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Tarsal Tunnel Syndrome

Syndromes Tarsal Tunnel

Tarsal tunnel syndrome is a common syndrome resulting from compression of the posterior tibial nerve or of the plantar nerves in the tarsal tunnel, characterized by pain and paresthesias.


Presentation

The early clinical presentation of Tarsal Tunnel Syndrome may start with a mild tingling (like an electrical charge) and burning sensation in the sole of the foot. Symptoms are aggravated by prolonged standing and walking but relieved by rest. Paresthesia or “pins and needles pricking sensation” occurs in the distribution of the tibial nerve and its branches.

The affected foot may feel weak and numb in chronic cases. The area under the medial malleolus (inner bone bit of the ankle) may feel pain to palpation and resonate paresthesia if gently tapping by a neurologic hammer, otherwise known as the “Tinel’s sign” which is pathognomonic for Tarsal Tunnel Syndrome. Soft tissue masses like retention cysts, ganglioma or lipoma may directly be palpable below the medial malleolus. Chronic disease may show muscle wasting and loss of bone density in the affected foot.

Asymptomatic
  • These patients suggest that a pre-existing asymptomatic TTS may become manifest after a mechanism akin to that described in the "double crush" syndrome.[ncbi.nlm.nih.gov]
  • The patient remains asymptomatic 40 months following surgery.[ncbi.nlm.nih.gov]
  • 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.[ncbi.nlm.nih.gov]
  • After enucleation of this tumor, the patient was asymptomatic and had no related sequelae except for minor numbness in the plantar aspects of his digits.[ncbi.nlm.nih.gov]
  • ATTS is often asymptomatic or olygosymptomatic. There are few reports describing the ATTS.[ncbi.nlm.nih.gov]
Soft Tissue Mass
  • If the Tarsal Tunnel Syndrome is caused by a soft tissue mass, then surgical removal of the mass may be necessary. Surgical correction of Tarsal Tunnel Syndrome in the absence of a soft tissue mass has a very low success rate.[ahni.com]
  • Ganglionic Cyst or other soft tissue mass; The growth of a cyst or any soft tissue mass behind the ankle bone can compress the nerve.[kansascityfootandankle.com]
  • Soft tissue masses like retention cysts, ganglioma or lipoma may directly be palpable below the medial malleolus. Chronic disease may show muscle wasting and loss of bone density in the affected foot.[symptoma.com]
  • tissue mass, or lump, in the tarsal tunnel.[fortiusclinic.com]
  • Of the more common causes of the syndrome are soft tissue masses located within the tunnel. These masses include lipomas, swelling of the tendon sheaths, nerve sheath and nerve tumors, accessory muscles and bony protrusions.[optimalperformanceclinic.ca]
Toe Swelling
  • Symptoms Pain and tingling in and around ankles and sometimes the toes Swelling of the feet Painful burning, tingling, or numb sensations in the lower legs.[hudsonspine.com]
  • Some of the symptoms are: Pain and tingling in and around ankles and sometimes the toes Swelling of the feet and ankle area. Painful burning, tingling, or numb sensations in the lower legs.[en.wikipedia.org]
Soft Tissue Swelling
  • 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.[ncbi.nlm.nih.gov]
Gouty Tophus
  • Gouty tophus of the tarsal tunnel is a rare cause of posterior tarsal tunnel syndrome.[ncbi.nlm.nih.gov]
Tinel's Sign
  • For patients with tarsal tunnel syndrome and the comorbidity of diabetic polyneuropathy (DPN), it is concluded that a positive Tinel sign at the tarsal tunnel can predict a positive outcome for pain relief and restoration of sensation in 80% of the people[ncbi.nlm.nih.gov]
  • 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.[ncbi.nlm.nih.gov]
  • Tinel's sign may be used as a prognostic factor. Copyright 2014 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.[ncbi.nlm.nih.gov]
  • Unusually the symptoms were mainly due to the lateral planter nerve compression with a positive Tinel's sign. A surgical decompression was successful in relieving the dysaesthesia in spite of a 7 years history.[ncbi.nlm.nih.gov]
  • A 46-year-old woman had pain in the left foot, sensory loss on the plantar surface, and positive Tinel sign over the TT. TTS was confirmed by magnetic resonance imaging (MRI) scan and surgery.[ncbi.nlm.nih.gov]
Foot Pain
  • Both patients had a long duration of severe foot pain and had been treated with various therapeutic modalities without lasting relief.[ncbi.nlm.nih.gov]
  • Our aim is to stress the relevance of this syndrome to foot pain in these athletes.[ncbi.nlm.nih.gov]
  • Herein, we describe a 46-year-old man who presented with left foot pain. Work up revealed a venous aneurysm impinging on the posterior tibial nerve. Following resection of the aneurysm and lysis of the nerve, his symptoms were alleviated.[ncbi.nlm.nih.gov]
  • Two patients with foot pain and dysesthesias had prolonged peroneal distal latencies with reduced amplitudes from the extensor digitorum brevis (EDB). Electromyographic (EMG) abnormalities were confined to the EDB.[ncbi.nlm.nih.gov]
  • A 26-year-old male presented with left ankle and foot pain that increased with activity and playing football.[ncbi.nlm.nih.gov]
Suggestibility
  • These patients suggest that a pre-existing asymptomatic TTS may become manifest after a mechanism akin to that described in the "double crush" syndrome.[ncbi.nlm.nih.gov]
  • These findings suggest an arterial etiology of tarsal tunnel syndrome.[ncbi.nlm.nih.gov]
  • Lidocaine injection of the tarsal tunnel diminished the flexor-withdrawal reflex, which was easily elicited by light pinching or sustained compression over the tarsal tunnel, and strongly suggested the existence of the tarsal tunnel syndrome.[ncbi.nlm.nih.gov]
  • Two of the 11 had foot symptoms suggestive of TTS. These 11 patients with prolonged distal motor latencies did not otherwise differ from RA patients without TTS in terms of disease duration or severity, treatment, or the presence of foot deformity.[ncbi.nlm.nih.gov]
  • The authors suggest that epineural ganglion should be clinically distinctive from an intrafascicular ganglion because of the differences in surgical treatment, postoperative nerve function, and the recurrence rate.[ncbi.nlm.nih.gov]
Paresthesia
  • Only a minor degree of paresthesia remains in the forefoot.[ncbi.nlm.nih.gov]
  • Because of burning paresthesias, it was felt that reflex sympathetic dystrophy was the etiology. Only through persistence of the treating podiatrists and the patient's agreeing to an exploration was this entity discovered.[ncbi.nlm.nih.gov]
  • Ultrasound-guided injection of 0.5% lidocaine temporarily resolved the paresthesia. These findings suggest an arterial etiology of tarsal tunnel syndrome.[ncbi.nlm.nih.gov]
  • Conservative treatment was unsuccessful, but surgical decompression of the nerve provided immediate improvement, and by 2 weeks postoperatively she had no residual pain or paresthesia, although there was some numbness in the first web space.[ncbi.nlm.nih.gov]
  • The syndrome consists of pain, paresthesias, and vasomotor changes. Surgical correction via release of the flexor retinaculum is the treatment of choice.[ncbi.nlm.nih.gov]
Peripheral Neuropathy
  • After excluding four patients with peripheral neuropathy, a definite delay in the distal motor latency of the tibial nerve was documented in 11 subjects (25%). Two of the 11 had foot symptoms suggestive of TTS.[ncbi.nlm.nih.gov]
  • BACKGROUND: Decompressive tarsal tunnel surgery may improve dysfunctional plantar foot sensation in, patients with tarsal tunnel syndrome and peripheral neuropathy. However, quantitative sensory, assessment is lacking.[ncbi.nlm.nih.gov]
  • THE occurrence of peripheral neuropathies caused by compression incident to anatomic alteration has received considerable attention in recent years.[nejm.org]
  • Diabetes and peripheral neuropathy: keeping people on their own two feet. Br J Community Nurs. Jan 2005;10(1):33-36.[massagetoday.com]
Mononeuropathy
  • ICD-10-CM Codes › G00-G99 Diseases of the nervous system › G50-G59 Nerve, nerve root and plexus disorders › G57- Mononeuropathies of lower limb › Tarsal tunnel syndrome, unspecified lower limb 2016 2017 2018 2019 Billable/Specific Code G57.50 is a billable[icd10data.com]
  • Carpal tunnel syndrome is the most common form of mononeuropathy. It is more common than tarsal tunnel syndrome. Carpal tunnel syndrome is one of the most disabling work-related conditions.[disabled-world.com]
  • Given the unclear role of electrodiagnostics in the diagnosis of tarsal tunnel syndrome, efforts have been made in the medical literature to determine which nerve conduction studies are most sensitive and specific for tibial mononeuropathy at the level[hudsonspine.com]
Motor Symptoms
  • Motor symptoms are rarely detected. Diagnosis is made primarily by electroneuromyographic studies and physical examination. Surgery is the treatment of choice and the outcome is generally favourable.[ncbi.nlm.nih.gov]
  • There are usually no associated motor symptoms (abnormalities of muscle function) unless it is extremely affected, but this is rare. The posterior tibial nerve divides into the medial plantar nerve and the lateral plantar nerve.[drlox.com]

Workup

A good detailed clinical history revealing the characteristic early tingling and pain in the foot may point in the direction of an early nerve compression disease. History of injury and inflammation of the ankle will also be a mitigating clue in the diagnosis of Tarsal Tunnel Syndrome.

A comprehensive neurologic exam may elicit a positive Tinel’s sign which is positive in 67% of all cases [5]. Radiographic X-ray may not be of value for it does not show signs of a damaged nerve but could be helpful in determining the extent of over-pronation while weight is applied.

Sonogram imaging, Computed Tomography Scan and Magnetic Resonance Imaging may elucidate masses and cysts that impedes the tunnel space. Nerve conduction studies may only be positive distally during the late course of the disease.

Treatment

The goal of the treatment of Tarsal Tunnel Syndrome is to relieve the impending stress that compresses the tunnel. Corrective shoes or the use of orthotic appliances to restore the normal arch of the foot may alleviate the symptoms. Custom orthotics have been found to alleviate symptoms of Tarsal Tunnel Syndrome and restore functionality in a study group of factory workers [6]. Inflammation of the ankle and the persistent irritation of the nerve may be allayed by oral anti-inflammatory agents.

Refractory cases may benefit from corticosteroid injection to the tunnel to control swelling. Physical therapy using the Graston’s manual technique or the active decompression release techniques have shown promising results in alleviating pain with professional hands [7]. On the average, surgical intervention ensues at the sixteenth (16th) month of unsatisfactory non-surgical approach [8].

The surgical approach to the decompression is to release the flexor retinaculum by resecting the tendon along the line of the tibial nerve. When the fibrous sheath is released, the tarsal tunnel will loosen up relieve the compression symptoms. Physical therapy post-surgically is also required to properly position the tibial nerve during the healing process and the scar tissue formation of the retinaculum.

When the tibial nerves are not aligned, the scarring tissue may impinge it again and cause a relapse in symptomatology; thus requiring a scar tissue or fascial stripping operation [9]. A Gondring scoring system to determine the intensity of the pain during follow-up visits could help quantify the pain symptoms and predict patient’s recovery outcome [10].

Prognosis

The outlook for patients suffering from Tarsal Tunnel Syndrome is basically encouraging. Segments which are treated medically may experience pain-free remissions of long duration.

Surgical decompression of the trapped nerve gives a better prognosis to patients. Physical therapy alleviates pain and function in both medical and surgical cases of Tarsal Tunnel Syndrome.

Complications

The compression signs and symptoms of Tarsal Tunnel Syndrome like gnawing pain and numbness may remain the only fleeting remnant of a mild disease if left untreated.

However, complications from severe and long standing nerve compression may present with muscle atrophy and loss of tactile and temperature sensation of the affected distal digits. Neuro-arthropathy may result from the chronic compression of the proximal afferent nerve. Trophic signs of hair loss and ulcerations may be eminent in with irreversible nerve damage.

Etiology

There are a number of health conditions that results to Tarsal Tunnel Syndrome, all of these compress the small space of the tarsal tunnel through which the tibial nerve, nerve branches, and vessels pass. Most common of which occurs among middle aged adults with flat foot.

Soft tissue masses may causes compression to the tunnel like ganglioma, ranula, varicosities, neuroma, schwannoma, tendon sheath ganglia and lipoma [2]. Bony spurs like exostoses may also compress this space. A valgus deformity of the rear foot was also demonstrated to have caused these symptoms as well [3]. Ankle injuries and systemic diseases like Diabetes Mellitus and Rheumatoid Arthritis can cause localized swelling impinges the tarsal nerve in this tunnel.

Epidemiology

Tarsal Tunnel Disease is a slow and progressive disease that is most commonly seen in patients with ages 30 to 40 years old. People who tend to roll their foot inward or “overpronate” tend to develop compression signs in time.

Obese people with recent foot and ankle injury may have a higher risk for Tarsal Tunnel Syndrome. Studies have shown that people who often run or jog notices the signs and symptoms the earliest. In a significant percentage of these patients Tarsal Tunnel Syndrome has no particular cause and thus labelled idiopathic in origin.

Sex distribution
Age distribution

Pathophysiology

The pathophysiology of Tarsal Tunnel Syndrome stems as a compression neuropathy of the tibial nerve and its branches. Current studies of podiatry and neurosciences have demonstrated that compression injuries to the foot can cause both tension and compression symptoms.

Tension is caused by the direct pulling of the nerve causing a local effect like those exemplified in nerve injuries. Nerve compression injuries dwell with the premise that the axoplasm (nerve endoplasm) transmits and receives nerve impulse, thus any compression may damage the whole segment distally.

Nutrient flow is usually towards the distal axoplasm making the distal nerves more susceptible to injury than the compressed segment proximal nerve segment [4].

Prevention

Patients born with flat foot or Pes planus deformity should submit to early physical therapy or the use of othotics to mimic the planar arch of the foot to prevent the occurrence of Tarsal Tunnel Syndrome before they reach the age of 30 – 40 years old.

Diabetics who are more prone to Tarsal Tunnel Syndrome must make regular visits to their podiatrists for a regular foot assessment. Arthritic patients must medically control foot inflammation to prevent nerve compression in the Tarsal tunnel.

Summary

Tarsal Tunnel Syndrome is a clinical disease caused by the compression of the posterior tibial nerve in the tarsal tunnel of the foot. The tarsal tunnel is just a small and narrow space inside the ankle which lies directly under the bony protrusion in the medial side of the foot. The tibial nerve and its branches are compressed at the level of the flexor retinaculum (thick fibrous band in the ankle) of the foot [1].

Mechanical pressure on the tibial nerve causes numbness and a burning sensation at the plantar (bottom) aspect of the foot. Tarsal Tunnel Syndrome is very common in people with flat foot (Pes Planus) that are devoid of the natural arch in the foot causing the weight of the body to compress the tarsal tunnel.

Patient Information

The early identification of the risk factors for the Tarsal Tunnel Syndrome and the early detection of its primary signs is as important as its treatment. Patients should continually be conscious of any unusual sensation or deformity in their foot and should seek medical consult. One must also remember that compression in the tarsal tunnel is governed by many modifiable factors like weight control, proper walking and running gait, and correct use of footwear.

References

Article

  1. Bracilovic A, Nihal A, Houston VL, et al. Effect of foot and ankle position on tarsal tunnel compartment volume. Foot Ankle Int. Jun 2006;27(6):431-7. 
  2. Ahn J, El-Khoury G. Radiologic evaluation of chronic foot pain. Am Fam Phys. 2007;76(7):975–983. 
  3. Daniels TR, Lau JT, Hearn TC. The effects of foot position and load on tibial nerve tension. Foot Ankle Int. Feb 1998;19(2):73-8. 
  4. Almeida DF, Scremin L, Zúniga SF, Oh SJ. Focal conduction block in a case of tarsal tunnel syndrome.Muscle Nerve. Sep 2010;42(3):452-5. 
  5. Mondelli M, Morana P, Pauda L. An electrophysiological severity scale in Tarsal Tunnel Syndrome. ACTA Neurol Scand. 2004;109:284–289. 
  6. Zhang J. Chiropractic adjustments and orthotics reduced symptoms for standing workers. J Chiro Med. 2005;4(4):177–181. 
  7. Burke J, Buchberger D, Carey-Loghmani T, Dougherty P, Greco D, Dishman J. A pilot study comparing two manual therapy interventions for carpal tunnel syndrome. J Manip Physiol Ther. 2007;30(1):50–61.
  8. Bailie DS, Kelikian AS. Tarsal tunnel syndrome: diagnosis, surgical technique, and functional outcome.Foot Ankle Int. Feb 1998;19(2):65-72. 
  9. Aspergen D, et al. Conservative treatment of a female collegiate volleyball player with costochondritis. JMPT. 2007 May;:321–325. 
  10. Gondring WH, Trepman E, Shields B. Tarsal tunnel syndrome: assessment of treatment outcome with an anatomic pain intensity scale. Foot Ankle Surg. 2009;15(3):133-8. 

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Last updated: 2019-07-11 20:47