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.

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.

Pulsed radiofrequency under ultrasound guidance for the tarsal tunnel syndrome: two case reports.

Tarsal tunnel syndrome (TTS) is a compression neuropathy that results from entrapment of the posterior tibial nerve or its branches. TTS may be treated either by conservative measures, including physical therapy, medications, and steroid injections, or by surgical decompression. Despite a variety of treatments, a few cases of TTS will relapse, and many cases of recurrent TTS will require re-operation. Pulsed radiofrequency (PRF) is known to have a number of advantages for pain management, particularly as this technique does not cause neural compromise such as motor weakness. Here, we report a new application of ultrasound-guided PRF in two cases of intractable TTS. Both patients had a long duration of severe foot pain and had been treated with various therapeutic modalities without lasting relief. We applied ultrasound-guided PRF to the affected posterior tibial nerve in each patient, and both had significantly reduced pain intensity scores and analgesic requirements without any complications. Ultrasound-guided PRF for intractable TTS relieved severe foot pain. It may supersede surgery as a reliable treatment for intractable TTS.

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.

Tarsal tunnel syndrome in hemodialysis patients: a case series.

BACKGROUND: The purpose of our study was to investigate tarsal tunnel syndrome (TTS) arising in patients who have undergone maintenance dialysis at our facility and to evaluate the frequency, pathological characteristics, and diagnosis of TTS. METHODS: We evaluated 1011 patients (mean age 65.1 years) undergoing maintenance dialysis from 2000 to 2006 at our hospital. In patients diagnosed with TTS, we examined clinical symptoms and imaging findings. In addition, we evaluated intraoperative findings in patients who had undergone surgery. A follow-up study was conducted for at least 1 year. RESULTS: Five patients (7 ankles) (mean age 57.8 years) were diagnosed as have TTS, with a mean dialysis duration of 23.4 years (range, 7-30 years). With conservative treatment consisting of rest and a steroid injection, 4 ankles showed improvement. Surgery was performed on 3 ankles. Amyloidoma, nodular tumor fragile deposits in the soft tissue or thecal surface, proliferation of the synovial tendon sheath, and thickened joint capsule were recognized in 3 ankles, and a concomitant ganglion was recognized in 1 ankle. Histologically, the deposition of hyaline material was recognized in all tissues, including the walls of the ganglion or joint capsule, by staining to a pale red color using Congo red stain. An immunohistochemical study indicated positive staining by ß-2 microglobulin staining. The flexor retinaculum was thin in all cases, with retinaculum-like thickness not found in carpal tunnel syndrome. CONCLUSIONS: We believe that the occurrence of TTS in dialysis patients was 0.5%, with a tendency to be more prevalent among patients undergoing maintenance dialysis for 5 or more years. The pathological process of TTS may be different from that of carpal tunnel syndrome. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Post-traumatic pseudoaneurysm of the medial plantar artery combined with tarsal tunnel syndrome: two case reports.

Pseudoaneurysms in the foot are more often reported in the lateral plantar artery than the medial plantar artery, most likely because of its more superficial location. There are no reports of pseudoaneurysm of the medial plantar artery after trauma. We present two cases of pseudoaneurysm of the medial plantar artery after blunt foot trauma and foot laceration. This pseudoaneurysm compressed a posterior tibial nerve, resulting in tarsal tunnel syndrome. The patients were treated successfully using transcatheter embolization without the need for surgical intervention. The tarsal tunnel syndrome also subsided. Here, the authors report these cases and provide a review of literature.

Injection of the Abductor Hallucis Muscle in the Diagnosis and Treatment of Distal Tarsal Tunnel Syndrome.

BACKGROUND: Tarsal tunnel syndrome (TTS) can be divided into proximal TTS and distal TTS (DTTS). Research on methods to differentiate these two syndromes is sparse. A simple test and treatment is described as an adjunct to assist with diagnosing and providing treatment for DTTS. METHODS: The suggested test and treatment is an injection of lidocaine mixed with dexamethasone administered into the abductor hallucis muscle at the site of entrapment of the distal branches of the tibial nerve. This treatment was studied with a retrospective medical record review in 44 patients with clinical suspicion of DTTS. RESULTS: The lidocaine injection test and treatment (LITT) was positive in 84% of patients. Of patients available for follow-up evaluation (35), 11% of those with a positive LITT test (four) had complete lasting symptom relief. One-quarter of patients with initial complete symptom relief at LITT administration (four of 16) maintained this level of symptom relief at follow-up. Thirty-seven percent of patients evaluated at follow-up (13 of 35) who had a positive response to the LITT experienced partial or complete symptom relief. No association was found between level of symptom relief maintenance and the immediate level of symptom relief (Fisher exact test = 0.751; P = .797). The results showed no difference in the distribution of immediate symptom relief by sex (Fisher exact test = 1.048; P = .653). CONCLUSIONS: The LITT is a simple, safe, invasive method to help diagnose and treat DTTS, and it provides an additional method to assist with differentiating DTTS from proximal TTS. The study also provides additional evidence that DTTS has a myofascial etiology. The proposed mechanism of action of the LITT suggests a new paradigm in diagnosing muscle-related nerve entrapments that may lead to nonsurgical treatments or less invasive surgical interventions for DTTS.

Tarsal tunnel syndrome: A literature review.

BACKGROUND: Tarsal tunnel syndrome (TTS) is an entrapment neuropathy of the posterior tibial nerve or its branches within its fibro-osseous tunnel beneath the flexor retinaculum on the medial side of the ankle. It is a rare but important condition which is regularly under diagnosed leading to a range of symptoms affecting the plantar aspect of the foot. Management of this entrapment neuropathy remains a challenge and we have therefore reviewed the published literature in an attempt to clarify aspects of initial presentation, investigation and definitive treatment including surgical decompression. We also assessed the continuing controversial role of electrodiagnostic techniques in its diagnosis. CONCLUSION: Recommendations from literature: Excellent results with decompression in selected patients. To prevent nerve fibrosis, decompression should be performed early. Remain aware of false negative NCS (under-diagnosing of those with symptoms but 'normal' NCS. Role of NCS remains controversial with inability to predict which cases respond to decompression. Poor outcome may be due to nerve fibrosis.

Diagnosis and treatment of chronic ankle pain.

The differential diagnosis for chronic ankle pain is quite broad. Ankle pain can be caused by intra-articular or extra-articular pathology and may be a result of a traumatic or nontraumatic event. A detailed patient history and physical examination, coupled with judicious selection of the appropriate imaging modalities, are vital in making an accurate diagnosis and providing effective treatment. Chronic ankle pain can affect all age groups, ranging from young athletes to elderly patients with degenerative joint and soft-tissue disorders. It has been estimated that 23,000 ankle sprains occur each day in the United States, representing approximately 1 sprain per 10,000 people per day. Because nearly one in five ankle injuries result in chronic symptoms, orthopaedic surgeons are likely to see patients with chronic ankle pain. Many patients with chronic ankle pain do not recall any history of trauma. Reviewing the management of the various disorders that can cause chronic ankle pain will help orthopaedic surgeons provide the best treatment for their patients.

Effects of nerve mobilization exercise as an adjunct to the conservative treatment for patients with tarsal tunnel syndrome.

OBJECTIVE: This study was carried out with the aim of investigating the contribution of nerve mobilization exercises to the conservative treatment of tarsal tunnel syndrome. METHODS: In this clinical trial, 28 patients were randomly allocated into 2 groups. The control group was composed of 14 patients who were treated conservatively with a program consisting of physiotherapy and supportive inserts, whereas 14 patients in the study group were given nerve mobilization exercises in addition to the same treatment. Allpatients were followed up for 6 weeks. Before treatment, subjects were evaluated for muscle strength, range of motion, pain, sensory tests, and clinical manifestations of tarsal tunnel syndrome. The evaluations were repeated after 6 weeks. RESULTS: There was a significant difference in favor of posttreatment values for range of motion, muscle strength, and pain in both groups (P < .05). Intergroup comparisons showed no difference between the groups for these parameters. Significant results were attained in the study group for 2-point discrimination and light touch and Tinel sign after treatment (P < .05). CONCLUSION: Patients in both groups showed improvement from conservative treatment. The results of the study group showed that nerve mobilization exercises have a positive effect on 2-point discrimination and light touch and Tinel sign.

Tarsal Tunnel Syndrome.

Tarsal tunnel syndrome is paresthesia and pain in the foot and ankle caused by entrapment and compression of the tibial nerve within the fibro-osseous tarsal tunnel beneath the flexor retinaculum. The most helpful diagnostic criteria are a positive Tinel sign at the ankle and objective sensory loss along the distribution of the tibial nerve. Treatment is designed to reduce the compression of the nerve, and surgical nerve release is indicated with failure of conservative options. It is important to identify the causative factor of the nerve compression and eliminate it to obtain excellent results.

Magnetic resonance diagnosis of tarsal tunnel syndrome due to flexor digitorum accessorius longus and peroneocalcaneus internus muscles.

Anomalous muscles of the ankle are common. Although they are often asymptomatic, they can sometimes cause tarsal tunnel syndrome. We report a case of tarsal tunnel syndrome due to flexor digitorum accessorius longus and peroneocalcaneus internus muscles diagnosed on magnetic resonance imaging. Recognition of the most common accessory muscles of the ankle on magnetic resonance imaging and tarsal tunnel syndrome are also reviewed.

Acupotomy for patients with tarsal tunnel syndrome: A protocol for systematic review and meta analysis.

BACKGROUND: Tarsal tunnel syndrome (TTS) is a painful condition of the ankle that affects patients' quality of life and ability to work. Multiple clinical studies of nerve decompression by acupotomy have been published in China, and the results are encouraging. However, the efficacy and security of this treatment have not been evaluated scientifically and systematically. The purpose of this systematic review protocol is to evaluate the efficacy and security of acupotomy treatment in patients with TTS, which will be helpful to clinical acupotomy doctors. METHODS: Relevant randomized controlled trials will be identified by searching 9 databases (PubMed, Embase, Cochrane Library, Chinese literature databases, the Chinese Biomedical Literature Database, China National Knowledge Infrastructure, SinoMed, Technology Journal and the Wanfang Database. Randomized controlled trials examining the use of acupotomy for TTS patients will be identified independently by 2 reviewers by searching the databases from inception to March 2020. Clinical effects will be evaluated as the primary outcome. Visual analog scale scores will be assessed as a secondary outcome. Review Manager 5.3 will be used to perform a fixed effects meta-analysis, and the evidence level will be evaluated by using the Grading of Recommendations Assessment, Development, and Evaluation framework. Continuous outcomes will be presented as mean differences or standard mean differences, while dichotomous data will be expressed as relative risks. RESULTS: This study will evaluate the effectiveness and safety of acupotomy in the treatment of TTS in randomized controlled trials with high-quality visual analog scale and Roles and Maudsley score. CONCLUSION: This systematic review will provide evidence to determine whether acupotomy is an effective intervention for patients with TTS. REGISTRATION NUMBER: DOI 10.17605/OSF. IO/9PYC2 (https://osf.io/9pyc2/).

[Assessing the treatment for sacroiliac joint dysfunction, piriformis syndrome and tarsal tunnel syndrome associated with lumbar degenerative disease].

OBJECTIVE: Sacroiliac joint (SIJ) dysfunction, piriformis syndrome (PFS) and tarsal tunnel syndrome (TTS) produce symptoms similar to lumbar degenerative disease (LDD). Patients who have these diseases plus LDD sometimes experience residual symptoms after surgery for LDD. We therefore assessed the results of treatment of SIJ dysfunction, PFS and TTS associated with LDD. PATIENTS AND METHODS: We assessed 25 patients who underwent surgery for LDD and were affected with SIJ dysfunction (12 patients), PFS (7 patients) or TTS (6 patients). SIJ dysfunction was treated with rest, drugs, pelvic band and sacroiliac joint block. PFS was treated with rest, drugs, physical exercise, injection of local anesthetic into the piriformis muscle, and surgical resection of the piriformis muscle. TTS was treated with drugs and tarsal tunnel opening. We analyzed the improvement score and recovery rate (JOA score) for both LDD surgery and the treatment of SIJ dysfunction, PFS and TTS. RESULTS: Symptom improvement was observed in all patients with SIJ dysfunction and PFS and in 4 patients with TTS. The improvement score and recovery rate of treatments for SIJ dysfunction, PFS and TTS were lower than those of surgery for LDD. CONCLUSION: The improvement score and recovery rate of treatment for SIJ dysfunction, PFS and TTS were not as high as those for LDD. To enhance patient satisfaction, it is important to consider these complicating diseases when designing treatments for LDD.

Tarsal tunnel syndrome: assessment of treatment outcome with an anatomic pain intensity scale.

BACKGROUND: Assessment of treatment outcomes for tarsal tunnel syndrome may be improved with a standardized pain rating scale using a descriptive anatomical foot model for pretreatment and post-treatment plantar foot pain analysis. METHODS: Prospective evaluation of 46 consecutive patients (56 feet) who had non-operative and surgical treatment for tarsal tunnel syndrome. Pain intensity was documented before and after treatment with the Wong-Baker FACES Pain Rating Scale applied to the anatomic nerve regions of the plantar aspect of the foot. RESULTS: In patients who had successful non-operative treatment, overall pain intensity was significantly improved in the medial calcaneal, medial plantar, and lateral plantar nerve regions. In patients who had ongoing symptoms despite non-operative treatment, surgical treatment resulted in significant pain improvement in the medial calcaneal and medial plantar, but not lateral plantar, nerve regions. Pretreatment motor nerve conduction latency was significantly greater in patients who had surgical treatment than those who had only non-operative treatment. CONCLUSIONS: Anatomic pain intensity rating models may be useful in the pretreatment and follow-up evaluation of tarsal tunnel syndrome. Predictors of failed non-operative treatment included longer motor nerve conduction latency and greater predominance of foot comorbidities.

Tarsal Tunnel Syndrome Secondary to Accessory Musculature: A Case Report.

Tarsal tunnel syndrome (TTS) is a relatively uncommon compression neuropathy caused by impingement of the tibial nerve or one of the terminal branches. The presence of accessory musculature at the posteromedial aspect of the ankle has been identified as a rare cause of this condition. Despite the rarity of this condition, it must be considered in patients with refractory symptoms consistent with tibial nerve dysfunction. The accurate diagnosis of this condition relies heavily on a detailed history and physical examination, adequate imaging read by both surgeon and trained musculoskeletal radiologist, as well as a high level of suspicion for such pathology. In this case report, we describe a 46-year-old male with history, examination, and imaging all consistent with TTS secondary to accessory musculature. Following excision of an accessory soleus and flexor digitorum accessorius longus, as well as simultaneous tarsal tunnel release, the patient experienced full resolution of his symptoms. This highlights the importance of considering accessory musculature as a potential cause of TTS in patients presenting with tibial compression neuropathy. Levels of Evidence: Level V: Case Report.

Managing the patient with heel pain.

Heel pain presents frequently to primary care, commonly affecting athletic and elderly patients. Its presentation can be a common source of confusion for clinicians given the wide variety of differential diagnoses and the similarities in presenting symptoms and signs. This review classifies heel pain according to site of pain and explores the common pathologies clinicians may encounter. A brief summary of common imaging modalities used is provided. The literature is reviewed to guide evidence-based practice and to provide a framework to help clinicians investigate and manage heel pain before onward referral for specialist intervention. A linked article detailing the imaging of heel pain is included in this issue ( https://doi.org/10.12968/hmed.2019.80.4.192 ).

Anterior tarsal tunnel syndrome.

Compression of the deep peroneal nerve is commonly referred to as anterior tarsal tunnel syndrome. Although rare, this syndrome remains poorly diagnosed. The syndrome is characterized by pain, weakness, and sensory changes of the foot and ankle. Non-operative measures should be attempted to reduce or remove the external compression along the anterior aspect of the foot and ankle. Other options include shoe modifications, cortisone injections,and physical therapy. If conservative management fails to relieve the symptoms, surgical decompression of the entrapped nerve can be performed. The deep peroneal nerve is released from compressive forces in the entrapment site. This can be performed at the more proximal level at the extensor retinaculum or more distally at the level of the tarsal metatarsal site.

Evidence-based treatment of foot and ankle injuries in runners.

Foot and ankle injuries are common in runners. Treatment is becoming more evidence-based for the most common of these conditions; however, further research is needed to determine the best treatments for injuries that are encountered less commonly.