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Tarsal Tunnel Syndrome

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  • Tarsal tunnel syndrome can occur during pregnancy, typically secondary to local compression caused by fluid retention and volume changes (1).

  • Care is supportive. Most cases resolve after pregnancy.

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EPIDEMIOLOGY


  • Women are slightly more affected than men (56%).
  • All postpubescent ages are affected.

ETIOLOGY AND PATHOPHYSIOLOGY


  • The posterior tibial nerve passes through the tarsal tunnel, which is formed by three osseus structures " ösustentaculum tali, medial calcaneus, and medial malleolus " öcovered by the laciniate ligament.
  • Compression of the posterior tibial nerve within the the tarsal tunnel results in decreased blood flow, ischemic damage, and resultant symptoms (1).
  • Chronic compression can destroy endoneurial microvasculature, leading to edema and (eventually) fibrosis and demyelination (2).
  • Increased pressure in the tarsal tunnel is caused by a variety of mechanical and biochemical mechanisms. The specific cause for compression is identifiable in only 60 " ô80% of patients (1).
  • Three general categories: trauma, space-occupying lesions, deformity (1)
    • Trauma including displaced fractures, deltoid ligament sprains, or tenosynovitis
    • Varicosities
    • Hindfoot varus or valgus
    • Fibrosis of the perineurium
  • Other causes:
    • Osseous prominences
    • Ganglia; lipoma; neurolemmoma
    • Inflammatory synovitis
    • Pigmented villonodular synovitis
    • Tarsal coalition
    • Accessory musculature
  • In patients with systemic disease (e.g., diabetes), the "double crush " Ł syndrome refers to the development of a second compression along the same nerve at a site of anatomic narrowing in patients with previous proximal nerve damage (3).
  • Tarsal tunnel decompression may improve sensory impairment and restore protective sensation in diabetic peripheral neuropathies if there is nerve entrapment at the tarsal tunnel.

RISK FACTORS


  • Tarsal tunnel syndrome is associated with certain occupations and activities involving repetitive weight bearing on the foot and ankle (jogging, dancing).
  • Other possible risk factors include (4):
    • Diabetes
    • Systemic inflammatory arthritis
    • Connective tissue disorders
    • Obesity
    • Varicosities
    • Heel varus or valgus
    • Bifurcation of the posterior tibial nerve into medial and lateral plantar nerves proximal to the tarsal tunnel

DIAGNOSIS


Tarsal tunnel syndrome is largely a clinical diagnosis, characterized by pain and paresthesias in a predictable distribution along the medial aspect of the ankle and plantar surface of the foot (1). é á

HISTORY


  • History of trauma (may be trivial) to the foot precipitating pain
  • Pain behind medial malleolus radiating to the longitudinal arch and plantar aspect of foot including the heel
  • Tightness, burning, tingling, and numbness (1)
  • Pain usually worsens during standing or activity.
  • Pain radiates proximally up the medial leg (Valleix phenomenon) in 33% of patients with severe compression.
  • Some patients have substantial night pain (may be related to venostasis).
  • Symptoms improve with rest, wearing loose footwear, and elevation.
  • In advanced nerve compression, motor involvement may cause weakness, atrophy, and digital contractures of the intrinsic foot muscles (4).

ALERT

Other systemic neuropathies (diabetes, alcoholism, HIV, drug reactions) present with similar symptoms.

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PHYSICAL EXAM


  • Foot alignment
    • Examine for hindfoot varus or valgus deformity.
    • Exaggerating heel dorsiflexion, inversion, or eversion may reproduce symptoms by stretching or compressing the posterior tibial nerve.
  • Palpate the tarsal tunnel and the course of the tibial nerve for tenderness and swelling.
  • Tinel sign: Percussion over the the tibial nerve may reproduce paresthesias that radiate distally.
  • Valleix sign: Percussion over the tibial nerve may produce paresthesias that radiate proximally.
  • Cuff test: Inflating a pneumatic cuff engorges varicosities and reproduces symptoms.
  • Compression test: Applying pressure to the tarsal tunnel for 60 seconds may reproduce symptoms.
  • Sensory examination
    • The medial calcaneal nerve usually is spared, but numbness and altered sensation may be present in the distribution of the medial or lateral plantar nerves.
    • Vibratory sensation and two-point discrimination are decreased early in the disease process.
  • Motor examination
    • Intrinsic foot muscle weakness (difficult to assess)
    • Rarely, weakness of toe plantar flexion may be present.
    • Atrophy of the abductor hallucis or abductor digiti minimi may be seen late in the disease process.

DIFFERENTIAL DIAGNOSIS


  • Peripheral neuropathies (diabetes, alcoholism, HIV, or drug related)
  • Inflammatory arthritis (rheumatoid arthritis)
  • Morton neuroma
  • Metatarsalgia
  • Subtalar joint arthritis
  • Tibialis posterior tendinitis/dysfunction
  • Plantar fasciitis
  • Plantar callosities
  • Peripheral vascular disease
  • Lumbar radiculopathy
  • Proximal injury or compression of the tibial branch of the sciatic nerve

DIAGNOSTIC TESTS & INTERPRETATION


Initial Tests (lab, imaging)
Routine lab tests help rule out other conditions that may mimic tarsal tunnel syndrome, including diabetic neuropathy, rheumatoid arthritis, thyroid dysfunction, or other systemic illnesses (5). é á
  • Routine weight-bearing radiographs, followed by CT (if necessary) to assess for fracture or structural abnormality
  • Consider evaluation of lumbar spine x-ray if double crush (injury to lumbar nerve results in compensatory injury to posterior tibial nerve) is suspected (5).
  • MRI: helps assess the tarsal tunnel for soft tissue masses or other sources of nerve compression before surgery (1)
  • Ultrasound: Gaining importance and with several advantages over MRI (6); can assess for tenosynovitis, ganglia, varicose veins, or lipomas (1)

Pediatric Considerations

MRI is recommended for evaluating pediatric tarsal tunnel syndrome to exclude neoplastic mass.

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Diagnostic Procedures/Other
Electrodiagnostic studies é á
  • Electromyography (EMG) of the intrinsic muscles of the foot can confirm the diagnosis of tarsal tunnel syndrome (7). A normal EMG does not exclude the diagnosis (false-negative rate is ó ł ╝10%) (1).
  • Nerve conduction studies may reveal slowed conduction of the tibial nerve.
  • Evaluate for proximal nerve compression, including a lumbar radiculopathy or a double crush phenomenon.

TREATMENT


Conservative management is recommended, except for acute onset tarsal tunnel syndrome or in the setting of a known space-occupying lesion (excluding synovitis). é á

MEDICATION


First Line
  • Analgesics and anti-inflammatory medications
  • Local corticosteroid injection
  • Medications that alter neurogenic pain (tricyclic antidepressants, antiepileptic drugs, nerve blockers)

ADDITIONAL THERAPIES


  • Rest/immobilization
  • Taping and bracing
  • Orthotics or shoe modification
  • Physical therapy to strengthen the intrinsic and extrinsic muscles of the foot and to restore the medial longitudinal arch
  • Other modalities (stretching, US, massage, icing)
  • Compression stockings to decrease swelling
  • Weight loss for obese patients

SURGERY/OTHER PROCEDURES


  • Surgery is indicated (1,2,8).
    • If nonoperative measures fail following a 3- to 6-month trial
    • In the setting of acute tarsal tunnel syndrome
    • If a space-occupying lesion is identified
  • The surgical outcome is dependent on technique and postoperative management. 50 " ô95% of cases have good to excellent outcomes.
  • At the time of surgery, assess focal swelling, scarring, or nerve abnormalities and look for a pathologic source of compression.
  • Postoperative management includes:
    • Non " ôweight-bearing splint until incision heals (2 to 3 weeks), followed by progressively increased weight-bearing and range of motion exercises
    • Rest, ice, compression, elevation to limit swelling

ONGOING CARE


PATIENT EDUCATION


  • Discuss conservative and surgical options based on individual patient circumstance and preference.
  • A decision about surgical intervention should be made with a clear understanding risks, benefits, and potential adverse outcomes.

PROGNOSIS


Surgery is most helpful for: é á
  • Patients with a positive Tinel sign (3)[B]
  • Young patients
  • Short period between occurrence of symptoms and surgery <1 year (9)[B].
  • Localized space-occupying lesion (1)
  • No motor neuron involvement

COMPLICATIONS


  • The main adverse outcome is an unsuccessful surgical intervention characterized by lack of improvement or recurrence of symptoms (1).
  • Causes for a failed tarsal tunnel release include (10):
    • Incorrect diagnosis
    • Incomplete release
    • Adhesive neuritis (external scar formation)
    • Intraneural damage (systemic disease, direct nerve injury)
    • Failure to treat all sources of nerve compression in a double crush phenomenon
  • Electrodiagnostic studies are rarely helpful in determining the cause of a failed tarsal tunnel release.
  • Results with surgical revision are poorer than those for the primary surgical release.

REFERENCES


11 Ahmad é áM, Tsang é áK, Mackenney é áPJ, et al. Tarsal tunnel syndrome: a literature review. Foot Ankle Surg.  2012;18(3):149 " ô152.22 Dellon é áAL. The four medial ankle tunnels: a critical review of perceptions of tarsal tunnel syndrome and neuropathy. Neurosurg Clin N Am.  2008;19(4):629 " ô648.33 Dellon é áAL, Muse é áVL, Scott é áND, et al. A positive Tinel sign as predictor of pain relief or sensory recovery after decompression of chronic tibial nerve compression in patients with diabetic neuropathy. J Reconstr Microsurg.  2012;28(4):235 " ô240.44 Franson é áJ, Baravarian é áB. Tarsal tunnel syndrome: a compression neuropathy involving four distinct tunnels. Clin Podiatr Med Surg.  2006;23(3):597 " ô609.55 Fantino é áO. Role of ultrasound in posteromedial tarsal tunnel syndrome: 81 cases. J Ultrasound.  2014;17(2):99 " ô112.66 Patel é áAT, Gaines é áK, Malamut é áR, et al. Usefulness of electrodiagnostic techniques in the evaluation of suspected tarsal tunnel syndrome: an evidence-based review. Muscle Nerve.  2005;32(2):236 " ô240.77 Sung é áKS, Park é áSJ. Short-term operative outcome of tarsal tunnel syndrome due to benign space-occupying lesions. Foot Ankle Int.  2009;30(8):741 " ô745.88 Reichert é áP, Zimmer é áK, Wnukiewicz é áW, et al. Results of surgical treatment of tarsal tunnel syndrome. Foot Ankle Surg.  2015;21(1):26 " ô29.99 Gould é áJS. Recurrent tarsal tunnel syndrome. Foot Ankle Clin.  2014;19(3):451 " ô467.

ADDITIONAL READING


  • Abouelela é áAA, Zohiery é áAK. The triple compression stress test for diagnosis of tarsal tunnel syndrome. Foot (Edinb).  2012;22(3):146 " ô149.
  • Allen é áJM, Greer é áBJ, Sorge é áDG, et al. MR imaging of neuropathies of the leg, ankle, and foot. Magn Reson Imaging Clin N Am.  2008;16(1):117 " ô131.
  • Gondring é áWH, Tarun é áPK, Trepman é áE. Touch pressure and sensory density after tarsal tunnel release in diabetic neuropathy. Foot Ankle Surg.  2012;18(4):241 " ô246.
  • Imai é áK, Ikoma é áK, Imai é áR, et al. Tarsal tunnel syndrome in hemodialysis patients: a case series. Foot Ankle Int.  2013;34(3):439 " ô444.

SEE ALSO


Algorithm: Foot Pain é á

CODES


ICD10


  • G57.50 Tarsal tunnel syndrome, unspecified lower limb
  • G57.51 Tarsal tunnel syndrome, right lower limb
  • G57.52 Tarsal tunnel syndrome, left lower limb

ICD9


355.5 Tarsal tunnel syndrome é á

SNOMED


47374004 Tarsal tunnel syndrome é á

CLINICAL PEARLS


  • Tarsal tunnel syndrome typically presents with pain and tingling of the medical ankle and plantar foot.
  • Tinel sign is the most sensitive and specific physical examination test for diagnosing tarsal tunnel.
  • EMG cannot independently diagnose tarsal tunnel syndrome; it is used to confirm a clinical diagnosis.
  • Conservative management is recommended, except for patients with an acute onset tarsal tunnel syndrome or known space-occupying lesion.
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