It becomes more superficial to travel sustenaculum tali (a bony medial calcaneal ridge 2–3 cm below the malleolus).įor block at the level of the malleoli, the saphenous, sural, and superficial peroneal nerves are blocked with a circumferential subcutaneous injection of 10–15 mL of local anesthetic along with a line just proximal to the malleoli and anterior from the Achilles tendon medially to laterally ( Figures 8 through 10). The deep peroneal nerve passes lateral to the anterior tibial artery, extensor hallucis longus, and tibialis anterior tendons, and medial to the extensor digitorum longus tendon, deep to the extensor retinaculum. The nerve then divides into medial and lateral plantar nerves. The posterior tibial nerve passes with the artery posterior to the medial malleolus deep to the flexor retinaculum, giving off a medial calcaneal branch to supply the lower and posterior surface of the heel. The nerve and artery then become superficial and more accessible as they curve behind and underneath the sustentaculum tali, a bony ridge on the calcaneus about 2–3 cm below the medial malleolus.
The posterior tibial and deep peroneal nerves are deep to the flexor and extensor retinaculi, respectively, and are more difficult to locate. 1, Superficial peroneal nerve 2, sural nerve.Īt the level of the malleoli, the saphenous, superficial peroneal, and sural nerves are relatively superficial and subcutaneous. Shown is the emergence of the superficial nerve and its distribution on the dorsum of the foot. The deep dorsal structures and web space between the first and second toes are innervated by the deep peroneal nerve (see Figure 2).įIGURE 6.The dorsum of the foot is innervated by the superficial peroneal nerve, arising from the common peroneal branch ( Figure 6).The deep ventral structures, muscles, and sole of the foot are innervated by the posterior tibial nerve, arising from the tibial branch ( Figure 5).The lateral aspect is innervated by the sural nerve arising from the tibial and communicating superficial peroneal branches ( Figure 4).The rest of the foot is innervated by branches of the sciatic nerve: The medial aspect is innervated by the saphenous nerve, a terminal branch of the femoral nerve ( Figure 3). The foot is innervated by five nerves ( Figures 1 and 2). Ankle block can be life saving by avoiding the risks of general anesthesia in very ill patients having foot surgery (e.g.Ankle block is well suited for ambulatory foot surgery.
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