Deep Peroneal Research Articles

Combined distal tibial nerve transfer and tibialis posterior tendon transfer for foot drop correction: A surgical technique and case illustration

Tendon transfers have traditionally been the mainstay for treating foot drop and improving gait and mobility. Recently, distal nerve transfers from the tibial to the deep peroneal nerve have been explored, but with limited success in achieving ankle dorsiflexion. We present a novel surgical technique combining both distal tibial nerve transfers (to both deep and superficial peroneal nerves) and tibialis posterior tendon transfer to the tibialis anterior (internal splint). This dual approach aims to achieve comprehensive foot drop correction through the reinnervation of foot dorsiflexors and improved ankle function. A case illustration highlights this combined technique’s surgical steps and potential benefits.

Stem Cells Rehabilitate Diabetic Neuropathy

To report the effectiveness of stem cell treatment in diabetic neuropathy. This study recruited 83 Iraqi females from 45 to 73 years old who had NIDDM between August 31, 2020 and June 30, 2023. All of them had a "Diabetic neuropathy symptom score (DNS)" (grade 3–4) and a "Diabetic foot sensory neuropathy score" (grade 1-2). They all had HbA1c (10-13%) from 7 to 10 years. The patient/family provided informed permission when they visited the "Al Zahrawy Center for Stem Cells in Baghdad". For four treatment sessions (once every three weeks), Hamad dispersed stem cells around the tibial and deep peroneal nerves. Among 83 Iraqi females, 49 (59.1%) had a grade 4 "Diabetic neuropathy symptom score" upon presentation, which decreased to 24.2% in 20 females after three months of medication. Their "Diabetic foot sensory neuropathy (DNS)" was (54.3%) in 45 females at presentation and decreased to (21.8%) in 18 females after three months of treatment. The satisfaction rate for therapy was 74.6% for the "Diabetic neuropathy symptom score" and 78.3% for "Diabetic foot sensory neuropathy (DNS)". Stem cell therapy is a good treatment option for diabetic neuropathy. The researchers supported it and suggested a greater sample size in other places.

A Variation of the Double Deep Fibular Nerve with Multiple Connections to the Superficial Fibular Nerve on the Dorsal Aspect of the Foot

In this case report, we aim to present our observation of a rare variation on the dorsum of the foot, including the double deep fibular (peroneal) nerve and its connections to superficial nerves. The cutaneous nerves of both feet ' dorsum were examined during a routine dissection on a formalin-fixed adult male cadaver. During the dissection of the dorsum of the right foot, it was observed that the deep fibular nerve (DFN) surfaced at two distinct points by piercing the investing fascia. Then, these two branches converged, and DFN had connections at three different points with the superficial fibular (peroneal) nerve (SFN). However, the superficial nerve anatomy of the dorsum of the left foot exhibited the anatomical structure commonly described in classical textbooks. To the best of our knowledge, the variation of double DFN with multiple connections to the SFN has not been previously described in the literature. Understanding the innervation of the dorsum of the foot may be clinically substantial in preventing nerve injuries during surgical interventions. The knowledge regarding rare superficial nerve variations may contribute to the success of anaesthesia applications, especially in the ankle and dorsum of the foot.

Initial findings using high-resolution magnetic resonance imaging for visualisation of the sural nerve and surrounding anatomy in healthy volunteers at 7 Tesla.

Histopathological diagnosis is the gold standard in many acquired inflammatory, infiltrative and amyloid based peripheral nerve diseases and a sensory nerve biopsy of sural or superficial peroneal nerve is favoured where a biopsy is deemed necessary. The ability to determine nerve pathology by high-resolution imaging techniques resolving anatomy and imaging characteristics might improve diagnosis and obviate the need for biopsy in some. The sural nerve is anatomically variable and occasionally adjacent vessels can be sent for analysis in error. Knowing the exact position and relationships of the nerve prior to surgery could be clinically useful and thus reliably resolving nerve position has some utility. 7T images of eight healthy volunteers' (HV) right ankle were acquired in a pilot study using a double-echo in steady-state sequence for high-resolution anatomy images. Magnetic Transfer Ratio images were acquired of the same area. Systematic scoring of the sural, tibial and deep peroneal nerve around the surgical landmark 7 cm from the lateral malleolus was performed (number of fascicles, area in voxels and mm2, diameter and location relative to nearby vessels and muscles). The sural and tibial nerves were visualised in the high-resolution double-echo in steady-state (DESS) image in all HV. The deep peroneal nerve was not always visualised at level of interest. The MTR values were tightly grouped except in the sural nerve where the nerve was not visualised in two HV. The sural nerve location was found to be variable (e.g., lateral or medial to, or crossing behind, or found positioned directly posterior to the saphenous vein). High-resolution high-field images have excellent visualisation of the sural nerve and would give surgeons prior knowledge of the position before surgery. Basic imaging characteristics of the sural nerve can be acquired, but more detailed imaging characteristics are not easily evaluable in the very small sural and further developments and specific studies are required for any diagnostic utility at 7T.

Double-Flap Elevation From the Ipsilateral Lower Extremity: The Anterior Approach to Fibula Osteo-Cutaneous Flap Elevation.

The free fibular flap has been elevated by a "lateral approach" from the posterior edge of the peroneal muscle for more than 40 years. However, in this approach, the surgical view is limited because flap elevation in mandibular reconstruction is performed simultaneously with tumor resection in the supine position, even when using positioning pillows. We herein propose an "anterior approach" as a new surgical method. We retrospectively investigated free fibular flap surgeries performed using the anterior approach, which consists of three anterior approaches, over a seven-year period. First, to avoid the course of the superficial peroneal nerve, the crural fascia was incised 1-2 cm posterior to the anterior edge of the peroneal muscle. The anterior edge of the peroneus muscle is detached from the anterior intermuscular septum. After performing osteotomies distal and proximal to the fibula, the interosseous membrane was incised from the anterior view. Pulling out the fibula to the anterior space between the anterior intermuscular septum and the peroneal muscle made the surgical field shallow. No postoperative superficial or deep peroneal nerve palsies were found in the 55 patients. Only one tourniquet was used in 31 of the 55 cases (56.4%), with an average of 95 min. Twenty-four patients (43.6%) required a second tourniquet 38 min after an interval. Only one tourniquet was used in 25 of the 30 (83.3%) cases in the last 3 years. Moreover, double flaps were used in 21 cases (38.2%), all of which involved ipsilateral ALT flaps. In 18 cases, double-flap elevation and prefabrication were successfully finished before the completion of tumor resection by otorhinolaryngologists.

Unravelling the Anatomy of the Anterior Tarsal Tunnel and Its Clinical Implications.

Anterior tarsal tunnel (ATT) syndrome is caused by the compression of the deep fibular nerve (DFN) within the ATT beneath the inferior extensor retinaculum, bounded by the tendons of the extensor hallucis longus (EHL) and extensor digitorum longus (EDL). Compression may result from direct trauma, repetitive mechanical irritation, and thrombosis of the dorsalis pedis artery. Injury to the contents of ATT could occur during ankle arthroscopy. Therefore,thisstudy was undertaken to provide a detailed description of the anatomy of the ATT and its clinical implications. Ten formalin-fixed cadavers were utilized for the study. The ATT was identified between the tendons of the EHL and EDL. The length at the medial and lateral boundaries and the width at the proximal end, middle, and distal end of the ATT were measured using a digital Vernier calliper. The mean length of the medial border of the tunnel was 31.42±8.44 mm, while the lateral border was 20.39±4.39 mm. The width of the ATT increased from the proximal to the distal end. DFN was related to the DPA laterally in 15 limbs and medially in five limbs within the tunnel. The present study not only describes the intricate anatomy of the ATT but also describes the patterns of DFN and DPA within the tunnel. Understanding the anatomy of ATT is crucial, as it paves the way for safe and efficient surgical interventions, thereby significantly reducing the risk of neurovascular damage during surgical procedures.

Deep Peroneal Neurectomy for Midfoot Arthritis: A Comprehensive Review, Surgical Technique, and Case Series

Patients with painful midfoot arthritis unsuccessfully treated with conservative measures have been historically left with the surgical option of midfoot arthrodesis as a definitive treatment. In recent years, excision of the deep peroneal nerve has been offered as a potential alternative. Existing literature on the outcomes of patients undergoing deep peroneal neurectomy for the treatment of midfoot arthritis is limited and piecemeal. In this comprehensive review, technique guide, and retrospective case series, we consolidate the evidence around deep peroneal neurectomy for midfoot arthritis, review operative technique, and determine the outcomes of 4 patients who underwent deep peroneal neurectomy from February 2021 to December 2022 using Patient-Reported Outcome Measurement Information System Physical Function and Pain Interference scores. Four original articles from National Center for Biotechnology Information Medline, published through May 2023, were included. The outcomes of patients treated with deep peroneal neurectomy for midfoot arthritis are discussed. In our case series, the average amount of time between surgery and final postoperative Patient-Reported Outcome Measurement Information System scores was 289 days. The average preoperative physical function score was 36.8. Three patients showed a minimal clinically important difference in physical function; postoperative average was 41.3. Three patients had a minimally clinical important reduction in pain levels (average preoperative pain interference score was 65.8; average postoperative pain interference score was 59.3). One patient underwent a revision neurectomy for inadequate pain relief, and another sought additional treatment for inadequate pain relief. All patients returned to walking in a shoe within 1 month. The outcomes of our case series are similar to those of previously published case series, which demonstrate satisfactory results and acceptable complication rates. For patients with symptomatic midfoot arthritis, deep peroneal neurectomy can be an effective treatment option to reduce pain and improve physical function while requiring minimal postoperative recovery time.

A unique variation of the common peroneal nerve: a case report

This variation was observed in the left lower extremity of a 75-year-old male cadaver fixed with formalin, ethanol and glycerol solution. The common peroneal nerve was divided into six terminal branches. These branches were identified as deep peroneal nerve, superficial peroneal nerve, two muscular branches to the tibialis anterior and two muscular branches to the peroneus longus. Knowledge of the variations of the common peroneal nerve and its branches is important in knee and proximal leg operations.

Management of Superficial and Deep Peroneal Nerve Neuromas with Targeted Muscle Reinnervation in Nonamputees: Operative Technique and Early Outcomes.

Targeted muscle reinnervation (TMR), a surgical technique developed by the senior authors that coapts proximal ends of nerves to distal motor nerves of adjacent muscles, has demonstrated efficacy in the treatment and prevention of neuroma pain. The objective of this study is to describe the surgical technique for TMR of the superficial peroneal nerve (SPN) and deep peroneal nerve (DPN) in nonamputee patients and provide data on postoperative functional outcomes. A single-institution retrospective chart review was performed between March 2018 and April 2021. Patients were de-identified and included if they were nonamputees receiving TMR for pain in the peroneal nerve distribution. Data extracted included demographic information, symptoms before operation, relevant nerve coaptation, peri-, and postoperative complications, and long-term functional outcomes. Of the 19 patients reviewed, 11 patients underwent TMR of the SPN alone: eight had complete resolution of their symptoms; two indicated partial improvement in pain; and one patient had no improvement. Four patients underwent TMR of the DPN alone: two patients had complete resolution of their pain, and two patients had partial improvement with pain. Four patients underwent TMR of both the SPN/DPN: two patients had complete resolution of their symptoms, and two patients were noted to have significant improvement but had persistent pain from prior foot operations. Average follow-up time was 260 days. TMR is a successful technique in the management of SPN and DPN neuroma pain. Our technique revealed excellent clinical outcomes, no procedure-specific complications, and improved subjective pain reports.

Tibial nerve branching pattern and compatibility of branches for the deep fibular nerve.

In individuals who develop drop foot due to nerve loss, several methods such as foot-leg orthosis, tendon transfer, and nerve grafting are used. Nerve transfer, on the other hand, has been explored in recent years. The purpose of this study was to look at the tibial nerve's branching pattern and the features of its branches in order to determine the suitability of the tibial nerve motor branches, particularly the plantaris muscle motor nerve, for deep fibular nerve transfer. There were 36 fixed cadavers used. Tibial nerve motor branches were observed and measured, as were the lengths, distributions, and thicknesses of the common fibular nerve and its branches at the bifurcation region. The motor branches of the tibial nerve that supply the soleus muscle, lateral head, and medial head of the gastrocnemius were studied, and three distinct forms of distribution were discovered. The motor branch of the gastrocnemius medial head was commonly observed as the first branch to divide, and it appeared as a single root. The nerve of the plantaris muscle was shown to be split from many origins. When the thickness and length of the motor branches measured were compared, the nerve of the soleus muscle was determined to be the most physically suited for neurotization. In today drop foot is very common. Traditional methods of treatment are insufficient. Nerve transfer is viewed as an application that can both improve patient outcomes and hasten the patient's return to society. The nerve of the soleus muscle was shown to be the best candidate for transfer in our investigation.

Evaluation of Quantitative and Selective Sensory Fiber Dysfunction in Patients with Cirrhosis.

Chronic liver disease has been reported to be associated with peripheral neuropathy. However, which sensory fibers are affected remains unknown. The objective of this study was to examine the function of sensory nerve fibers in patients with cirrhosis using the current perception threshold (CPT) test, as well as the correlation between blood biochemical indicators related to cirrhosis and CPT values. We recruited 44 patients with liver cirrhosis and 37 healthy controls of the same age and gender. The Neurometer® system for the CPT test was used to stimulate the median nerve on the right index finger, as well as the deep and superficial peroneal nerves on the right hallux, using three distinct parameters (2000 Hz, 250 Hz, and 5 Hz). Comparative analysis was performed on the CPT values of the sensory nerves. Additionally, the correlation between CPT values and biochemical blood indicators in the study participants was analyzed. Under 2000 Hz electrical stimulation, there was a significant difference between the cirrhosis and healthy control groups in the median nerve as well as the deep and superficial peroneal nerves (p < 0.05). In addition, the median nerve CPT value of the cirrhosis group was significantly higher than that of the control group at an electrical stimulation frequency of 250 Hz (p = 0.005). There was no correlation between CPT values and blood biochemical indicators. According to the results, the sensory peripheral neuropathy in liver cirrhosis is mainly manifested as Aβ fiber neuropathy.

Anatomical Structures at Risk in Percutaneous Preparation Talonavicular Fusion.

The stability of the hindfoot greatly relies on the integrity of the talonavicular joint. Pathologies affecting this joint often necessitate fusion. Our study explores the risks posed to neurovascular and tendon structures during simulated percutaneous talonavicular joint preparation for fusion. In 9 fresh cadaver specimens, the talonavicular joint was accessed through two portals. A 2-mm Shannon burr was employed for joint surface preparation with distraction provided by a pin-based distractor. Dissections were performed to assess potential damage to critical structures, including the dorsalis pedis artery, superficial and deep peroneal nerves, extensor hallucis longus (EHL), and tibialis anterior (TA) tendons. The dorsal portal site was found to be significantly closer to important structures compared to the medial portal site. The Shannon burr made contact with various structures, with a single transection identified for both deep and superficial peroneal nerve branches. During the dorsal portal site approach, potential injury to the EHL tendon was identified as concern. This study sheds light on the potential risks associated with percutaneous dorsal and medial joint preparation approaches using a Shannon burr.Level of Evidence:Level V, mechanism-based reasoning..

A Variant Dorsalis Pedis Artery and Its Relationship with the Deep Fibular Nerve

During a cadaveric dissection session, a distinctive neurovascular pattern was identified in the left leg of a 66-year-old female cadaver. The Anterior Tibial Artery (ATA), while maintaining a normal origin and luminal diameter, exhibited a shortened course, terminating in the upper third of the leg. In the lower third of the leg, the Fibular Artery (FA), known as the peroneal artery, traversed through the interosseous membrane to the anterior compartment, persisting as the Dorsalis Pedis Artery (DPA). The Deep Fibular Nerve (DFN), displaying a usual course in the upper two-thirds of the leg, crossed the variant DPA posteriorly and divided into two terminal branches on its posterolateral side. The medial terminal branch proceeded to cross the artery anteriorly within the anterior tarsal tunnel. This distinctive relationship between the DFN and the variant DPA renders the nerve susceptible to compression and may result in “anterior tarsal tunnel syndrome”.

Minimally invasive subtalar joint and talonavicular joint preparation for hindfoot arthrodesis: A Cadaveric study evaluating structures at risk

Minimally invasive surgery (MIS) is growing in popularity due to smaller incisions, faster recovery times with less post-operative pain, and measurable decreases in morbidity. Our center performed an MIS hindfoot joint preparation about the talonavicular and subtalar joints and defined structures at risk in order to make this procedure more reproducible. Using ten fresh frozen cadaver limbs, we created a medial and lateral portal for talonavicular joint (TN) access, and an additional portal for subtalar joint (STJ) access to prepare the subtalar joint. After denuding the aforementioned joints of cartilage, the specimens were dissected to identify nearby anatomical structures. We documented the position of the peroneal sheath and sural nerve relative to the STJ portal, and the position of the dorsalis pedis artery (DP), medial dorsal cutaneous nerve (MDCN), extensor hallucis longus (EHL), extensor digitorum longus (EDL), tibialis anterior (TA), and tibialis posterior (TP) tendons relative to the TN portals. The average distance of the sural nerve and the peroneal sheath from the STJ portal was 34.21 mm and 14.12 mm respectively. The average distance of the DP, MDCN, and deep peroneal nerve from the medial and lateral TN portals were 13.31 mm, 11.54 mm, and 17.14 respectively. No neurovascular structures were transected throughout joint preparation. To our knowledge this is the first study looking into structures at risk for this specific procedure.

Dellon Triple Decompression under WALANT

The Wide-Awake Local Anesthesia No Tourniquet (WALANT) Approach to Dellon Triple decompression involves the use of local anesthetic with epinephrine and no tourniquet. This study shows that WALANT is a safe and effective procedure and can be performed in an outpatient setting for the decompression of the common peroneal nerve in the knee, tibial nerve in the ankle and deep peroneal nerve in the dorsum of the foot in diabetic patients with superimposed nerve compressions to diabetic neuropathy. WALANT technique demonstrated to be a safe procedure to surgically treat diabetic patients with superimposed compressive neuropathy to diabetic neuropathy in the lower limbs and had no complications.

Effectiveness of tibial transverse transport combined with modified neurolysis in treatment of diabetic foot ulcers

To investigate the effectiveness of tibial transverse transport (TTT) combined with modified neurolysis in treatment of diabetic foot ulcer (DFU) through a prospective randomized controlled study. The patients with DFU and diabetic peripheral neuropathy, who were admitted between February 2020 and February 2022, were selected as the research objects, of which 31 cases met the selection criteria and were included in the study. The patients were divided into two groups by random number table method. The 15 patients in the trial group were treated with TTT combined with modified neurolysis, and the 16 patients in the control group received treatment with TTT alone. There was no significant difference in gender, age, duration of DFU, ulcer area, Wagner classification, as well as preoperative foot skin temperature, visual analogue scale (VAS) score, ankle-brachial index (ABI), motor nerve conduction velocity (MNCV) of the common peroneal nerve, MNCV of the tibial nerve, MNCV of the deep peroneal nerve, two-point discrimination (2-PD) of heel, and cross-sectional area (CSA) of the common peroneal nerve between the two groups ( P>0.05). The time for ulcer healing, foot skin temperature, VAS scores, ABI, 2-PD of heel, and CSA of the common peroneal nerve before operation and at 6 and 12 months after operation were recorded and compared between groups. The differences in MNCV of the common peroneal nerve, MNCV of the tibial nerve, and MNCV of the deep peroneal nerve between pre-operation and 12 months after operation were calculated. All patients in both groups were followed up 12-24 months (mean, 13.9 months). The surgical incisions in both groups healed by first intention and no needle tract infections occurred during the bone transport phase. Ulcer wounds in both groups healed successfully, and there was no significant difference in the healing time ( P>0.05). During the follow-up, there was no ulcer recurrences. At 12 months after operation, the MNCV of the common peroneal nerve, the MNCV of the tibial nerve, and the MNCV of the deep peroneal nerve in both groups accelerated when compared to preoperative values ( P<0.05). Furthermore, the trial group exhibited a greater acceleration in MNCV compared to the control group, and the difference was significant ( P<0.05). The foot skin temperature, VAS score, ABI, 2-PD of heel, and CSA of the common peroneal nerve at 6 and 12 months after operation significantly improved when compared with those before operation in both groups ( P<0.05). The 2-PD gradually improved over time, showing significant difference ( P<0.05). The 2-PD of heel and VAS score of the trial group were superior to the control group, and the differences were significant ( P<0.05). There was no significant difference in ABI, foot skin temperature, and CSA of the common peroneal nerve between groups after operation ( P>0.05). Compared with TTT alone, the TTT combined with modified neurolysis for DFU can simultaneously solve both microcirculatory disorders and nerve compression, improve the quality of nerve function recovery, and enhance the patient's quality of life.

A "messenger zone hypothesis" based on the visual three-dimensional spatial distribution of motoneurons innervating deep limb muscles.

Abstract JOURNAL/nrgr/04.03/01300535-202407000-00036/figure1/v/2023-11-20T171125Z/r/image-tiff Coordinated contraction of skeletal muscles relies on selective connections between the muscles and multiple classes of the spinal motoneurons. However, current research on the spatial location of the spinal motoneurons innervating different muscles is limited. In this study, we investigated the spatial distribution and relative position of different motoneurons that control the deep muscles of the mouse hindlimbs, which were innervated by the obturator nerve, femoral nerve, inferior gluteal nerve, deep peroneal nerve, and tibial nerve. Locations were visualized by combining a multiplex retrograde tracking technique compatible with three-dimensional imaging of solvent-cleared organs (3DISCO) and 3-D imaging technology based on lightsheet fluorescence microscopy (LSFM). Additionally, we propose the hypothesis that “messenger zones” exist as interlaced areas between the motoneuron pools that dominate the synergistic or antagonist muscle groups. We hypothesize that these interlaced neurons may participate in muscle coordination as messenger neurons. Analysis revealed the precise mutual positional relationships among the many motoneurons that innervate different deep muscles of the mouse. Not only do these findings update and supplement our knowledge regarding the overall spatial layout of spinal motoneurons that control mouse limb muscles, but they also provide insights into the mechanisms through which muscle activity is coordinated and the architecture of motor circuits.

Adenosine A2A receptors in the rostral ventrolateral medulla participate in blood pressure decrease with electroacupuncture in hypertensive rats.

Acupuncture is increasingly used to manage high blood pressure (BP) as a complementary therapy. However, the mechanisms underlying its hypotensive effects remain unclear. Our previous studies have shown that electroacupuncture (EA) at the ST36-37 acupoints, overlying the deep peroneal nerve, attenuates pressor responses through adenosine A2A receptors (A2AR) in the rostral ventrolateral medulla (rVLM). However, it is uncertain whether rVLM A2AR contributes to EA's BP-lowering effect in sustained hypertension. We hypothesized that a course of EA treatment lowers BP, in part, through the activation of adenosine A2AR in the rVLM in hypertensive rats. To mimic essential hypertension in the clinic, we performed EA in conscious Dahl salt-sensitive hypertensive rats (DSHRs). EA (0.1-0.4 mA, 2 Hz) was applied at ST36-37 for 30 min twice weekly for four weeks, while sham-EA was conducted in a similar manner but without electrical input. In hypertensive rats, BP was reduced by EA (n = 14) but neither by sham-EA (n = 14) nor in the absence of needling (n = 8). Following four weeks of eight treatments and then under anesthesia, EA's modulatory effect on elevated BP was reversed by unilateral rVLM microinjection of SCH 58261 (1 mM in 50 nl; an A2AR antagonist; n = 7; P < 0.05) but not the vehicle (n = 5) in EA-treated DSHRs. Activation of rVLM A2AR in DSHRs treated with sham-EA by an A2AR agonist, CGS-21680 (0.4 mM in 50 nl; n = 8), decreased BP. Unilateral administration of SCH 58261 or CGS-21680 into the rVLM did not alter basal BP in Dahl salt-sensitive rats fed a regular diet with normal BP. The A2AR level in the rVLM after EA was increased compared to the sham-EA and untreated DSHRs (n = 5 in each group; all P < 0.05). These data suggest that a 4-week twice weekly EA treatment reduced BP in salt-sensitive hypertensive rats likely through adenosine-mediated A2AR in the rVLM.

Normal Values of Nerve Conduction Studies in Children Aged 7 Days to 14 Years Referred to Electrodiagnosis Clinic of Iranian Children's Medical Center

Background: The normal values of nerve conduction studies (NCS) are different in children compared to adults. Moreover, racial and geographical factors can affect these values. Objectives: The present study aimed to investigate the normal NCS values in children of different ages. Methods: The present cross-sectional study included children referred to the Electrodiagnosis Clinic of the Children's Medical Center in Iran, who had normal NCS results based on the references and had no exclusion criteria. The patients were divided into 8 age groups (7 days to one month, 1 - 3 months, 3 - 6 months, 6 - 12 months, 1 - 2 years, 2 - 4 years, 4 - 6 years, and 6 - 14 years), and the NCS was performed using a Nihon Kohden electromyogram. The NCS values in the normal range were included in the analysis. Results: The normal ranges of amplitude and conduction velocity of 4 motor nerves (median, ulnar, deep peroneal, and tibial) and 2 sensory nerves (median and medial plantar), as well as the F-wave latency values of 2 nerves (ulnar and tibial), were established as the reference values for the pediatric patients. Conclusions: The NCS parameters of Iranian children were slightly different from the normal references reported by studies in other countries. Moreover, the SNAP and CMAP amplitudes and motor conduction velocity of these children usually reached the normal values of the adult population earlier.

Anterior Tarsal Tunnel Syndrome: Entrapment of the Articular Branch of Deep Peroneal Nerve

Case: A 28-year-old male patient who injured his ankle 2 years ago presented with unilateral ankle pain, tingling, and numbness for 1 year. Clinically, tenderness and positive Tinel sign were localized on anterior aspect of ankle. On exploration, deep peroneal nerve and mainly its articular branch were encased in fibrotic tissue. Decompression of both nerves resulted in symptomatic relief after surgery. Conclusion: High index of suspicion, a thorough medical history, meticulous clinical examination, complete knowledge of nerve anatomy, proper radiological studies, and careful surgical decompression are all necessary for the diagnosis and management of such atypical cases.