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Tarsal tunnel syndrome complete review

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Dr-Anuj Nigam

Tarsal tunnel syndrome is caused by entrapment of the posterior tibial nerve as it passes through the tarsal tunnel behind the ankle. It results in pain, tingling, and numbness in the sole of the foot. Diagnosis is made through physical exam maneuvers like Tinel's test and imaging like MRI or electrodiagnostic testing. Conservative treatment includes splinting, anti-inflammatories, and steroid injections, while surgery to decompress the nerve through tarsal tunnel release is considered if conservative measures fail. Differential diagnoses include other causes of foot pain like Achilles tendinitis, plantar fasciitis, or lumbar nerve impingement.

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TARSAL TUNNEL SYNDROME Presented By - Dr Anuj Nigam DNB Ortho Resident UNIQUE Super Speciality Hospital Indore (M.P)
Definition • Entrapment neuropathy of Posterior Tibial Nerve or its branches as it passes through tarsal tunnel deep to the flexor retinaculum. • Branches of tibial nerve may also get compressed individually.
Anatomy • Branches of tibial nerve 1. Calcaneal : Sensory heel in medial & posterior distribution 2. Medial Plantar : Sensory medial sole of foot Motor branch Abductor hallucis Flexor Digitorum brevis 3. Lateral Plantar : Sensory fifth toe Motor branch Abductor digiti quinti Quadratus Plantae
Tarsal Tunnel • Fibro – osseous space • Postero-medial aspect of ankle • Passage way for tendons, nerves, vessles from posterior leg to foot Borders : Floor :- • Concave • Medial aspect of Tibia, Talus & Calcaneum. Roof:- • Flexor Retinaculum (converts the floor into a tunnel) • Obliquely spans between medial malleolus & medial Tubercle of Calcaneus • Continous from deep fascia of leg & foot
Contents: • Tibialis Posterior Tendon • Flexor digitorum longus tendon • Posterior tibial artery & vein • Tibial Nerve • Flexor hallucis longus tendon
Etiology EXTRINSIC • Poor fitting shoes • Fractures & malunion • Tarsal coalition • Post surgical scarring • Valgus deformity of hindfoot INTRINSIC • Inflammotory conditions: tenosynovitis, RA • Space occupying lesions: lipoma, ganglion, schwanoma, exostosis • Varicosities • Neural tumor • Perineural fibrosis • Osteophytes • Double crush syndrome: lumbar spondylosis or PIVD at S1, tibial nerve more susecptible to compression Risk Factors: • DM • Hypothyroidism • Gout • Mucopolysaccharidoses • Hyperlipidemia
Clinical Features Presenting Symptoms • Pain in foot & sole – sharp shooting type radiating to distribution of posterior tibial nerve • Pain increases on extremes of dorsiflexion & eversion, increses on walking and relieves on rest. • Tingling & burning sensation. • Pain & Paresthesia usually distal to the site of compression, but in 1/3rd population pain may radiate radiate proximally to mid calf. (Valleix Phenomenon)
Examination Inspection • Visible foot deformities, scar • Atrophy of intrinsic foot muscles in late cases • Long standing cases – neuropathic changes with deformity like pes cavus, atrophic changes like loss of hair, skin ulceration etc Palpation • Tenderness over tarsal tunnel • Perineural thickening may be palpable in patients with leprosy & amyloid neuropathy. Percussion • Tinel’s test : - repeated tapping over posterior tibial nerve cause paresthesisas of the supplying region • Light touch & two point discrimination test: may have diminished planter senses in areas supplioed by either medial or lateral branch Movements • Muscle strength and foot range of motion should be checked • Gait : examining foot deformities
Provocative test • Dorsiflexion- eversion test : Triple Compression Stress Test maximal dorsiflexion of ankle and MTP joint and firm eversion of foot for sometime produces similar symptoms • Tourniquet test : increase the pressure over ankle with tourniquet to produce similar symptoms
Investigations • X ray – ankle & foot for osteophytes, anomalies, old trauma. • MRI – not sensitive for diagnosis, may help include or exclude other causes like tendonitis, tenosynovitis, lipoma, ganglion, varicose veins • USG – Nerve & its bifurcations, other soft tissue structures can be evaluated. • EMG & NCV – best diagnostic modality  Site of compression  Type (sensory/motor)  Cause (axonal/demyelinating)  Neurological changes in muscle • Sensory nerve conduction studies are more abnormal than motor. Hematological: • HbA1c • ESR • BUN • Creatinine • Vit B12
Osteochondroma of calcaneum Soft tissue growth on usg
NORMAL/ASYMPTOMATIC SYMPTOMATIC
Treatment • Medical Management ▫ In absence of demonstrable nerve compression ▫ NSAIDS, oral steriods, neurotropic vitamins ▫ For non responsive patients – local steriod injection in tarsal tunnel ▫ Correection of plano valgus deformity with physiotherapy or orthosis ▫ Night splints to maintain plantar flexion and inversion for symptomatic relief
• Surgical Management  Unresponsive patients after 3-6 months or with demonstrable pathology on MRI or Clinically deformity is present  Failed conservative treatment : ▫ longer motor nerve conduction latency = 7.4 milliseconds or greater ▫ Greater predominance of foot deformities
• Tarsal tunnel release  Incision made posterior to the tibia  Layers that must be released: ➢ flexor retnaculum ➢ Deep investing fascia of lower leg ➢ Superficial & deep fascia of Abductor hallucis  Identify tibial nerve, leave it undisturbed unless there is fibrosis for which neurolysis is required.  Neuroma or compressing lesion should be identified and removed. • External neurolysis : of adhesions and scar tissue causing nerve impingement • Space occupying masses: specific removal. • Correction of deformities of foot.
Tarsal tunnel syndrome complete review
Diffrential Diagnoses • Achilles tendinitis • Compartment syndrome of deep flexor compartment • Calcaneal spurs • Plantar fasciitis • L5 S1 root compression • Morton metatarsalgia • Neurogenic claudication • Polyneuropathy • Retrocalcaneal bursitis
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Tarsal tunnel syndrome complete review

  • 1. TARSAL TUNNEL SYNDROME Presented By - Dr Anuj Nigam DNB Ortho Resident UNIQUE Super Speciality Hospital Indore (M.P)
  • 2. Definition • Entrapment neuropathy of Posterior Tibial Nerve or its branches as it passes through tarsal tunnel deep to the flexor retinaculum. • Branches of tibial nerve may also get compressed individually.
  • 3. Anatomy • Branches of tibial nerve 1. Calcaneal : Sensory heel in medial & posterior distribution 2. Medial Plantar : Sensory medial sole of foot Motor branch Abductor hallucis Flexor Digitorum brevis 3. Lateral Plantar : Sensory fifth toe Motor branch Abductor digiti quinti Quadratus Plantae
  • 4. Tarsal Tunnel • Fibro – osseous space • Postero-medial aspect of ankle • Passage way for tendons, nerves, vessles from posterior leg to foot Borders : Floor :- • Concave • Medial aspect of Tibia, Talus & Calcaneum. Roof:- • Flexor Retinaculum (converts the floor into a tunnel) • Obliquely spans between medial malleolus & medial Tubercle of Calcaneus • Continous from deep fascia of leg & foot
  • 5. Contents: • Tibialis Posterior Tendon • Flexor digitorum longus tendon • Posterior tibial artery & vein • Tibial Nerve • Flexor hallucis longus tendon
  • 6. Etiology EXTRINSIC • Poor fitting shoes • Fractures & malunion • Tarsal coalition • Post surgical scarring • Valgus deformity of hindfoot INTRINSIC • Inflammotory conditions: tenosynovitis, RA • Space occupying lesions: lipoma, ganglion, schwanoma, exostosis • Varicosities • Neural tumor • Perineural fibrosis • Osteophytes • Double crush syndrome: lumbar spondylosis or PIVD at S1, tibial nerve more susecptible to compression Risk Factors: • DM • Hypothyroidism • Gout • Mucopolysaccharidoses • Hyperlipidemia
  • 7. Clinical Features Presenting Symptoms • Pain in foot & sole – sharp shooting type radiating to distribution of posterior tibial nerve • Pain increases on extremes of dorsiflexion & eversion, increses on walking and relieves on rest. • Tingling & burning sensation. • Pain & Paresthesia usually distal to the site of compression, but in 1/3rd population pain may radiate radiate proximally to mid calf. (Valleix Phenomenon)
  • 8. Examination Inspection • Visible foot deformities, scar • Atrophy of intrinsic foot muscles in late cases • Long standing cases – neuropathic changes with deformity like pes cavus, atrophic changes like loss of hair, skin ulceration etc Palpation • Tenderness over tarsal tunnel • Perineural thickening may be palpable in patients with leprosy & amyloid neuropathy. Percussion • Tinel’s test : - repeated tapping over posterior tibial nerve cause paresthesisas of the supplying region • Light touch & two point discrimination test: may have diminished planter senses in areas supplioed by either medial or lateral branch Movements • Muscle strength and foot range of motion should be checked • Gait : examining foot deformities
  • 9. Provocative test • Dorsiflexion- eversion test : Triple Compression Stress Test maximal dorsiflexion of ankle and MTP joint and firm eversion of foot for sometime produces similar symptoms • Tourniquet test : increase the pressure over ankle with tourniquet to produce similar symptoms
  • 10. Investigations • X ray – ankle & foot for osteophytes, anomalies, old trauma. • MRI – not sensitive for diagnosis, may help include or exclude other causes like tendonitis, tenosynovitis, lipoma, ganglion, varicose veins • USG – Nerve & its bifurcations, other soft tissue structures can be evaluated. • EMG & NCV – best diagnostic modality  Site of compression  Type (sensory/motor)  Cause (axonal/demyelinating)  Neurological changes in muscle • Sensory nerve conduction studies are more abnormal than motor. Hematological: • HbA1c • ESR • BUN • Creatinine • Vit B12
  • 11. Osteochondroma of calcaneum Soft tissue growth on usg
  • 13. Treatment • Medical Management ▫ In absence of demonstrable nerve compression ▫ NSAIDS, oral steriods, neurotropic vitamins ▫ For non responsive patients – local steriod injection in tarsal tunnel ▫ Correection of plano valgus deformity with physiotherapy or orthosis ▫ Night splints to maintain plantar flexion and inversion for symptomatic relief
  • 14. • Surgical Management  Unresponsive patients after 3-6 months or with demonstrable pathology on MRI or Clinically deformity is present  Failed conservative treatment : ▫ longer motor nerve conduction latency = 7.4 milliseconds or greater ▫ Greater predominance of foot deformities
  • 15. • Tarsal tunnel release  Incision made posterior to the tibia  Layers that must be released: ➢ flexor retnaculum ➢ Deep investing fascia of lower leg ➢ Superficial & deep fascia of Abductor hallucis  Identify tibial nerve, leave it undisturbed unless there is fibrosis for which neurolysis is required.  Neuroma or compressing lesion should be identified and removed. • External neurolysis : of adhesions and scar tissue causing nerve impingement • Space occupying masses: specific removal. • Correction of deformities of foot.
  • 17. Diffrential Diagnoses • Achilles tendinitis • Compartment syndrome of deep flexor compartment • Calcaneal spurs • Plantar fasciitis • L5 S1 root compression • Morton metatarsalgia • Neurogenic claudication • Polyneuropathy • Retrocalcaneal bursitis