S.P., G.B.) and Plastic
and Reconstructive Surgery (C.H.) and the Ludwig
Boltzmann Institute of Quality Control in Plastic
Surgery (C.H.), University Hospital, and Department
of Anatomy, Leopold Franzens University (P.K.),
Innsbruck, Austria. Revision requested October 16,
2001. Revised manuscript accepted for publication
November 15, 2001.
Address correspondence and reprint requests to
Siegfried Peer, MD, Department of Radiology,
University Hospital, Anichstrasse 35, A-6020
Innsbruck, Austria.
espite early promising reports on the value of
sonography for imaging of nerve conditions
such as nerve entrapment syndromes,1 to our
knowledge there is no widespread use of nerve
sonography in routine clinical practice. This is mainly
because of limitations of equipment and lack of exper-
tise. With the introduction of high-frequency linear array
transducers with a range of 5–12 to 5–15 MHz and high
near-field resolution as well as extended field imaging,
direct evaluation of peripheral nerves with sonography
has now become more feasible. One notable drawback
still is operator ability: the quality of sonographic exami-
nations relies heavily on the familiarity of the examiner
with the local anatomy and the typical appearance of
normal structures and pathologic conditions. Recent
articles have addressed the value of sonography for imag-
ing of peripheral nerves and nerve tumors,2–4 but many
radiologists and clinicians are still unaware of the poten-

© 2002 by the American Institute of Ultrasound in Medicine • J Ultrasound Med 21:315–322, 2002 • 0278-4297/02/$3.50
High-Resolution Sonography of Lower Extremity Peripheral Nerves
tial application of sonography for assessment of
different nerve diseases, especially in the lower
extremity. This image presentation is therefore
intended to provide information about the
anatomic-sonographic correlation of lower
extremity peripheral nerves and to give an
overview of commonly encountered diseases.
Anatomic-Sonographic Correlation
The general echo structure of a peripheral nerve
on longitudinal sonograms consists of multiple
parallel hypoechoic linear areas separated by
hyperechoic bands (Fig. 1). With histologic corre-
lation, the latter was shown to represent the
interfascicular epineurium, whereas the hypo-
echoic elements correspond to the nerve fasci-
cles.5 The number and size of individual fascicles
visualized with high-resolution sonography
depend on the frequency of the applied trans-
ducer as well as the type of nerve studied.
In the following paragraph, the anatomic corre-
lation of high-resolution sonography of lower
extremity nerves is given in 4 locations (Fig. 2),
which correspond to the regions where lower
extremity nerve diseases typically occur. A pre-
served right leg cadaver specimen was used for
acquisition of sonograms on an HDI 5000 system
(Philips Ultrasound, Bothell, WA) with a 5- to 12-
MHz linear array transducer. After sonographic
identification of a nerve, blue dye was injected
into the adjacent soft tissue under sonographic
guidance to guarantee the representative loca-
tions for anatomic dissections. The latter were
acquired with a fine-needle-tooth band saw.
Figure 3A shows a transverse cut through the
distal thigh 10 cm above knee level. The sciatic
nerve, which traverses at the rear of the upper
leg, gives a typical example for the appearance
of a peripheral nerve on transverse sonograms,
with small hypoechoic dots (nerve fascicles)
within a dense network of hyperechoic ele-
ments (epineurium).
Figure 3B was acquired at the level of the
popliteal fossa and shows the common peroneal
and tibial nerves, which may easily be assessed
on sonographic examinations of the knee. The
common peroneal and tibial nerves give an
example of the variability in the sonographic
appearance of peripheral nerves, with the tibial
nerve showing the typical echo structure (hypo-
echoic fascicles and hyperechoic epineurium)
and the common peroneal nerve consisting of
316
fewer and thicker fascicles with less echogenic
stroma. This appearance was previously reported
by Silvestri et al,5 who stated that this distinct
appearance may most probably be caused by a
different number of fascicles within a nerve.
Figure 3C was acquired at a level just distal to
that shown in Figure 3B, where the common
peroneal nerve splits into 2 branches. Although
the superficial peroneal nerve is easily assessed
with sonography, the deep-lying and smaller
deep peroneal nerve is hardly visualized.
Figure 3D was acquired just above the ankle,
representing the medial structures at the level of
the tarsal tunnel. When comparing the sono-
graphic appearance of the superficial peroneal
nerve in Figure 3C and the distal portion of the
tibial nerve in Figure 3D, we must note that both
nerves share the same morphologic character-
istics as their parent nerves at knee level on
sonography.
Spectrum of Diseases
In this section, typical cases of nerve diseases in
the lower extremity are discussed. All cases in this
series had electrodiagnostic findings suggesting
nerve diseases, and the sonographic diagnoses
were confirmed by surgery.
Edematous (“Swollen”) Nerve
The occurrence of nerve edema is not a disease
entity on its own but a quite common nonspe-
cific reaction of a nerve to various exogenous
stimuli. The underlying pathophysiologic
process for nerve swelling consists of dis-
turbed vascularization with vasocongestion,6
which may be of a traumatic or nontraumatic
nature. Possible causes include long-lasting
direct compression of a nerve by a plaster cast,
metallic implant, or hematoma; stretching of a
nerve due to joint dislocation or during opera-
tions; encasement within osteofibrous tun-
nels; thermal injuries; infection; and blunt
trauma. In many cases a nerve with a uniform
hypoechoic appearance and thickened fasci-
cles or a sudden change in echo texture at the
level of injury is the only apparent sonograph-
ic finding (Fig. 4). In these cases, knowledge
about the normal echo structure of an exam-
ined nerve is crucial, but because interindividual
variations may result in misleading findings, a
comparison with the contralateral normal side
is highly recommended.
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 Peer et al

A B
Figure 1. Images from a 38-year-old healthy volunteer. A, Longitudinal sonogram showing the typical echo structure of a normal peripheral nerve (sci-
atic nerve), with hypoechoic fascicles (thin arrow) and a surrounding hyperechoic epineurium (thick arrow). B, Transverse sonogram showing the dotted
appearance of nerve fascicles within dense stroma.

Compressive Lesions Figure 2. Schematic drawing of lower leg nerve anatomy with
In these lesions, direct compression of a nerve location of sonograms and corresponding gross anatomic dis-
by surrounding tissue exists, which may be sections.
caused by normal anatomic structures such as
in nerve entrapment syndromes (“tarsal tun-
nel syndrome”), vascular malformations, gan-
glia, or tumors. Ganglia may occur in any
location adjacent to joints or tendon sheaths;
common locations with nerve compression
are the proximal tibiofibular joint, with com-
pression of the superficial peroneal nerve, and
the ankle region, with peroneal or tibialis
nerve compression (Fig. 5).
In addition to the more commonly known
tarsal tunnel syndrome, a compression syn-
drome of the common peroneal nerve can
often be seen at the level of the fibular head.
Although a true osteofibrous tunnel does not
exist in this location, the nerve lies in a tight
space between the fibular head and the fascia
just under the skin. Any reason for a change in
the normal alignment of the nerve with the
bone, such as malaligned fibular fractures,
may therefore result in a kind of entrapment
syndrome. Even prolonged sitting with
crossed legs has been reported to cause pero-
neal nerve compression.7
Direct compression of a nerve may also be
caused by posttraumatic hematoma or callus
formation as well as postoperative scars (Fig. 6).

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High-Resolution Sonography of Lower Extremity Peripheral Nerves

C
Figure 3. Sonographic-anatomic correlations. A, Transverse sonogram and anatomic dissection at the level of the distal femur. The sonogram shows
the typical fibrillar echo structure of the sciatic nerve, with hypoechoic fascicles and dense endoneurial stroma. B, Transverse sonogram and anatomic
dissection through a popliteal fossa at the level of the fibular head. Note the different echo texture of the on peroneal nerve (CPN) and tibialis nerve
(TN). C, Transverse sonogram and anatomic dissection at the proximal lower leg just below the fibular head. The superficial peroneal nerve (SPN) is seen
traversing between the extensor hallucis longus (EHLM) and the peroneal muscle (PM). Note again the rather homogeneous hypoechoic fibrillar echo
texture of the peroneal nerve, with only sparse stroma. (continued)

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 Peer et al

Figure 3. (continued) D, Transverse sonogram and anatomic dissection at the medial side of the ankle, the tarsal tunnel. The deep-lying tibialis nerve
is show between the flexor hallucis longus muscle (FHLM) and the vascular bundle (PTA/V). Compared with the superficial peroneal nerve in C, more
hyperechoic elements with a distinct fascicular echo structure are shown. AT indicates Achilles tendon; BM, biceps muscle; EDLM, extensor digitorum
longus muscle; F, femur; FDLM, flexor digitorum longus muscle; Fi, fibula; FiA/V, fibular artery/vein; FiH, fibular head; GLM, gastrocnemius lateralis mus-
cle; GM, gracilis muscle; GMM, gastrocnemius medialis muscle; PA/V, popliteal artery/vein; PPM, popliteus muscle; PTA/V, posterior tibial artery/vein; SFA,
superficial femoral artery; SFV, superficial femoral vein; SMM, semimembranous muscle; SN, sciatic nerve; SoM, soleus muscle; StM, sartorius muscle;
STM, semitendinosus muscle; T, tibia; and VIM, vastus intermedius muscle.

Figure 5. Longitudinal sonogram from a 59-year-old man with a palpa-

Figure 4. Longitudinal sonogram from a 62-year-old woman with
chronic polyarthritis and left total hip and knee replacement. The
patient had a worsening sensorimotor deficit in the left leg after knee
replacement. Electrophysiologic tests revealed evidence of a sciatic
nerve lesion above knee level. Thickened nerve fascicles of the sciatic
nerve are shown (thin arrows; compare with the sciatic nerve of the
healthy volunteer in Figure 1).
ble mass above the medial malleolus and dysesthesia in the forefoot. An
ovoid, lobulated hypoechoic mass is shown, with a smooth surface and
subtle internal echoes (thick arrow) compressing the distal portion of the
tibial nerve (short thin arrows). At the upper pole of the mass, the nerve
fascicles are slightly thickened because of compression edema (long thin
arrow). On surgical exploration, a ganglion cyst with compression of the
tibial nerve was confirmed.

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High-Resolution Sonography of Lower Extremity Peripheral Nerves
Figure 6. Longitudinal sonogram from a 24-year-old man after ankle fracture and
surgical refixation of the fractured medial malleolus. He had hypesthesia of the
forefoot and denervation of the abductor hallucis muscle. The distal portion of the
tibialis nerve (thin arrows) compressed by hypertrophic scar tissue (thick arrow) is
shown. The nerve fascicles are markedly swollen with an enlarged nerve diameter.
Again, the apparent finding on sonography of the
nerve itself is mainly edematous swelling of nerve
fascicles. In these cases, however, evaluation of
the underlying pathologic condition is equally
important to evaluation of the nerve itself: a
detailed description of the extent of scars encas-
ing a nerve, for example, is important information
for the planning of surgical interventions.
Figure 7. Images from a 74-year-old man with a long history of a palpable mass on the left lower leg. A, Longitudinal sonogram showing a globoid-
shaped hypoechoic but slightly inhomogeneous mass in continuation of a small subcutaneous nerve structure (superficial peroneal nerve). Note the
nerve entering the mass from the right side and running along the outer diameter of the mass (arrows). B, Longitudinal Doppler sonogram showing
hypervascularity of the mass.
A B
320
Nerve Tumors
The most commonly encountered benign
tumors of peripheral nerves are neurofibromas
and schwannomas, whereas other benign histo-
logic types and malignant peripheral nerve
sheath tumors are rare entities. A reliable sono-
graphic diagnosis of a nerve tumor can only be
made when continuity between a mass and a
nerve can be established.8 This may often be dif-
ficult even with a careful scanning technique,
because the nerve itself may be distorted or com-
pressed by the mass. Once this relationship has
been established, however, distinct features
allow for reliable sonographic differentiation
between schwannomas and neurofibromas.
Because schwannomas derive from cells repre-
senting the supporting tissue of a nerve, they typ-
ically appear as ovoid masses arising from the
surface of a nerve separated from the un-
impaired nerve fascicles (Fig. 7). The nerve itself
may be stretched over the capsule of the mass. In
neurofibromas, tumor cells spread within the
nerve fascicles, giving the nerve a spindle-
shaped appearance. The fascicular pattern typi-
cally disappears at the site of the lesion.
Neuromas are masslike nerve lesions not rep-
resenting true tumors but reactive local thicken-
ing of a nerve due to various extrinsic causes,
such as severe traction injuries (Fig. 8) or com-
plete dissection of a nerve. In these lesions,
some or all nerve fascicles are severed, with loss
of continuity. If nerve continuation is not
reestablished by surgery, or only some of the
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 Peer et al

Figure 8. Longitudinal sonogram from a 73-year-old woman after hip
surgery who had hypesthesia and electrophysiologic evidence of a lesion
of the sciatic nerve (tibialis portion). A small, spindle-shaped mass (thin
arrow) is shown within the sciatic nerve (thick arrows), consistent with a
small traction neuroma.
Figure 9. Longitudinal sonogram from a 76-year-old man who under-
went amputation of the lower leg because of severe arteriosclerotic dis-
ease and had a tingling sensation as well as pain in the stump. A hypo-
echoic ovoid mass is shown (thick arrow), with proximal continuation and
a small nerve fascicle (thin arrow) entering centrally into the mass, con-
sistent with a stump neuroma.

fascicles are correctly sutured, regenerating

Schwann cells and axons will grow randomly,
thus producing a local overgrowth of nerve ele-
ments with formation of a hypoechoic ovoid
mass. This may lie within a nerve if only some
of the fascicles are involved or at the free end if
a gap exists between the proximal and distal
parts of the nerve. The latter entity is called a
stump neuroma and typically occurs in limb
amputations (Fig. 9). A special subset of neuro- Figure 10. Transverse sonogram from a 58-year-old woman with pain in
mas with distinct pathophysiologic features the forefoot and painful palpation in the second interdigital space. A
exists in the interdigital spaces at the level of the small, ovoid mass is shown at level of the metatarsal head (arrow). The
metatarsals.9 These lesions, known as Morton mass extends superficially from the intermetatarsal space between the
second and third toes; it is 5 mm in diameter, slightly hypoechoic com-
neuromas and typically located at the level of the
pared with surrounding soft tissues, and consistent with a Morton neu-
metatarsal heads in the second or third inter- roma.
space, are caused by repeated chronic micro-
trauma with resulting painful fibrosis of an
interdigital nerve (Fig. 10).

Conclusions

We have presented the anatomic-sonographic

correlation of lower extremity nerves and typi-
cal cases for various nerve pathologic condi-
tions. Such conditions are accessible by
sonography, which constitutes an inexpensive
and noninvasive diagnostic tool.

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High-Resolution Sonography of Lower Extremity Peripheral Nerves

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