Comparison of Four Different Nerve Conduction Techniques of the Superficial Fibular

Sensory Nerve

Authors: Mathew R. Saffarian DO, Nathan C. Condie DO, Erica A. Austin DO, Katie E.
McCausland DO, Michael T. Andary MD, James R. Sylvain DO, Iian R. Mull MS, Eric D.
Zemper PhD, Mary L. Jannausch MS

Affiliations: Department of Physical Medicine and Rehabilitation, Michigan State University,

East Lansing, Michigan

Grants/ Acknowledgments: None

Author Address: Mathew Saffarian

1200 E. Michigan Ave. Suite 520
Lansing MI 48912
saffarianmr@gmail.com

Running Title: Superficial Fibular NCS

Word Count Abstract: 151

Word Count Paper: 2,480

We confirm that we have read the Journal’s position on issues involved in ethical publication and
affirm that this report is consistent with those guidelines. None of the authors have any conflicts
of interest to disclose.

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process which may lead to
differences between this version and the Version of Record. Please cite this article as an
‘Accepted Article’, doi: 10.1002/mus.25543

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Introduction: There are many different nerve conduction study (NCS) techniques to study the

superficial fibular sensory nerve (SFSN).

Objectives: We present reference distal latency values and comparative data regarding 4

different NCS for the SFSN.

Methods: Four different NCS techniques, Spartan technique (ST), Izzo techniques-medial and

intermediate dorsal cutaneous branches- (IMT and IIT), and Daube technique, were performed

on (114) healthy volunteers. A total of 108 subjects with 164 legs were included.

Results: The mean latency of the ST was longest (3.9 ± 0.3ms) while the Daube technique was

the shortest (3.6±0.7ms). The mean amplitude of the Daube technique displayed the highest

(15.2 ± 8.2uV) with the ST having the lowest (8.7 ± 4.2uV). Among the absent sensory nerve

action potentials (SNAPs), the ST was absent only twice (1.2%) and the IMT was absent more

than the other techniques (2.9%).

Discussion: All 4 techniques were reliable methods for obtaining the superficial fibular nerve

SNAP, present in 95% of individuals.

Key Words: superficial fibular sensory nerve, nerve conduction study, distal latency, amplitude,

Spartan method, Izzo method, Daube method

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Introduction: There are a variety of different nerve conduction study (NCS) techniques to study

the superficial fibular sensory nerve (SFSN). The different techniques differ in the placement of

the active and reference electrode as well as in the position of stimulation. There is variability in

the anatomic location of where the SFSN exits the fascia in the distal leg. It is unclear in the

literature which technique is more reliable than others.

DiBenedetto described one of the earliest techniques in 19701. She was the first to describe an

antidromic NCS for both the SFSN as well as the sural nerve. DiBenedetto noted that in her

laboratory she had difficulty obtaining the SFSN response in 2-3% of healthy appearing

individuals. Due to the relative ease and consistency of obtaining a SNAP in both children and

adults, the sural sensory nerve has been relied upon as the main sensory nerve for evaluation of

peripheral neuropathies of the lower extremity.1

Due in part to a lack of details regarding exact electrode placement in the DiBenedetto paper, a

wide range of different techniques have been described in the literature.1-3 Nearly a decade after

DiBenedetto’s work, Izzo et al described 2 different techniques based on the 2 main branches of

the SFSN in the lower leg, the medial and intermediate dorsal cutaneous branches. They used

these 2 techniques to study the sural and saphenous sensory nerves. Their data showed the

saphenous NCS to be unreliable (absent in 13% of healthy subjects). The intermediate dorsal

cutaneous branch SNAP was present in 98% of subjects while the medial dorsal cutaneous

branch SNAP mimicked that of the sural nerve, having a 100% response rate. However, the Izzo

techniques rely upon palpation and visualization for electrode placement, and the description of

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the area of stimulation is vague, allowing for subjectivity and interpretation errors in an objective

study.4

In an attempt to further standardize a technique, Daube et al. offered a more detailed explanation

of the stimulation site for the SFSN describing it as “just anterior to the edge of the palpable

shaft of the fibula”5. Issues remained with their technique, including an 8.6% absent response

rate, likely attributable to the more proximal location of their stimulation site compared to those

documented by Izzo et al.5 and DiBenedetto.1

In the electrodiagnostic laboratory at Michigan State University, a modified procedure has been

used that integrates aspects of the previously described techniques, we are calling the “Spartan

technique.” This technique was developed to account for the location of the SFSN as it exits the

fascia in the distal leg and by describing the stimulation and recording sites as precisely as

possible in an effort to eliminate subjectivity. This Spartan technique has yet to be validated and

compared to the others in the literature.

In the lower leg, the common fibular nerve gives rise to the superficial fibular nerve distal to the

head of the fibula as it passes between the fibularis longus muscle and the fibula itself.7 The

nerve continues to travel distally between the fibularis muscles to provide motor innervation to

both the fibularis longus and brevis muscles. In the lower third of the leg, the nerve becomes

superficial.4 Previous studies have localized the nerve piercing the fascia and becoming

superficial 10.5cm proximal to the lateral malleolus, but new studies have shown that it could be

anywhere from 7to 9cm.6 Once the nerve pierces the fascia it divides into the medial dorsal

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cutaneous and intermediate dorsal cutaneous sensory nerves. Both nerves travel over the

extensor retinaculum to provide sensation to the dorsum foot.

The medial dorsal cutaneous branch travels just lateral to the extensor hallucis longus tendon to

provide sensation to the dorsomedial aspect of the foot and the medial aspect of the first 3 toes.

The intermediate cutaneous sensory branch provides sensation to the anterolateral aspect of the

ankle, just medial to the lateral malleolus, the lateral dorsum of the foot, and the lateral sides of

the last 3 toes.4

In this report we introduce a new NCS technique developed at Michigan State University called

the Spartan technique and present comparative data regarding the presence or absence of a

SNAP, distal latency, amplitude, and stimulation strength required for 4 different NCS

techniques for the SFSN.

Material and Methods: After obtaining IRB approval from Michigan State University, 4

different antidromic NCS techniques, the Spartan technique, the Izzo techniques (medial and

intermediate dorsal cutaneous branches), and the Daube technique, were performed on 114

healthy volunteers. Informed consent was obtained from all participants. Subjects were recruited

from the local community and included hospital employees, university students, and patients in

maintenance therapy programs, among others, in an attempt to follow the recent American

Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) Normative Data

Taskforce Guidelines. Participants either had 1 or 2 legs tested, based primarily on subject

preference and time constraints.

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Participants were excluded from the study if they had a history of a neuropathy, diabetes

mellitus, or symptoms of weakness or numbness in the lower extremities. NCS were performed

with the subject in the supine position. A bar electrode was placed on the foot or at the ankle,

depending on the technique being studied, with stimulation 14 cm proximal to the active

electrode over the SFSN. Temperature was maintained >32º C in all subjects. The temperature

measurement was obtained at the halfway point between the medial and lateral malleolus along

the inframalleolar line. An Xlteck NeuroMax® EMG System was used for all studies with the

following settings: low frequency filter of 30 Hz, high-frequency filter of 2000 Hz, pulse

duration of 0.2 ms, sweep speed of 1 ms/division, and gain of 20µV. The ground electrode was

placed on the anterior leg between the bar electrode and the stimulation site. Variables obtained

included distal latency (ms), amplitude (µV), and amount of stimulation current (mA) required to

obtain a waveform. The studies were carried out by 4 different electrodiagnosticians.

Techniques:

Spartan technique (Figure 1): A line is drawn to connect the most distal portion of the lateral

malleolus to the most distal portion of the medial malleolus (inframalleolar line). A bar electrode

was placed in the spaces between the first and second metatarsals 4-5 cm distal to that line. This

is in the distribution of the medial dorsal cutaneous branch. The recording active electrode was

proximal. The stimulator was placed 14 cm proximally and laterally along the anterior border of

the fibula with the stimulating cathode distal.

Izzo Techniques:

Medial Dorsal Cutaneous Branch (Figure 2): The medial branch passes over the anterior ankle to

the dorsum of the foot, lateral to the tendon of the EHL. 4

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Intermediate Dorsal Cutaneous Branch (Figure 3): The intermediate branch is 1-2 cm medial to

the lateral malleolus.

In both Izzo techniques, a recording bar electrode is placed over the nerve with the active

electrode proximal at the level of the ankle. The site for stimulation is 14 cm from the proximal

recording electrode on the anterolateral aspect of the leg with the anode proximal. 4

Daube Technique (Figure 4): A recording bar electrode is placed 3 cm proximal to a point on the

bimalleolar line, midway between the edge of the tibia and the tip of the lateral malleolus and

overlying the intermediate dorsal cutaneous branch, with the reference electrode 3 cm distal on

the dorsum of the ankle. The site of stimulation is 14 cm proximal to the active recording

electrode, just anterior to the palpable edge of the shaft of the fibula. 5

Statistical analysis: A total of 6 volunteers (9 legs) were excluded from the numerical

calculations due to inability to obtain SNAPS with all of the techniques. These were counted as

absent. A total of 108 subjects with 164 legs were included in the final statistical analysis. Data

were collected and maintained in an Excel spreadsheet. Analysis of the data was performed using

IBM SPSS Statistics, Version 21. Since data were not collected on both legs of all subjects, and 3

variables were compared across the 4 techniques, we determined that the optimal statistical

analyses should be performed with a linear mixed-effects model.

Since most nerve conduction data do not follow a Gaussian distribution, a percentile cutoff was

used as a second set of statistical analysis. The percentile cutoff was set at 2.5%. The data were

analyzed with both absent values included (114 subjects and 173 total legs) and with absent

values excluded (108 subjects and 164 total legs).

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Results: A total of 164 legs in 108 subjects were included in the final ANOVA statistical

analysis, mean age of 38 (±13.7, 20-70). The average ±1 standard deviation of the distal latency,

amplitude, and amount of stimulation required to obtain a response are listed in Table 1. A

SNAP in at least 1 technique was obtained in 100% of subjects. All 4 techniques produced a

measurable SNAP in 95% of subjects tested.

The mean distal latency of the Spartan technique was longest (3.9 ± 0.3ms) compared to the

other techniques, while the Daube technique was the shortest (3.6±0.7ms). The Spartan

technique was significantly slower (P<0.0001) when compared to the other 3 techniques

(Supplemental table S1, available online). The Izzo Medial technique distal latency was also

significantly longer (P=0.007) when compared to the Daube technique. There was no statistically

significant difference between the Izzo Medial and Izzo Intermediate techniques or between the

Daube and Izzo Intermediate techniques.

The Daube technique produced the highest mean amplitude (15.2 ± 8.2uV), and the Spartan

technique produced the smallest (8.7 ± 4.2uV). The amplitude of the Spartan technique was

significantly smaller (P<0.0001) compared to the other 3 techniques (Supplemental table S2).

The Daube technique SNAP amplitude was significantly larger (P<0.0001) than the other 3

techniques. There was no statistically significant difference between the amplitudes of the Izzo

Medial and Izzo Intermediate techniques.

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The amount of stimulation required to obtain a maximal response was lowest for the Spartan

technique (18.4 ± 9.1 mA), and the Daube technique required the highest stimulation (27.3 ±13.2

mA). The Spartan technique required significantly lower stimulation current (P<0.0001)

compared to the other 3 techniques (Supplemental table S3). The Daube technique required a

significantly stronger stimulation (P< 0.0001) when compared to the other 3 techniques. The

Izzo Medial and Izzo Intermediate techniques required a lower stimulation current to obtain a

SNAP and were not statistically different from each other.

A summary of the absent SNAPs is shown in Table 2. At least 1 absent SNAP was seen in 6

subjects (9 legs). Among the absent responses, the Spartan technique was absent only twice

(1.2%), while the Izzo Medial technique was absent more than the others (2.9%). The Izzo

Intermediate and Daube technique had the same rate of absent SNAPs (2.3%).

Tables 3 and 4 show the percentile cutoff distribution of the data. When absent values are

included in the data analysis, they are considered “normal” for the Izzo Medial technique for

latency, amplitude, and stimulation current. Additionally, with absent values included the high

end of normal does not change, except for the latency of the Izzo Medial Technique. With absent

SNAPs excluded, the low end of normal is higher for all techniques in latency, amplitude, and

stimulation current. Edited to here

Discussion: Numbness on the dorsum of the foot is a common presenting symptom in the

electrodiagnostic lab. The most common etiologies include: L5 radiculopathy, fibular

neuropathy, and generalized peripheral polyneuropathy. When testing this nerve, an absent or

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very small SNAP is highly suggestive of a diffuse neuropathy or focal entrapment of the fibular

nerve. If the SFSN SNAP is absent in otherwise normal subjects, the ability to diagnose disease

is limited. Previous studies have documented difficulty in obtaining a response, with an absent

potential in 3-8% of normal healthy individuals.1,5 Documenting that this SNAP is present in all,

or nearly all, healthy patients will allow physicians to diagnose nerve injury when the SFSN

SNAP is absent. The goals of this paper were to: 1) introduce the Spartan technique developed at

Michigan State University as a modification of the DiBenedetto technique, and 2) compare the 4

main techniques used for investigating the SFSN by documenting the presence or absence of a

SNAP and analyzing the distal latency, amplitude, and amount of stimulation necessary to obtain

a response.

In all the subjects enrolled in the study, a response on at least 1 technique was obtained in every

subject. All four techniques produced a SNAP in 95% of subjects, thus demonstrating 4 different

reliable methods of a SFSN SNAP.

The exact reason behind absent responses in normal subjects is unknown. As previously stated,

previous studies have shown an absent response rate of 3-8% in normal subjects. A possibility is

anatomical variation in normal subjects. Operator error may account for the fact that some

responses were seen with the use of one technique but were absent with another technique

performed on the same individual. Finally, undiagnosed peripheral neuropathy may contribute to

the absent SNAPs seen in our study.

Although there were statistically significant differences between distal latencies, amplitudes, and

stimulation current required to obtain some results, there seems to be no clinically significant

difference between the techniques. The distal latency tended to be the longest and the amplitude

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the smallest with the Spartan technique. The opposite was true for the Daube technique, which

had the shortest latency and the largest amplitude. The Spartan SNAP was obtained at a more

distal location in the foot compared to the other techniques. As the SFSN travels distally and

branches into the foot, the diameter of the nerve decreases. This likely influences the distal

latency and SNAP amplitude. This could also help explain the results of the Daube technique,

which were obtained more proximal than the other techniques.

The Daube technique required a stronger stimulation to obtain a SNAP than the other techniques.

The anatomy of the SFSN could explain this finding as well. A study performed by Park et al.

found that the SFSN SNAP was optimally obtained on the fibula 7-9 cm proximal to the

intermalleolar line.6 A stronger stimulation current may have been necessary to penetrate the

fibularis longus and brevis muscles, as the SFSN has not yet pierced the fascia at that level. This

could be verified in future studies with the use of ultrasound.

Some limitations of this study are worth noting. Four different electrodiagnosticians obtained the

data. To our knowledge, the inter-rater reliability of the four different techniques has yet to be

studied. Finally, the patient population was a convenience sample and may not represent the

general population.

Conclusion: All 4 of the techniques studied were reliable methods for obtaining the SFSN

SNAP, which was found in 95% of individuals studied. Although there were significant

statistical differences, there seems to be minimal clinical difference between the 4 techniques.

Abbreviations:

Nerve conduction study (NCS)

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Spartan technique (ST)

Izzo intermediate technique (IIT)

Izzo medial technique (IMT)

Superficial fibular sensory nerve (SFSN)

American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM)

Milliseconds (ms)

Microvolts (µV)

Milliamps (mA)

Sensory nerve action potential (SNAP)

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References

1. DiBenedetto M. Sensory nerve conduction in lower extremities. Arch Phys Med Rehabil.

1970 May;51(5):253-8.

2. Lee HJ, DeLisa JA. Manual of nerve conduction study and surface anatomy for needle

electromyography. Ed 4, Philadelphia: Lippincott Williams & Wilkins, 2005. pp 76-77.

3. Weiss K, Silver JK, Weiss J. Easy EMG: A guide to performing nerve conduction studies

and electromyography. Philadelphia: Butterworth-Heinemann, 2004. pp 38.

4. Izzo KL, Sridhara CR, Rosenholtz H, Lemont H. Sensory conduction studies of the

branches of the superficial peroneal nerve. Arch Phys Med Rehabil. 1981 Jan;62(1):24-7.

5. Levin KH, Stevens JC, Daube JR. Superficial peroneal nerve conduction studies for

electromyographic diagnosis. Muscle Nerve. 1986 May;9(4):322-6.

6. Park GY, Im S, Lee JI, Lim SH, Ko YJ, Chung ME, et al. Effect of superficial peroneal

nerve fascial penetration site on nerve conduction studies. Muscle Nerve. 2010

Feb;41(2):227-33.

7. Jenkins, DB. Hoolinshead’s functional anatomy of the limbs and back. Ed 9, Missouri:

Saunders Elsevier, 2009. pp 311, 321, 340

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Table 1: ANOVA Analysis

Spartan Izzo- Medial Izzo- Daube
Intermediate
Latency (ms) 3.9 ±0.3 3.7 ±0.4 3.7 ±0.3 3.6 ±0.7
(3.2-5.0) (3.1-5.3) (3.0-4.7) (2.8-5.5)
Amplitude (µV) 8.7 ±4.2 11.3 ±5.9 11.8 ±7.6 15.2 ±8.2
(1.7-21.0) (1.2-30.8) (1.0-40.0) (1.3-37.3)
Stimulation 18.4 ±9.1 21.5 ±9.5 21.7 ±10.7 27.3 ±13.2
(mA) (5.0-58.0) (8.1-57.4) (5.0-54.4) (9-80.0)
Ranges in parentheses

Table 2: Absent SNAPs

Subject 1 Subject 2 Subject 3 Subject 4 Subject 5 Subject 6
Age 26 89 66 79 47 56
# Legs Studied 2 1 1 1 2 2
Spartan Present Present Absent Present Absent (1/2) Present
IMT Present Absent Present Absent Absent (2/2) Absent (1/2)
IIT Present Present Present Absent Absent (2/2) Absent (1/2)
Daube Absent (1/2) Present Present Absent Absent (2/2) Absent (1/2)
Parentheses indicate number of absent SNAPs in subjects in which both legs were studied

Table 3: Percentile ranks with absent values included

Spartan Izzo- Izzo- Daube
Medial Intermediate
Latency (ms) 3.2-5.0 Absent-5.3 3.0-4.8 2.8-5.5
Amplitude (µV) 1.7-21.0 Absent-30.8 1.0-40.0 1.3-37.3
Stimulation (mA) 5.5-58.0 Absent-57.4 5.0-54.4 9-80.0
Ranges indicated

Table 4: Percentile ranks with absent values excluded

Spartan Izzo- Izzo- Daube
Medial Intermediate
Latency (ms) 3.3-5.0 3.1-5.3 3.2-4.7 2.9-5.5
Amplitude (µV) 2.3-21.0 2.2-30.8 2.5-40.0 3.0-37.3
Stimulation (mA) 6.6-58.0 10-57.4 9.0-54.4 10.2-80.0
Ranges indicated

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Figure 1: The Spartan technique is demonstrated by placing the bar electrode on the dorsum of

the foot, 4-5cm distal to the infra-malleolar line between the first and second metatarsals and

stimulating 14cm proximally to the anterior edge of the fibula.

Figure 2: The Izzo Medial technique is demonstrated by placing a bar electrode over the medial

cutaneous branch of the SFSN, just lateral to the extensor hallucis longus tendon and stimulating

14 cm from the proximal recording electrode on the anterolateral aspect of the leg.

Figure 3: The Izzo Intermediate technique is demonstrated by placing a bar electrode over the

intermediate branch of the SFSN, 1-2cm medial to the lateral malleolus and stimulating 14 cm

from the proximal recording electrode on the anterolateral aspect of the leg.

Figure 4: The Daube technique is demonstrated by placing a bar electrode over the proximal

portion of the SFSN, 3cm proximal to the bimalleolar line between the tibia and fibula and

stimulating 14cm proximal to the anterior fibula.

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Figure 1: Spartan Technique is demonstrated by placing the bar electrode on the dorsum of the foot, 4-5cm
distal to the infra-malleolar line between the 1st and 2nd metatarsals and stimulating 14cm proximally to
the anterior of the fibula.

139x66mm (300 x 300 DPI)

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Figure 2: Izzo Medial Technique is demonstrated by placing a bar electrode over the medial cutaneous
branch of the SFSN, just lateral to the EHL tendon and stimulating 14 cm from the proximal recording
electrode on the anterolateral aspect of the leg.

139x66mm (300 x 300 DPI)

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Figure 3: Izzo Intermediate Technique is demonstrated by placing a bar electrode over the intermediate
branch of the SFSN, 1-2cm medial to the lateral malleolus and stimulating 14 cm from the proximal
recording electrode on the anterolateral aspect of the leg.

139x66mm (300 x 300 DPI)

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Figure 4: Daube Technique is demonstrated by placing a bar electrode over the proximal portion of the
SFSN, 3cm proximal to the bimalleolar line between the tibia and fibula and stimulating 14cm proximal to
the anterior fibula.

140x66mm (300 x 300 DPI)

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