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.

Lateralizing calcaneal osteotomy performed with a percutaneous burr results in a significantly lower increase in tarsal tunnel pressure.

PURPOSE: Tarsal tunnel syndrome is well documented following lateralizing calcaneal osteotomy to manage varus hindfoot deformity. Traditionally, calcaneal osteotomy is performed with an oscillating saw. No studies have investigated the effect of alternative surgical techniques on postoperative tarsal tunnel pressure. The purpose of this study was to investigate the difference in tarsal tunnel pressures following lateralizing calcaneal osteotomy performed using a high-torque, low-speed "minimally invasive surgery" (MIS) Shannon burr versus an oscillating saw. METHODS: Lateralizing calcaneal osteotomy was performed on 10 below-knee cadaveric specimens. This was conducted on 5 specimens each using an oscillating saw (Saw group) or MIS burr (Burr group). The calcaneal tuberosity was translated 1 cm laterally and transfixed using 2 Kirschner wires. Tarsal tunnel pressure was measured before and after osteotomy via ultrasound-guided percutaneous needle barometer. Mean pre/post-osteotomy pressures were compared between groups. Differences were analyzed using Student's t test. RESULTS: The mean pre-procedure tarsal tunnel pressure was 25.8 ± 5.1 mm Hg in the Saw group and 26.4 ± 4.3 mm Hg in the Burr group (p = 0.85). The mean post-procedure pressure was 63.4 ± 5.1 in the Saw group and 47.8 ± 4.3 in the Burr group (p = 0.01). Change in tarsal tunnel pressure was significantly lower in the Burr group (21.4 ± 4.5) compared to the Saw group (37.6 ± 12.5) (p = 0.03). The increase in tarsal tunnel pressure was 43% lower in the Burr group. CONCLUSION: In this cadaveric study, tarsal tunnel pressure increase after lateralizing calcaneal osteotomy was significantly lower when using a burr versus a saw. This is likely because the increased width ("kerf") of the 3 mm MIS burr, compared to the submillimeter saw blade width, causes calcaneal shortening. Given the smaller increase in tarsal tunnel pressure, using the MIS burr for lateralizing calcaneal osteotomy may decrease the risk of postoperative tarsal tunnel syndrome. Future research in vivo should explore this.

The bifurcation and topography of the posterior tibial artery within the tarsal tunnel.

PURPOSE: The tarsal tunnel (TT) is a fibro-osseous anatomical space coursing from the medial ankle to the medial midfoot. This tunnel acts as a passage for both tendinous and neurovascular structures, including the neurovascular bundle containing the posterior tibial artery (PTA), posterior tibial veins (PTVs) and tibial nerve (TN). Tarsal tunnel syndrome (TTS) is the entrapment neuropathy that describes the compression and irritation of the TN within this space. Iatrogenic injury to the PTA plays a significant role in both the onset and exacerbation of TTS symptoms. The current study aims to produce a method to allow clinicians and surgeons to easily and accurately predict the bifurcation of the PTA, to avoid iatrogenic injury during treatment of TTS. METHODS: Fifteen embalmed cadaveric lower limbs were dissected at the medial ankle region to expose the TT. Various measurements regarding the location of the PTA within the TT were recorded and multiple linear regression analysis performed using RStudio. RESULTS: Analysis provided a clear correlation (p < 0.05) between the length of the foot (MH), length of hind-foot (MC) and location of bifurcation of the PTA (MB). Using these measurements, this study developed an equation (MB = 0.3*MH + 0.37*MC - 28.24 mm) to predict the location of bifurcation of the PTA within a 23° arc inferior to the medial malleolus. CONCLUSIONS: This study successfully developed a method whereby clinicians and surgeons can easily and accurately predict the bifurcation of the PTA, to avoid iatrogenic injury that would previously lead to an exacerbation of TTS symptoms.

An update on imaging of tarsal tunnel syndrome.

Tarsal tunnel syndrome (TTS) is an entrapment neuropathy of the tibial nerve (TN) within the tarsal tunnel (TT) at the level of the tibio-talar and/or talo-calcaneal joints. Making a diagnosis of TTS can be challenging, especially when symptoms overlap with other conditions and electrophysiological studies lack specificity. Imaging, in particular MRI, can help identify causative factors in individuals with suspected TTS and help aid surgical management. In this article, we review the anatomy of the TT, the diagnosis of TTS, aetiological factors implicated in TTS and imaging findings, with an emphasis on MRI.

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: Outcome According to Etiology.

Surgical results in tarsal tunnel syndrome are variable, and etiology seems to be a factor. Three possible etiologies can be distinguished. The aim of the present study was to compare surgical results according to etiology. Three continuous retrospective series (45 patients overall) of tarsal tunnel syndrome were compared. Group 1 presented a permanent intra- or extra-tunnel space-occupying compressive structure. Group 2 presented intermittent intra-tunnel venous dilatations. Group 3 comprised idiopathic tarsal tunnel syndrome. The mean follow-up was 3.6 +/- 1.8 years. The main endpoint was subjective postoperative improvement on Likert scale. Group 1 reported greater improvement than groups 2 and 3. Preoperative neuropathy on ultrasound was associated with poorer improvement, which was not the case for neuropathy on electromyography. Surgical treatment of tarsal tunnel syndrome provides better results in etiologies involving structural compression.

Predictive factors of effective tibial nerve release in tarsal tunnel syndrome.

BACKGROUND: Factors that may affect surgical decompression results in tarsal tunnel syndrome are not known. METHODS: A retrospective single-center study included patients who had undergone surgical tibial nerve release. The effectiveness of decompression was evaluated according to whether the patient would or would not be willing to undergo another surgical procedure in similar preoperative circumstances. RESULTS: The patients stated for 43 feet (51%) that they would agree to a further procedure in similar circumstances. Six feet with space-occupying lesions on imaging had improved results, but neurolysis failed in 9 feet with bone-nerve contact. Neurolysis was significantly less effective when marked hindfoot valgus (p = 0.034), varus (p = 0.014), or fasciitis (p = 0.019) were present. CONCLUSIONS: If imaging reveals a compressive space-occupying lesion, surgery has a good prognosis. In feet with static hindfoot disorders or plantar fasciitis, conservative treatment must be optimized. Bone-nerve contact should systematically be sought.

Anatomy of the tibial nerve in relation to the tarsal tunnel: A cadaveric study.

BACKGROUND: Tarsal tunnel syndrome (TTS) is typically caused by an anatomical variant or mechanical compression of the tibial nerve (TN) with variable success after surgical treatment. METHOD: 40 lower-leg specimens were obtained. Dissections were appropriately conducted. Extremities were prepared under formaldehyde solution. The tibial nerve and branches were dissected for measurements and various characteristics. RESULTS: The flexor retinaculum had a denser consistency in 22.5% of the cases and the average length was 51.9 mm. The flexor retinaculum as an independent structure was absent and 77.2% of cases as an undistinguished extension of the crural fascia. The lateral plantar nerve (LPN) and abductor digiti minimi (ADM) nerve shared same origin in 80% of cases, 34.5% bifurcated proximal to the DM (Dellon-McKinnon malleolar-calcaneal line) line 31.2% distally and 34.3% at the same level. CONCLUSION: Understanding the tibial nerve anatomy will allow us to adapt our surgical technique to improve the treatment of this recurrent pathology.

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.

Tarsal tunnel syndrome secondary to osteochondroma of the calcaneus: a case report.

BACKGROUND: Tarsal tunnel syndrome is an entrapment neuropathy that can be provoked by either intrinsic or extrinsic factors that compresses the posterior tibial nerve beneath the flexor retinaculum. Osteochondroma, the most common benign bone tumor, seldom occur in foot or ankle. This is a rare case of tarsal tunnel syndrome secondary to osteochondroma of the sustentaculum tali successfully treated with open surgical excision. CASE PRESENTATION: A 15-year-old male presented with the main complaint of burning pain and paresthesia on the medial plantar aspect of the forefoot to the middle foot region. Hard mass-like lesion was palpated on the posteroinferior aspect of the medial malleolus. On the radiological examination, 2.5 × 1 cm sized bony protuberance was found below the sustentaculum tali. Surgical decompression of the posterior tibial nerve was performed by complete excision of the bony mass connected to the sustentaculum tali. The excised mass was diagnosed to be osteochondroma on the histologic examination. After surgery, the pain was relieved immediately and hypoesthesia disappeared 3 months postoperatively. Physical examination and radiographic examination at 2-year follow up revealed that tarsal tunnel was completely decompressed without any evidence of complication or recurrence. CONCLUSIONS: As for tarsal tunnel syndrome secondary to the identifiable space occupying structure with a distinct neurologic symptom, we suggest complete surgical excision of the causative structure in an effort to effectively relieve symptoms and prevent recurrence.

Quality of life effects of pain from para-lumbar- and lower extremity entrapment syndrome and carpal tunnel syndrome and comparison of the effectiveness of surgery.

INTRODUCTION: We compared the preoperative quality of life (QOL) of patients with carpal tunnel syndrome, lower extremity-, and para-lumbar entrapment syndrome, and the effect of surgery on their QOL. PATIENTS AND METHODS: We prospectively enrolled 66 consecutive patients who underwent surgery for carpal tunnel syndrome (group 1, n = 23), lower extremity entrapment syndrome (group 2, n = 22), and para-lumbar entrapment syndrome (group 3, n = 21). Their pre- and postoperative overall health status was assessed on the Medical Outcomes Study Short-Form 36 Health Survey, v2 (SF-36). RESULTS: Except for the mental component summary, the preoperative score for items rated on the SF-36 was significantly lower in group 3 than in groups 1 and 2 (p < 0.05). In all 66 patients, the scores for bodily pain (BP) and the physical component summary (PCS) were significantly lower (p < 0.05) than the national standard, as was the score for physical functioning (PF) in groups 2 and 3. After surgery, PF of group 2 and PF, BP, and PCS of group 3 improved significantly (p < 0.05). CONCLUSION: The detrimental QOL effects are stronger in patients with para-lumbar- or lower extremity entrapment syndrome than in patients with carpal tunnel syndrome.

Ultrasound-Guided Release of the Tibial Nerve and Its Distal Branches: A Cadaveric Study.

OBJECTIVES: The purpose of the study was to determine whether ultrasound (US)-guided surgery is a viable type of surgery for performing an effective release/decompression of the constricting structures that are responsible for focal nerve compression in tarsal tunnel syndrome. METHODS: Ultrasound guidance was used on cadaveric specimens to delineate the anatomic course of the nerves and vessels in the medial ankle that comprise the structures involved in tarsal tunnel syndrome. Ultrasound guidance was used on cadaveric specimens and assisted in delineating a safe surgical zone to adequately and effectively release these constrictive structures of the proximal and distal tarsal tunnels. The US-guided tarsal tunnel release/decompression was performed through 2 small 1- to 2-mm portals. After US-guided release, anatomic dissection was used to check the efficacy (release of the flexor retinaculum and deep abductor hallucis muscle) and safety (absence of neurovascular or tendon injury) of the procedure. RESULTS: In 12 fresh cadaveric specimens, US-guided release of the tibial nerve (proximal tarsal tunnel) and its branches (distal tarsal tunnel) at the medial ankle was effective in all 12 specimens (100% release rate), without any signs of compromise or injury into the neurovascular structures. CONCLUSIONS: Ultrasound-guided tarsal tunnel release is a feasible surgical procedure that can be safe and effective with the proper training, although further investigation is warranted. This type of surgery may promote faster recovery with less postoperative morbidity, including pain, but this will be the subject of a further investigation.

Partial anterior tunnel syndrome: a retrospective analysis of ultrasound findings in four surgically proven cases.

We present the cases of four patients (two men and two women, mean age of 48.5 years) with surgically confirmed partial anterior tarsal syndrome, diagnosed by ultrasound. All patients reported pain in the dorsal aspect of the forefoot radiating to the first intermetatarsal space. Ultrasound showed compression of the medial branch of the deep fibular nerve by the extensor hallucis brevis tendon at the level of the Lisfranc joint, associated with a hypoechoic neuroma. The ultrasound allowed a correct diagnosis to be obtained, which was not evident from clinical examination or by standard radiographs (four patients) or MRI (three patients). Surgery confirmed the sonographic findings, and all patients showed complete recovery.

Ultrasound-guided decompression surgery of the tarsal tunnel: a novel technique for the proximal tarsal tunnel syndrome-Part II.

BACKGROUND: The aim of this study is to provide a safe ultrasound-guided minimally invasive surgical approach for a proximal tarsal tunnel release concerning nerve entrapments. METHODS AND RESULTS: The study was carried out on ten fresh-frozen feet. All of them were examined by high resolution ultrasound at the medial ankle region. The surgical approach was marked throughout the course of the flexor retinaculum (laciniate ligament). Once the previous steps were done, the flexor retinaculum release technique was carried out with a 2-mm entry only. As a result, an effective and safe release of the flexor retinaculum was obtained in all fresh-frozen feet. CONCLUSION: The results of our anatomic study indicate that our novel ultrasound-guided minimally invasive surgical approach for the release of the flexor retinaculum might be an effective, safe and quick decompression technique treating selected patients with a proximal tarsal tunnel syndrome.

Ultrasound-guided decompression surgery of the distal tarsal tunnel: a novel technique for the distal tarsal tunnel syndrome-part III.

BACKGROUND: The aim of this study was to provide a safe ultrasound-guided minimally invasive surgical approach for a distal tarsal tunnel release concerning nerve entrapments. METHODS AND RESULTS: The study was carried out on ten fresh-frozen feet. All of them have been examined by high-resolution ultrasound at the distal tarsal tunnel. The surgical approach has been marked throughout the course of the medial intermuscular septum (MIS, the lateral fascia of the abductor hallucis muscle). After the previous steps, nerve decompression was carried out through a MIS release through a 2.5 mm (± 0.5 mm) surgical portal. As a result, an effective release of the MIS has been obtained in all fresh-frozen feet. CONCLUSION: The results of our anatomic study indicate that this novel ultrasound-guided minimally invasive surgical approach for the release of the MIS might be an effective, safe and quick decompression technique treating selected patients with a distal tarsal tunnel syndrome.

Clinical-anatomic mapping of the tarsal tunnel with regard to Baxter's neuropathy in recalcitrant heel pain syndrome: part I.

PURPOSE: Neuropathy of the Baxter nerve (BN) seems to be the first cause of the heel pain syndrome (HPS) of neurological origin. METHODS: 41 alcohol-glycerol embalmed feet were dissected. We documented the pattern of the branches of the tibial nerve (TN) and describe all relevant osteofibrous structures. Measurements for the TN branches were related to the Dellon-McKinnon malleolar-calcaneal line also called DM line (DML) for the proximal TT and the Heimkes Triangle for the distal TT. Additionally, we performed an ultrasound-guided injection procedure of the BN and provide an algorithm for clinical usage. RESULTS: The division of the TN was 16.4 mm proximal to the DML. The BN branches off 20 mm above the DML center or 30 mm distally to it. In most of the cases, the medial calcaneal branch (MCB) originated from the TN proximal to the bifurcation. Possible entrapment spots for the medial and lateral plantar nerve (MPN, LPN), the BN and the MCB are found within a circle of 5 mm radius with a probability of 80%, 83%, and 84%, respectively. In ten out of ten feet, the US-guided injection was precisely allocated around the BN. CONCLUSIONS: Our detailed mapping of the TN branches and their osteofibrous tubes at the TT might be of importance for foot and ankle surgeons during minimally invasive procedures in HPS such as ultrasound-guided ankle and foot decompression surgery (UGAFDS).

Intraoperative Nerve Monitoring for Tarsal Tunnel Decompression: A Surgical Technique to Improve Outcomes.

The aim of the current study was to evaluate the effectiveness of intraoperative neuromonitoring (INM) as an adjunct in performing tarsal tunnel decompression surgery. We reviewed 38 patients who met inclusion criteria. INM was used to measure the voltage of the abductor hallucis and digiti quinti muscles both before and after decompression. Observed changes intraoperatively were acute and within minutes of the decompression performed by the surgeon. Patient outcomes were ascertained from clinical findings and classified as excellent, fair, or poor. Patient outcomes and the voltage change were measured and assessed for association, and statistically significant differences were found between outcome groups. Of the 38 patients, 29 (76%) had excellent outcomes, with a mean change in microvolts of 2088.28 ± 1172.44 (684%) (p = .0004) and 2173.24 ± 1228.39 (742%) (p = .0014) for abductor hallucis and abductor digiti quinti, respectively. The study supports INM as a useful adjunct in performing tarsal tunnel decompression.

A Case Report and Literature Review: Intraneural Ganglion Cyst Causing Tarsal Tunnel Syndrome.

Intraneural ganglion cysts are benign mucinous lesions that form within joints and enter adjacent nerves via an articular branch. Despite being morphologically characterized as benign, they can demonstrate considerable intrafascicular destruction and expansion, resulting in worsening compressive neuropathies or nerve injury. There have been several suggested theories of pathogenesis, but the most widely accepted articular (synovial) theory describes a capsular defect in a neighboring joint that allows joint fluid to egress and track along the epineurium of the innervating articular branch. In this case report, we describe an intraneural ganglionic cyst located in the tarsal tunnel with extensive involvement of the tibial nerve. We describe the symptoms, diagnosis, and treatment as well as review the current literature on intraneural ganglionic cysts.

Tarsal Tunnel Syndrome Caused by a Schwannoma of the Posterior Tibial Nerve.

Schwannoma is the most common tumor of the peripheral nerve sheath. However, there have been few reports on schwannoma of the posterior tibial nerve causing tarsal tunnel syndrome. We report on a 60-year-old man with tarsal tunnel syndrome caused by a schwannoma of the posterior tibial nerve, which was first diagnosed as a ganglion cyst. After enucleation of this tumor, the patient was asymptomatic and had no related sequelae except for minor numbness in the plantar aspects of his digits. Although schwannoma of the posterior tibial nerve is rare, it should be considered even if a ganglion is clinically suspected.

Venous malformation as source of a tarsal tunnel syndrome: treat the source or the cause of the complaints? A case report.

Painful tarsal tunnel syndrome is a compression neuropathy with a variety of possible sources. As it presents a challenging differential diagnostic problem, it is often under-diagnosed. Among the intrinsic and extrinsic factors, varicose veins are the main source in case of a venous etiology. We report a case of a 39-year old male patient who presented with complaints of paresthesia and excessive pain of the right foot, especially the medial side. Further work up by ultrasonography, magnetic resonance imaging and electromyography revealed an extensive congenital venous malformation of the right lower limb with subsequent compression of the tibial nerve in the tarsal tunnel. We did not treat the source, but the cause by open tarsal tunnel release. Excellent result with immediate full relieve of the patients complaints was achieved.