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Updated: Mar 6 2023

Tarsal Tunnel Syndrome

  • 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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