Updated: 6/8/2021

Tarsal Tunnel Syndrome

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  • Summary
    • Tarsal Tunnel Syndrome is a compressive neuropathy of the tibial nerve at the level of the tarsal tunnel which can lead to pain and paresthesias of the plantar foot.
    • Diagnosis can be suspected clinically with burning plantar foot pain with a positive Tinel's sign over the tibial nerve. EMG/NCS can help confirm the diagnosis. 
    • Treatment is an initial trial of pain management and orthotics. Operative tarsal tunnel release is indicated in patients with persistent symptoms who fail nonoperative management. 
  • Etiology
    • 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
  • 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
  • Prognosis
    • Results vary between 50-90% success
    • Worse results with 'double crush' injuries and post-operative scarring
    • Revision surgery less successful than index operation
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(SBQ12FA.43) A 45-year-old male recreational marathoner presents with burning pain over the medial ankle with radiation to the plantar foot and occasionally up into the calf. Physical exam is significant for pes planovalgus and reproduction of his symptoms with combined ankle dorsiflexion, heel eversion, and dorsiflexion of the toes. The patient fails conservative management and requires operative intervention. During complete surgical release, all of the following are potential sites of nerve involvement that require surgical decompression EXCEPT:

QID: 3850

Deep fascia of the abductor hallucis



Deep fascia of the leg



Flexor retinaculum



Medial band of the plantar fascia



Superficial fascia of the abductor hallucis



L 1 C

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