Síndrome del túnel del tarso: secundario a insuficiencia venosa. Reporte de un caso / Tarsal tunnel syndrome secondary to venous insufficiency: Case report

El síndrome del túnel del tarso se define como una neuropatía compresiva extrínseca y/o intrínseca del nervio tibial posterior o de una de sus ramas siendo una de sus causas la insuficiencia vascular. Caso clínico: femenina de 51 años, originaria de León, Guanajuato. Hipertensa, síndrome de Guillain-Barré hace ocho años, insuficiencia vascular y obesidad. Inicia con dolor en tobillo y talón izquierdo, manejada con AINES y rehabilitación con mejoría parcial, se realizan radiografías y resonancia magnética nuclear del tobillo izquierdo con datos de pinzamiento posterior, se realiza artroscopía y mejora un mes presentándose dolor intenso en el tobillo y la planta del pie y disestesias, se hace electromiografía con datos de lesión del tibial posterior. Cuenta con historia clínica, perfil prequirúrgico, dorsoplantar y lateral, se realiza una artroscopía encontrándose una tendinitis del Flexor Hallucis Longus (FHL), sinovitis y un pinzamiento posterior del tobillo, se hace sinovectomía, descompresión y un peinado del FHL. Mala evolución, se realiza electromiografía con axonotmesis de la rama plantar medial. Se realiza la liberación del nervio encontrándose el plexo venoso de Lazhortes tortuoso comprimiendo en todo su trayecto. Una de las causas es por la compresión intrínseca secundaria a tumores, modificaciones de la anatomía del túnel del tarso; sin embargo, menos frecuente, las várices pueden confundir el diagnóstico y llegar a producir un daño irreparable para el paciente si no se trata a tiempo. La paciente se encuentra actualmente sin dolor que le posibilita la marcha, con disestesias leves del primer dedo y movilidad limitada para su flexión.

Tarsal tunnel syndrome is defined as an extrinsic and/or intrinsic compressive neuropathy of the posterior tibial nerve or one of its branches. Its causes include venous insufficiency. Clinical case: 51 year-old female patient from León, Guanajuato. Hypertensive, with Guillain-Barré syndrome for eight years, vascular insufficiency and obesity. Her condition started with left ankle and heel pain; she was treated with NSAIDs and rehabilitation and achieved partial improvement. X-rays and MRI of the left ankle showed posterior impingement. She underwent arthroscopy and improved but one month later she presented with severe pain in the left ankle and sole and dysesthesias. Electromyography showed a lesion of the posterior tibial nerve. We had the patient's case history, preoperative tests, and dorsoplantar and lateral X-ray views. The arthroscopic diagnosis was flexor hallucis longus (FHL) tendinitis, synovitis and posterior ankle impingement. Synovectomy, decompression and smoothening of the FHL tendon were performed. The patient did poorly and underwent electromyography with axonotmesis of the medial plantar branch. After the nerve was released, Lazorthes venous plexus was found to be tortuous and compressing the entire nerve tract. The possible causes for this include intrinsic compression secondary to tumors, and anatomical changes of the tarsal tunnel. However, less often varices may confound the diagnosis and cause irreversible damage if not treated timely. The patient is currently pain free and can walk, has mild dysesthesias of the first toe and limited flexion.

[Tarsal tunnel syndrome secondary to venous insufficiency. Case report]. / Síndrome del túnel del tarso: secundario a insuficiencia venosa. Reporte de un caso.

Tarsal tunnel syndrome is defined as an extrinsic and/or intrinsic compressive neuropathy of the posterior tibial nerve or one of its branches. Its causes include venous insufficiency. Clinical case: 51 year-old female patient from León, Guanajuato. Hypertensive, with Guillain-Barré syndrome for eight years, vascular insufficiency and obesity. Her condition started with left ankle and heel pain; she was treated with NSAIDs and rehabilitation and achieved partial improvement. X-rays and MRI of the left ankle showed posterior impingement. She underwent arthroscopy and improved but one month later she presented with severe pain in the left ankle and sole and dysesthesias. Electromyography showed a lesion of the posterior tibial nerve. We had the patient's case history, preoperative tests, and dorsoplantar and lateral X-ray views. The arthroscopic diagnosis was Flexor Hallucis Longus (FHL) tendinitis, synovitis and posterior ankle impingement. Synovectomy, decompression and smoothening of the FHL tendon were performed. The patient did poorly and underwent electromyography with axonotmesis of the medial plantar branch. After the nerve was released, Lazorthes venous plexus was found to be tortuous and compressing the entire nerve tract. The possible causes for this include intrinsic compression secondary to tumors, and anatomical changes of the tarsal tunnel. However, less often varices may confound the diagnosis and cause irreversible damage if not treated timely. The patient is currently pain free and can walk, has mild dysesthesias of the first toe and limited flexion.

[Anatomical variants of the medial calcaneal nerve and the Baxter nerve in the tarsal tunnel]. / Variantes anatómicas del nervio calcáneo medial y nervio de Baxter en el túnel del tarso.

The tarsal tunnel is composed of the posterior border of the medial malleoulus, the posterior aspect of the talus and the medial aspect of the calcaneus. The medial calcaneal nerve emerges from the posterior aspect of the posterior tibial nerve in 75% of cases and from the lateral plantar nerve in the remaining 25%. Finally, the medial calcaneal nerve ends as a single terminal branch in 79% of cases and in numerous terminal branches in the remaining 21%. To describe the anatomical variants of the posterior tibial nerve and its terminal branches. To describe the steps for tarsal tunnel release. To describe Baxter nerve release. The anatomical variants of the posterior tibial nerve and its terminal branches within the tarsal tunnel were studied. Then the Lam technique was performed; it consists of: 1) opening of the laciniate ligament, 2) opening of the fascia over the abductor hallucis muscle, 3) exoneurolysis of the posterior tibial nerve and its terminal branches, identifying the emergence and pathway of the medial calcaneal branch, the lateral plantar nerve and its Baxter nerve branch and the medial plantar nerve. Baxter nerve was found in 100% of cases. In 100% of cases in our series the nerve going to the abductor digiti minimi muscle of the foot was found; 87.5% of cases had two terminal branches. The dissections proved that a crucial step was the release of the distal tarsal tunnel.