The Effectiveness of Indonesia's Seven - Step Return to Work Assessment on a Distal Tarsal Tunnel Syndrome : A Case Report Study.

Tarsal tunnel syndrome (TTS) is a nerve entrapment of the posterior tibial nerve. This uncommon condition frequently goes undiagnosed or misdiagnosed even though it interferes with the daily activities of workers. Here we discuss the return to work status of a 37-year-old male patient who manages a manufacturing plant. He was identified as having Tarsal Tunnel Syndrome as a result of a foot abnormality and improper shoe wear. He had moderate pes planus and underwent tarsal tunnel release on his right foot. What are the determinant factors in defining a patient's status for returning to work after a tarsal tunnel release? We conducted a literature review using PubMed, Science Direct, and Cochrane. The Indonesian Occupational Medicine Association used the seven-step return-to-work assessment as a protocol to avoid overlooking the process. Duration of symptoms, associated pathology, and the presence of structural foot problems or a space-occupying lesion are factors affecting outcome. Post-operative foot scores, including Maryland Foot Score (MFS), VAS, and Foot Function Index, can be used to evaluate patient outcomes. Early disability limitation and a thorough return-to-work assessment are needed.

Weight-bearing Ultrasound to Diagnose Talar Dislocation Causing Tarsal Tunnel Syndrome.

The neuropathic compression of the tibial nerve and/or its branches on the medial side of the ankle is called tarsal tunnel syndrome (TTS). Patients with TTS presents pain, paresthesia, hypoesthesia, hyperesthesia, muscle cramps or numbness which affects the sole of the foot, the heel, or both. The clinical diagnosis is challenging because of the fairly non-specific and several symptomatology. We demonstrate a case of TTS caused by medial dislocation of the talar bone on the calcaneus bone impacting the tibial nerve diagnosed only by ultrasound with the patient in the standing position.

Accessory Flexor Digitorum Longus Presenting as Tarsal Tunnel Syndrome: A Case Series.

ABSTRACT: Tarsal tunnel syndrome (TTS) typically occurs from extrinsic or intrinsic sources of compression on the tibial nerve. We present 3 cases of patients, all of whom have a prolonged time to diagnosis after evaluation with multiple specialties, with foot pain ultimately secondary to an accessory flexor digitorum longus muscle causing TTS. The literature describing the association between TTS and accessory musculature has been limited to single case reports and frequently demonstrate abnormal electrodiagnostic testing. In our series, 2 cases had normal electrodiagnostic findings despite magnetic resonance imaging (MRI) that later revealed TTS and improvement with eventual resection. A normal electromyogram should not preclude the diagnosis of TTS and MRI of the ankle; it should be considered a useful diagnostic tool when examining atypical foot pain.

Tarsal tunnel syndrome secondary to accessory or variant muscles: a clinical and anatomical systematic review.

PURPOSE: Many etiologies are known to lead to a tarsal tunnel syndrome (TTS). One rare cause is mass-occupying lesions, and particularly accessory or variant muscles (AVM). This study aimed to systematically collect published clinical cases of TTS caused by AVM. METHODS: An electronic literature search was conducted from inception to April 2021. The diagnosis of AVM should be reported in one of the following methods: ultrasonography, magnetic resonance imaging (MRI), or per-operatively. Data extraction included types and prevalence of accessory muscles, clinical presentation and diagnosis, and treatment modalities. Twenty-five studies were identified with a total 39 patients (47 ankles). RESULTS: The prevalence of TTS was reported in only two studies (9%). Forty-nine AVM were identified with the accessory flexor digitorum longus being the most common (52%). The most common sign/symptoms were tenderness (78.7%), pain (82.9%), dysesthesia (57.4%), Tinel sign (44.6%), and a swelling (25.5%). Decompression and excision were the most commonly performed procedures. Four accessory/variant muscles in the ankle have the potential to induce a tarsal tunnel syndrome. CONCLUSION: This review highlights the clinical and imagery specificities of TTS secondary to accessory or variant muscles. Mass-occupying etiology should be included in the list of differential diagnoses whenever a posterior tibial nerve compression is suspected.

Surgical efficacy analysis of tarsal tunnel syndrome: a retrospective study of 107 patients.

Tarsal tunnel syndrome (TTS) is an entrapment neuropathy of the posterior tibial nerve or its terminal branches compressed by its fibro-osseous tunnel beneath the flexor retinaculum on the medial side of the ankle. The current study was a retrospective study of 107 cases of patients with TTS, in which the onset characteristics were summarized, the factors that might affect the surgical treatment effects of TTS were discussed and analyzed. The syndrome diagnoses and treatment experiences of TTS were extracted and analyzed. In our cohort, TTS was more often found in middle-aged and older women. And the medial plantar nerve bundle was the most frequently affected nerve structure. The efficacy of surgical treatment were correlated to the causes of the disease, involved nerve bundles, methods of operation, and whether neurolysis of the epineurium was performed. Neurolysis of the epineurium is was recommended for patients with an enlarged tibial nerve due to impingement. The Singh method was recommended to release the tibial nerve and its branches. Patients with negative preoperative EMG results should carefully be cautious when considering their decision to undergo surgical treatment.

Dimensional Changes of the Tibial Nerve and Tarsal Tunnel in Different Ankle Joint Positions in Asymptomatic Subjects.

The tarsal tunnel is a clinically important fibrous osseous conduit for the tibial nerve and associated tendons. It is mechanically dynamic, and normal ankle movements appear to change the tunnel shape, potentially having an impact on the tibial nerve. The objective of this study was to measure changes in the tibial nerve and tarsal tunnel dimensions in plantarflexion and dorsiflexion of the ankle joint in healthy subjects. A cross-sectional study with 13 volunteer subjects and a total of 18 records was designed. The cross-sectional area, anterior-posterior distance, transverse distance, and flattening ratio of the tibial nerve were measured by using ultrasound in plantarflexion and dorsiflexion of the ankle joint. The anterior-posterior distance of the tarsal tunnel was also measured. The tunnel anterior-posterior distance significantly increased during plantarflexion (p < .001) and decreased during dorsiflexion (p = .027) of the ankle. From plantarflexion to dorsiflexion of the ankle, the tibial nerve cross-sectional area significantly decreased (p = .035). The anterior-posterior distance also decreased significantly (p < .001), whereas the transverse distance increased (p < .001), thus decreasing the flattening ratio of the tibial nerve (p < .001). Ankle joint position determined significant changes in the shape and dimensions of the tibial nerve at the tarsal tunnel.

Posterior Tibial Nerve Lymphoma Presenting as Tarsal Tunnel Syndrome: A Case Report.

We report a case of isolated posterior tibial B-cell lymphoma of the posterior tibial nerve presenting as tarsal tunnel syndrome. This diagnosis was considered because of the clinical presentation and electrophysiologic abnormalities. It was further confirmed by the magnetic resonance imaging findings of the ankle and tissue pathologic findings. Whole body positron emission tomography confirmed this to be a localized lymphoma involving the peripheral nerve. The patient underwent chemotherapy with complete tumor resolution. She had had no relapse after 8 months of follow-up. Isolated peripheral nerve lymphomas are very rare, and involvement of the posterior tibial nerve has not been previously reported. Furthermore, the present case report highlights the importance of the clinical examination in the diagnosis of tarsal tunnel syndrome before performing surgical decompression.

Tarsal tunnel syndrome: still more opinions than evidence. Status of the art.

Tarsal tunnel syndrome is an entrapment neuropathy of the posterior tibial nerve or its terminal branches within its fibro-osseous tunnel beneath the flexor retinaculum on the medial side of the ankle. The condition is frequently underdiagnosed leading to controversies regarding its epidemiology and to an intense debate in the literature. With the advent of nerve imaging techniques, the diagnostic confirmation and the etiological identification have become more accurate. However, management of this entrapment neuropathy remains challenging because of many intervention strategies but limited robust evidence. Uncertainties still exist about the best conservative treatment, timing of surgical intervention, and best surgical approach. In the attempt to clarify these aspects and to provide the reader some understanding of the status of the art, we have reviewed the published literature on this controversial condition.

Glomus Tumor in the Tarsal Tunnel: A Case Report.

Glomus tumors are painful benign neoplasms. They commonly present in the hand and are mostly solitary lesions. We report a rare case of multiple glomus tumors in the lower leg. Moreover, 1 of the tumors was in the tarsal tunnel. Resection of the tumors resulted in the early diagnosis of glomus tumors and complete symptom relief. Because of its rarity, diagnosing an extradigital glomus tumor is difficult. Recognition of glomus tumors allows for an early diagnosis and resection, and preoperative magnetic resonance imaging helps in the detection of multiple lesions. Before resection, we considered tarsal tunnel syndrome in the differential diagnosis because of the symptoms and location of the tumor. Tarsal tunnel syndrome is a comparatively well-known disease in the foot. When tarsal tunnel syndrome is suspected, a glomus tumor should also be considered in the differential diagnosis.

Proposed Sonographic Criteria for the Diagnosis of Idiopathic Tarsal Tunnel Syndrome.

OBJECTIVE: To propose new sonographic criteria for the diagnosis of idiopathic tarsal tunnel syndrome (TTS). DESIGN: Prospective case-control study. SETTING: Academic referral center. PARTICIPANTS: Adult healthy volunteers (n=17) and adult patients (n=14) with electrodiagnostically proven idiopathic TTS (mean age, 43.4±8.7y; height, 161.4±7.0cm; weight, 90.6±13.9kg) (N=31). The exclusion criteria were patients with diabetes, neurological disorders, associated ankle and/or foot disorders, electrodiagnostic evidence of a widespread lesion, or feet that were electrophysiologically negative for TTS or with structural abnormalities detected via ultrasound imaging. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Tibial nerve CSA at the proximal tarsal tunnel, tibial nerve CSA within the tunnel, within tunnel-to-proximal tunnel CSA ratio. RESULTS: There was a significant difference in the within tunnel CSA and within tunnel-to-proximal tunnel CSA ratio between the TTS group and controls (P=.002 and P=.001, respectively). The optimum cutoff value was 19mm(2) for the within tunnel CSA and 1 for the within tunnel-to-proximal tunnel CSA ratio. Sensitivities were 61% and 74%, respectively. CONCLUSIONS: The within tunnel-to-proximal tunnel CSA ratio and the within tunnel CSA are the most accurate sonographic parameters and can be helpful in the assessment of idiopathic TTS.

The prevalence of tarsal tunnel syndrome in patients with lumbosacral radiculopathy.

PURPOSE: Tarsal tunnel syndrome (TTS) is a painful foot condition. Lumbosacral radiculopathy (LR) may also present with symptoms occurring in TTS. However, no studies have been reported to determine the possible coexistence of these two conditions. The aim of our study was to identify the prevalence of TTS in patients with confirmed LR and to analyze the clinical and electrodiagnostic features of patients with both TTS and LR. METHODS: Medial and lateral plantar nerve mixed studies, peroneal motor studies and deep peroneal sensory studies were performed in 81 normal subjects and 561 patients with LR. The Tinel's test and other provocative tests were performed in the LR patient group, and the clinical symptoms of TTS were also analyzed. The frequency of TTS was investigated in all radiculopathy group patients with different nerve root lesions. RESULTS: Concomitant TTS was found in 27 (4.8%) patients with LR. Abnormal results of sensory/mixed conduction tests were observed in 25/27 (92.6%) patients, and 11/27 (40.7%) patients had abnormal results of motor conduction tests. Positivity for the Tinel's test and special provocative tests was found in 15/27 (55.6%) and 17/27 (63.0%) patients, respectively. Overall, 9/27 (33.3%) patients had typical symptoms, and suspicious clinical symptoms were found in the other 14/27 (51.9%) patients. The frequency of coexisting TTS was not statistically different among the single-level L4, L5 or S1 radiculopathy, or between the single-level and multi-level radiculopathies (P > 0.05). CONCLUSIONS: The findings suggest that the prevalence of TTS is significant in patients with LR. Thus, more caution should be paid when diagnosing and managing patients with LR due to the possible existence of TTS, as their management strategies are quite different.

Tarsal Tunnel Syndrome Secondary to an Unreported Ossicle of the Talus: A Case Report.

Tarsal tunnel syndrome (TTS) is a compression neuropathy of the posterior tibial nerve in the tarsal tunnel. In about 80% of patients, a specific cause can be identified for TTS. We present a case of TTS secondary to an ossicle in close relation to the talus that, to our knowledge, has not previously been reported. A 26-year-old male presented with left ankle and foot pain that increased with activity and playing football. He had a tingling sensation and paresthesia in the sole and medial border of the foot along the distribution of the medial and lateral plantar nerves. Clinically, he had hard swelling at the floor of the tarsal tunnel, and Tinel's sign was positive. Computed tomography showed an accessory ossicle articulating with the posteromedial aspect of the talus, separating the flexor digitorum longus and flexor hallucis longus tendons, with tenosynovitis of the tibialis posterior, flexor digitorum longus and flexor hallucis longus tendons. Surgical release of the tarsal tunnel and excision of the ossicle were performed. Postoperatively, the patient showed dramatic improvement and had no complications or recurrence of symptoms after 8 months of follow-up. More interestingly, to the best of our knowledge, this ossicle has not been previously reported to cause TTS.

Posterior tibial vein aneurysm presenting as tarsal tunnel syndrome.

Tarsal tunnel syndrome is a compressive neuropathy of the posterior tibial nerve within the tarsal tunnel. Its etiology varies, including space occupying lesions, trauma, inflammation, anatomic deformity, iatrogenic injury, and idiopathic and systemic causes. Herein, we describe a 46-year-old man who presented with left foot pain. Work up revealed a venous aneurysm impinging on the posterior tibial nerve. Following resection of the aneurysm and lysis of the nerve, his symptoms were alleviated. Review of the literature reveals an association between venous disease and tarsal tunnel syndrome; however, this report represents the first case of venous aneurysm causing symptomatic compression of the nerve.

[The anterior tarsal tunnel syndrome: a case report]. / LE CAS CLINIQUE DU MOIS. Le syndrome tarsien antérieur.

The anterior tarsal tunnel syndrome is a rare entrapment neuropathy of the deep peroneal nerve beneath the inferior extensor retinaculum of the ankle. It is frequently unrecognized and may lead to misdiagnosis and delayed treatment. We report the case of a 77 year old patient complaining of symptoms of an anterior tarsal tunnel syndrome with neuropathic pain located at the dorsal part of the foot, without any sensorimotor loss. The ENMG was in favour of a motor impairment of the deep peroneal nerve. MRI exploration of the ankle showed a millimetric bony overgrowth of the upper pole of the navicular bone, irritative to the deep peroneal nerve. Infiltration at overgrowth of the navicular provided a partial and temporary decrease in pain symptoms. Surgical nerve decompression was then considered.

Results of surgical treatment of tarsal tunnel syndrome.

BACKGROUND: The aim of our study is to evaluate retrospectively the prognostic factors affecting the final outcome of surgical treatment of tarsal tunnel syndrome. MATERIAL AND METHODS: Surgical decompression were performed on 31 patients. All patients had EMG and anesthetic test confirmation. The results were evaluated according to VAS scale and modified AOFAS score. Follow-up was after 12 months. RESULTS: 22 patients received very good or good (71%), 7 satisfactory (22%), 2 poor (7%) results in the subjective and objective patient's assessment. The outcomes decreased from 5.19 (SD 1.01) points to 1.19 (SD 0.83) points according to VAS scale, and modified AOFAS increased from 31.77 (SD 9.08) points to 57.58 (SD 9.90). Patients with diagnosed cause, short period of time between onset of disease till surgery, and positive Tinel's sign achieved the best results. CONCLUSION: Etiology of the tarsal tunnel syndrome has influence on the results. Immediate diagnosis and short period between occurrences of symptoms in surgical treatment improves the outcomes. Tinel's sign may be used as a prognostic factor.

Tarsal tunnel syndrome associated with a perforating branch from posterior tibial artery: a case report.

Tarsal tunnel syndrome, a compressive neuropathy of the tibial nerve or its branches with in the tarsal tunnel, is an uncommon condition. Various etiologies of the syndrome have been described. We report a rare case of tarsal tunnel syndrome associated with a perforating branch from the posterior tibial artery. A 56-year-old woman presented with 1-year history of paresthesia and hypoesthesia in the medial and lateral plantar area of the left foot. Tinel's sign was elicited at the tarsal tunnel. Electrodiagnostic studies confirmed the diagnosis of left tarsal tunnel syndrome. Intraoperatively, the perforating branch from posterior tibial artery which traveled through a split in the tibial nerve was encountered. The patient's symptom improved significantly at 2 years after tarsal tunnel release and vascular ligation. Only a minor degree of paresthesia remains in the forefoot.

Anterior tarsal tunnel syndrome: a misunderstood and a misleading entrapment neuropathy.

Anterior tarsal tunnel syndrome (ATTS) is a rare entrapment neuropathy of the deep peroneal nerve beneath the extensor retinaculum on the top of the ankle. ATTS is often asymptomatic or olygosymptomatic. There are few reports describing the ATTS. We describe the clinical and electrophysiological features of 85 patients with unilateral or bilateral ATTS prospectively collected between January 2000 and December 2010 in our laboratory of Clinical Neurophysiology. This entrapment neuropathy remains poorly diagnosed and it might be misleading when performing a diagnostic EMG-ENG examination for suspected polyneuropathy or lumbosacral radiculopathy.

Plantar and medial heel pain: diagnosis and management.

Heel pain is commonly encountered in orthopaedic practice. Establishing an accurate diagnosis is critical, but it can be challenging due to the complex regional anatomy. Subacute and chronic plantar and medial heel pain are most frequently the result of repetitive microtrauma or compression of neurologic structures, such as plantar fasciitis, heel pad atrophy, Baxter nerve entrapment, calcaneal stress fracture, and tarsal tunnel syndrome. Most causes of inferior heel pain can be successfully managed nonsurgically. Surgical intervention is reserved for patients who do not respond to nonsurgical measures. Although corticosteroid injections have a role in the management of select diagnoses, they should be used with caution.

Neurolysis for failed tarsal tunnel surgery.

The purpose of the present study was to investigate the causes of failure after tarsal tunnel release and the operative findings in the secondary interventions and the outcomes. The data from 8 patients who had undergone revision surgery for failed tarsal tunnel release at least 12 months earlier were evaluated retrospectively. Only the patients with idiopathic tarsal tunnel syndrome were included, and all had unilateral symptoms. Neurophysiologic tests confirmed the clinical diagnosis of failed tarsal tunnel release in all patients. Magnetic resonance imaging revealed varicose veins within the tarsal tunnel in 1 patient (12.5%) and tenosynovitis in another (12.5%). Open tarsal tunnel release was performed in all patients, and the tibialis posterior nerve, medial and lateral plantar nerves (including the first branch of the lateral plantar nerve), and medial calcaneal nerve were released in their respective tunnels, and the septum between the tunnels was resected. The outcomes were assessed according to subjective patient satisfaction as excellent, good, fair, or poor. During revision surgery, insufficient release of the tarsal tunnel, especially distally, was observed in all the patients, and fibrosis of the tibialis posterior nerve was present in 1 (12.5%). The outcomes according to subjective patient satisfaction were excellent in 5 (62.5%), good in 2 (25%), and fair in 1 (12.5%). The fair outcome was obtained in the patient with fibrosis of the nerve. Insufficient release of the tarsal tunnel was the main cause of failed tarsal tunnel release. Releasing the 4 distinct tunnels and permitting immediate mobilization provided satisfactory results in patients with failed tarsal tunnel release.

Lower extremity nerve entrapments in athletes.

Nerve entrapments are a potential cause of lower extremity pain in athletes. Signs and symptoms suggestive of nerve entrapment include anesthesia, dysesthesias, paresthesias, or weakness in the distribution of a peripheral nerve. The physical examination may reveal an abnormal neurologic examination finding in the distribution of a peripheral nerve, positive nerve provocative testing, and positive Tinel sign over the area of entrapment. Electrodiagnostic studies, radiographs, magnetic resonance imaging studies, and sonographic evaluation may assist with the diagnosis of these disorders. Initial treatment usually involves conservative measures, but surgical intervention may be required if conservative treatment fails. This article discusses the diagnosis and treatment of common lower extremity nerve entrapments in athletes. A high index of suspicion for nerve entrapments enables the clinician to identify these conditions in a timely manner and institute an appropriate management program, thus improving patient outcomes.