Ultrasonographic aspects of sural nerve anatomy

Duarte, Márcio Luís; Soares, Ocacir de Souza Reis; Brasseur, Jean-Louis

doi:10.1590/0100-3984.2024.0120

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Pictorial Essay • Radiol Bras 58 • 2025 • https://doi.org/10.1590/0100-3984.2024.0120 linkcopy

Ultrasonographic aspects of sural nerve anatomy

Aspectos ultrassonográficos da anatomia do nervo sural

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

The anatomy of the sural nerve is highly variable, and the nerve can present injuries of various etiologies, including iatrogenic injury during surgery. Precise knowledge of the course and morphology of the sural nerve is valuable, and the ability to assess the nerve properly before surgery increases the postoperative success rate, as well as facilitating the execution of nerve conduction studies and biopsies. The purpose of this article is to describe and illustrate the anatomy of the sural nerve, as seen on ultrasonography, which is a practical and economical imaging method.

Keywords:
Diagnosis; Sural nerve; Ultrasonography; Anatomy.

Authorship

person Márcio Luís Duarte

schoolUniversidade de Ribeirão Preto (Unaerp), Campus Guarujá, Guarujá, SP, BrazilUniversidade de Ribeirão PretoBrazilGuarujá, SP, BrazilUniversidade de Ribeirão Preto (Unaerp), Campus Guarujá, Guarujá, SP, BrazilschoolDiagnósticos da América S.A. (Dasa), Barueri, SP, BrazilDiagnósticos da América S.A.BrazilBarueri, SP, BrazilDiagnósticos da América S.A. (Dasa), Barueri, SP, Brazil

0000-0002-7874-9332

person Ocacir de Souza Reis Soares

schoolClínica Radiológica Ocacir Soares, Presidente Prudente, SP, BrazilClínica Radiológica Ocacir SoaresBrazilPresidente Prudente, SP, BrazilClínica Radiológica Ocacir Soares, Presidente Prudente, SP, Brazil

0000-0002-1643-2217

person Jean-Louis Brasseur

schoolHôpital de la Pitié-Salpêtrière, Paris, FranceHôpital de la Pitié-SalpêtrièreFranceParis, FranceHôpital de la Pitié-Salpêtrière, Paris, France

0009-0004-7427-5493

Correspondence: Dr. Ocacir de Souza Reis Soares. Clínica Radiológica Ocacir Soares. Avenida Coronel José Soares Marcondes, 2044, Vila Euclides. Presidente Prudente, SP, Brazil, 19013-050. Email:
ocacirsoares@gmail.com

SCIMAGO INSTITUTIONS RANKINGS

Universidade de Ribeirão Preto (Unaerp), Campus Guarujá, Guarujá, SP, BrazilUniversidade de Ribeirão PretoBrazilGuarujá, SP, BrazilUniversidade de Ribeirão Preto (Unaerp), Campus Guarujá, Guarujá, SP, Brazil

Diagnósticos da América S.A. (Dasa), Barueri, SP, BrazilDiagnósticos da América S.A.BrazilBarueri, SP, BrazilDiagnósticos da América S.A. (Dasa), Barueri, SP, Brazil

Clínica Radiológica Ocacir Soares, Presidente Prudente, SP, BrazilClínica Radiológica Ocacir SoaresBrazilPresidente Prudente, SP, BrazilClínica Radiológica Ocacir Soares, Presidente Prudente, SP, Brazil

Hôpital de la Pitié-Salpêtrière, Paris, FranceHôpital de la Pitié-SalpêtrièreFranceParis, FranceHôpital de la Pitié-Salpêtrière, Paris, France

Figures

Figures (8)

Thumbnail

Figure 1 Sensory distribution of the distal sural nerve.

Thumbnail

Figure 2 Anatomical distribution of the distal sural nerve. In the proximal portion of the calf, the tibial (a) and common peroneal (b) nerves give rise to the roots of the sural nerve (white arrow), including the medial and lateral sural cutaneous branches (1 and 2, respectively). Those two roots join at the middle or distal third of the calf. The sural nerve runs distally near the small saphenous vein (SSV) in a close relationship with the calcaneal tendon (black arrow). In the distal portion of the leg, the nerve is located between the calcaneal tendon and the peroneus longus tendon (PLT) and peroneus brevis tendon (PBT).

Thumbnail

Figure 3 Classification of variations in the formation of the sural nerve. (SCN, sciatic nerve; TN, tibial nerve; CPN, common peroneal nerve; PCN, peroneal communicating nerve; SN, sural nerve; LDCN, lateral dorsal cutaneous nerve).

Thumbnail

Figure 4 Axial ultrasonography depicting the anatomy of the sural nerve (sn) in the right calf, from proximal to distal (A-D). In A, the lscn and mscn are shown running superficial to the lateral and medial gastrocnemius muscles (lg and mg, respectively) and below the sural aponeurosis (sa). In B, the union of the two branches can be seen in a more distal position, from which they give rise to the sn and the deep sural aponeurosis (dsa). Note that the sa presents two layers: the dsa and the superficial sural aponeurosis (ssa). In C, the sn is shown crossing the dsa and subsequently running between the two aponeuroses. In D, the sn is shown crossing the dsa lateral to the small saphenous vein (ssv).

Thumbnail

Figure 5 Longitudinal ultrasonography of the right calf, showing the sural nerve (sn) crossing the deep sural aponeurosis (dsa, orange arrow). Note that in the upper left part of the image there are two sural aponeuroses-the dsa and the superficial sural aponeurosis (ssa)-whereas there is only one (the ssa) in the upper right part.

Thumbnail

Figure 6 The anatomy of the lateral aspect of the ankle. (SN, sural nerve; SSV, small saphenous vein; PLT, peroneus longus tendon; PBT, peroneus brevis tendon; PLTS, peroneus longus tendon sheath; PBTS, peroneus brevis tendon sheath; SPR, superior peroneal retinaculum; LCB, lateral calcaneal branch (of the sural nerve); CFL, calcaneofibular ligament; IPR, inferior peroneal retinaculum).

Thumbnail

Figure 7 Ultrasonography in the axial plane (A,B) and in the coronal oblique plane (C-E), depicting the anatomy of the sural nerve (sn) in the right ankle and foot from proximal to distal (A-E). In A, the sn and the small saphenous vein (ssv) are seen lateral to the Achilles tendon (at). In B, the sn and ssv are located between the at and the flexor hallucis longus and peroneus brevis muscles (fhlm and pbm, respectively). More distally (C), the sn lies posterolateral to the peroneal retinaculum (ret) and superficial to the calcaneofibular ligament (cfl, in D). At the level of the base of the fifth metatarsal (E), just below the skin, the two branches of the lateral dorsal cutaneous nerve-the dorsomedial and dorsolateral branches (dmb and dlb, respectively)-run superficial to the peroneus brevis tendon (pbt). (cal, calcaneus; plt, peroneus longus tendon).

Thumbnail

Figure 8 Proper positioning of the ultrasound transducer for examination of the sural nerve in the calf (A) and ankle (B).

imageFigure 1 Sensory distribution of the distal sural nerve. open_in_new

imageFigure 2 Anatomical distribution of the distal sural nerve. In the proximal portion of the calf, the tibial (a) and common peroneal (b) nerves give rise to the roots of the sural nerve (white arrow), including the medial and lateral sural cutaneous branches (1 and 2, respectively). Those two roots join at the middle or distal third of the calf. The sural nerve runs distally near the small saphenous vein (SSV) in a close relationship with the calcaneal tendon (black arrow). In the distal portion of the leg, the nerve is located between the calcaneal tendon and the peroneus longus tendon (PLT) and peroneus brevis tendon (PBT). open_in_new

imageFigure 3 Classification of variations in the formation of the sural nerve. (SCN, sciatic nerve; TN, tibial nerve; CPN, common peroneal nerve; PCN, peroneal communicating nerve; SN, sural nerve; LDCN, lateral dorsal cutaneous nerve). open_in_new

imageFigure 4 Axial ultrasonography depicting the anatomy of the sural nerve (sn) in the right calf, from proximal to distal (A-D). In A, the lscn and mscn are shown running superficial to the lateral and medial gastrocnemius muscles (lg and mg, respectively) and below the sural aponeurosis (sa). In B, the union of the two branches can be seen in a more distal position, from which they give rise to the sn and the deep sural aponeurosis (dsa). Note that the sa presents two layers: the dsa and the superficial sural aponeurosis (ssa). In C, the sn is shown crossing the dsa and subsequently running between the two aponeuroses. In D, the sn is shown crossing the dsa lateral to the small saphenous vein (ssv). open_in_new

imageFigure 5 Longitudinal ultrasonography of the right calf, showing the sural nerve (sn) crossing the deep sural aponeurosis (dsa, orange arrow). Note that in the upper left part of the image there are two sural aponeuroses-the dsa and the superficial sural aponeurosis (ssa)-whereas there is only one (the ssa) in the upper right part. open_in_new

imageFigure 6 The anatomy of the lateral aspect of the ankle. (SN, sural nerve; SSV, small saphenous vein; PLT, peroneus longus tendon; PBT, peroneus brevis tendon; PLTS, peroneus longus tendon sheath; PBTS, peroneus brevis tendon sheath; SPR, superior peroneal retinaculum; LCB, lateral calcaneal branch (of the sural nerve); CFL, calcaneofibular ligament; IPR, inferior peroneal retinaculum). open_in_new

imageFigure 7 Ultrasonography in the axial plane (A,B) and in the coronal oblique plane (C-E), depicting the anatomy of the sural nerve (sn) in the right ankle and foot from proximal to distal (A-E). In A, the sn and the small saphenous vein (ssv) are seen lateral to the Achilles tendon (at). In B, the sn and ssv are located between the at and the flexor hallucis longus and peroneus brevis muscles (fhlm and pbm, respectively). More distally (C), the sn lies posterolateral to the peroneal retinaculum (ret) and superficial to the calcaneofibular ligament (cfl, in D). At the level of the base of the fifth metatarsal (E), just below the skin, the two branches of the lateral dorsal cutaneous nerve-the dorsomedial and dorsolateral branches (dmb and dlb, respectively)-run superficial to the peroneus brevis tendon (pbt). (cal, calcaneus; plt, peroneus longus tendon). open_in_new

imageFigure 8 Proper positioning of the ultrasound transducer for examination of the sural nerve in the calf (A) and ankle (B). open_in_new

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