Identification of brain functional connectivity during acute transcutaneous tibial nerve stimulation: A 3T fMRI study.

OBJECTIVES: A feasibility proof-of-concept study was conducted to assess the effects of acute tibial nerve stimulation (TNS) on the central nervous system in healthy volunteers using functional magnetic resonance imaging (fMRI). MATERIALS AND METHODS: Fourteen healthy volunteers were included in a prospective, single-site study conducted on a clinical 3T MRI scanner. Four scans of functional MRI, each lasting 6 min, were acquired: two resting-state fMRI scans (prior and following the TNS intervention) and in-between two fMRI scans, both consisting of alternating rest periods and noninvasive acute transcutaneous TNS (TTNS). Whole brain seed-based functional connectivity (FC) correlation analysis was performed comparing TTNS stimulation with rest periods. Cluster-level familywise error (FWE) corrected p and a minimal cluster size of 200 voxels were used to explore FC patterns. RESULTS: Increased FC is reported between inferior frontal gyrus, posterior cingulate gyrus, and middle temporal gyrus with the precuneus as central receiving node. In addition, decreased FC in the cerebellum, hippocampus, and parahippocampal areas was observed. CONCLUSIONS: Altered FC is reported in areas which have been described to be also involved in lower urinary tract control. Although conducted with healthy controls, the assumption that the underlying therapeutic effect of TNS involves the central nervous system is supported and has to be further examined in patients with incomplete spinal cord injury.

Shear wave elastography of tibial nerve in patients with diabetic peripheral neuropathy-A cross-sectional study.

OBJECTIVE: To explore the role of shear wave elastography of the tibial nerve as a potential ultrasonographic method for the diagnosis of tibial neuropathy in patients with type 2 diabetes. MATERIALS AND METHODS: This cross-sectional study included 50 subjects each in case (patients with diabetic tibial neuropathy diagnosed on the basis of clinical features and nerve conduction study) and control groups (non-diabetic non-neuropathic healthy volunteers). The exclusion criteria included the presence of type 1 diabetes, a known history of neuropathy from other causes except for type 2 diabetes, or a history of leg or ankle fracture. Cross-sectional area and shear wave velocity values of the tibial nerve were measured in both groups. Demographic details and body mass index were obtained in both groups and additionally, the duration of type 2 diabetes and HbA1c values in the case group were also noted. Wilcoxon Mann-Whitney U test was used to compare these variables in study groups. ROC curve analysis provided additional findings. RESULTS: Tibial nerve stiffness was significantly higher in the case group (p-value < 0.001). The study groups did not significantly differ in the Cross-sectional area of the tibial nerve (p-value 0.57). The case group exhibited a higher frequency of loss of the fascicular pattern of the tibial nerve (40% vs 18%, p-value 0.027). Duration of diabetes mellitus and HbA1c values did not significantly affect Shear wave velocity values in the case group. At the cut-off value of Shear wave velocity of 3.13 m/s, sensitivity and specificity to diagnose diabetic peripheral neuropathy were 94% and 88% respectively. CONCLUSION: Increased nerve stiffness is seen in patients with diabetic peripheral neuropathy. Shear wave elastography might prove as a novel noninvasive technology for screening/early diagnosis of diabetic peripheral neuropathy.

Tarsal tunnel ganglion cyst: intraneural or extraneural site?

Intraneural ganglion cysts are very uncommon lesions, whose diagnosis has increased since the articular theory and the description of the MRI findings were established. We present a case report of a 59-year-old man with symptoms of tarsal tunnel syndrome. Foot and ankle MRI demonstrated the presence of an intraneural cystic lesion in the posterior tibial neve and its connection with the subtalar joint through an articular branch. The identification of the specific radiological signs like the «signet ring sign¼ allowed establishing an adequate preoperative diagnosis, differentiating it from an extraneural lesion and facilitating the articular disconnection of the nerve branch during surgery.

Automatic Identification of Ultrasound Images of the Tibial Nerve in Different Ankle Positions Using Deep Learning.

Peripheral nerve tension is known to be related to the pathophysiology of neuropathy; however, assessing this tension is difficult in a clinical setting. In this study, we aimed to develop a deep learning algorithm for the automatic assessment of tibial nerve tension using B-mode ultrasound imaging. To develop the algorithm, we used 204 ultrasound images of the tibial nerve in three positions: the maximum dorsiflexion position and -10° and -20° plantar flexion from maximum dorsiflexion. The images were taken of 68 healthy volunteers who did not have any abnormalities in the lower limbs at the time of testing. The tibial nerve was manually segmented in all images, and 163 cases were automatically extracted as the training dataset using U-Net. Additionally, convolutional neural network (CNN)-based classification was performed to determine each ankle position. The automatic classification was validated using five-fold cross-validation from the testing data composed of 41 data points. The highest mean accuracy (0.92) was achieved using manual segmentation. The mean accuracy of the full auto-classification of the tibial nerve at each ankle position was more than 0.77 using five-fold cross-validation. Thus, the tension of the tibial nerve can be accurately assessed with different dorsiflexion angles using an ultrasound imaging analysis with U-Net and a CNN.

Tibial intraneural ganglion cysts at the superior tibiofibular joint treated with joint resection alone: a proof of concept.

BACKGROUND: Intraneural ganglion cysts involving the tibial nerve are rare. Recent evidence has supported an articular (synovial) theory to explain the joint-related origin of these cysts; however, optimal operative treatment for cysts originating from the STFJ remains poorly understood. Therefore, we present a novel strategy: addressing the joint itself without addressing the articular branch and/or the cyst. METHODS: Records of patients with tibial intraneural ganglion cysts with a connection to the STFJ who were treated with a joint resection alone at a single academic institution were reviewed. The clinicoradiographic features, operative intervention, and postoperative course were recorded. RESULTS: We identified a consecutive series of 7 patients. These patients (4/7 male, 57%) were 43 (range 34-61) years of age and all presented with symptoms of neuropathy. The patients underwent resection of the synovial surfaces of the STFJ without disconnection of the articular branch or decompression of the cyst. Postoperatively, three patients regained partial motor function (43%, n=7), although four patients noted continued sensory abnormality (57%, 4/7). All six patients with postoperative MRIs had some evidence of regression of the cyst. CONCLUSIONS: This novel surgical technique serves as a proof of concept-highlighting the fact that treating the primary source (the joint origin) can be effective in eliminating the secondary problem (the cyst itself). While this study shows that this simplified approach can be employed in select cases, we believe that superior results (faster, fuller recovery) can be achieved with combinations of disconnecting the articular branch, decompressing the cyst, and/or resecting the joint.

Longitudinal Movements and Stiffness of Lower Extremity Nerves Measured by Ultrasonography and Ultrasound Elastography in Symptomatic and Asymptomatic Populations: A Systematic Review With Meta-analysis.

This study was aimed at analyzing the effectiveness of ultrasonography (US) and ultrasound elastography (UE) in evaluating longitudinal sliding and stiffness of nerves. In line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, we analyzed 1112 publications (range: 2010-2021) extracted from MEDLINE, Scopus and Web of Science focusing on specific outcomes, including shear wave velocity (m/s), shear modulus (kPa), strain ratio (SR) and excursion (mm). Thirty-three papers were included and evaluated for overall quality and risk of bias. From the analysis of data concerning 1435 participants, mean shear wave velocity (SWV) in the sciatic nerve was 6.70 ± 1.26 m/s in controls and 7.51 ± 1.73 m/s in participants presenting with leg pain; in the tibial nerve, mean SWV was 3.83 ± 0.33 m/s in controls and 3.42 ± 3.53 m/s in participants presenting with diabetic peripheral neuropathy (DPN). The mean shear modulus (SM) was 20.9 ± 9.33 kPa for sciatic nerve, whereas it was an average of 23.3 ± 7.20 kPa for the tibial nerve. Considering 146 subjects (78 experimental, 68 controls) no significant difference was observed in SWV when comparing participants with DPN with controls (standard mean difference [SMD]: 1.26, 95% confidence interval [CI]: 0.54, 1.97), whereas a significant difference was observed in the SM (SMD: 1.78, 95% CI: 1.32, 2.25); furthermore, we found significant differences between left and right extremity nerves (SMD:1.14. 95% CI: 0.45, 1.83) among 458 participants (270 with DPN and 188 controls). No descriptive statistics are available for excursion because of the variability in participants and limb positions, whereas SR is considered only a semiquantitative outcome and therefore not comparable among different studies. Despite the presence of some limitations in study designs and methodological biases, on the basis of our findings, we can conclude that US and UE are effective methods in assessing longitudinal sliding and stiffness of lower extremity nerves in both symptomatic and asymptomatic subjects.

Predictive value of ultrasonography in polyneuropathy diagnosis: electrophysiological and ultrasonographic analysis.

Peripheral neuropathy may cause serious complications such as foot ulcers and Charcot joint which can prevent by early diagnosis. We aimed to analyze the diagnostic value of ultrasonographic measurements of nerves and muscles in distal symmetric axonal polyneuropathy (DSAP). Study included 51 DSAP patients and 51 controls. Nerve conduction studies were performed. Median, ulnar, tibial, superficial peroneal, and sural nerves and the abductor pollicis brevis (APB), abductor digiti minimi (ADM), first dorsal interosseous (FDI), extensor digitorum brevis (EDB), abductor hallucis (AH) and tibialis anterior (TA) muscles were evaluated with ultrasound. The Toronto clinical scoring system (TCSS) was used to assess the severity of neuropathy. The median, ulnar, and tibial nerve cross-sectional areas (CSA) were higher in the DSAP group (p = 0.025, p = 0.011, p < 0.001 respectively) while superficial peroneal and sural nerve CSAs were not differed. Only AH and EDB ultrasonographic findings from the muscles differed between the two groups. Effect of diabetes and DSAP on sonographic findings were assessed with two-way ANOVA. Results indicated that only DSAP had a significant effect on sonographic nerve and muscle examination. The area under the ROC curve was 0.831 ± 0.042 for tibial nerve CSA (p < 0.001) with a cut-off value of 15.5 mm2 (sensitivity 74% and specificity 83%). Median, ulnar and tibial nerve CSAs were found to be larger in polyneuropathy patients and they were associated with the clinical and electrophysiological severity of polyneuropathy. ROC analysis showed that tibial nerve CSA may have a predictive value in the diagnosis of DSAP.

Distal Tibial Mononeuropathy From Compression by the Posterior Tibial Artery: Clinical-Electrophysiological-Ultrasonographic Correlations.

SUMMARY: The tibial nerve is bound tightly to the posterior tibial artery in the tarsal tunnel where expansion capacity is limited. Therefore, the nerve may be vulnerable to, and damaged by chronic pulsatile trauma from an atypically positioned overriding artery, labeled "punched-nerve syndrome". In this article, we present a 49-year-old woman who presented with two months of severe burning pain in the left medial ankle and sole of the foot without antecedent trauma. Neurological examination identified dysesthetic sensation to light touch in the left medial sole of the foot, and both active and passive dorsiflexion worsened the painful paresthesia. Nerve conduction studies demonstrated a reduced left medial plantar mixed nerve action potential amplitude, 50% less than the right. High-resolution ultrasound (HRUS) showed an increased left tibial nerve cross-sectional area of 26 mm2 (normal <22.3 mm2) at the level of the ankle with side-to-side difference of 6 mm2 (normal <5.7 mm2). The distal tibial nerve and its medial plantar branch were atypically positioned immediately deep to the left posterior tibial artery and abnormally flattened with focal enlargement of the nerve on longitudinal view. Dynamic analysis demonstrated the nerve being compressed with each pulsation of the tibial artery immediately above. Active dorsiflexion of the ankle narrowed the space underneath the flexor retinaculum resulting in further compression of the nerve against the artery. In conclusion, HRUS as an adjunct to electrophysiological studies identified punched-nerve arterial compression as an etiology of tarsal tunnel syndrome.

Tibial nerve dynamics during ankle dorsiflexion: The relationship between stiffness and excursion of the tibial nerve.

Peripheral nerves extend with a gradual increase in stiffness and also with excursion, namely reduction of fiber bundle waviness, to adapt to joint movements. Although the close relationships between the tibial nerve (TN) excursion and stiffness during ankle dorsiflexion in cadaver studies, the precise in vivo their relationships remain unclear. We hypothesized that the excursion of the TN can be estimated from its stiffness in vivo using shear-wave elastography. This study aimed to analyze the relationships between the TN stiffness at the plantarflexion and dorsiflexion and TN excursion during dorsiflexion using ultrasonography. Twenty-one healthy adults participated in constant-velocity movements of the ankle joint with a 20° range from the maximum dorsiflexion, and the TN was imaged using an ultrasound imaging system. The maximum flow velocity value and the TN excursion distance per dorsiflexion were then calculated as indexes of excursion using the application software Flow PIV. The shear wave velocities of the TN at plantarflexion and dorsiflexion were also measured. Based on our single linear regression, the shear wave velocities of the TN at the plantarflexion had the strongest effect on the excursion indexes, followed by the those at dorsiflexion. Ultrasonographic shear wave velocity could predict the TN excursion if measured under mild plantarflexion of the ankle joint, and might have a close biomechanical relation to the total waviness of the TN.

Anatomical study of the medial calcaneal nerve using high-resolution ultrasound.

OBJECTIVES: To determine whether high-resolution ultrasound (US) can identify the course and relations of the medial calcaneal nerve (MCN). METHODS: This investigation was initially undertaken in eight cadaveric specimens and followed by a high-resolution US study in 20 healthy adult volunteers (40 nerves) by two musculoskeletal radiologists in consensus. The location and course of the MCN as well as its relationship to adjacent anatomical structures were evaluated. RESULTS: The MCN was consistently identified by US along its entire course. The mean cross-sectional area of the nerve was 1 mm2 (range 0.5-2). The level at which the MCN branched from the tibial nerve was variable, located a mean of 7 mm (range - 7-60) proximal to the tip of the medial malleolus. At the level of the medial retromalleolar fossa, the MCN was located inside the proximal tarsal tunnel a mean of 8 mm (range 0-16) posterior to the medial malleolus. More distally, the nerve was depicted in the subcutaneous tissue at the surface of the abductor hallucis fascia with a mean direct distance to the fascia of 1.5 mm (range 0.4-2.8). CONCLUSIONS: High-resolution US can identify the MCN at the level of the medial retromalleolar fossa, as well as more distally in the subcutaneous tissue at the surface of the abductor hallucis fascia. In the setting of heel pain, precise sonographic mapping of the MCN course may enable the radiologist to make diagnosis of nerve compression or neuroma, and perform selective US-guided treatments. CLINICAL RELEVANCE STATEMENT: In the setting of heel pain, sonography is an attractive tool for diagnosing compression neuropathy or neuroma of the medial calcaneal nerve, and enables the radiologist to perform selective image-guided treatments such as diagnostic blocks and injections. KEY POINTS: • The MCN is a small cutaneous nerve which rises from the tibial nerve in the medial retromalleolar fossa to the medial side of the heel. • The MCN can be depicted by high-resolution ultrasound along its entire course. • In the setting of heel pain, precise sonographic mapping of the MCN course may enable the radiologist to make diagnosis of neuroma or nerve entrapment, and perform selective ultrasound-guided treatments such as steroid injection or tarsal tunnel release.

Quantification and Proximal-to-Distal Distribution Pattern of Tibial Nerve Lesions in Relapsing-Remitting Multiple Sclerosis : Assessment by MR Neurography.

PURPOSE: Recent studies suggest an involvement of the peripheral nervous system (PNS) in multiple sclerosis (MS). Here, we characterize the proximal-to-distal distribution pattern of peripheral nerve lesions in relapsing-remitting MS (RRMS) by quantitative magnetic resonance neurography (MRN). METHODS: A total of 35 patients with RRMS were prospectively included and underwent detailed neurologic and electrophysiologic examinations. Additionally, 30 age- and sex-matched healthy controls were recruited. 3T MRN with anatomical coverage from the proximal thigh down to the tibiotalar joint was conducted using dual-echo 2­dimensional relaxometry sequences with spectral fat saturation. Quantification of PNS involvement was performed by evaluating microstructural (proton spin density (ρ), T2-relaxation time (T2app)), and morphometric (cross-sectional area, CSA) MRN markers in every axial slice. RESULTS: In patients with RRMS, tibial nerve lesions at the thigh and the lower leg were characterized by a decrease in T2app and an increase in ρ compared to controls (T2app thigh: p < 0.0001, T2app lower leg: p = 0.0040; ρ thigh: p < 0.0001; ρ lower leg: p = 0.0098). An additional increase in nerve CSA was only detectable at the thigh, while the semi-quantitative marker T2w-signal was not altered in RRMS in both locations. A slight proximal-to-distal gradient was observed for T2app and T2-signal, but not for ρ. CONCLUSION: PNS involvement in RRMS is characterized by a decrease in T2app and an increase in ρ, occurring with proximal predominance at the thigh and the lower leg. Our results indicate microstructural alterations in the extracellular matrix of peripheral nerves in RRMS and may contribute to a better understanding of the pathophysiologic relevance of PNS involvement.

Sonographic peripheral nerve cross-sectional area in adults, excluding median and ulnar nerves: A systematic review and meta-analysis.

INTRODUCTION/AIMS: Although electromyography remains the "gold standard" for assessing and diagnosing peripheral nerve disorders, ultrasound has emerged as a useful adjunct, providing valuable anatomic information. The objective of this study was to conduct a systematic review and meta-analysis evaluating the normative sonographic values for adult peripheral nerve cross-sectional area (CSA). METHODS: Medline and Cochrane Library databases were systematically searched for healthy adult peripheral nerve CSA, excluding the median and ulnar nerves. Data were meta-analyzed, using a random-effects model, to calculate the mean nerve CSA and its 95% confidence interval (CI) for each nerve at a specific anatomical location (= group). RESULTS: Thirty groups were identified and meta-analyzed, which comprised 16 from the upper extremity and 15 from the lower extremity. The tibial nerve (n = 2916 nerves) was reported most commonly, followed by the common fibular nerve (n = 2580 nerves) and the radial nerve (n = 2326 nerves). Means and 95% confidence interval (CIs) of nerve CSA for the largest number of combined nerves were: radial nerve assessed at the spiral groove (n = 1810; mean, 5.14 mm2 ; 95% CI, 4.33 to 5.96); common fibular nerve assessed at the fibular head (n = 1460; mean, 10.18 mm2 ; 95% CI, 8.91 to 11.45); and common fibular nerve assessed at the popliteal fossa (n = 1120; mean, 12.90 mm2 ; 95% CI, 9.12 to 16.68). Publication bias was suspected, but its influence on the results was minimal. DISCUSSION: Two hundred thirty mean CSAs from 15 857 adult nerves are included in the meta-analysis. These are further categorized into 30 groups, based on anatomical location, providing a comprehensive reference for the clinician and researcher investigating adult peripheral nerve anatomy.

Mapeo sonográfico de los nervios de la cara medial del tobillo y del pie / Sonographic mapping of the nerves of the medial side of the ankle and foot

El uso de los ultrasonidos en el examen, la identificación y el intervencionismo de las diferentes ramas nerviosas del tobillo y del pie son una herramienta de gran apoyo en el ámbito clínico. En la actualidad, la ecografía es un método que se ha ido universalizando en el mundo de la podología, bien por su mayor accesibilidad debido al abaratamiento de los costes, a los avances tecnológicos y a sus beneficios de inocuidad, fácil disponibilidad para el examen inmediato y su aplicación dinámica en la evaluación de las diferentes estructuras anatómicas. El presente trabajo trata de presentar a la comunidad podológica una descripción detallada del mapeo mediante ecografía de los nervios en cara medial del pie. Entendemos que esta descripción puede ayudar a los profesionales en el diagnóstico de las patologías de atrapamiento nervioso a dicho nivel, así como en procedimientos mínimamente invasivos guiados ecográficamente en dicha área anatómica.(AU)

The use of ultrasound in clinical practice is a great tool for the examination, identification and intervention of the different nerve branches in the foot and ankle. Nowadays, sonography is an exploratory method that has been universally expanded in podiatry because of lowering of costs associated to its use, technological progresses and its benefits of safety, disposal for the inmediate clinical exam and its dynamic application in the evaluation of different structures. The aim of the present paper is to present to the podiatry community a detailed description of sonographic mapping of the nerves in the medial side of the ankle. It is intended to help professionals involved in the management of foot ankle disorders regarding the diagnosis of entrapment neuropathies at this level and also to help with minimally invasive treatments sonographically guided.(AU)

Cross-Sectional Area of the Tibial Nerve in Diabetic Peripheral Neuropathy Patients: A Systematic Review and Meta-Analysis of Ultrasonography Studies.

Background: There is a link between diabetic peripheral neuropathy (DPN) progression and the increase in the cross-sectional area (CSA) of the tibial nerve at the ankle. Nevertheless, no prior meta-analysis has been conducted to evaluate its usefulness for the diagnosis of DPN. Methods: We searched Google Scholar, Scopus, and PubMed for potential studies. Studies had to report tibial nerve CSA at the ankle and diabetes status (DM, DPN, or healthy) to be included. A random-effect meta-analysis was applied to calculate pooled tibial nerve CSA and mean differences across the groups. Subgroup and correlational analyses were conducted to study the potential covariates. Results: The analysis of 3295 subjects revealed that tibial nerve CSA was 13.39 mm2 (CI: 10.94−15.85) in DM patients and 15.12 mm2 (CI: 11.76−18.48) in DPN patients. The CSA was 1.93 mm2 (CI: 0.92−2.95, I2 = 98.69%, p < 0.01) larger than DPN-free diabetic patients. The diagnostic criteria of DPN and age were also identified as potential moderators of tibial nerve CSA. Conclusions: Although tibial nerve CSA at the ankle was significantly larger in the DPN patients, its clinical usefulness is limited by the overlap between groups and the inconsistency in the criteria used to diagnose DPN.

Supersonic shear wave imaging of the tibial nerve for diagnosis of diabetic peripheral neuropathy: A meta-analysis.

Background: Diabetic peripheral neuropathy (DPN) is the most common diabetes-associated complication and imposes a significant burden to healthcare systems. Thus, early diagnosis of DPN is extremely critical for management and outcome of diabetic patients. Supersonic Shear Wave Imaging (SSI) enables the noninvasive measurement of nerve stiffness. However, previous studies on SSI in the diagnosis of DPN were limited in sample sizes and reported various results. In this meta-analysis, we aimed to obtain comprehensive evidence on the value of tibial nerve stiffness measurement by SSI in the diagnosis of DPN. Methods: A comprehensive literature search in English and Chinese electronic database was conducted for studies (published until January 25, 2022) that investigated the diagnostic performance of tibial nerve stiffness measurement by SSI for detecting DPN. Summary receiver operating characteristics (SROC) modelling was constructed to conduct the meta-analysis of diagnostic accuracy of SSI for detecting DPN. Results: Finally, a total of 12 eligible studies with 1325 subjects were included for evaluation, and a meta-analysis was conducted to evaluate the diagnostic performance of tibial nerve stiffness measurement by SSI for detecting DPN. For tibial nerve stiffness measurement by SSI, the summary sensitivity and specificity for the diagnosis of DPN were 80% (95% confidence interval [CI]: 73%-86%) and 86% (95% CI: 82%-89%), respectively. The summary area under the ROC curve (AUROC) value of the SROC was 0.90 (95% CI: 0.87-0.92), for diagnosing DPN. A subgroup analysis of 11 SSI studies from China revealed similar diagnostic performance, with a summary sensitivity of 79% (95% CI: 72%-85%), specificity of 86% (95% CI: 82%-89%) and summary AUROC value of the SROC of 0.90 (95% CI: 0.87-0.92) for diagnosing DPN. Conclusions: Our meta-analysis suggests that a tibial nerve stiffness measurement by SSI shows good performance in diagnosing DPN and has considerable potential as a noninvasive tool for detecting DPN.

Shear wave elastography as a quantitative biomarker of diabetic peripheral neuropathy: A systematic review and meta-analysis.

Background: Diabetic peripheral neuropathy (DPN) is one of the most common chronic complications of diabetes and the strongest initiating risk factor for diabetic foot ulceration. Early diagnosis of DPN through screening measures is, therefore, of great importance for diabetic patients. Recently, shear wave elastography (SWE) has been used as a method that is complementary to neuroelectrophysiological examination in the diagnosis of DPN. We aimed to conduct a meta-analysis based on currently available data to evaluate the performance of tibial nerve stiffness on SWE for diagnosing DPN. Methods: Both PubMed, EMBASE, the Cochrane Library, and Web of Science were searched for studies that investigated the diagnostic performance of SWE for DPN up to March 1th, 2022. Three measures of diagnostic test performance, including the summary area under receiver operating characteristics curve (AUROC), the summary sensitivity and specificity, and the summary diagnostic odds ratios were used to assess the diagnostic accuracy of SWE. All included studies were published between 2017 and 2021. Results: Six eligible studies (with 170 DPN patients, 28 clinically defined DPN patients, 168 non-DPN patients, and 154 control participants) that evaluated tibial nerve stiffness were included for meta-analysis. The summary sensitivity and specificity of SWE for tibial nerve stiffness were 75% (95% confidence interval [CI]: 68-80%) and 86% (95% CI: 80-90%), respectively, and the summary AUROC was 0.84 (95% CI: 0.81-0.87), for diagnosing DPN. A subgroup analysis of five two-dimensional SWE studies revealed similar diagnostic performance, showing the summary sensitivity and specificity of 77% (95% CI: 69-83%) and 86% (95% CI: 79-91%), respectively, and a summary AUROC value of 0.86 (95% CI: 0.83-0.89). Conclusions: SWE is found to have good diagnostic accuracy for detecting DPN and has considerable potential as an important and noninvasive adjunctive tool in the management of patients with DPN.