https://orcid.org/0009-0000-1322-7720
Figures
Abstract
Early recognition of DPN gives physicians the opportunity to deliver appropriate treatment and counseling to minimize subsequent complications. This study aimed to evaluate the diagnostic performance of tibial nerve cross-sectional area (CSA) in detecting DPN using a Modified Toronto Clinical Neuropathy Score (mTCNS) ≥ 3 as the diagnostic reference in Thai diabetic patients. A total of 67 diabetic patients (120 limbs) were enrolled from Srinagarind Hospital between 2022 and 2023. A total of 120 limbs belonging to 67 patients were categorized into two groups: non-DPN group (mTCNS < 3) (n = 42) and DPN group (mTCNS ≥ 3) (n = 78). Tibial nerve CSA was measured 3 cm proximal to the medial malleolus using ultrasound. Clinical parameters and metabolic profiles were recorded. Receiver operating characteristic analysis, correlation analyses, and multivariable logistic regression were performed to evaluate diagnostic utility and associations between CSA and clinical parameters. The tibial nerve CSA was significantly higher in the DPN group (13.49 mm2, 95% CI: 12.84–14.13) compared to the non-DPN group (11.98 mm2, 95% CI: 10.95–13.02) (p = 0.015). A CSA threshold of 13 mm2 yielded a sensitivity of 58.5% and specificity of 74.2%. CSA positively correlated with mTCNS (r = 0.49, p < 0.001) and sensation score (r = 0.37, p = 0.002) in DPN patients. Logistic regression identified CSA and estimated glomerular filtration rate as independent predictors of DPN status. Tibial nerve CSA may serve as a useful structural marker to support the identification of DPN. When used alongside established clinical assessments, CSA measurement could contribute to earlier detection and improved risk stratification in diabetic populations.
Citation: Suwannakhan A, Khamsai S, Pratipanawatr T, Kirisattayakul W, Munkong W, Prab Na Sak N, et al. (2026) Ultrasound assessment of tibial nerve cross-sectional area in diabetic peripheral neuropathy in the Thai Population. PLoS One 21(2): e0343128. https://doi.org/10.1371/journal.pone.0343128
Editor: Fentahun Adane Nigat, Debre Markos University, ETHIOPIA
Received: September 23, 2025; Accepted: February 2, 2026; Published: February 25, 2026
Copyright: © 2026 Suwannakhan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Data cannot be shared publicly because of ethical restrictions. Data are available from the Khon Kaen University Ethics Committee for Human Research (contact via eckku@kku.ac.th) for researchers who meet the criteria for access to confidential data.
Funding: (i) Khon Kaen University (KKU), (ii) Thailand Science Research and Innovation (TSRI), and (iii) National Science Research and Innovation Fund (NSRF), [research no. 200689]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Diabetes mellitus (DM) is a chronic disease that poses a global public health challenge, with reports indicating that the incidence of DM is steadily increasing each year [1]. Similarly, in Thailand, the prevalence of DM rose from 6.9% in 2009 to 8.9% in 2014, and this trend is expected to continue [2,3]. It is well known that DM is often accompanied by complications if not properly treated, which significantly impact patients’ daily lives and economic conditions. These complications include retinopathy, chronic kidney disease, cardiovascular and cerebrovascular diseases, and complications in the hands and feet, known as diabetic peripheral neuropathy (DPN). Studies have shown that foot and leg complications are the most common complications among DM patients worldwide, affecting up to 20% of patients and leading to amputation of limbs in 40–50% of cases [4], causing disability and death. Early diagnosis before the onset of complications could enable physicians to provide timely treatment and guidance to prevent, reduce, or delay DPN-related complications [5].
Ultrasound is a diagnostic tool is recognized as a non-invasive, highly effective, low-cost procedure which can be used to detect nerve abnormalities and diseases [6,7]. Ultrasound offers a non-invasive and real-time assessment of nerve morphology, allowing visualization of structural changes such as nerve enlargement or altered echotexture in DPN. Unlike electromyography, ultrasonography can identify early anatomical alterations even before clinical symptoms or electrophysiological changes appear [6,7]. MRI neurography can also provide CSA measurements with high soft-tissue contrast but is less practical for routine use due to cost and time [8]. Previous studies [9–12] and a recent meta-analysis [13] has investigated the cross-sectional area (CSA) of the tibial nerve, demonstrating that DPN patients tend to have a larger CSA compared to diabetic patients without DPN. This enlargement of the tibial nerve CSA aligns with typical DPN symptoms, such as absent ankle reflexes and impaired sensations of vibration, pinprick, temperature, and light touch along the tibial nerve distribution. In contrast, peroneal and common peroneal nerve measurements are more useful in focal mononeuropathies and are less specific for the distal, length-dependent changes typical of DPN [14]. The distal tibial nerve demonstrates more pronounced CSA enlargement in length-dependent polyneuropathy than the sural nerve [15]. Despite the potential use of tibial nerve CSA as a diagnostic marker for DPN, a recent meta-analysis has recognized that tibial nerve CSA could be influenced by other factors such as ethnicity, age, weight, and body mass index, limiting its clinical utility [16]. Furthermore, no prior study has specifically examined the tibial nerve CSA in the Thai population.
Therefore, further research and population-specific data are needed to validate the feasibility of tibial nerve CSA as a potential diagnostic marker for DPN. The aim of this study is to investigate the CSA of the tibial nerve in DM patients with and without DPN in the Thai population.
Methods
Study population and neuropathy assessment
This study was approved by Khon Kaen University Ethics Committee for Human Research (HE651022). Participants were recruited from Srinagarind Hospital, Khon Kaen Province, between 19/09/2022 and 19/12/2022. Prior to participation, all volunteers provided written informed consent. Eligible participants were required to be over 18 years of age and capable of effective communication, excluding those who were unable to communicate due to advanced age or cognitive decline. Participants confirmed diagnosis of type 2 diabetes mellitus based on HbA1c results obtained within the past three months. The subjects could additionally exhibit clinical evidence of diabetic peripheral neuropathy, including a foot ulcer that did not interfere with tibial nerve ultrasound assessment. Participants were excluded if they had type 1 diabetes, a history of neuromuscular disorders or any other conditions affecting the peripheral nervous system. Additionally, limbs with ulcers or wounds on the soles of the feet or ankles, which could interfere with the study procedures, were not eligible for participation. Sample size was calculated using G*Power software based on a predetermined statistical power, effect size, and significance level. The suggested sample size was determined to be 125.
The sensory assessment in this study includes multiple tests to evaluate neuropathy status. The monofilament test (10g) was performed protective sensation by pressing a nylon filament against the foot. Failure to perceive it indicates sensory loss. The vibration test (128 Hz tuning fork) was used to measure vibratory sensation at the great toe and heel, with early loss suggesting neuropathy. The pinprick test evaluated pain sensation, while the cold sensation test assesses temperature perception using a cold rod. The proprioception test checked position sense by moving the great toe up or down with the patient’s eyes closed. The Modified Toronto Clinical Neuropathy Score (mTCNS) was used to quantify neuropathy severity by combining symptom assessment and sensory tests. Symptoms like pain, numbness, tingling, weakness, ataxia, and upper limb involvement are scored from 0 (none) to 3 (severe). The mTCNS also integrates monofilament, vibration, pinprick, cold sensation tests, and reflex assessments to classify neuropathy severity. In addition, fasting blood sugar (FBS), HbA1C, estimated glomerular filtration rate (eGFR), low-density lipoprotein (LDL), and triglycerides levels are recorded for all participants.
In total, 67 patients were enrolled, comprising 120 lower limb sides. Some limbs were excluded from the study because due to prior amputation or severe foot ulcers. Based on the mTCNS, participants were categorized into two groups: the non-DPN group (mTCNS < 3) (42 limbs) and the DPN group (mTCNS ≥ 3) (78 limbs). This classification was used as the gold standard for diabetic peripheral neuropathy diagnosis [17].
Ultrasonography of the tibial nerve
Participants were asked to lie on their backs in a relaxed position. For the right tibial nerve measurement, the right leg was rotated to lateral position. The tibial nerve level located 3 cm proximal to the apex of the medial malleolus was used for measurement. This site was the most commonly used location for tibial nerve measurement, as indicated by our previous meta-analysis [13]. The ultrasound was performed by 2 well-trained radiological technologists, who were blinded to the DPN status. The ultrasound imaging was conducted using a linear array transducer (12L-RS, GE Healthcare, USA) in brightness mode. The transducer was placed transversely and perpendicular to skin. The ultrasound imaging parameters, including frequency (10 MHz), imaging depth (3.0 cm), gain (12 dB), focal zones (two points), dynamic range (75 dB), grayscale mapping (H/0), and frame rate (15 Hz), were set by an ultrasound product specialist to ensure optimal image quality (Fig 1). These parameters were kept constant across all participants. The left tibial nerve measurement was measured later following the same procedure. For each limb, two images were acquired by each observer, and the CSA values from the paired images were averaged to yield an observer-specific mean. The final CSA used for analysis was obtained by averaging the measurements from both observers to ensure consistency and reduce inter-observer variability.
Statistical analysis
To explore associations between CSA and clinical parameters, Spearman’s rank correlation analysis were performed. Prior to the correlation analysis, Shapiro–Wilk test was performed to check data normality. A multivariable logistic regression analysis was performed to identify independent predictors of DPN among all study participants. The model was fitted using the statsmodels library in Python, and odds ratios (OR) with 95% confidence intervals (CI) were calculated by exponentiating the regression coefficients. Inter-rater reliability was assessed using the intraclass coefficient (ICC). Statistical significance was established at p = 0.05.
Results
Demographic and clinical characteristics of participants were compared between diabetic patients with mTCNS < 3 (non-DPN group) and those with mTCNS ≥ 3 (DPN group) (Table 1). Duration of diabetes was significantly longer in the DPN group (128.4 ± 80.2 months) compared to the non-DPN group (93.1 ± 90.8 months, p = 0.038). Additionally, eGFR was significantly lower in the DPN group (76.7 ± 25.1) than in the non-DPN group (90.5 ± 17.5, p < 0.01). No other significant differences were observed between the groups.
The mean tibial nerve CSA in the non-DPN group was 11.98 mm2 (95% CI: 10.95–13.02), while the DPN group had a significantly higher mean CSA of 13.49 mm2 (95% CI: 12.84–14.13) (p = 0.015) (Fig 2). The ICC was 0.81, indicating good agreement between the two observers.
To evaluate the diagnostic performance of tibial nerve CSA in detecting DPN, CSA thresholds ranging from 7 mm2 to 19 mm2 were analyzed using mTCNS ≥ 3 as the diagnostic reference standard (Table 2). The optimal CSA threshold, determined by the highest Youden’s Index, was identified at 13 mm2. At this threshold, the sensitivity was 58.5% (95% CI: 46.5–69.7) and the specificity was 74.2% (95% CI: 64.3–82.3). Thresholds lower than 11 mm2 demonstrated higher sensitivity but considerably lower specificity, while thresholds above 15 mm2 markedly reduced sensitivity without substantial gains in specificity. Correlation analyses (Fig 3) between CSA and clinical parameters were performed separately for non-DPN and DPN groups. In the DPN group, significant positive correlations were observed between CSA and several neuropathy-related measures. CSA demonstrated a moderate positive correlation with mTCNS (r = 0.49, p < 0.001), indicating that nerve enlargement was associated with increasing neuropathy severity. Additionally, CSA was positively correlated with sensation score (r = 0.37, p = 0.002), suggesting that impaired sensory function corresponded with increased tibial nerve CSA. In the non-DPN group, CSA showed a significant positive correlation with fasting blood sugar (FBS) (r = 0.47, p = 0.004) and glycated hemoglobin (HbA1c) (r = 0.44, p = 0.007), reflecting a potential association between poor glycemic control and nerve structural changes even in patients without clinically overt neuropathy. No significant correlations between CSA and age, body weight, BMI, diabetes duration, eGFR, LDL, or triglyceride levels were identified in either group.
Each panel (A–K) displays a scatter plot with separate regression lines for both groups. Spearman correlation coefficients (r) and p-values are shown.
A multivariable logistic regression model (Table 3) was developed to predict DPN status, defined by a Modified Toronto Clinical Neuropathy Score (mTCNS) ≥ 3. The predictors included tibial nerve cross-sectional area (CSA) and relevant clinical parameters, excluding mTCNS and sensation scores. In the full multivariable model, CSA (OR 2.01; 95% CI: 1.20–3.38; p = 0.008) and eGFR (OR 0.52; 95% CI: 0.31–0.87; p = 0.013) were significantly associated with DPN. Duration of diabetes, age, weight, BMI, FBS, HbA1c, LDL, and triglyceride levels were not significantly associated with DPN in the full model. Following stepwise backward elimination (Table 3), CSA (OR 1.95; 95% CI: 1.24–3.08; p = 0.004) and eGFR (OR 0.50; 95% CI: 0.32–0.80; p = 0.003) remained in the final model. Duration and other metabolic parameters were removed during the elimination process.
Discussion
Our findings demonstrated that tibial nerve CSA was significantly greater in diabetic patients with DPN compared to those without, reinforcing its role as a potential structural biomarker for neuropathy. Our findings align with prior studies indicating that tibial nerve CSA is enlarged in DPN patients compared to diabetic controls without neuropathy [13,16,18–20]. Hypoechoic changes and increased nerve fascicle thickness on ultrasound have been well documented as early sonographic signs of neuropathy [19,21]. Standard diagnostic modalities for DPN, such as nerve conduction studies are valuable for assessing functional impairment but have well-recognized limitations. Nerve conduction studies are time-consuming, require specialized expertise, and often detect abnormalities only after significant nerve damage has occurred [12]. Quantitative sensory testing relies heavily on patient cooperation and cannot localize structural changes. Ultrasound measurement of tibial nerve CSA offers a rapid, non-invasive method to visualize structural alterations that may appear earlier in the disease course [6,7].
The mean CSA was significantly higher in the DPN group (13.49 mm2) compared to the non-DPN group (11.98 mm2) (p = 0.015). ROC curve analysis determined that a CSA threshold of 13 mm2 achieved the most favorable diagnostic balance, with a sensitivity of 58.5% and specificity of 74.2%. Threshold selection for tibial nerve CSA plays a crucial role in optimizing its clinical utility. According to Table 2, thresholds lower than 10 mm2 demonstrated higher sensitivity but substantially lower specificity, making them more suitable for screening purposes where the priority is to capture as many potential DPN cases as possible. Conversely, thresholds above 15 mm2 markedly reduced sensitivity without significant gains in specificity, indicating that they are better suited for confirmatory diagnosis where minimizing false positives is essential. In the context of previous ultrasound studies, the tibial nerve CSA values observed in our Thai cohort fall within the lower-middle range of those reported elsewhere. Our prior meta-analysis [13] demonstrated that mean tibial CSA in patients with DPN varied widely, from approximately 6–8 mm2 in early- or lower-stage disease [11,19,22,23] to more than 20 mm2 in cohorts with longer diabetes duration or more advanced neuropathy [10,18,24,25]. Intermediate mean values of around 12–19 mm2 were reported in several other series [26–31]. The pooled mean CSA for DPN across all studies was 15.1 mm2 (95% CI 11.8–18.5), with marked heterogeneity (I2 ≈ 100%). In comparison, the mean CSA of 13.49 mm2 in our DPN group and the optimal diagnostic threshold of 13 mm2 are slightly below this pooled estimate but remain broadly consistent with the lower end of the global range. While enlargement of tibial nerve CSA was associated with neuropathy, it does not capture all clinically affected individuals and may miss early or mild cases. In practice, this limitation suggests that tibial CSA should not be used as a standalone. It should be used alongside a complementary measure alongside established clinical assessments such as mTCNS or nerve conduction studies. Also, an elevated CSA may help identify patients who warrant closer monitoring or further electrophysiological evaluation, whereas a normal CSA does not exclude neuropathy. Factors such as age, BMI, metabolic status, and ethnic differences [13,16], which are known to influence peripheral nerve size, may further reduce the generalizability of a single cutoff value.
In terms of clinical correlations, CSA was significantly associated with mTCNS in the DPN group, reinforcing its role as a marker of neuropathy severity. However, no significant correlation was observed between CSA and the duration of diabetes in either group. This finding is in agreement with Oduola-Owoo et al. [32], who found no relationship between CSA and diabetes duration or BMI. Conversely, Jiang et al. [33] reported a positive correlation between diabetes duration and CSA especially in patients with disease duration exceeding 10 years. These differences may be attributed to variation in population characteristics, diabetes management practices, and the stage of neuropathy at the time of evaluation. With respect to glycemic control, our findings are consistent with some studies that found no significant correlation between HbA1c and tibial CSA or nerve mechanical properties [12,34]. Although previous studies suggested a positive association between HbA1c and nerve enlargement [18,24], our data indicate that CSA may reflect long-term structural damage rather than short- to mid-term glycemic fluctuations. Similarly, Hsieh et al. [35] demonstrated that elevated HbA1c levels were correlated with clinical and sonographic markers of polyneuropathy, but these associations did not translate into measurable increases in CSA. Interestingly, in our non-DPN group, CSA showed strong positive correlations with both HbA1c and eGFR. These findings suggest that subclinical nerve changes may be occurring in metabolically stressed individuals prior to the onset of clinical neuropathy. This is in line with emerging perspectives that view nerve enlargement as an early indicator of peripheral nerve stress, even before clinical thresholds for DPN are met.
While promising, this study has limitations. The relatively modest sample size may have limited the detection of smaller effect sizes in subgroup analyses. The cross-sectional design precludes determination of causality or temporal relationships between metabolic dysfunction and CSA changes. Potential confounders such as medication use, vitamin deficiencies, or comorbidities were not systematically controlled for. The operator-dependent nature of ultrasound measurements and the lack of electrophysiological correlation should be acknowledged. Because all participants were recruited from a single center, broader population inferences should be made with caution, and larger multicenter studies are needed to validate these findings. Future research is required to define tibial nerve CSA thresholds tailored to specific populations.
Conclusion
Increased CSA was significantly associated with both neuropathy severity and reduced kidney function. A CSA threshold of approximately 13 mm2 provided the best diagnostic balance for detecting DPN, although its moderate sensitivity and specificity indicate that CSA should be interpreted as part of a multimodal assessment rather than a standalone diagnostic test. While tibial CSA shows promise as a structural marker that may aid severity classification, further longitudinal studies are required to determine its ability to predict neuropathy progression and to refine population-specific threshold values.
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