Tarsal Tunnel Syndrome

Tarsal Tunnel Syndrome

1. Tarsal Tunnel Syndrome Ade Wijaya MD September 2017

2. Outline: Introduction Anatomy Etiology Clinical Manifestation Differential Diagnosis Diagnosis (Electrodiagnostic Studies, MRI, Ultrasound) Treatment Summary

3. Introduction most common compressive neuropathy of the foot entrapment of the tibial nerve within the tarsal canal (under flexor retinaculum) behind the medial malleolus first described in 1960 by Kopell and Thompson H.P . Kopell, W.A. Thompson, [ Peripheral entrapment neuropathies of the lower extremity], N Engl J Med . 262 (1960) 56—60 . S.J . Lam, A tarsal-tunnel syndrome, Lancet. 2 (7270 ) (1962) 1354—1355. G.J. Sammarco, L. Chang, Outcome of surgical treatment of tarsal tunnel syndrome, Foot Ankle Int . 24(2 ) (2003) 125—131.

4. Anatomy M. De Prado, et al., The tarsal tunnel syndrome, Fuß & Sprunggelenk (2015) Electromyography and Neuromuscular Disorders 3 rd Edition. Preston

5. Anatomy M. De Prado, et al., The tarsal tunnel syndrome, Fuß & Sprunggelenk (2015)

6. Etiology Space Occupying Lesions (SOL) Ganglion Lipoma Nerve tumors Exostosis Talocalcaneal bar Accessory muscle ( abductor halluces or flexor digitorum longus ) Venous varicosities M. De Prado, et al., The tarsal tunnel syndrome, Fuß & Sprunggelenk (2015)

7. Etiology Food deformities (varus and valgus heel) Trauma Degenerative bone or connective tissue disorders Hypertrophy of flexor retinaculum from repetitive use W.R. Cimino, Tarsal tunnel syndrome: review of the literature, Foot Ankle. 11 (1) (1990) 47—52. J.T. Lau, T.R. Daniels, Tarsal tunnel syndrome : a review of the literature, Foot Ankle Int. 20 (3) ( 1999 ) 201—209. Electromyography and Neuromuscular Disorders 3 rd Edition. Preston

8. Clinical Manifestation Symptoms insidious, aggravated by activity, relieved by rest with elevation of lower extremity numbness pain burning electrical sensation tingling sensation over the base of food and heel big toe sensation nocturnal exacerbation SIGNS Tarsal Tinnel’s sign Valleix phenomenon; Proximal radiation of pain and paresthesia along the neuraxis on percussion at the point of nerve injury. Turks test; realised by placing a tourniquet above the malleolus at a pressure between systolic and diastolic . impairment in the sensory distribution of the plantar nerve terminal branches M. De Prado, et al., The tarsal tunnel syndrome, Fuß & Sprunggelenk (2015)

9. Differential Diagnosis tendinitis fasciitis proximal tibial neuropathy S1 radiculopathy lumbosacral plexopathy M. De Prado, et al., The tarsal tunnel syndrome, Fuß & Sprunggelenk (2015)

10. Electrodiagnostic Studies Electromyography and Neuromuscular Disorders 3 rd Edition. Preston

11. Electrodiagnostic Studies Electromyography and Neuromuscular Disorders 3 rd Edition. Preston

12. MRI evaluating bony deformities pinpoint soft tissue content within the tunnel find the etiology Ultrasound M. De Prado, et al., The tarsal tunnel syndrome, Fuß & Sprunggelenk (2015)

13. Treatment Physiotherapy (stretching exercises for extrinsic and intrinsic muscles) Injections (steroid and lidocaine/bupivacaine) NSAIDs (only for brief period of time) Orthotics Immobilization J.T. Lau, T.R. Daniels, Tarsal tunnel syndrome : a review of the literature, Foot Ankle Int. 20 (3) ( 1999 ) 201—209 S.J. Miller, Entrapment Neuropathies, in : V. Hetherington (Ed.), Hallux Valgus and Forefoot Surgery, Churchill Livingstone, 1994, pp. 401—428 L.C. Schon, Nerve entrapment, neuropathy, and nerve dysfunction in athletes, Orthop Clin North Am . 25 (1) (1994) 47—59.

14. Treatment Surgical indication: - Non-operative treatment failure - Space Occupying Lesions The success rate after surgery have been reported between 75 to 91 %, recognizing improvement in nerve function within 6 weeks. But some authors conclude recently that the results of surgical treatment are suboptimal, especially in the absence of space-occupying lesions. M. De Prado, et al., The tarsal tunnel syndrome, Fuß & Sprunggelenk (2015)

15. Summary: Tarsal tunnel syndrome is the most common compressive neuropathy of the foot due to entrapment of the tibial nerve within the tarsal canal (under flexor retinaculum) behind the medial malleolus. The most common symptoms are burning, tingling, or both , on the sole of the foot, and nocturnal exacerbation of symptoms Electrodiagnostic studies is the gold standard for diagnostic Treatment includes non-surgical and surgical approaches

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