Updated: 3/29/2017

Tarsal Tunnel Syndrome

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Introduction
  • compressive neuropathy caused by compression of the tibial nerve
    • may be subdivided into anterior  or posterior tarsal tunnel syndrome 
  • Mechanism
    • types of impingment
      • intrinsic
        • ganglion cyst  
        • tendonopathy
        • tenosynovitis
        • lipoma/tumor
        • peri-neural fibrosis
        • osteophytes
      • extrinsic
        • shoes
        • trauma
        • anatomic deformity (tarsal coalition, valgus hindfoot)
        • post-surgical scaring
        • systemic inflammatory disease
        • edema of the lower extremity
      • cause of impingement able to be identified in 80% of cases
  • Prognosis
    • results vary between 50-90% success
    • worse results with 'double crush' injuries and post-operative scarring
    • revision surgery less successful than index operation
Anatomy
  • Posterior tarsal tunnel  
    • an anatomic structure defined by
      • flexor retinaculum (laciniate ligament)
      • calcaneus (medial)
      • talus (medial)
      • abductor hallucis (inferior)
    • contents include
      • tibial nerve
      • posterior tibial artery
      • FHL tendon
      • FDL tendon
      • tibialis posterior tendon
  • Tibial nerve
    • has 3 distal branches
      • medial plantar
      • lateral plantar
      • medial calcaneal
      • the medial and lateral plantar nerves can be compressed in their own sheath distal to tarsal tunnel
      • bifurcation of nerves occurs proximal to tarsal tunnel in 5% of cases
  • Anterior tarsal tunnel  
    • flattened space defined by
      • inferior extensor retinaculum
      • fascia overlying the talus and navicular 
    • contents include
      • deep peroneal nerve and branches
      • EHL
      • EDL
      • dorsalis pedis artery 
Presentation
  • History
    • may have previous trauma or surgery
  • Symptoms
    • pain
      • pain with prolonged standing or walking
      • often vague and misleading medial foot pain
      • sharp, burning pains in the foot
    • numbness
      • intermittent paresthesias and numbness in the plantar foot
    • may present as part of the "heel pain triad"   
      • posterior tibial tendon deficiency (adult-acquired flatfoot), plantar fasciitis, tarsal tunnel syndrome
      • believed to be due to loss of static and dynamic stabilizers of the medial arch and susequent traction neuropathy on the tibial nerve
  • Physical exam
    • tenderness of tibial nerve (tinel's sign)
    • sensory exam equivocal
    • pes planus
    • muscle wasting of foot intrinsics
      • abductor digiti quinti or abductor hallucis
    • pain with dorsiflexion and eversion of the ankle
    • compression test
      • plantar flexion and inversion of ankle
      • digital pressure over tarsal tunnel
        • highly senstitive and specific
Imaging 
  • Radiographs
    • weight-bearing radiographs provide osseous structure
  • MRI
    • may be helpful to rule out accessory muscle or soft-tissue tumor
Studies
  • EMG
    • positive finding include
      • distal motor latencies of 7.0 msec or more
      • prolonged SENSORY latencies of more than 2.3 msec
        • sensory (SAP) more likely to be abnormal than motor
      • decreased amplitude of motor action potentials of
        • abductor hallucis
        • or abductor digiti minimi
  • Diagnosis
    • history is often most useful diagnostic aid
Treatment
  • Nonoperative
    • lifestyle modifications, medications
      • indications
        • usually ineffective
      • medications
        • anti-inflammatory medications
        • SSRIs have been used
      • bracing
        • orthosis or foot wear changes to address alignment of hindfoot
        • can try a period of short-leg cast
  • Operative
    • surgical release of tarsal tunnel
      • indications
        •  after 3-6 months of failed conservative management and
          • compressive mass (ganglion cyst) identified
          • positive EMG
          • reproducible physical findings
      • outcomes
        • best results following surgery are in cases where a compressing anatomic structure (ganglion cyst) is identified and removed 
        • traction neuritis does not respond as well to surgery
Technique
  • Tarsal Tunnel Surgical Release 
    • approach
      • identify the nerve proximally
    • decompression
      • layers that must be released include
        • flexor retinaculum
        • deep investing fascia of lower leg
        • superficial and deep fascia of abductor hallucis
Complications
  • Recurrence
    • usually caused by inadequate release
    • repeat tarsal tunnel release not recommended
 

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