Rare entrapment neuropathies of the lower extremity: A narrative review.

Lower limb entrapment neuropathies comprise a wide range of disorders, including less common conditions like tarsal tunnel syndrome, Morton neuroma, obturator nerve entrapment syndrome, superior gluteal nerve entrapment, and cluneal nerve entrapment syndrome. Despite being less prevalent, these syndromes are equally significant, presenting with symptoms such as pain, dysesthesia, muscular weakness, and distinct physical signs. Accurate diagnosis of these less common disorders is crucial for successful therapy and patient recovery, as they can sometimes be mistaken for lumbar plexopathies, radiculopathies, or musculotendinous diseases. This narrative review highlights the significance of identifying and diagnosing these particular neuropathies through a comprehensive assessment of the patient's medical history, detailed physical examination, and the use of electrodiagnostic and/or ultrasound investigations. When the diagnosis is uncertain, advanced imaging techniques like magnetic resonance neurography or magnetic resonance imaging are necessary to confirm the diagnosis. A positive diagnosis ensures prompt and targeted treatments, preventing further nerve impairments and muscle wasting. This article explores the epidemiology, anatomy, pathophysiology, etiology, clinical presentation, and electrodiagnostic interpretation of lower limb entrapment neuropathies, highlighting the importance of precise diagnosis in achieving favorable patient outcomes.

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.

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.

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/).

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 ).

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.

Tarsal tunnel syndrome-A narrative literature review.

BACKGROUND: Tarsal tunnel syndrome is classified as a focal compressive neuropathy of the posterior tibial nerve or one of its associated branches individually or collectively. The tunnel courses deep to fascia, the flexor retinaculum and within the abductor hallucis muscle of the foot/ankle. The condition is rare and regularly under-diagnosed leading to a range of symptoms affecting the plantar margins of the foot. There are many intervention strategies for treating tarsal tunnel syndrome with limited robust evidence to guide the clinical management of this condition. The role of conservative versus surgical interventions at various stages of the disease process remains unclear, and there is a need for a structured, step-wise approach in treating patients with this syndrome based on derived empirical evidence. This narrative review attempts to scrutinize the literature to date by clarifying initial presentation, investigations and definitive treatment for the purpose of assisting future informed clinical decision and prospective research endeavours. PROCESS: The literature searches that have been incorporated in compiling a rigorous review of this condition have included: the Cochrane Neuromuscular Group's Specialized Register (Cochrane Library 2013), the databases of EMBASE, AMED, MEDLINE, CINAHL, Physiotherapy evidence database (PEDRO), Biomed Central, Science Direct and Trip Database (1972 to the present). Reference listings of located articles were also searched and scrutinized. Authors and experts within the field of lower-limb orthopaedics were contacted to discuss applicable data. Subject-specific criteria searches utilizing the following key terms were performed across all databases: tarsal tunnel syndrome, tibial neuralgia, compression neuropathy syndromes, tibial nerve impingement, tarsal tunnel neuropathy, entrapment tibial nerve, posterior tibial neuropathy. These search strategies were modified with differing databases, adopting specific sensitivity-searching tools and functions unique to each. This search strategy identified 88 journal articles of relevance for this narrative literature review. FINDINGS: This literature review has appraised the clinical significance of tarsal tunnel syndrome, whilst assessing varied management interventions (non-surgical and surgical) for the treatment of this condition in both adults and children. According to our review, there is limited high-level robust evidence to guide and refine the clinical management of tarsal tunnel syndrome. Requirements for small-scaled randomized controlled trials in groups with homogenous aetiology are needed to analyse the effectiveness of specific treatment modalities. CONCLUSIONS: It is necessary that further research endeavours be pursued for the clinical understanding, assessment and treatment of tarsal tunnel syndrome. Accordingly, a structured approach to managing patients who have been correctly diagnosed with this condition should be formulated on the basis of empirical evidence where possible.

Entrapment Neuropathies of the Foot and Ankle.

Posterior tarsal tunnel syndrome is the result of compression of the posterior tibial nerve. Anterior tarsal tunnel syndrome (entrapment of the deep peroneal nerve) typically presents with pain radiating to the first dorsal web space. Distal tarsal tunnel syndrome results from entrapment of the first branch of the lateral plantar nerve and is often misdiagnosed initially as plantar fasciitis. Medial plantar nerve compression is seen most often in running athletes, typically with pain radiating to the medial arch. Morton neuroma is often seen in athletes who place their metatarsal arches repetitively in excessive hyperextension.

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.

Recurrent tarsal tunnel syndrome.

Recurrence of tarsal tunnel syndrome after surgery may be due to inadequate release, lack of understanding or appreciation of the actual anatomy involved, variations in the anatomy of the nerve(s), failure to execute the release properly, bleeding with subsequent scarring, damage to the nerve and branches, persistent hypersensitivity of the nerves, and preexisting intrinsic damage to the nerve. Approaches include more thorough release, use of barrier materials to decrease adherence of the nerve to surrounding tissues to avoid traction neuritis, excisions of neuromas using conduits, and consideration of nerve stimulators and systemic medications to deal with persistent neural pain.

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.

Considerations in footwear and orthotics.

This article is based on educating readers and physicians about the use of footwear and orthotics for themselves and their patients, to treat diseases and enhance functionality in sports and daily life.

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.

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.