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.

Ganglia-Induced Tarsal Tunnel Syndrome.

BACKGROUND: Tarsal tunnel syndrome (TTS) is a common entrapment neuropathy that is sometimes elicited by ganglia in the tarsal tunnel. METHODS: Between August 2020 and July 2022, we operated on 117 sides with TTS. This retrospective study examined data from 8 consecutive patients (8 sides: 5 men, 3 women; average age 67.8 years) with an extraneural ganglion in the tarsal tunnel. We investigated the clinical characteristics and surgical outcomes for these patients. RESULTS: The mass was palpable through the skin in 1 patient, detected intraoperatively in 1 patient, and visualized on MRI scanning in the other 6 patients. Symptoms involved the medial plantar nerve area (n = 5), lateral plantar nerve area (n = 1), and medial and lateral plantar nerve areas (n = 2). The interval between symptom onset and surgery ranged from 4 to 168 months. Adhesion between large (≥20 mm) ganglia and surrounding tissue and nerves was observed intraoperatively in 4 patients. Of the 8 patients, 7 underwent total ganglion resection. There were no surgery-related complications. On their last postoperative visit, 3 patients with a duration of symptoms not exceeding 10 months reported favorable outcomes. CONCLUSIONS: Because ganglia eliciting TTS are often undetectable by skin palpation, imaging studies may be necessary. Early surgical intervention appears to yield favorable 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.

Bilateral Flexor Digitorum Accessorius Longus Precipitating Bilateral Tarsal Tunnel Syndrome: A Case Report.

CASE: A 29-year-old woman presented with bilateral tarsal tunnel syndrome caused by bilateral flexor digitorum accessorius longus, experiencing immediate relief of symptoms after surgical intervention through 1 year. CONCLUSION: Accessory muscles can cause compressive neuropathies in multiple areas of the body. In patients who have FDAL as the cause of their tarsal tunnel syndrome, surgeons should have a high index of suspicion of bilateral FDAL if the same patient develops similar contralateral symptoms.

Tortuosity and Pulsatility of the Tibial Artery - Two Case Reports of a Rare Etiology of Tarsal Tunnel Syndrome.

Tarsal tunnel syndrome is a neuropathic compression of the tibial nerve and its branches on the medial side of the ankle. It is a challenging diagnosis that constitutes symptoms arising from damage to the posterior tibial nerve or its branches as they proceed through the tarsal tunnel below the flexor retinaculum in the medial ankle, easily forgotten and underdiagnosed. Neural compression by vascular structures has been suggested as a possible etiology in some clinical conditions. Tibial artery tortuosity is not that rare, but only that it affects the nerve can cause tarsal tunnel syndrome. Therefore, a study care must be taken to avoid false-positive errors.

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 secondary to accessory or variant muscles: a clinical and anatomical systematic review.

PURPOSE: Many etiologies are known to lead to a tarsal tunnel syndrome (TTS). One rare cause is mass-occupying lesions, and particularly accessory or variant muscles (AVM). This study aimed to systematically collect published clinical cases of TTS caused by AVM. METHODS: An electronic literature search was conducted from inception to April 2021. The diagnosis of AVM should be reported in one of the following methods: ultrasonography, magnetic resonance imaging (MRI), or per-operatively. Data extraction included types and prevalence of accessory muscles, clinical presentation and diagnosis, and treatment modalities. Twenty-five studies were identified with a total 39 patients (47 ankles). RESULTS: The prevalence of TTS was reported in only two studies (9%). Forty-nine AVM were identified with the accessory flexor digitorum longus being the most common (52%). The most common sign/symptoms were tenderness (78.7%), pain (82.9%), dysesthesia (57.4%), Tinel sign (44.6%), and a swelling (25.5%). Decompression and excision were the most commonly performed procedures. Four accessory/variant muscles in the ankle have the potential to induce a tarsal tunnel syndrome. CONCLUSION: This review highlights the clinical and imagery specificities of TTS secondary to accessory or variant muscles. Mass-occupying etiology should be included in the list of differential diagnoses whenever a posterior tibial nerve compression is suspected.

Electrophysiological Study of the Tibial Nerve Across the Tarsal Tunnel in Distal Symmetric Diabetic Polyneuropathy.

OBJECTIVE: The aim of the study was to demonstrate abnormalities of motor conduction of the tibial nerve across the tarsal tunnel in type 2 diabetes. DESIGN: One hundred twenty-four consecutive patients (mean age = 66.6 yrs, 62.1% male) with distal symmetric diabetic polyneuropathy clinically diagnosed were prospectively enrolled. Nerve conduction studies of deep peroneal, tibial, superficial peroneal, medial plantar, and sural nerves and standard needle electromyography in the lower limbs were performed. Demographic, anthropometric, and clinical findings were collected. RESULTS: Motor conduction velocity of the tibial nerve across tarsal tunnel was slowed in 60.5% of patients; another 4% showed conduction block across tarsal tunnel without reduction of motor conduction velocity. Overall percentage of abnormalities across tarsal tunnel (64.5%) exceeds that of the sensory conduction velocities of proximal sural and superficial peroneal nerves. Abnormal tibial motor conduction velocity across tarsal tunnel represents the most common abnormality among all motor nerve conduction study parameters and significantly correlates with hemoglobin level, diabetic neuropathic index score, and diabetic complications frequency. CONCLUSIONS: Tibial conduction abnormalities across tarsal tunnel are the most sensitive motor parameter in distal symmetric diabetic polyneuropathy, second only to conduction abnormalities of sensory/mixed distal nerves of the feet. The use of nerve conduction studies across tarsal tunnel of the tibial nerve may be useful in the electrophysiological protocol to confirm the diagnosis of distal symmetric diabetic polyneuropathy.

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.

Tarsal Tunnel Syndrome Caused by an Occult Schwannoma of the Posterior Tibial Nerve: Avoidance of Delay in Diagnosis.

Tarsal tunnel syndrome (TTS), resulting from compression of the posterior tibial nerve (PTN) within the tarsal tunnel, is a relatively uncommon entrapment neuropathy. Many cases of tarsal tunnel syndrome are idiopathic; however, some causes, including space-occupying lesions, may lead to occurrence of TTS symptoms. Schwannoma, the most common tumor of the sheath of peripheral nerves, is among these space-occupying lesions, and may cause TTS when it arises within the tarsal tunnel, and it may mimic TTS even when it is located outside the tarsal tunnel and cause a significant delay in diagnosis. The possibility of an occult space-occupying lesion compressing the PTN should be kept in mind in the differential diagnosis of TTS, and imaging studies that are usually not used in entrapment neuropathies may be of importance in such patients. This case report presents a 65-year-old woman with TTS symptoms and neurophysiologic findings secondary to an occult schwannoma of the PTN proximal to the tarsal tunnel. Avoidance of delay in diagnosis in secondary cases is emphasized.

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.

Comparison of tunnel ligament release instrument assisted minimally open surgery and conventional open surgery in the treatment of tarsal tunnel syndrome.

AIM: This study compared the results of tarsal tunnel syndrome release surgeries using mini-open incisions and standard incisions. PATIENTS AND METHODS: From January 2012 until April 2018, 31 feet of 29 patients diagnosed with tarsal tunnel syndrome were treated surgically. 15 feet of 15 patients underwent surgeries utilizing minimally open technique and 16 feet of 14 patients underwent surgeries utilizing standard incisions. The following preoperative and postoperative data was obtained: foot and ankle muscle testing results, posture analyses, anthropometric measurements, joint movement ranges, pain complaints, endurance evaluation results, and functional test results. The mean follow-up period was 38 months (13-88 months). RESULTS: The mean operation times were 26.8 min (23-30 min) using the standard incision and 13.3 min (9-17 min) using the mini-open incision (p < 0.05). In the preoperative and postoperative comparisons of the total muscle strength and total joint limit values of the healthy and affected feet, statistically significant improvements were observed in both the mini-open incision and standard incision groups (p < 0.05). Moreover, statistically significant improvements were seen in both groups in the postoperative repeated toe raises for 1 minute assessments of the affected foot (p < 0.05). In the foot function index and functional foot score values, statistically significant improvements were seen between the preoperative and postoperative values in both groups (p < 0.05). CONCLUSIONS: Based on the results of this study, using a tunnel ligament release instrument assisted minimally open surgery to loosen the laciniate ligament may present an alternative to the standard incision, with its significantly decreased morbidity rate and cosmetic success.

Unrecognized tibial nerve injury in total-ankle arthroplasty: Two case reports.

RATIONALE: Tibial nerve injury is a sustainable but rare complication during total-ankle arthroplasty (TAA). We outlined 2 previously unreported cases of tibial nerve injury in TAA, including the prognoses and possible causes. PATIENT CONCERNS: First, a 63-year-old woman complained of a 5-month history of persistent tingling sensation and numbness on the medial and plantar aspects of her foot after TAA. Second, a 50-year-old woman complained of a 6-month history of tingling sensation and numbness on the plantar surface of her forefoot after TAA. DIAGNOSIS: Explorations were performed on suspicion of tarsal tunnel syndrome; however, both patients exhibited complete laceration of tibial nerve with neuroma formation. INTERVENTIONS: In both patients, we excised the neuroma and performed end-to-end nerve repair. OUTCOMES: The sensory disturbance of the sole considerably improved at long-term follow-up over 8 years after the neurorrhaphy procedures. LESSONS: Tibial nerve injury is rare following TAA, and is sometimes unrecognized or misdiagnosed. If tibial nerve injury is suspected, prompt surgical exploration should be performed; great precaution must also be taken to prevent injury of the tibial nerve during TAA.

Dimensional Changes of the Tibial Nerve and Tarsal Tunnel in Different Ankle Joint Positions in Asymptomatic Subjects.

The tarsal tunnel is a clinically important fibrous osseous conduit for the tibial nerve and associated tendons. It is mechanically dynamic, and normal ankle movements appear to change the tunnel shape, potentially having an impact on the tibial nerve. The objective of this study was to measure changes in the tibial nerve and tarsal tunnel dimensions in plantarflexion and dorsiflexion of the ankle joint in healthy subjects. A cross-sectional study with 13 volunteer subjects and a total of 18 records was designed. The cross-sectional area, anterior-posterior distance, transverse distance, and flattening ratio of the tibial nerve were measured by using ultrasound in plantarflexion and dorsiflexion of the ankle joint. The anterior-posterior distance of the tarsal tunnel was also measured. The tunnel anterior-posterior distance significantly increased during plantarflexion (p < .001) and decreased during dorsiflexion (p = .027) of the ankle. From plantarflexion to dorsiflexion of the ankle, the tibial nerve cross-sectional area significantly decreased (p = .035). The anterior-posterior distance also decreased significantly (p < .001), whereas the transverse distance increased (p < .001), thus decreasing the flattening ratio of the tibial nerve (p < .001). Ankle joint position determined significant changes in the shape and dimensions of the tibial nerve at the tarsal tunnel.

Distal Fibular Osteochondroma Resulting in Tarsal Tunnel Syndrome: Case Report and Literature Review.

BACKGROUND: Osteochondromas are benign osseous tumors encountered most routinely by physicians responsible for diagnosing musculoskeletal disorders. Often, these osseous lesions are identified following symptoms related to their impingement on adjacent soft tissue or bone. METHODS: This article presents a unique case of an asymptomatic osteochondroma of the distal fibula in a 29-year-old Caucasian woman that manifested clinically as an impingement on the tibial nerve. RESULTS: After resection of the osteochondroma, the patient's tarsal tunnel syndrome symptoms resolved. CONCLUSIONS: This case report demonstrates a never-before-described osteochondroma of the distal fibula traversing posterior to the ankle joint and impinging on the tibial nerve. After resection, the patient's symptoms resolved.

Tarsal tunnel syndrome: a still challenge condition / Síndrome do túnel do tarso: uma condição ainda desafiadora

Tarsal tunnel syndrome is a rare, under diagnosed and often confused neuropathy with other clinical entities. There is a lack of population studies on this disease. Herein, we performed a non-systematic review of articles between January 1992 and February 2018. Although with a less complex anatomy comparing to the carpal tunnel, the tarsal tunnel is source of pain and some other conditions. Treatment involves conservative measures such as analgesics and physical therapy rehabilitation or surgical procedures in case of conservative treatment failure. Randomized control studies are lack and mandatory for uncover the best modality of treatment for this condition.

A Síndrome do túnel do tarso é uma rara e subdiagnosticada neuropatia geralmente confundida com outras entidades clínicas. Há falta de estudos populacionais sobre a doença. Assim sendo, realizamos uma revisão da literatura de artigos entre Janeiro de 1992 e fevereiro de 2018. Apesar de possuir uma anatomia de menor complexidade comparada ao túnel do carpo, o túnel do tarso é origem de dor e algumas outras condições. O tratamento envolve medidas conservadoras como analgésicos e terapia de reabilitação ou procedimentos cirúrgicos, em caso de falha do tratamento conservador. Estudos randomizados são escassos e necessários para descoberta da melhor modalidade de tratamento desta condição.

Validity of the Tinel Sign and Prevalence of Tibial Nerve Entrapment at the Tarsal Tunnel in Both Diabetic and Nondiabetic Subjects: A Cross-Sectional Study.

BACKGROUND: Nerve entrapments like carpal tunnel syndrome are more prevalent in patients with diabetes, especially in those with diabetic polyneuropathy. Our study aims were to investigate the validity of the Tinel sign in diagnosing tibial neuropathy and determine the prevalence of tibial nerve entrapment in both a diabetic and nondiabetic population. METHODS: Two hundred forty nonneuropathic subjects with diabetes and 176 diabetic subjects with neuropathy participating in the prospective Rotterdam Diabetic Foot Study and 196 reference subjects without diabetes and without neuropathy complaints were evaluated. All subjects underwent sensory testing of the feet, and complaints were assessed using the Michigan Neuropathy Screening Instrument. The Tinel sign was defined as discriminative and valid for diagnosing tibial nerve entrapment when the nerve-related Michigan Neuropathy Screening Instrument subscore of neuropathic symptoms differed at least 5 percent between the Tinel-positive and Tinel-negative subjects. When the sign was valid, prevalence estimates of tibial nerve entrapment at the tarsal tunnel were calculated. RESULTS: Significantly more neuropathic symptoms (p < 0.002) and higher sensory thresholds (p < 0.0005) were observed in (compressed) tibial nerve-innervated areas, indicating that a positive Tinel sign at the tarsal tunnel is a valid measure of tibial nerve abnormality. The prevalence of tibial nerve entrapment in diabetic patients was 44.9 percent (95 percent CI, 40.1 to 49.7 percent) versus 26.5 percent (95 percent CI, 20.3 to 32.7 percent) in healthy controls (p < 0.0001). CONCLUSIONS: Tibial nerve entrapment is more prevalent in diabetic subjects than in controls. The significantly more frequently reported neuropathic complaints and concomitant sensory disturbances provide evidence for the role of superimposed entrapment neuropathy in diabetes-related neuropathy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Tarsal tunnel syndrome caused by an uncommon ossicle of the talus: A case report.

RATIONALE: Tarsal tunnel syndrome (TTS) is a compressive neuropathy of the posterior tibial nerve or one of its branches within the tarsal tunnel that is often caused by a variety of space-occupying lesions, such as ganglia, lipomas, varicosities, neural tumors, trauma, or systemic disease. The os sustentaculi is a small accessory bone, bridged to the posterior aspect of the sustentaculum tali by fibrocartilage. To the best of our knowledge, this is a rare case of successful treatment of TTS caused by the os sustantaculi. PATIENT CONCERNS: A 37-year-old male presented with insidious onset of right ankle and foot pain for 1 year. He also complained of a tingling sensation and paresthesia from the plantar and medial aspect of the forefoot to the middle foot area along the main distribution of the medial plantar nerve. The symptoms were mild at rest, but increased upon prolonged walking. He had an ankle sprain history during a football game 2 years previously and recurrent ankle sprains had occurred more frequently in this ankle since that trauma. DIAGNOSES: Plain standing anteroposterior and lateral view radiographic findings of the right ankle reveled an accessory ossicle located posterosuperomedial to the sustentaculum tali. A computed tomography scan showed that the ossicle articulated between the talus and calcaneus. A magnetic resonance image revealed mild bone marrow edema in the ossicle and medial displacement of the tarsal structures. INTERVENTIONS: Surgery was performed under general anesthesia. The ossicle was delineated from its surrounding structures and was removed. Tension on the nerve was released. OUTCOMES: The patient's pain and hypoesthesia were immediately relieved, and the tingling sensation disappeared 6 months after surgery. The patient had no complications or recurrence of symptoms at the 1-year follow-up.