Potential sites of compression of tibial nerve branches in foot

NewsBot · Dec 21, 2012

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Potential sites of compression of tibial nerve branches in foot: A cadaveric and imaging study.
Ghosh SK, Raheja S, Tuli A.
Clin Anat. 2012 Dec 17.

Hypertrophy of abductor hallucis muscle is one of the reported causes of compression of tibial nerve branches in foot, resulting in tarsal tunnel syndrome. In this study, we dissected the foot (including the sole) of 120 lower limbs in 60 human cadavers (45 males and 15 females), aged between 45 and 70 years to analyze the possible impact of abductor hallucis muscle in compression neuropathy of tibial nerve branches. We identified five areas in foot, where tibial nerve branches could be compressed by abductor hallucis. Our findings regarding three of these areas were substantiated by clinical evidence from ultrasonography of ankle and sole region, conducted in the affected foot of 120 patients (82 males and 38 females), aged between 42 and 75 years, who were referred for evaluation of pain and/or swelling in medial side of ankle joint with or without associated heel and/or sole pain. We also assessed whether estimation of parameters for the muscle size could identify patients at risk of having nerve compression due to abductor hallucis muscle hypertrophy. The interclass correlation coefficient for dorso-planter thickness of abductor hallucis muscle was 0.84 (95% CI, 0.63-0.92) and that of medio-lateral width was 0.78 (95% CI, 0.62-0.88) in the imaging study, suggesting both are reliable parameters of the muscle size. Receiver operating characteristic curve analysis showed, if ultrasonographic estimation of dorso-plantar thickness is >12.8 mm and medio-lateral width > 30.66 mm in patients with symptoms of nerve compression in foot, abductor hallucis muscle hypertrophy associated compression neuropathy may be suspected
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Admin2 · Dec 21, 2012

Related threads:
Other threads tagged with tarsal tunnel syndrome

bruk · Dec 26, 2012

Since I work primarily with and athletic population, I can't speak much toward sedentary patients, but historically abd. hallucis hypertrophy is seen in athletes participating in sports requiring high velocity forefoot impact (sprinting, jumping, etc), as noted in "Baxter's The Foot And Ankle In Sport".

It is commonly misdiagnosed as plantar fasciitis, among other things. It is also one of the issues that I have seen grow over the past decade with an increase in runner's moving from heelstriking to midfoot or forefoot striking at initial ground contact. Those most affected are typically ones susceptible to excessive pronatory force, whether that stems from foot mechanics or hip mechanics.

I have not yet read through this article other than the abstract above, but it would be interesting to see what the activity level, and what, if any, kinds of sports the study population participate in.

Nice to have some objective testing methods available through ultrasound to identify a risk factor.

NewsBot · Dec 3, 2016

A STUDY OF TIBIAL NERVE BIFURCATION AND BRANCHING
PATTERN OF CALCANEAL NERVE IN THE TARSAL TUNNEL
D.Malar
Int J Anat Res 2016, Vol 4(1):2034-36. ISSN 2321-4287

Background: Tibial nerve in the distal part of the leg branches into the calcaneal branch, medial plantar nerve
and lateral plantat nerve.These branches inervate calcaneal,the medial plantar and the lateral plantar areas of
the foot, respectively and carry sensory information from these areas. Tibial nerve and its branches show
variation in branching pattern, and level of bifurcation. Detail knowledge of the anatomical variation of tibial
nerve and its branches is essential for diagnosis and therapy tarsal tunnel syndrome, fractures requiring
external nailing and nerve blocks.
Materials and Methods: Tibial nerve and its branches in the tarsal tunnel were dissected and studied in twenty
adult cadavers. Bifurcation levels of tibial nerve in relation to the Medio-malleolar-calcaneal axis were noted.
The ramification pattern of medial calcaneal nerve was observed and studied.
Results: In the present study tibial nerve bifurcation occurred within the tunnel in 100% cases. According to the
level of bifurcation, 85% cases was type I, 10% cases was type II and 5%cases was type III. Medial calcaneal
branches showed variations in number and origin, one medial calcaneal nerve was observed in 50% case , two
in 20% cases and three in 10% of cases. The medial calcaneal nerve originated from the tibial nerve in85% cases.
Conclusion: The knowledge of these variations may help in diagnosis and therapy of tarsal tunnel syndrome and
prevent damage to the structures in the tarsal tunnel during various surgical procedures in the tarsal region.
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NewsBot · Mar 11, 2021

Variable Branching Pattern of Tibial Nerve in the Tarsal Tunnel: A Gross Anatomical Study With Clinical Implications
Suranjana Banik Sr., Leon R. Guria
Cureus 13(3): e13729. doi:10.7759/cureus.13729

Introduction
Tibial nerve is a larger component of the sciatic nerve. It arises from ventral branches (Anterior Division) - L4, L5, S1-S3. Then it travels along the distal border of the popliteus muscle, deep to gastrocnemius and soleus. In the leg, it is accompanied by the posterior tibial vessels and lies in the tarsal tunnel. It divides into the medial calcaneal nerve at the ankle, medial, and lateral plantar nerves under the flexor retinaculum. It carries sensory information. It can adapt to repeated forces and undergo stretch especially in ankle joint dorsiflexion and inversion of the foot. Compression of the tibial nerve in the tarsal tunnel can cause tarsal tunnel syndrome. Many surgical procedures need tibial nerve block which demands detailed knowledge of its variation.

Materials and methods
The study was cross-sectional and included lower limbs of five embalmed cadavers and 10 separate cadaveric lower limbs and was performed in the Department of Anatomy of Regional Institute of Medical Sciences, Imphal, India. The reference line (1 cm width) joining two landmarks medial malleolus and medial tubercle of calcaneus called the mideo-malleolar-calcaneal axis was determined and bifurcation of the tibial nerve was classified with respect to the axis.

Results
The tibial nerve in all the cases also crossed the posterior tibial vessels. In 11 cases (55%), the bifurcation of the tibial nerve was proximal to the mideo-malleolar-calcaneal axis with a mean distance of 1.86 cm above the axis, and thus comprising the maximum Type I category. Type II category, having bifurcation at the level of the axis, was found in six (30%) cases. Type III category, having three (15%) cases, was recorded to have bifurcation at a mean distance of 1.16 cm.

Conclusion
Proper anatomical knowledge of tibial nerve branching is required to prevent surgical complications, effective nerve block, procurement of tibial nerve graft.
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NewsBot · Mar 18, 2021

An MRI study of the tibial nerve in the ankle canal and its branches: a method of multiplanar reformation with 3D-FIESTA-C sequences
Yan Zhang et al
BMC Med Imaging. 2021 Mar 17;21(1):51

Background: The visualization of the tibial nerve and its branches in the ankle canal is helpful for the diagnosis of local lesions and compression, and it is also useful for clinical observation and surgical planning. The aim of this study was to investigate the feasibility of three-dimensional dual-excitation balanced steady-state free precession sequence (3D-FIESTA-C) multiplanar reformation (MPR) display of the tibial nerve and its branches in the ankle canal.

Methods: The subjects were 20 healthy volunteers (40 ankles), aged 22-50 years, with no history of ankle joint disease. The 3D-FIESTA-C sequence was used in the 3.0 T magnetic resonance equipment for imaging. During scanning, each foot was at an angle of 90° to the tibia. The tibial nerve of the ankle canal and its branches were displayed and measured at the same level through MPR.

Results: Most of the tibial nerve bifurcation points were located in the ankle canal (57.5%), few bifurcation points (42.5%) were located at the proximal end of the ankle canal, and none of them were found away from the distal end. The bifurcation between the medial plantar nerve and the lateral plantar nerve was on the line between the tip of the medial malleolus and the calcaneus, and it's angle ranged between 6° and 35°. In MPR images, the display rates of both the medial calcaneal nerve and the subcalcaneal nerve were 100%, and the starting point of the subcalcaneal nerve was always at the distal end of the starting point of the medial calcaneal nerve. In 55% of cases, there were more than two medial calcaneal nerve innervations.

Conclusion: The 3D-FIESTA-C MPR can display the morphological features and positions of the tibial nerve and its branches and the bifurcation point's projection position can be marked on the body surface. This method not only benefited the imaging diagnosis of the tibial nerve and branch-related lesions in the ankle canal, but it also provided a good imaging basis to plan a clinical operation of the ankle canal and avoid surgical injury.
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NewsBot · May 1, 2022

Variations in the branching pattern of tibial nerve in foot: a review of literature and relevant clinical anatomy
A Priya et al
Folia Morphol (Warsz). 2022 Apr 28

Considerable variations have been reported regarding the branching pattern of tibial nerve (TN) close to its termination in foot. In order to comprehend the clinical anatomy of heel pain awareness of all the possible variations in relation to terminal branching pattern of TN (close to the tarsal tunnel) is essential. The present study was conducted to undertake a comprehensive review of the variations in tibial nerve branches in foot with particular emphasis on the implications for sensory distribution of these branches. Articles were searched in major online indexed databases using relevant key words. The pattern of termination of TN was noted as either trifurcation or bifurcation. Bifurcation pattern was more commonly observed and is associated with the medial calcaneal nerve (MCN) either arising high or low relative to the tarsal tunnel. The most commonly noted type of bifurcation was proximal to malleolar-calcaneal axis but within the tarsal tunnel. Across all five types of bifurcation reported in literature the termination point of TN ranged from 3 cm proximal to 3 cm distal to malleolar-calcaneal axis and therefore the area beyond this region can be considered as safe zone for performing invasive procedures. MCN showed considerable variations in its origin both in trifurcation and bifurcation pattern pertaining to number of branches (one/two/three) at the point of origin. The origin of inferior calcaneal nerve (ICN) was observed to be relatively less variable as it mostly arose as a branch of lateral plantar nerve (LPN) and sometimes as a direct branch from TN before termination. The frequent variation of MCN in the tarsal tunnel should be kept in mind while undertaking decompression measures in medial ankle region.
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NewsBot · Jun 6, 2022

AN ULTRASONOGRAPHY STUDY OF ANATOMICAL VARIABILITY AND
DIMENSIONAL CHANGES OF THE TIBIAL AND PLANTAR NERVES WITH
CHANGE IN FOOT AND ANKLE POSITION
Donald Spears Wilcox
Thesis

This anatomical study used high resolution ultrasonography (US) to compare the
plantar nerves to the tibial nerve after mapping branching patterns in relation to the
malleolar-calcaneal axis in the tarsal tunnel (TT). Additionally, dimensional changes in
the vertical diameter (VD), longitudinal diameter (LD), and cross-sectional area (CSA) of
the tibial and plantar nerves were examined in response to static changes of maximal
dorsiflexion (DF), plantarflexion (PF), and neutral weight bearing positions (WB) from
the neutral non-weight bearing (NWB) position. Finally, modifying effects due to age,
sex, footedness, body mass index, foot pronation and nerve dimensions were
investigated.
An US examination was conducted bilaterally to examine the nerves in the TT for
both feet of men (n=40) and women (n=38) in NWB, DF, PF, and WB. Analyses combined
the plantar nerve dimensions into composite values and aggregated these data with
corresponding tibial nerve values; tibial, lateral plantar, and medial plantar nerve sets were
analyzed separately.
Analysis demonstrated that US could be used to study plantar nerve branching
variability within the TT, with meaningful comparisons between the plantar nerves and the
TN. Effects due to sex were observed when transitioning from non-weight bearing PF to
a WB state for the TN and LPN. Pronation had no effect on the WB condition for this
young normative population, but LD lengthened from NWB to WB. Compressive forces
changed both the VD and CSA nerve dimensions from the PF condition in all nerves;
producing a rounding of the nerves in PF and a flattening in the other conditions
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NewsBot · Jun 28, 2022

Tibial nerve dynamics during ankle dorsiflexion:
Using ultrasonographic stiffness to measure
excursion
Keisuke Anegawa et al
Research Square

Decreased nerve mobility and increased nerve stiffness have been proposed as causes of tarsal tunnel
syndrome and diabetic neuropathy. The purpose of this study was to measure the stiffness of the tibial
nerve (TN) at the ankle joint at positions of plantarflexion (PF) and dorsiflexion (DF) and the mobility
(excursion) of the TN during dorsiflexion using shear-wave elastography ultrasonography. Twenty-one
healthy adults participated in constant-velocity movements of the ankle joint from the maximum
dorsiflexion angle to -20°, and the TN was imaged using an ultrasound imaging system. The maximum
flow velocity value and the TN excursion distance per dorsiflexion were then calculated as indexes of
excursion using the application software Flow PIV. The shear-wave velocities of the TN at PF and DF were
also measured. We observed a relationship between the TN excursion and stiffness that was stronger at
25% dorsiflexion than at 75% dorsiflexion. In addition, the ultrasonographic shear-wave velocity could
predict the excursion of the TN if measured under mild plantar flexion of the ankle joint (i.e., 25%
dorsiflexion).
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NewsBot · Aug 4, 2022

Anatomy of the Tibial Nerve in relation to the Tarsal Tunnel: A Cadaveric Study
IvanMattos et al
Foot and Ankle Surgery 4 August 2022

Background
Tarsal tunnel syndrome (TTS) is typically caused by an anatomical variant or mechanical compression of the tibial nerve (TN) with variable success after surgical treatment.

Method
40 lower-leg specimens were obtained. Dissections were appropriately conducted. Extremities were prepared under formaldehyde solution. The tibial nerve and branches were dissected for measurements and various characteristics.

Results
The flexor retinaculum had a denser consistency in 22.5% of the cases and the average length was 51.9 mm. The flexor retinaculum as an independent structure was absent and 77.2% of cases as an undistinguished extension of the crural fascia. The lateral plantar nerve (LPN) and abductor digiti minimi (ADM) nerve shared same origin in 80% of cases, 34.5% bifurcated proximal to the DM (Dellon-McKinnon malleolar-calcaneal line) line 31.2% distally and 34.3% at the same level.

Conclusion
nderstanding the tibial nerve anatomy will allow us to adapt our surgical technique to improve the treatment of this recurrent pathology.
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NewsBot · Mar 14, 2023

The bifurcation and topography of the posterior tibial artery within the tarsal tunnel
B Marchese, A McDonald, H McGowan
Surg Radiol Anat. 2023 Mar 13

Purpose: The tarsal tunnel (TT) is a fibro-osseous anatomical space coursing from the medial ankle to the medial midfoot. This tunnel acts as a passage for both tendinous and neurovascular structures, including the neurovascular bundle containing the posterior tibial artery (PTA), posterior tibial veins (PTVs) and tibial nerve (TN). Tarsal tunnel syndrome (TTS) is the entrapment neuropathy that describes the compression and irritation of the TN within this space. Iatrogenic injury to the PTA plays a significant role in both the onset and exacerbation of TTS symptoms. The current study aims to produce a method to allow clinicians and surgeons to easily and accurately predict the bifurcation of the PTA, to avoid iatrogenic injury during treatment of TTS.

Methods: Fifteen embalmed cadaveric lower limbs were dissected at the medial ankle region to expose the TT. Various measurements regarding the location of the PTA within the TT were recorded and multiple linear regression analysis performed using RStudio.

Results: Analysis provided a clear correlation (p < 0.05) between the length of the foot (MH), length of hind-foot (MC) and location of bifurcation of the PTA (MB). Using these measurements, this study developed an equation (MB = 0.3*MH + 0.37*MC - 28.24 mm) to predict the location of bifurcation of the PTA within a 23° arc inferior to the medial malleolus.

Conclusions: This study successfully developed a method whereby clinicians and surgeons can easily and accurately predict the bifurcation of the PTA, to avoid iatrogenic injury that would previously lead to an exacerbation of TTS symptoms.
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NewsBot · Jul 20, 2023

An anatomical approach to the Tarsal Tunnel Syndrome: What can ankle’s medial side anatomy reveal us?
Jorge Lopes et al
Source

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% and distal in none of the feet. The Baxter’s nerve (BN)
originated proximally in 50% and distally in 12.5% of the cases. The correlation between specimens’
height and DML’s length was weak (ρ: 0.336). There was a significant correlation between the length of
DML and the distance from the center of the medial malleolus to the lateral plantar (LPN) and medial
plantar (MPN) nerves (ρ: 0.910 and 0.866, respectively, p < 0.01) but not to BN (ρ: 0.083; p value: 0.70).
Conclusions
In our sample the TN divides distal to DML in none of the cases. Therefore, a compression of the TN itself
can be a more uncommon cause of heel pain. We also report a strong association between ankle size
and the distribution of the MPN and LPN but not for BN.
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NewsBot · Sep 14, 2023

Anatomical variations of the tibial nerve and their clinical correlation
Anita Soraya Soetoko, Dina Fatmawati
Anat Cell Biol. 2023 Sep 11.

The tibial nerve is a branch of the sciatic nerve, which innervates the legs and feet. Anatomical variations of this nerve at the ankle are commonly found. The variation of the tibial nerve in its branching point and cross-sectional area (CSA) at the ankle is commonly related to clinical condition such as foot neuropathy. Knowledge of these variations can support the clinician in making appropriate clinical decisions. This review aims at providing knowledge on the anatomical variations of tibial nerve at ankle, as well as its clinical correlation. This review outlined the variation of the terminal branching point and CSA of the tibial nerve at the ankle in cadaveric and clinical studies
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