1816
ORIGINAL ARTICLE
Needle Electrode Insertion Into the Tibialis Posterior: A
Comparison of the Anterior and Posterior Approaches
Seung-Nam Yang, MD, Sang-Heon Lee, MD, PhD, Hee-Kyu Kwon, MD, PhD
ABSTRACT. Yang S-N, Lee S-H, Kwon H-K. Needle elec-
trode insertion into the tibialis posterior: a comparison of the
anterior and posterior approaches. Arch Phys Med Rehabil
20082008;89:1816-8.
Objectives: To analyze and compare the safety of the ante-
rior and posterior approaches for needle electrode placement
and to examine the method for inserting the needle electrode
using the anterior approach.
Design: Cross-sectional study.
Setting: University hospital.
Participants: Lower-extremity radiographs and magnetic
resonance images of 22 patients (13 men, 9 women).
Interventions: Not applicable.
Main Outcome Measure: Measurement of lower-extremity
radiographs and magnetic resonance imaging.
Results: The anterior approach offers the advantage of a
larger safe window for needle insertion into the upper third of
the leg than the posterior approach. No significant differences
were observed between the anterior and posterior approaches in
terms of safety of needle insertion into the midpoint. The safe
zone of the overlying skin for needle insertion was found to be
approximately 40% to 80% of the width of the tibia away from
the lateral margin of the tibia shaft on the upper third of the leg
and 32% to 58% of the width of the tibia at the midpoint of the
leg in the anterior approach.
Conclusions: The method suggested in this article can be
used for needle electromyography and deserves more wide-
spread use in clinical practice.
Key Words: Electromyography; Magnetic resonance imag-
ing; Needles; Rehabilitation; Tibia.
© 2008 by the American Congress of Rehabilitation Medi-
cine and the American Academy of Physical Medicine and
Rehabilitation
HE TIBIALIS POSTERIOR originates from the proximal
T two thirds of the lateral side of the tibia, the medial side of
the fibula, and the interosseous membrane between these 2
bones. It is inserted into the tarsal bones, mainly the navicular
bone, and receives innervation from the tibial nerve.1,2
The tibialis posterior is a useful muscle in the electrodiag-
nosis of lumbosacral plexopathy, lumbosacral radiculopathy,
tibial neuropathy, and sciatic neuropathy. It is particularly
useful for the differential diagnosis of peroneal neuropathy and
From the Department of Rehabilitation Medicine, Korea University Anam Hospi-
tal, Korea University College of Medicine, Seoul, Republic of Korea.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the authors or upon any
organization with which the authors are associated.
Reprint requests to Hee-Kyu Kwon, MD, PhD, Dept of Rehabilitation Medicine,
Korea University Anam Hospital, Korea University College of Medicine, 5 ga 126-1,
Anam-dong, Seongbuk-gu, Seoul 136-705, Republic of Korea, e-mail: hkkwon@
korea.ac.kr.
0003-9993/08/8909-00927$34.00/0
doi:10.1016/j.apmr.2008.01.027
Arch Phys Med Rehabil Vol 89, September 2008
L5 radiculopathy. A careful approach is needed because the
tibialis posterior muscle is located deep within the area of the
lower extremity and because the neurovascular bundle is lo-
cated near the tibialis posterior muscle.
There are 2 methods currently used to place the needle
electrode. One is the traditionally used posterior approach, and
the other is the anterior approach. In the posterior approach, the
electrode is inserted under the medial tibial shaft and directed
deep along the bone, where the muscle lies against the in-
terosseous membrane at the junction of the middle and lower
thirds of the leg.3 In the anterior approach, the electrode is
inserted at the midpoint between the tibia and fibula at the
mid-third of the leg penetrating either the anterior tibial muscle
or the extensor digitorum longus posteriorly and is advanced
toward the interosseous membrane connecting the tibia and
fibula. The tibialis posterior is reached after passing the in-
terosseous membrane.4
According to a study based on 6 cadavers, access to the
tibialis posterior muscle for electrode insertion is safer with
the anterior approach than with the posterior approach because
the anterior approach has a larger safe access window.5
Little is known about the method for placing the needle
electrode, the depth of insertion, or the location in the muscle.
Moreover, there is no confirmed technique for the location of
the needle insertion into the tibialis posterior muscle.
The aim of this study was to determine whether the anterior
or posterior approach is the safest approach to needle electrode
insertion. We also attempted to standardize the method of
needle electrode insertion through the anterior approaches.
MRI was used in this study to examine the insertion of the
needle electrode into the muscle using both approaches.
METHODS
Two different techniques for electrode placement into the
tibialis posterior muscle were reviewed and compared using
lower-extremity MRI.
Between 2002 and 2005, a total of 124 lower-extremity
magnetic resonance images were reviewed. Those with ana-
tomic abnormalities of the lower extremity such as tumor and
inflammation swelling were excluded from the study. Twenty-
two patients (13 men, 9 women) were selected after reviewing
both lower-extremity radiographs and magnetic resonance im-
ages. Ten cases were on the left side, and 12 cases were on the
right side. The participants were between the ages of 18 and 65
years (mean age, 45.73y). This study protocol was approved by
the Korea University Institutional Review Board.
Several anatomic landmarks were defined, including the
anterior and posterior tibial artery and vein as well as the
anterior border of the tibia on MRI, and the tibial tubercle and
bimalleolar line on the simple radiograph.6
After the length of the tibia (from the tibial tubercle to the
bimalleolar line) was measured using simple radiograph, the
List of Abbreviations
MRI magnetic resonance imaging
 NEEDLE INSERTION IN TIBIALIS POSTERIOR, Yang
Fig 1. Parameters measured in MRI. Abbreviations: DA, depth to the
tibialis posterior in anterior approach; DP, depth to the tibialis
posterior in posterior approach; SWA, safety window in anterior
approach; SWP, safety window in posterior approach; SZA, safety
zone of overlying skin in anterior approach; WP, width of tibia.
upper one third, the midpoint, and the lower one third of the leg
were marked. These points were chosen based on the findings
of a previous study in which the anterior approach was used to
insert the needle electrode into the tibialis posterior in the
mid-third of the lower leg.3,4 The width of the tibia and the
depth to the tibialis posterior by both the anterior and posterior
approaches were measured using MRI. The perpendicular dis-
tance from the overlying skin to the tibialis posterior was
measured as the depth to the tibialis posterior in each of the 2
approaches.
A safe window (tibia to neurovascular bundle) was measured
on the coronal MRI scan to avoid the neurovascular bundle in
the anterior and posterior approaches. A safe zone of overlying
skin for needle insertion into the safe window was measured
using the anterior approach (fig 1).
Four legs from fresh cadavers were used to validate our
results. The standardized method for needle insertion into the
upper third and midpoint of the leg was carried out using the
anterior approach.
Statistical Analysis
We used the paired t test to compare the anterior and pos-
terior approaches. Data were analyzed by SPSS.a
RESULTS
In the upper third of the tibia, the mean width of the tibia was
31.71mm (range, 24.77– 44.77mm). The mean safe windows
for insertion through the anterior and posterior approaches ⫾
SD were 12.34⫾3.59 and 6.76⫾4.67, respectively. The mean
Table 1: Results in the Upper Third of the Tibia
Variables Anterior Approach (mm) Posterior Approach (mm)
Safety window 12.34* 6.76
Depth 36.19 (116.17%) 35.67 (118.38%)
NOTE. Percentages are ratio to width of tibia.
*P⬍.05.
1817
Table 2: Safety Zone Overlying Skin for Needle Insertion in
Anterior Approach
Variable Upper Third of Tibia (mm) Mid-Third of Tibia (mm)
Safety zone
overlying
skin* 12.85⫺25.19 (40%⫺80%) 9.65⫺17.36 (32%⫺58%)
NOTE. Percentages are ratio to width of tibia.
*Distance from the lateral margin to tibia.
depths from the skin to the tibialis posterior muscle using the
anterior and posterior approaches were 36.19mm (range,
27.07– 45.58mm) and 35.67mm (range, 23.90 –50.42mm), re-
spectively, which corresponds to 116.17% and 118.38% of
the width of the tibial shaft at the skin using the anterior
and posterior approach, respectively. The safe window of the
anterior approach was significantly larger than that of the
posterior approach (P⬍.05). The safe zone of overlying skin
for insertion using the anterior approach was located be-
tween 12.85mm (range, 5.09 –20.45mm) and 25.19mm (range,
17.14 –32.97mm) from the lateral margin of the tibia, which
corresponds to approximately 40% to 80% of the width of the
tibia (tables 1, 2).
The mean width of the tibia at the midpoint was 30.05mm
(range, 23.94 –37.32mm). The mean safe windows for needle
insertion using the anterior and posterior approaches ⫾ SD
were 7.71⫾2.62mm and 7.58⫾2.25mm, respectively. There
was no significant difference in the safety window between the
2 methods at the midpoint of the tibia. The safe zone of
overlying skin for needle insertion using the anterior approach
was located between 9.65mm (range, 5.87–15.36mm) and
17.36mm (range, 10.01–26.12mm) from the lateral margin of
the tibia, which corresponds to 32% to 58% of the width of the
tibia. At the midpoint along the length of the tibia, the mean
depth from the skin to the tibialis posterior muscle using the
anterior and posterior approach were 35.01mm (range, 25.17–
42.5mm) and 33.5mm (range, 25.86 – 47.83mm), respectively,
which corresponds to approximately 113.7% and 114.24% of
the width of the anterior tibia using the anterior and posterior
approach, respectively.
The safety window in the upper third and at the midpoint of
the tibia were compared during needle insertion using the
anterior approach. The safety window of the upper third of the
leg was larger than that of the midpoint of the leg (tables 2, 3).
In the lower third along the length of tibia, the tibialis
posterior was a tendon in several cases. Therefore, this point
was determined to be an inappropriate needle insertion point.
In 4 fresh cadavers, the needle did not puncture the neuro-
vascular bundle and was well placed in the tibialis posterior
muscle using the standardized method of anterior approach in
all cases.
DISCUSSION
These results confirmed the findings of a previous cadaver
study by Lee et al,5 who reported that the anterior approach was
Table 3: Results in the Midpoint of the Tibia
Variables Anterior Approach (mm) Posterior Approach (mm)
Safety window 7.71* 7.58
Depth 35.01 (113.70%) 33.50 (114.24%)
NOTE. Percentages are ratio to width of tibia.
*P⬎.05.
Arch Phys Med Rehabil Vol 89, September 2008
1818 NEEDLE INSERTION IN TIBIALIS POSTERIOR, Yang
safer than the posterior approach for needle insertion into the
upper third of the leg. We also evaluated the safety of insertion
into the midpoint of the leg but found no significant differences
in the safety window between the anterior and posterior ap-
proaches for needle insertion. Needle insertion into the lower
third of the leg was not considered because it was deemed to be
an unsuitable site.
MRI was used to evaluate the safety of the needle electrode
insertion technique and to identify the insertion point. The
utility of MRI was verified by applying the same measure to
cadavers. Because MRI is among the most widely used ad-
vanced techniques, it is a useful tool for determining the
appropriate technique for needle electrode insertion into the
muscles. Measurement using MRI applied directly to a living
person has the benefit of not having a loss in volume or
distance, which is often the case when taking measurements in
cadavers. Therefore, all of the measurements obtained from
living subjects may be more accurate than those obtained from
cadavers. In the present study, the standardized method of
anterior approach obtained from this study was confirmed
using fresh cadavers.
The safety window for needle electrode insertion is closely
related to the muscle volume. A small leg volume is associated
with a small safety zone. In the case of a patient with progres-
sive severe muscle atrophy over a short period or a very thin
patient, the safety window for needle insertion may be smaller
than in general cases. Careful attention is needed in these cases.
The distance from the skin to the tibialis posterior varies
from patient to patient. Therefore, regarding the depth of nee-
dle insertion, the mean length and muscle action need to be
considered in each patient. In addition, it is important that the
practitioner is familiar with the proper feeling when puncturing
the interosseous membrane.
Arch Phys Med Rehabil Vol 89, September 2008
Because the tibialis posterior is the principal inverter of the
foot, it needs to be blocked in patients with an equinovarus
deformity. The method suggested herein can also be applied to
these cases.
CONCLUSIONS
The use of MRI is becoming increasingly more widespread,
which makes it relatively easy to obtain subjects. Thus, we
conclude that the method suggested in this study can be used
for needle electromyography and deserves more widespread
use in clinical practice.
Acknowledgment: We thank Hang Lee, MD, for his kind help
and support for this study.
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2. Jenkins DB, Hollinshead WH. Hollinshead’s functional anatomy of
the limbs and back. 8th ed. Philadelphia: WB Saunders; 2002.
3. Geiringer SR, Davidson S. Anatomic localization for needle elec-
tromyography. Philadelphia: Hanley & Belfus; 1994.
4. Lee HJ, DeLisa JA. Surface anatomy for clinical needle electro-
myography. New York: Demos; 2000.
5. Lee HJ, Bach JR, DeLisa JA. Needle electrode insertion into tibialis
posterior: a new approach. Am J Phys Med Rehabil 1990;69:126-7.
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skeletal. Salt Lake City: Amirsys; 2006.
Supplier
a. Version 10; SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL
60606.