Tarsal tunnel syndrome caused by posterior facet talocalcaneal coalition: A case report.

RATIONALE: Tarsal tunnel syndrome (TTS) is a compressive neuropathy of the posterior tibial nerve and its branches. Tarsal coalition is defined as a fibrous, cartilaginous, or osseous bridging of 2 or more tarsal bones. TTS with tarsal coalition is uncommon. Here, we present a rare example of successful surgical management of TTS with posterior facet talocalcaneal coalition. PATIENT CONCERNS: A 74-year-old woman presented with hypoesthesia, numbness, and an intermittent tingling sensation on the plantar area over the right forefoot to the middle foot area. The hypoesthesia and paresthesia of the right foot began 6 years previously and were severe along the lateral plantar aspect. The symptoms were mild at rest and increased during daily activities. Tinel sign was positive along the posteroinferior aspect of the medial malleolus. DIAGNOSIS: Lateral ankle radiography showed joint-space narrowing and sclerotic bony changes with a deformed C-sign and humpback sign. Oblique coronal and sagittal computed tomography revealed an irregular medial posterior facet, partial coalition, narrowing, and subcortical cyst formation of the posterior subtalar joint. Magnetic resonance imaging showed an abnormal posterior talocalcaneal coalition compressing the posterior tibia nerve. Electromyography and nerve conduction velocity studies were performed, and the findings indicated that there was an incomplete lesion of the right plantar nerve, especially of the lateral plantar nerve, around the ankle level. INTERVENTIONS: Surgical decompression was performed. Intraoperatively, the lateral plantar nerve exhibited fibrotic changes and tightening below the posterior facet talocalcaneal coalition. The coalition was excised, and the lateral plantar nerve was released with soft-tissue dissection. OUTCOMES: The patient's symptoms of tingling sensation and hypoesthesia were almost relieved at 4 months postoperatively, but she complained of paresthesia with an itching sensation when the skin of the plantar area was touched. The paresthesia had disappeared almost completely at 8 months after surgery. She had no recurrence of symptoms at the 1-year follow-up. LESSONS: The TTS with tarsal coalition is rare. Supportive history and physical examination are essential for diagnosis. Plain radiographs and computed tomography or magnetic resonance imaging are helpful to determine the cause of TTS and verify the tarsal coalition. After diagnosis, surgical excision of the coalition may be appropriate for management with a good outcome.

Medial calcaneal neuropathy: A rare cause of prolonged heel pain.

Pain heel constitutes 15% of foot pain. Pain may be caused by plantar fasciitis, calcaneal fractures, calcaneal apophysitis, heel pad atrophy, inflammatory diseases or related with nerve involvement. Tibial, plantar and/or medial nerve entrapment are the neural causes of pain. Most of the heel soft tissue sensation is provided by medial calcaneal nerve. Diagnosis of heel pain due to neural causes depends on history and a careful examination. Surgery should not be undertaken before excluding other causes of heel pain. Diagnosis should be reconsidered following conservative therapy.

Síndrome del túnel del tarso posterior bilateral por músculo flexor digitorum longus accesorio; reporte de un caso y descripción de técnica quirúrgica / Bilateral posterior tarsal tunnel syndrome caused by accessory flexor digitorum longus; case report and surgical technique

Objetivo. Describir un caso de síndrome de túnel del tarso posterior (STTP) bilateral causado por un tendón flexor digitorum longus accesorio (FDLA), la técnica de resección quirúrgica y una revisión de la literatura. Materiales y métodos. Reportamos el caso de un paciente varón de 29 años con diagnóstico de STTP bilateral, refractario al manejo conservador con una puntuación AOFAS de 53 puntos. Se solicitó una RM de ambos tobillos encontrándose la presencia del músculo FDLA dentro del túnel tarsiano, en íntima relación con el nervio tibial posterior. Se realiza una descompresión bilateral del túnel tarsiano resecando el músculo FDLA que producía un conflicto de espacio con el nervio tibial posterior. Resultados. El paciente no presentó complicaciones postoperatorias. A los 6 meses de cirugía, presentaba una puntuación final AOFAS de retropié de 87 puntos. Discusión. El STTP consiste en una neuropatía por atrapamiento del nervio tibial posterior o una de sus ramas terminales. Una de sus causas es la presencia FDLA, y su resección está asociada a buenos resultados clínicos. Se recomienda la neurólisis del tejido cicatricial y adherencias alrededor del nervio. Conocer la anatomía normal y su variabilidad para liberar el nervio tibial posterior y sus ramas es fundamental para evitar lesiones iatrogénicas. En nuestro caso clínico, la RM identificó un FDLA bilateral, que al ser resecado se encontraba en íntima relación con el flexor digitorum común, hallazgo poco común en la literatura. Conclusiones. La descompresión cuidadosa del túnel del tarso en un paciente con STTP bilateral sintomático por un FDLA se asocia a buenos resultados, particularmente en aquellos pacientes con diagnóstico y tratamiento precoz. Nivel de evidencia. IV (AU)

Objective. To present a case report of bilateral posterior tarsal tunnel syndrome (PTTS) caused by an accessory flexor digitorum longus (AFDL), including the surgical technique and a review of the literature. Materials and methods. Twenty-nine year old male diagnosed with bilateral PTTS, refractory to conservative management, with 53 points on the preoperative AOFAS score. MR of both ankles showed an AFDL within the tarsal tunnel, in close relationship to the posterior tibial nerve. Bilateral tarsal tunnel decompression and AFDL resection was performed. Results. There were no post-operative complications. At 6 months after surgery, the patient had no pain and had 87 points on the AOFAS score. Discussion. The PTTS is an entrapment neuropathy of the posterior tibial nerve or one of its terminal branches. A rare cause is the presence of an AFDL, and its resection is associated with good clinical results. Careful scar tissue resection and neurolysis is recommended. Knowing the normal pathway and anatomical variability of the posterior tibial nerve and its branches is essential to avoid iatrogenic injury. In our case report, MR and intraoperative findings identified a bilateral FDLA in close relationship to the common flexor digitorum, an unusual finding, with few reports in current literature. Conclusions. Careful tarsal tunnel decompression and AFDL resection in our patient with bilateral symptomatic PTTS has good clinical results and no complications, particularly when diagnosed and treated early (AU)

Utilidad de la imagen híbrida tomografía por emisión de fotón único/tomografía computarizada con 99mTc-hidroximetileno-difosfonato en el estudio del síndrome del túnel tarsiano / Usefulness of 99mTc-hydroxymethylene-diphosphonate single photon emission computed tomography/computed tomography hybrid imaging in the study of tarsal tunnel syndrome

No disponible

Uridine monophosphate, folic acid and vitamin B12 in patients with symptomatic peripheral entrapment neuropathies.

BACKGROUND: Carpal tunnel syndrome is the most common type of peripheral entrapment neuropathy. PATIENTS & METHODS: We performed an exploratory, open-label, multicenter, observational study of 48 patients with peripheral entrapment neuropathy. Patients received a daily capsule of uridine monophosphate, folic acid + vitamin B12 for 2 months and were evaluated using the Pain DETECT questionnaire. RESULTS: The global score for pain decreased from 17.3 ± 5.9 at baseline to 10.3 ± 6.1 at the final evaluation (p < 0.001). Concomitant analgesic and anti-inflammatory treatment was stopped or the dose reduced in 77.4% of patients. CONCLUSION: Uridine monophosphate + folic acid + vitamin B12 reduced total pain score, intensity and characterization of pain and associated symptoms. These results should be tested in a well-designed, adequately powered randomized controlled trial.

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.

Accessory Soleus: A Case Report of Exertional Compartment and Tarsal Tunnel Syndrome Associated With an Accessory Soleus Muscle.

An accessory soleus muscle is a rare anatomic variant that frequently presents as an asymptomatic soft tissue swelling in the posteromedial ankle. Less frequently, the anomalous muscle can cause pain and swelling with activity. We present the case of a 17-year-old male with exertional compartment syndrome and associated tarsal tunnel syndrome secondary to a very large accessory soleus muscle. After surgical excision, the patient was able to return to full activity with complete resolution of symptoms.

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.

Dolor en el pie y cojera. Osteocondrosis del escafoides tarsiano / Foot pain and limp. Tarsal navicular osteochondrosis

El concepto nosológico de necrosis ósea presupone la existencia de un trastorno circulatorio, aunque este pueda no ser anatómicamente demostrable. La multitud de términos empleados para designar esta entidad demuestra la confusión existente acerca de sus mecanismos y características; incluso el término “necrosis avascular” es erróneo, ya que los vasos siguen estando presentes: el trastorno es circulatorio (funcional), no anatómico (estructural). El término osteocondrosis hace referencia al trastorno isquémico exclusivamente del hueso en crecimiento. El dolor en el pie y la cojera son síntomas comunes de presentación, y cuando la osteocondrosis se localiza en los huesos del pie el diagnóstico puede ser complicado si esa enfermedad no se tiene presente (AU)

The nosologic concept of bony tissue necrosis presupposes the existence of a circulatory derangement, even though this derangement may not be anatomically demonstrable. The multitude of terms used for designating this entity just demonstrate the prevailing confusion regarding its mechanisms and characteristics; even “avascular necrosis”, is erroneous, as the vessels themselves are still present: the derangement is a circulatory (functional), not a structural (anatomic) one. Osteochondrosis is a term used to describe a group of disorders that affect the growing skeleton. Foot pain and a limp are common presenting symptoms, and its diagnosis can be really challenging when ostechondrosis is located on foot bones and this condition is not in our mind (AU)

Treatment of anterior tarsal tunnel syndrome through an endoscopic or open technique.

Anterior tarsal tunnel syndrome is often underdiagnosed, due to lack of clinical awareness and vague clinical presentation. Most often patients complain of pain located to the dorsum of the foot. The present study is a consecutive series of 13 patients treated according to a fixed protocol followed for a minimum of 24 months. A total of 12/13 cases presented with a bulge in the anterior part of the ankle or the dorsal foot and Tinel's sign was positive over it. Only half had decreased sensation. Surgical technique was either endoscopic or open. Endoscopy is preferable when compression is due to an osteophyte (4/13) or an isolated ganglion 2/13). In other cases presenting with synovitis (5/13) or unknown etiology (2/13) performing open surgery was deemed as safer. The American Orthopedic Foot and Ankle Society (AOFAS) hindfoot scores improved from an average of 55 ± 8 to 83 ± 11 at 12 months after surgery and 88 ± 10 at 24 months after surgery. The anterior tarsal tunnel syndrome accounts for approximately 5% of cases complaining of feet numbness, which undergo electromyographic and nerve conduction testing. Reports in the scientific literature are scarce, perhaps due to underdiagnosis, while it is amenable to surgical management. Clinical diagnosis supported by imaging studies demonstrated osteophytes, ganglions or localized synovitis. Endoscopic treatment can be performed safely provided a clear-cut single compressing element is identified.

Estudos de condução nervosa no nervo tibial através do tunel do tarso em pacientes de hanseníase / Nerve conduction studies of the tibial nerveacross the tarsal tunnel in leprosy patients

Os autores avaliaram todos os exames de condução nervosa do nervo tibial dos pacientes com suspeita de neuropatia da hanseníase, aguda ou subaguda, atendidos no Ambulatório de Hansenologia do Instituto Lauro de Souza Lima (ILSL) no período de dois anos. Foram incluídos 75 pacientes, 52 masculinos e 23 femininos, com média de idade de 44,5 anos (21 a 73 anos), totalizando 150 nervos. Procurou-se caracterizar o comprometimento neurofisiológico individualizando-se os ramos plantar medial (PM) e plantar lateral (PL), observou-se que o mais envolvido foio PL com 57,4%, seguido do PM com 42,6%. O tipo de lesão nervosa mais frequente foi a de predomínio axonal, com 66%, seguida pela mielínica, com 28,7%.O envolvimento mais freqüente e desproporcional dor amo PL, além de evidenciar o caráter compressivo do comprometimento do tibial no túnel do tarso, remete a uma mononeuropatia múltipla compressiva nos membros inferiores. A alta prevalência do comprometimento do nervo tibial foi considerada uma marcada doença, da mesma forma que a neuropatia ulnar.

The authors assessed all tibial nerve conduction studies (NCS) of the patients under suspicious of acute or subacute leprosy neuropathy, who have been attended the Leprosy Ambulatory Clinic of the ILSL during a period of two years. Seventy-five patients have been included as follows: 52 male and 23 female, between 21 and 73 years old, with the mean age of 44.5 totaling 150 nerves The medial plantar (MP) and lateral plantar ( (LP) branches were studied separately. The most involved was the LP with 57.4%, followed bythe MP with 42.6%. The most frequent injury among the abnormal nerves was the axonal lesion with 66%, followed by the myelin lesion with 28.7%. The most frequent and disproportional involvement of thePL branch not only demonstrates the compressivecharacter of the tibial nerve injury in the tarsaltunnel but also indicates a multiple entrapment mononeuropathy in the lower limbs. The high prevalence of the tibial nerve injury was considered a hallmark of the disease, as well as the ulnar neuropathy.

Síndrome del túnel tarsiano bilateral por sinovitis. Aportación diagnóstica combinada de ecografía y electrofisiología / No disponible

No disponible

The accessory deep peroneal nerve and anterior tarsal tunnel syndrome: case report.

The accessory deep peroneal (ADPN) nerve has been regarded as an anomalous nerve derived from the superficial peroneal nerve or its branch and supplies motor innervations for extensor digitorum brevis (EDB) and sensory innervations for the lateral part of the ankle and foot regions. The EDB is usually innervated exclusively by the deep peroneal nerve, a major branch of the the common peroneal nerve, however, in as many as 28% of patients (with same male/female frequency), one or both of the EDB muscles are (partially or exclusively) innervated by the ADPN nerve. This anomaly appears to be inherited in autosomal dominant fashion with incomplete gene penetrance. ADPN existence is of great clinical and surgical importance, and the aim of this study is to describe a very rare case of coexistence ADPN and anterior tarsal tunnel syndrome.

[Surgical treatment of tarsal tunnel syndrome in diabetic neuropathy]. / Tratamentul chirurgical al sindromului de canal tarsian în neuropatia periferica diabetica.

UNLABELLED: Posterior tibial nerve decompression surgery in tarsal tunnel syndrome in patients with diabetic neuropathy reduces pain, improves sensitivity and prevents foot ulcers and lower leg amputations. AIM: To observe and assess the recovery of plantar sensitivity recovery and the healing of ulcerative lessions of the foot, by clinical examination, exploration and analysis of quantitative neurosensory by surgical decompression of the tarsal tunnel. MATERIAL AND METHODS: We evaluated a total of 10 patients and 12 symptomatic diabetic neuropathy feet in a prospective clinical study, surgically treated in the Clinic of Plastic Surgery and Reconstructive Microsurgery Iasi, during January 2008 - June 2011, where we practiced tibial nerve decompression and neurolysis in tarsal tunnel syndrome. RESULTS: Gender distribution of patients in the study group was predominantly male (60%), the ratio M/F = 1.5/1. Posterior tibial nerve decompression surgery resulted in recovery of plantar foot sensitivity in 90% patients in the study group. Testing Semmes-Weinstein 10 g monofilament was positive in 83.3% of the feet preoperatively whereas postoperatively only 25%, distribution of statistically significant (chi2 = 6.04, GL = 1, p = 0.014). Postoperative score to test a range of Riedel-Seiffer returned to normal in all patients: score 7 to 58.3% and score 8 to 41.7% of total standing tested. CONCLUSIONS: Tarsal tunnel decompression in diabetic patients with peripheric neuropathy improves plantar sensitivity, leads to healing of ulcerative plantar lesions and improves quality of life and should be performed in all patients with diabetic peripheral neuropathy in which conservative and/or medical treatment failed.

Síndrome del túnel del tarso en paciente con neurilemoma de nervio tibial posterior. A propósito de un caso / Tarsal tunnel syndrome in a patient with a posterior tibial nerve neurilemmoma. A case report

El síndrome del túnel del tarso (STT) es una neuropatía por compresión del nervio tibial posterior (NTP) y/o sus ramas en el túnel osteofibroso retromaleolar medial. La clínica es variada siendo los síntomas más frecuentes el dolor neuropático e hipoestesia en la planta del pie, con empeoramiento en bipedestación. Su etiología es variada siendo los tumores poco frecuente, como es nuestro caso. Los neurilemomas o schwannomas son lesiones nerviosas benignas con origen en las células de Schwann. Habitualmente aparecen como tumores solitarios con comportamiento benigno, siendo excepcional su transformación maligna. Presentamos un caso clínico de neurilemmoma de nervio tibial posterior a nivel retromaleolar en un varón de 37 años, con clínica de síndrome del túnel del tarso. Destacamos las principales características de esta afección incluyendo presentación clínica, estudio radiológico y tratamiento quirúrgico (AU)

Tarsal tunnel syndrome is a compression neuropathy of the posterior tibial nerve and/or its branches in the fibro-osseous tunnel behind the medial malleolus. Clinical symptoms are usually neuropathic pain and loss of sensation that get worse on standing up. Its aetiology includes various pathologies, although tumours are infrequent. Neurilemmomas or schwannomas are benign tumours that arise from Schwann cells. Usually present as solitary tumours with good prognosis and malignancy is extremely rare. A case of a 37 year-old man with a neurilemmoma in the posterior tibial nerve of the tarsal tunnel is presented along with the clinical, radiological and treatment features (AU)

[Anterolateral ankle pain: differential diagnosis and approach. A case report]. / Dolor anterolateral de tobillo, diagnóstico diferencial y abordaje. Presentación de un caso.

The ankle soft tissue pathology represents a very painful disorder for patients who, often times, are not precisely diagnosed. Anterolateral ankle impingement is a condition that occurs in young people and athletes due to a plantar flexion-inversion mechanism. We report a case of anterolateral ankle impingement describing the arthroscopic technique and making the differential diagnosis considering other conditions.

Medial ankle and heel: ultrasound evaluation and sonographic appearances of conditions causing symptoms.

The complex anatomy of the medial ankle and hindfoot can make clinical assessment of medial ankle and heel pain challenging. Ultrasound is an accessible, relatively inexpensive modality, and modern high-resolution probes allow eloquent demonstration of the main structures that are implicated as potential causes of medial ankle pain. In this work we review highlights the clinically relevant anatomy and normal sonographic appearances of structures around the medial ankle and heel and discuss key techniques to allow optimal ultrasound assessment. The conditions that cause medial-sided ankle and heel symptoms are discussed with their characteristic sonographic appearances.

[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.

Peripheral nerve sheath tumor of the medial plantar nerve without tarsal tunnel syndrome: a case report.

UNLABELLED: Peripheral nerve sheath tumors are relatively uncommon soft tissue tumors, and the incidence of peripheral nerve sheath tumors localized to the plantar surface of the foot, without symptoms of tarsal tunnel syndrome, is even more rare. In this report, we present the rare case of a patient with a peripheral nerve sheath tumor originating from the medial plantar nerve in the plantar vault. The tumor was enucleated and fully excised under microscopic inspection using fine-tipped instrumentation, without en bloc resection of the associated nerve trunk. Surgeons should consider peripheral nerve sheath tumor as a cause of plantar foot pain, despite the rarity of this disorder. LEVEL OF CLINICAL EVIDENCE: 4.