Tarsal Tunnel Syndrome

NewsBot · Jun 23, 2022

The Course of Tarsal Tunnel Syndrome after Ultrasound-Guided Injections.
Atesok K, Pierce J, Small B, Perumal V, Cooper T, Park J.
Orthopedic Reviews. 2022;14(4). doi:10.52965/001c.35455

BACKGROUND
Local ultrasound (US)-guided injections of anesthetics with corticosteroids are commonly performed for the conservative treatment of tarsal tunnel syndrome (TTS).

OBJECTIVE
This retrospective study aimed to investigate the outcomes of TTS after US-guided injections.

METHODS
The study included patients who were diagnosed with TTS and received US-guided injections as part of their initial treatment. The pain levels were noted on a scale between zero and ten before and after each injection. The patients were divided into non-surgical and surgical groups. The nonsurgical group included patients who had received US-guided injections and did not proceed to surgical treatment, and the surgical group included those who received US-guided injections and ultimately underwent tarsal tunnel release (TTR). The two groups were compared in terms of age, post-injection follow-up time, and the amount of pain reduction immediately after injection (ΔPN). In the surgical group, outcomes of surgical treatment were also assessed.

RESULTS
A total of 218 patients were diagnosed with TTS and received US-guided injections. After the injections, 169 patients (77.5%) did not go on to TTR (nonsurgical group) and 49 patients (22.5%) underwent TTR (surgical group). The average ages for the nonsurgical and surgical groups were 53.8 and 48.9 years (P = 0.03). The average time between the injection and final follow-up for the nonsurgical group was 339 days. The average time between the injection and TTR for the surgical group was 145 days. There were no differences in pain relief after the injections between the nonsurgical and surgical groups (mean ΔPN: 3.6 and 3.8, respectively). The average post-surgical follow-up time was 117 days. At final follow-up, 41 patients (84%) in the surgical group had complete resolution of pain and neurological symptoms.

CONCLUSION
US-guided injection can be an effective conservative treatment option for patients with TTS. Younger patients may be more likely to proceed to TTR.
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NewsBot · Jun 26, 2022

Clinical anatomical study on the treatment of tarsal tunnel syndrome with four-point vertical acupotomy
Xiao-Jie Sun et al
Zhongguo Gu Shang. 2022 Jun 25;35(6):543-7

Objective: To explore safety and accuracy of four-point acupotomy for the treatment of tarsal tunnel syndrome regarding release of ankle tunnel flexor retinaculum to provide an anatomical basis of clinical treatment.

Methods: Twenty-nine adult specimens (15 males and 14 females) fixed with 10% formalin, aged from 47 to 98 years old with an average age of (81.10±11.14) years old, 29 on the right side and 29 on the left side, which were selected for the study from September 2020 to October 2020. Simulate the operation of loosening flexor retinaculumt with a needle knife on the human specimen, and place the specimen on the frog position of lower limbs with medial malleolus upward to determine the center of medial malleolus. Choose 4 different positions near the flexor retinaculum to insert the needle so that the needle body was perpendicular to skin and cutting edge direction was perpendicular to the running direction of the flexor retinaculum. The needle knife penetrates the skin and explores slowly. When the flexor retinaculum was reached, the needle tip may touch the tough tissue. At this time, the cutting is loosened for 4 times. After acupotomy release operation was completed, make a lateral incision on the skin surface along acupotomy direction, open the area of the exposed flexor retinaculum, dissecting layer by layer, observe and record the needle knife and its surrounding anatomical structure. The length of acupotomy cutting marks of flexor retinaculum was measured by electronic vernier caliper. The safety and accuracy of acupotomy loosening of ankle canal flexor retinaculum were evaluated by observing the number and degree of ankle canal contents such as tendons and nerves injured by needle knife. The safety is to count the number of cases of acupotomy injury to the contents of the ankle canal, and to calculate the injury rate, that is, the number of injury cases/total cases × 100%. The effective release was defined as the release length L ≥ W/2(W is the width of the flexor retinaculum, defined as 20 mm).
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NewsBot · Jul 1, 2022

An Update on Posterior Tarsal Tunnel Syndrome
Luc M Fortier et al
Orthop Rev (Pavia). 2022 May 31;14(4):35444

Posterior tarsal tunnel syndrome (PTTS) is an entrapment neuropathy due to compression of the tibial nerve or one of its terminal branches within the tarsal tunnel in the medial ankle. The tarsal tunnel is formed by the flexor retinaculum, while the floor is composed of the distal tibia, talus, and calcaneal bones. The tarsal tunnel contains a number of significant structures, including the tendons of 3 muscles as well as the posterior tibial artery, vein, and nerve. Focal compressive neuropathy of PTTS can originate from anything that physically restricts the volume of the tarsal tunnel. The variety of etiologies includes distinct movements of the foot, trauma, vascular disorders, soft tissue inflammation, diabetes mellitus, compression lesions, bony lesions, masses, lower extremity edema, and postoperative injury. Generally, compression of the posterior tibial nerve results in clinical findings consisting of numbness, burning, and painful paresthesia in the heel, medial ankle, and plantar surface of the foot. Diagnosis of PTTS can be made with the presence of a positive Tinel sign in combination with the physical symptoms of pain and numbness along the plantar and medial surfaces of the foot. Initially, patients are treated conservatively unless there are signs of muscle atrophy or motor nerve involvement. Conservative treatment includes activity modification, heat, cryotherapy, non-steroidal anti-inflammatory drugs, corticosteroid injections, opioids, GABA analog medications, tricyclic antidepressants, vitamin B-complex supplements, physical therapy, and custom orthotics. If PTTS is recalcitrant to conservative treatment, standard open surgical decompression of the flexor retinaculum is indicated. In recent years, a number of alternative minimally invasive treatment options have been investigated, but these studies have small sample sizes or were conducted on cadaveric models.
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NewsBot · May 4, 2023

Injection of the Abductor Hallucis Muscle in the Diagnosis and Treatment of Distal Tarsal Tunnel Syndrome
Michael S Nirenberg
J Am Podiatr Med Assoc. 2023 Mar-Apr;113(2):20-238

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.
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NewsBot · Aug 8, 2023

Efficacy and safety of a novel technique for endoscopic tarsal tunnel release: A cadaveric study.
Mishko A, Bernstein B.
J Int Foot Ankle [Internet]. 2023 Jul. 1 [cited 2023 Aug. 7];2(7).

Tarsal tunnel syndrome (TTS) is an entrapment neuropathy of the tibial nerve and its branches that can cause burning, tingling, numbness, and pain to the medial ankle and plantar aspects of the foot. It can be a difficult pathology for the foot and ankle surgeon with variable results published in the literature. In this manuscript, we evaluate the safety and efficacy of a novel technique for endoscopic tarsal tunnel release utilizing the Tarsal Clip system (Nanice Medical Solutions, LLC., Trappe, PA). Six cadaver limbs were utilized for this study. The procedure was performed through a 1.5cm incision and the superficial and deep portions of the flexor retinaculum (FR) were directly visualized endoscopically to ensure no crossing neurovascular structures were present. The FR was transected in an anterograde fashion. Post-procedure, the cadaver limbs were dissected to evaluate transection of the FR and to examine underlying neurovasculature for damage. Upon dissection, the FR was completely transected in all six cadaver limbs. No noted neurovascular damage was present upon inspection, nor was any noted with injection of methylene blue. Overall, endoscopic tarsal tunnel release utilizing the Tarsal Clip system appears to be a safe and effective option for treatment of TTS in the correct patient population.
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NewsBot · Sep 27, 2023

Prevalence of Obesity in High Tarsal Tunnel Syndrome: A Cross-Sectional Study
Roberto P Segura, Michael S Nirenberg
J Am Podiatr Med Assoc. 2023 Jul-Aug;113(4):22-056. doi: 10.7547/22-056.

Background: Tarsal tunnel syndrome (TTS) occurs when an individual suffers from tibial nerve compression at the tarsal tunnel. Symptoms of TTS may include pain, burning, or tingling on the bottom of the foot and into the toes. Tarsal tunnel syndrome can be divided into distal and proximal TTS. Furthermore, a high tarsal tunnel syndrome (HTTS) has also been described as a fascial entrapment proximal to the laciniate ligament at the level of the high ankle. Multiple risk factors, including obesity, have been said to be associated with TTS. This study aimed to determine the frequency of obesity in the form of body mass index (BMI) with HTTS.

Methods: A cross-sectional descriptive study using a nonprobability sampling method retrospectively surveyed the BMI of 73 patients whose clinical presentation suggested HTTS or TTS, and in which electrodiagnostic testing found HTTS. The age of the patients ranged from 25 to 90 years (mean, 56.4 years). Thirty-five patients were men and 38 patients were women.

Results: Based on BMI, nine patients with HTTS had normal weight (12.9%), 17 patients were overweight (23.3%), and the remaining 47 patients were obese (64.3%).

Conclusions: The frequency of obesity in the form of BMI was 64.3% in patients with HTTS, which is a significantly high correlation.
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NewsBot · Nov 19, 2023

An anatomical approach to the tarsal tunnel syndrome: what can ankle's medial side anatomy reveal to us?
Jorge Gomes Lopes et al
J Foot Ankle Res. 2023 Nov 14;16(1):80

Background: The heel is a complex anatomical region and is very often the source of pain complaints. The medial heel contains a number of structures, capable of compressing the main nerves of the region and knowing its anatomical topography is mandatory. The purpose of this work is to evaluate if tibial nerve (TN) and its main branches relate to the main anatomical landmarks of the ankle's medial side and if so, do they have a regular path after emerging from TN.

Methods: The distal part of the legs, ankles and feet of 12 Thiel embalmed cadavers were dissected. The pattern of the branches of the TN was registered and the measurements were performed according to the Dellon-McKinnon malleolar-calcaneal line (DML) and the Heimkes Triangle (HT).

Results: The TN divided proximal to DML in 87.5%, on top of the DML in 12,5% and distal in none of the feet. The Baxter's nerve (BN) originated proximally in 50%, on top of the DML in 12,5% and distally in 37.5% of the cases. There was a strong and significant correlation between the length of DML and the distance from the center of the medial malleolus (MM) to the lateral plantar nerve (LPN), medial plantar (MPN) nerve, BN and Medial Calcaneal Nerve (MCN) (ρ: 0.910, 0.866, 0.970 and 0.762 respectively, p < 0.001).

Conclusions: In our sample the TN divides distal to DML in none of the cases. We also report a strong association between ankle size and the distribution of the MPN, LPN, BN and MCN. We hypothesize that location of these branches on the medial side of the ankle could be more predictable if we take into consideration the distance between the MM and the medial process of the calcaneal tuberosity.
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NewsBot · Apr 29, 2024

Postoperative Outcomes Between Positive and Negative Electrodiagnosis in Patients With Tarsal Tunnel Syndrome: A Retrospective Comparative Study
Chamnanni Rungprai, et al
Source

Background:
The sensitivity of diagnosing tarsal tunnel syndrome with an electrodiagnostic study is just over 50%. Given this low reliability, many surgeons prefer to make a diagnosis solely from a physical examination, despite reported electrodiagnostic findings. Thus, to understand the clinical ramifications between these 2 methods of diagnosis, this investigation compared the postoperative outcomes following a tarsal tunnel release between patients with positive and negative preoperative electrodiagnosis (EDx).
Methods:
This study retrospectively reviewed 53 consecutive patients who underwent tarsal tunnel release by a single surgeon between 2015 and 2022. The primary outcome was pain level using visual analog scale (VAS) whereas the secondary outcomes were 36-Item Short Form Health Survey questionnaire, Foot and Ankle Ability Measure, recovery times (time to return to activities of daily living, work, and sports), and complications. Pre- and postoperative functional outcomes were compared within each EDx group using a paired sample t test. Postoperative outcomes between groups were compared using a generalized linear model adjusted for potential confounders.
Results:
Both EDx groups (positive studies = 31 patients and negative studies = 22 patients) demonstrated significant improvement of all functional outcomes (P < .001). We found no significant difference in recovery time or postoperative outcomes between the 2 groups (P > .05). Multivariable analysis showed diabetes (risk ratio [RR] = 1.79, 95% CI 1.11-2.90) and longer duration of symptoms before surgery (RR = 1.02, 95% CI 1.00-1.04) as prognostic factors for residual pain following tarsal tunnel release.
Conclusion:
In our series, we found that preoperative electrodiagnostic results did not prognosticate postoperative functional outcomes or recovery times after tarsal tunnel release.
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NewsBot · May 28, 2024

A Patient with Tarsal Tunnel Syndrome Associated with the Flexor Digitorum Accessorius Longus Muscle
Kosuke MIWA et al
NMC Case Report Journal 11, 125-129, 2024

The flexor digitorum accessorius longus muscle (ALM) can be overlooked as the eliciting factor in patients with tarsal tunnel syndrome (TTS), an entrapment neuropathy of the posterior tibial nerve that elicits sole numbness and pain. Most elicitations are idiopathic, however, mass lesions within the tarsal tunnel can be also implicated. We report an 80-year-old woman whose flexor digitorum ALM led to the onset of bilateral TTS. She had suffered numbness in both soles for 3 years. Magnetic resonance imaging (MRI) of the bilateral tarsal tunnel showed that the posterior tibial nerve was compressed by the arteriovenous complex and in contact with the flexor digitorum ALM. We diagnosed bilateral TTS based on her symptoms and imaging findings, and performed bilateral decompression surgery of the posterior tibial nerve under local anesthesia. The artery on both sides was dislocated for nerve decompression. Because the posterior tibial nerve on the right side was strongly compressed in ankle plantar flexion we excised a portion of the tendon compressing the nerve. Postoperatively her symptoms gradually improved and she reported surgical satisfaction 6 months after the operation. In patients with flexor digitorum ALM-related TTS, the effect of dynamic factors on MRI findings and on surgical treatment decisions must be considered. Intraoperatively, not only the flexor digitorum ALM, but also other potential etiologic factors eliciting TTS must be kept in mind.
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NewsBot · Jun 10, 2024

Safety and efficacy of ultrasound-guided percutaneous flexor retinaculum release of the ankle: an anatomical study
Xiaojie Sun et al
Quant Imaging Med Surg. 2024 Jun 1;14(6):3875-3886

Background: Tarsal tunnel syndrome (TTS) is a condition in which the tibial nerve (TN) (or its terminal branches) is compressed by the flexor retinaculum (FR) and the deep fascia of the abductor hallucis muscle at the tarsal tunnel, causing symptoms that negatively impact the patient's quality of life, including numbness, a sensation of a foreign object, coldness, and pain. FR release via microtrauma using needle-knife has proven to be effective in China and is widely used by clinicians. The traditional acupotomy, however, is the "blind knife" treatment, which cannot guarantee patient safety due to risk of injury to important structures, particularly the neurovascular bundle. Compared with the conventional treatments, ultrasound-guided percutaneous FR release possesses noteworthy advantages including high efficacy and safety.

Methods: Percutaneous release of the FR was performed on 51 formalin-fixed specimens. The specimens were divided into two groups: an ultrasound-guided acupotomy pushing group comprising 20 legs (group U) and a nonultrasound-guided acupotomy pushing group comprising 31 legs (group N). After high-frequency ultrasound exploration, those with clear vascular imaging were included in group U; otherwise, they were included in group N. The FR was released percutaneously, soft tissue was dissected layer by layer, and anatomical data were recorded.

Results: There no cases of injury in group U (0%) and four in group N (12.9%). Among the different intervention methods, there were no significant differences in tissue injury types (χ2=2.80; P=0.09). The percentage of released FR in group U was 80.00% while that in group N was 61.29% (χ2=1.977; P=0.16), which did not represent a significant difference between the two groups. However, group U had a significantly greater release length than that in the group N (t=3.359; P=0.002), indicating that the flexor release length guided by ultrasound is significantly greater than the unguided one.

Conclusions: Ultrasound-guided percutaneous release of the FR using a needle-knife can provide greater length and percentage of released FR while maintaining a comparable safety rate to the unguided procedure.
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NewsBot · Jul 15, 2024

Acute tarsal tunnel syndrome after pes cavus correction. Can the foot position be a triggering factor?
Rozis Meletis MD, PhD (Orthopedic Consultant), Sakellariou Evangelos MD, MSc (Orthopedic Resident), Spyrou Ioannis MD (Orthopedic Resident), Pnaumaticos Spyros (Professor of Ortjopaedics)
Foot & Ankle Surgery: Techniques, Reports & Cases 6 July 2024, 100411

Acute tarsal tunnel syndrome is a rare entity in general population. We present a case report of an acute onset after pes cavus correction, treated with gradual foot plantigrade repositioning with an external fixator, without need of tunnel release. The patient's vivid symptomatology and the good clinical course after conservative treatment, underlines the vulnerability of the tibial nerve when treating patients with stiff varus deformities, and further highlights the importance of gradual corrections by utilising the external fixators in the treatment plan.
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NewsBot · Aug 5, 2024

The management of tarsal tunnel syndrome: A scoping review
Ibrahim Inzarul Haq et al
J Clin Orthop Trauma. 2024 Jul 4

Background: Tarsal tunnel syndrome, also known as posterior tibial neuralgia, is a compressive neuropathy of the posterior tibial nerve or one of its divisions (calcaneal, lateral plantar or medial plantar nerve) within the tarsal tunnel. This scoping review aims to systematically map and summarise current literature regarding the management of tarsal tunnel syndrome.

Methods: PubMed, Embase, Emcare, Medline and Cinahl were searched using the terms 'tarsal tunnel', 'syndrome', 'entrapment', 'compression', 'posterior tibial', 'neuropathy' and 'neuralgia. Two stage title abstract screening was performed. Observational studies reporting the outcome of treatment of tarsal tunnel syndrome were included.

Results: A total of 32 studies were included in the review. Excellent or good results are seen in 75.3 % of cases, with the remainder (24.7 %) achieving fair or poor outcomes. Factors which may influence outcome include patient age, symptom duration, aetiology, co-morbidities, pre-treatment symptom severity and nerve fibrosis.

Conclusions: Although favourable outcomes are seen in the majority of cases, poor results are not uncommon. A range of prognostic factors are identified; however, firm conclusions cannot be drawn from the findings of individual low-quality studies. Further research in identifying prognostic factors may aid in clinical decision making and management of patient expectations.
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Tarsal Tunnel Syndrome

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Tarsal Tunnel Syndrome

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