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Tarsal Tunnel Syndrome

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Other Names

  • Entrapment neuropathy of the posterior tibial nerve
  • Tarsal Tunnel Syndrome (TTS)
  • Posterior tibial neuralgia

Background

History

  • First clinical description in 1918 by Von Malaise (need citation)
  • Named by Keck and Lam in 1962 in two separate reports[2][3]

Epidemiology

  • Relatively rare condition; epidemiology is not well described in the literature

Pathophysiology

  • General
    • Entrapment neuropathy of the PTN as it courses through the flexor retinaculum on the medial side of the ankle
    • Rare disorder which causes motor and sensory deficits on the plantar aspect of the foot
    • Diagnosis and management remain challenging to clinicians

Etiology

  • Intrinsic
    • Osteophytes from Ankle Arthritis
    • Hypertrophic retinaculum
    • Tendonopathy
    • Space-occupying lesions such as enlarged veins, ganglia, lipoma, tumour and neuroma
    • Haemorrhage secondary to trauma can lead to scarring, fibrosis
    • Tarsalcalcaneal Coalition[4]
  • Extrinsic
    • Direct trauma
    • Constrictive foot wear
    • Hind foot varus or valgus
    • Generalized lower limb edema (pregnancy, venous congestion)
    • Systemic inflammatory arthropathies
    • Diabetes Mellitus
    • Post surgical scarring
  • Mixed
    • Can be due to more than one intrinsic or extrinsic cause
  • Idiopathic

Pathoanatomy

Illustration of the contents of the tarsal tunnel[5]

Risk Factors

  • Female > Male[8]

Differential Diagnosis


Clinical Features

Clinical demonstration of the dorsiflexion-eversion test[9]

History

  • Predominant symptom is pain directly over tarsal tunnel, behind medial mal radiating into the heel and plantar foot
  • Paraesthesia, dysesthesia and hyperaesthesia along the medial ankle radiating into the sole, heel or digits [10]
  • Burning, numbness, or tingling in the foot
  • Worsens with standing and walking
  • Night symptoms may be reported
  • Improve with rest, elevation
  • Note the dorsum of the foot should be asymptomatic
  • Symptoms are rarely bilateral

Physical Exam: Physical Exam Ankle

  • Tenderness on deep palpation of the tarsal tunnel
  • Valleix Phenomenon may be present
  • Recommended to test two point discrimination on plantar surface[10]

Special Tests


Evaluation

Radiology

  • Standard Radiographs Ankle
    • Often normal but looking for structural abnormalities
  • Potential findings
    • Hind foot varus/valgus
    • tarsal coalitions
    • Osteophytes
    • Evidence of previous trauma

MRI

  • General
    • Highly accurate (83%) when investigating space-occupying lesions[7]
    • Frey found 88% of symptomatic tarsal tunnel patients had significant findings[11]

Ultrasound

  • May provide evidence of direct nerve compression
    • Hypoechoic and never enlargement proximally to entrapment [12]
    • Numkarunarunrote found it may provide evidence of nerve compression by demonstrating nerve enlargement, changes in echogenicity[13]
    • Therimadasamy et al. found patients averaged a cross-sectional area of 0.17 cm2 on the pathological side vs. 0.10 cm2 on the unaffected side[14]
    • Lee et al found mean cross-sectional area of 24 mm2 in patients with diabetic tibial nerve pathology vs. 12 mm2 in people without a neuropathy[15]
  • Can be used to evaluate for[16]
    • Ganglia
    • Varicose veins
    • Lipomas
    • Tenosynovitis
    • Talocalcaneal coalition

CT

  • Can be considered if osseous abnormalities found in plain xray

EMG/NCS

  • General
    • Adjunct study that should be taken in context with history and exam
    • Can not be used in isolation to make the diagnosis
  • Evaluate motor and sensory function
  • Sensitivity of EMG is 90% [17]
  • Useful to distinguish patients with TTS and more proximal lesions

Classification

  • Not applicable

Management

Nonoperative

  • Indications
    • Vast majority of cases are nonoperative initially
    • However treatment should be directed at the specific cause
  • Overall, the literature is weak regarding management of TTS
  • NSAIDS
  • Activity modification
  • Physical Therapy
    • Consider taping, bracing
    • Stretching and strengthening of the calf, tibialis anterior and posterior, peroneal and short toe-flexor muscles
  • Orthotics
    • Orthotic shoes may decrease pressure over the nerve[18]
    • Also consider night splint, removal boot walker
    • Custom orthoses to support the medial and lateral longitudinal arches of the affected foot
  • Procedures

Operative

  • Indications
    • Failure of conservative management
    • Definitive indications of entrapment
  • Technique
    • Tarsal tunnel release [19]
    • Cryosurgery

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/ Work

  • Needs to be updated

Complications and Prognosis

Prognosis

  • Surgical release
    • May improve and resolve the overall symptoms of tarsal tunnel syndrome in up to 85–90% of cases[20]
    • Surgical outcomes are better if the etiology is a space occupying lesion[21]
  • Predictors of good surgical outcome[22]
    • Short history of foot pain
    • Presence of a ganglion
    • No history of trauma or sprain
    • Light working duties
    • Delay in decompression more than 10 months[21]
  • Predictors of poor relief from surgery[23]
    • Incorrect initial diagnosis
    • Incomplete surgical release of the tarsal tunnel
    • Adhesive neuritis following initial decompression measures
    • Intraneural damage/disruption associated with direct neural trauma or systemic disease
    • Presence of a space-occupying lesion or double crush syndrome
  • Cryosurgery
    • May be an effective alternative to standard surgical interventions[24]

Complications


See Also


References

  1. Luis Beltran, J. B. (2010). Entrapment Neuropathies III: Lower Limb. Seminars in Musculoskeletal Radiology, 501-511
  2. Keck C. The tarsal-tunnel syndrome. J Bone Joint Surg Am. 1962;44:180-2.
  3. Lam, S. J. S. "A tarsal-tunnel syndrome." The Lancet 280.7270 (1962): 1354-1355.
  4. Lee, M. F., et al. "Tarsal tunnel syndrome caused by talocalcaneal coalition." Clinical imaging 26.2 (2002): 140-143.
  5. McSweeney, Simon C., and Matthew Cichero. "Tarsal tunnel syndrome—a narrative literature review." The Foot 25.4 (2015): 244-250.
  6. Havel PE, Ebraheim NA, Clark SE. Tibial branching in the tarsal tunnel. Foot Ankle 1988;9:117–9.
  7. 7.0 7.1 Reade BM, Longo DC, Keller MC. Tarsal tunnel syndrome. Clin Podiatr Med Surg 2001;18(3):395–408.
  8. Lau, John TC, and Tim R. Daniels. "Tarsal tunnel syndrome: a review of the literature." Foot & ankle international 20.3 (1999): 201-209.
  9. M Kinoshita, R. O. (2001). The Dorsiflexion-Eversion Test for Diagnosis of Tarsal Tunnel Syndrome. The Journal of Bone and Joint Surgery, 1835-1839
  10. 10.0 10.1 John Lau, T. D. (1999). Tarsal Tunnel Syndrome: A Review of the Literature. Foot & Ankle International, 201-209
  11. Frey, Carol, and Roger Kerr. "Magnetic resonance imaging and the evaluation of tarsal tunnel syndrome." Foot & ankle 14.3 (1993): 159-164.
  12. Jon Jacobson, T. W. (2016). Sonography of Common Peripheral Nerve Disorders With Clinical Correlation. The American Institute of Ultrasound in Medicine , 683-693.
  13. Numkarunarunrote, Numphung, et al. "Retinacula of the foot and ankle: MRI with anatomic correlation in cadavers." American Journal of Roentgenology 188.4 (2007): W348-W354.
  14. Therimadasamy, A., et al. "Combination of ultrasound and nerve conduction studies in the diagnosis of tarsal tunnel syndrome." Neurology India 59.2 (2011): 296.
  15. Lee, Doohi, and Damien M. Dauphinée. "Morphological and functional changes in the diabetic peripheral nerve: using diagnostic ultrasound and neurosensory testing to select candidates for nerve decompression." Journal of the American Podiatric Medical Association 95.5 (2005): 433-437.
  16. Nagaoka M, Matsuzaki H. Ultrasonography in tarsal tunnel syndrome. J Ultrasound Med 2005;24:1035–40.
  17. Troy Watson, R. A. (2002). Distal Tarsal Tunnel Release With Partial Plantar Fasciotomy for Chronic Heel Pain: An Outcome Analysis. Foot & Ankle International.
  18. Gessini L, Jandolo B, Pietrangeli A. The anterior tarsal syndrome. J Bone Joint Surg 1984;66A:786–7.
  19. Eric Ferkel, W. D. (2015). Entrapment Neuropathies of the Foot and Ankle. Clinics in Sports Medicine, 791-801
  20. Radin, Eric L. "Tarsal tunnel syndrome." Clinical orthopaedics and related research 181 (1983): 167-170.
  21. 21.0 21.1 Takakura, Y., et al. "Tarsal tunnel syndrome. Causes and results of operative treatment." The Journal of bone and joint surgery. British volume 73.1 (1991): 125-128.
  22. Baba, H., et al. "The tarsal tunnel syndrome: evaluation of surgical results using multivariate analysis." International orthopaedics 21.2 (1997): 67-71.
  23. Raikin, Steven M., and John M. Minnich. "Failed tarsal tunnel syndrome surgery." Foot and ankle clinics 8.1 (2003): 159-174.
  24. Goldstein, S. H. "Cryosurgery for the Treatment of Tarsal Tunnel Syndrome." PODIATRY MANAGEMENT 25.8 (2006): 163.
  25. Wallach, D. M., and S. D. Katchis. "Tarsal tunnel syndrome." Disorders of the heel, rear foot, and ankle. Churchill: Livingston (1999): 125-34.
Created by:
John Kiel on 14 June 2019 08:40:12
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Last edited:
25 May 2023 07:07:43
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