Kholoud J. Sandougah1
Mohamed A. Bedewi2*Saeed M. Alamri3Nawaf A. Alzain3Abdulrahman A. Alharthi3
Mohammed Ayesh Zayed4Mohamed Sherif El-Sharkawy4Saleh M. Alfawaz5Husain Alturkistani4Elsayed Abbas Beheri4Rasha Ali6Muneerah Al-Aqeel7Sitah F. Alanazi7Mohammad W. Marashdeh7- 1Department of Radiology, College of Medicine, Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, Saudi Arabia
- 2Department of Internal Medicine, College of Medicine, Prince Sattam bin Abdulaziz University, Al-Kharj, Saudi Arabia
- 3Department of Medical Rehabilitation, King Saud University Medical City, Riyadh, Saudi Arabia
- 4Department of Radiology and Medical Imaging, College of Medicine, King Saud University Medical City, Riyadh, Saudi Arabia
- 5Department of Family Medicine, Prince Sattam Bin Abdulaziz University Hospital, Al-Kharj, Saudi Arabia
- 6Arish university, College of sports science, Department of Training Sports and kinesiology, El-Arish, Saudi Arabia
- 7Department of Physics, College of Sciences, Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, Egypt
Objective: This study aims to assess changes in the cross-sectional area of the tibial nerve in the disabled elderly.
Materials and methods: The study sample included 124 tibial nerves in 62 participants; 16 of which were disabled elderly patients (13 males, 3 females), with a mean age of 66.6, a mean height of 167.1 cm, a mean weight of 83.9 kg, and a mean BMI of 29.9. Twenty-three young controls (6 males, 17 females), a mean age of 48.4, a mean height of 154.9 cm, a mean weight of 79.8 kg, a mean BMI of 32.7, and 23 elderly non-disabled participants (13 males, 10 females), a mean age of 63.6, a mean height of 161.9 cm, a mean weight of 80.56 kg, and a mean BMI of 30.88.
Results: The mean CSA of the TN in the elderly disabled group was 28.5 mm2. The mean CSA of the young control group’s TN was 20.45 mm2. The mean CSA of the TN in the elderly non-disabled group (both diabetic and non-diabetic) was 27.6 mm2. The mean CSA of the TN in the elderly diabetic non-disabled group was 29.9 mm2. The mean CSA of the TN in the elderly (non-diabetic) non-disabled group was 24.6 mm2.
Conclusion: In conclusion, although our study suggests that nerve ultrasound could be a helpful tool for assessment of the tibial nerve in disabled elderly patients, disability status was not an independent predictor of tibial nerve CSA. Future studies with a larger sample size and a homogenous group are suggested.
Introduction
Disability in the elderly population is a complex, multidimensional subject. The disabled elderly population face long-term physical, mental problems, and sensorimotor difficulties, which could cause partial or full restriction of social engagement (1–4). Many of these patients suffer from neuromuscular symptoms with weakness/atrophy of the skeletal muscles and/or changes in the peripheral nerve morphology. The presence of polyneuropathies, especially those related to chronic disease, can be disabling for the elderly (5). In the past, the diagnosis of chronic polyneuropathies was mainly based on clinical assessment and nerve conduction studies (6). Recently, musculoskeletal ultrasound has emerged as an efficient imaging tool in the diagnosis of different neuromuscular disorders (7, 8). The tibial nerve is one of the two branches of the sciatic nerve and was successfully used for the assessment of chronic peripheral nerve disease (9–12). Ultrasound is a cheap imaging tool with dynamic capability, without risk of ionizing radiation, with shorter acquisition time compared to MRI, and with the capability of bilateral examination (13). The cross-sectional area (CSA) is an important sonographic parameter for differentiation of normal and abnormal nerves (14). This study aims to assess the CSA changes of the tibial nerve in disabled elderly patients.
Methods
Participants
After institutional review board approval, participants for the study were recruited between February 2025 and May 2025, and written consent was obtained. A total of 16 elderly patients with different types of motor disability were recruited to a teaching university hospital. Inclusion criteria included elderly patients at least 60 years old with motor disabilities (DE). This group of four cases is due to motor disability due to cerebrovascular disease, four cases due to spinal acquired and congenital causes, five cases due to chronic peripheral vascular causes, two cases due to muscular degenerative and dystrophic diseases, and one case due to chronic peripheral nerve disease. Patients with temporary disability were excluded.
A second group included elderly patients at least 60 years old without motor disability, non-disabled elderly (NDE); these were subdivided into diabetic (type II) and non-diabetic. A nerve conduction study was performed on a quarter of the participants. The third group included healthy subjects below 60 years old. For each participant, data including age, sex, BMI, weight, and height were recorded.
Technique
We used an L12–5 MHz linear transducer (Epic 7 version 1.5, Ultrasound system: Philips, Bothell, WA, USA). All participants were scanned by a radiologist (M.B.) with 13 years’ experience in neuromuscular ultrasonography. Each nerve was scanned three times, with the ultrasound probe removed from the skin in between. The tibial nerve was scanned in the popliteal fossa after division from the sciatic nerve and posterior to the popliteal artery and vein, and then the CSA was measured in mm2. The CSA of the TN was measured inside the hyperechoic epineurium using the tracer method; minimal pressure was exerted on the probe to optimize image quality (Figure 1).
Figure 1. Short axis scan of the tibial nerve at the popliteal fossa, with measurement taken using the tracer method.
Statistical analysis
Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) version 27 software (SPSS Inc., Chicago, IL, USA). All data were presented as mean, standard deviation (SD), and range. The Shapiro–Wilk test was used to assess the normality of the data distribution. The correlations between the CSA of the scanned nerves, age, weight, height, and BMI were evaluated using Pearson’s correlation coefficient (r). A p-value of <0.05 was considered significant. The ANOVA test was used to compare CSA between different groups. An ANCOVA test was performed to control for confounding variables.
Results
The study sample included 124 tibial nerves in 62 participants; 16 of them were disabled elderly patients (13 males, 3 females), mean age 66.6 ± 4.16, mean height 167.1 cm ± 9.2, mean weight 83.9 kg ± 13.1, mean BMI 29.9 ± 4.2; 23 young controls (6 males, 17 females), mean age 48.4 ± 5.8, mean height 154.9 cm ± 6.48, mean weight 79.8 kg ± 13.1, mean BMI 32.7 ± 4.2; and 23 elderly non-disabled participants (13 males, 10 females), mean age 63.6 ± 4.93, mean height 161.9 cm ± 9.11, mean weight 80.56 kg ± 15.88, and mean BMI 30.88 ± 5.3 (Table 1). The intra-observer reliability calculations resulted in an overall intra-class correlation coefficient of 0.88. The mean CSA of the TN in the elderly disabled group was 28.5 mm2 ± 9.9. The mean CSA of the young control group TN was 20.45 mm2 ± 7.9. The mean CSA of the TN in the elderly non-disabled group (both diabetic and non-diabetic) was 27.6 mm2 ± 8. The mean CSA of the TN in the elderly diabetic non-disabled group was 29.9 mm2 ± 9. The mean CSA of the TN in the elderly (non-diabetic) non-disabled group was 24.6 mm2 ± 5.1 (Table 2). The TN CSA in the non-disabled elderly group (NDE) showed moderate negative correlation with weight (p = 0.110) and BMI (p = 0.074). Otherwise, all three groups showed no significant statistical correlation with all other demographic factors (Table 3). One-way ANOVA and post-hoc Bonferroni test results are presented in Table 4.
Table 1. The demographic features of the study participants of the three groups in our study.
Table 2. The mean tibial nerve CSA measured in square millimeter in different age groups.
Table 3. Correlation between TIB nerve, age, height, weight, and BMI in the disabled elderly group.
Table 4. One-way ANOVA comparing TIB CSA between groups.
Discussion
In our study, the tibial nerve CSA in the disabled elderly group (28.5 mm2) was larger compared to the control young population group (20.45 mm2), and was also increased compared to other studies in the literature, such as Kerasnoudis et al. (8.43 mm2), Soek et al. (24.4 mm2), Fisse et al. (25.9 mm2) (15–17). The TN CSA in the elderly disabled group was also larger than the elderly non-disabled non-diabetic group (24.6 mm2); however, the elderly disabled group showed slightly lower values than the elderly diabetic non-disabled group (29.9 mm2). Analyzing our data with the ANOVA test and the ANCOVA model revealed that the difference in CSA between the disabled elderly group and the control young group was not statistically significant, and that none of the covariates (age, weight, height, BMI) could be significant predictors of tibial nerve CSA. This means that after controlling for confounding variables, the difference between these two was attenuated. Our results suggest an increase in CSA of the TN in disabled elderly patients in comparison to the control groups, except diabetic patients. The CSA of the TN in diabetic patients is reported in the literature to be increased in comparison to healthy controls. Diabetic patients with polyneuropathy are also reported to have higher CSA compared to both healthy controls and diabetic patients without polyneuropathy (18). The similarity in CSA (p < 0.05) between the elderly disabled group and the elderly diabetic non-disabled group could suggest a more influential role of aging and diabetes on CSA enlargement rather than disability itself as a sole factor. This study has several limitations. First, it is the small sample size. Second, a major limitation is the heterogeneity of the sample of the disabled elderly group, including a variety of patients with uneven distribution of nerve involvement. Third, examining the TN was challenging in some cases of disability due to the body habitus of some patients. In conclusion, although our study suggested that nerve ultrasound could be a helpful tool for assessment of the tibial nerve in disabled elderly patients, disability status was not an independent predictor of tibial nerve CSA. Future studies with a larger sample size and a homogenous group are suggested.
Data availability statement
The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.
Ethics statement
The studies involving humans were approved by the Al Imam Mohammed Ibn Saud Islamic University, Institutional Review Board. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.
Author contributions
KS: Investigation, Writing – original draft, Writing – review & editing, Conceptualization. MB: Conceptualization, Data curation, Methodology, Investigation, Project administration, Supervision, Writing – original draft, Writing – review & editing. SaeA: Investigation, Writing – review & editing, Methodology. NA: Writing – review & editing, Investigation, Methodology. AA: Writing – review & editing, Methodology, Investigation. MZ: Supervision, Writing – review & editing, Methodology. ME-S: Writing – review & editing, Software. SalA: Methodology, Investigation, Writing – review & editing. HA: Writing – review & editing, Methodology. EB: Writing – review & editing, Investigation. RA: Conceptualization, Writing – original draft, Software, Formal analysis, Validation, Methodology. MA-A: Supervision, Writing – review & editing. SitA: Supervision, Writing – review & editing. MM: Writing – review & editing, Supervision.
Funding
The author(s) declared that financial support was received for this work and/or its publication. This work was supported and funded by the Deanship of Scientific Research at Imam Mohammad Ibn Saud Islamic University (IMSIU) (grant number IMSIU-DDRSP2601).
Conflict of interest
The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Generative AI statement
The author(s) declared that Generative AI was not used in the creation of this manuscript.
Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
References
1. Azevedo, GA, Sampaio, RR, Filho, ASN, Moret, MA, and Murari, TB. Sustainable urban mobility analysis for elderly and disabled people in São Paulo. Sci Rep. (2021) 11:791. doi: 10.1038/s41598-020-80906-w
2. Chen, Y, and Sloan, FA. Explaining disability trends in the U.S. elderly and near-elderly population. Health Serv Res. (2015) 50:1528–49. doi: 10.1111/1475-6773.12284,
3. Hanewinckel, R, van Oijen, M, Ikram, MA, and van Doorn, PA. The epidemiology and risk factors of chronic polyneuropathy. Eur J Epidemiol. (2016) 31:5–20. doi: 10.1007/s10654-015-0094-6,
4. Widerström-Noga, E, and Finlayson, ML. Aging with a disability: physical impairment, pain, and fatigue. Phys Med Rehabil Clin N Am. (2010) 21:321–37. doi: 10.1016/j.pmr.2009.12.010,
5. Granger, A, and Zakin, E. Immunotherapy for peripheral nerve disorders. Clin Geriatr Med. (2021) 37:347–59. doi: 10.1016/j.cger.2021.01.007,
6. Taams, NE, Drenthen, J, Hanewinckel, R, Ikram, MA, and van Doorn, PA. Age-related changes in neurologic examination and sensory nerve amplitude in the general population: aging of the peripheral nervous system. Neurology. (2023) 101:e1351–8. doi: 10.1212/WNL.0000000000207665,
7. Baute Penry, V, and Cartwright, MS. Neuromuscular ultrasound for peripheral neuropathies. Semin Neurol. (2019) 39:542–8. doi: 10.1055/s-0039-1688987,
8. Le Corroller, T. High-resolution ultrasound of peripheral nerve disorders. Semin Musculoskelet Radiol. (2024) 28:708–17. doi: 10.1055/s-0044-1790528,
9. Desai, SS, and Cohen-Levy, WB. Anatomy, bony pelvis and lower limb: tibial nerve In: StatPearls. Treasure Island (FL): StatPearls Publishing (2023)
10. Kelle, B, Evran, M, Ballı, T, and Yavuz, F. Diabetic peripheral neuropathy: correlation between nerve cross-sectional area on ultrasound and clinical features. J Back Musculoskelet Rehabil. (2016) 29:717–22. doi: 10.3233/BMR-160676,
11. Singh, A, Arora, M, Awal, G, and Sood, MK. Evaluation of tibial and median nerves in patients with diabetic peripheral neuropathy using shear wave elastography. Indian J Radiol Imaging. (2025) 35:424–30. doi: 10.1055/s-0044-1801761,
12. Oduola-Owoo, LT, Adeyomoye, AA, Omidiji, OA, Idowu, BM, Oduola-Owoo, BB, and Odeniyi, IA. Posterior tibial nerve ultrasound assessment of peripheral neuropathy in adults with type 2 diabetes mellitus. J Med Ultrasound. (2023) 32:62–9. doi: 10.4103/jmu.jmu_13_23,
13. Telleman, JA, Herraets, IJ, Goedee, HS, van Asseldonk, JT, and Visser, LH. Ultrasound scanning in the diagnosis of peripheral neuropathies. Pract Neurol. (2021) 21:186–95. doi: 10.1136/practneurol-2020-002645,
14. Senarai, T, Suwannakhan, A, Pratipanawatr, T, Yammine, K, Yurasakpong, L, Sathapornsermsuk, T, et al. Normative reference values of the tibial nerve in healthy individuals using ultrasonography: a systematic review and meta-analysis. J Clin Med. (2023) 12:6186. doi: 10.3390/jcm12196186
15. Fisse, AL, Katsanos, AH, Gold, R, Krogias, C, and Pitarokoili, K. Cross-sectional area reference values for peripheral nerve ultrasound in adults: a systematic review and meta-analysis-part II: lower extremity nerves. Eur J Neurol. (2021) 28:2313–8. doi: 10.1111/ene.14850,
16. Kerasnoudis, A, Pitarokoili, K, Behrendt, V, Gold, R, and Yoon, MS. Cross sectional area reference values for sonography of peripheral nerves and brachial plexus. Clin Neurophysiol. (2013) 124:1881–8. doi: 10.1016/j.clinph.2013.03.007,
17. Seok, HY, Jang, JH, Won, SJ, Yoon, JS, Park, KS, and Kim, BJ. Cross-sectional area reference values of nerves in the lower extremities using ultrasonography. Muscle Nerve. (2014) 50:564–70. doi: 10.1002/mus.24209,
18. Senarai, T, Pratipanawatr, T, Yurasakpong, L, Kruepunga, N, Limwachiranon, J, Phanthong, P, et al. Cross-sectional area of the tibial nerve in diabetic peripheral neuropathy patients: a systematic review and meta-analysis of ultrasonography studies. Medicina (Kaunas). (2022) 58:1696. doi: 10.3390/medicina58121696
Abbreviations
CSA, cross-sectional area; BMI, body mass index; TN, tibial nerve.
Keywords: cross sectional area, disabled, elderly, peripheral nerves, tibial nerve, ultrasound
Citation: Sandougah KJ, Bedewi MA, Alamri SM, Alzain NA, Alharthi AA, Zayed MA, El-Sharkawy MS, Alfawaz SM, Alturkistani H, Beheri EA, Ali R, Al-Aqeel M, Alanazi SF and Marashdeh MW (2026) Age-related changes of the tibial nerve cross-sectional area in the disabled elderly. Front. Neurol. 16:1721797. doi: 10.3389/fneur.2025.1721797
Edited by:
Gabriele Siciliano, University of Pisa, ItalyReviewed by:
Glauber Voltan, Instituto Humanizare, BrazilEliane Florencio Gama, Federal University of São Paulo, Brazil
Ahmed Noury, Orotta College of Medicine and Health Sciences, Eritrea
Copyright © 2026 Sandougah, Bedewi, Alamri, Alzain, Alharthi, Zayed, El-Sharkawy, Alfawaz, Alturkistani, Beheri, Ali, Al-Aqeel, Alanazi and Marashdeh. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Mohamed A. Bedewi, bS5iZWRld2lAcHNhdS5lZHUuc2E=