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Tarsal Tunnel/small mass

Discussion in 'Foot Surgery' started by drsarbes, Jan 6, 2012.

  1. drsarbes

    drsarbes Well-Known Member

    Members do not see these Ads. Sign Up.
    Here's an interesting case.
    62 y/o M with 12 month Hx of pain right heel and arch, radiating at times. Had been treated for plantar fasciitis with NSAIDs, orthotics, cortisone, etc.... no real help.
    Came to us with obvious neurological symptoms as well as "minor" symptoms attributed to fasciitis.

    We found a small mass (fibrolipoma) overlying the P. Tib N just at the opening of the porta pedis, resting on the fascia rim of the abd. Hal B muscle belly.

    Here's some intraop pics.

    Attached Files:

  2. RobinP

    RobinP Well-Known Member

    Great picture Steve. Just out of interest, was the mass palpable or did you pick it up on a scan or was the surgery exploratory?
  3. Out of interest Steve, do you ever use the retractors to have the patients foot "talk" to you? I wouldn't be able to resist. Is that wrong? ;):D:morning:
  4. Ian Drakard

    Ian Drakard Active Member

    If Steve's next clinical pictures have eyes and a nose drawn above the incision I'm going to laugh ;) Guess you could try and claim it was a form of initialling the site
  5. Admin2

    Admin2 Administrator Staff Member

  6. drsarbes

    drsarbes Well-Known Member

    funny funny ..and yes. Wrong!
    Of course I'll be thinking of that the next time I do one of these.
    Mass was not palpable.
    The surgery was not exploratory. The patient had nerve pain and I scheduled him for a TT release.
    When you do TT releases, you never really know what you're going to find. It's amazing all the different pathologies and anatomic variations.
    This happened to be a small mass.
  7. Draw a nose and eyes on for the boys... go on, you know you want to.;):D

    Apply a set of these with the nose on the medial malleolus and take a photo and frankly it is game over. Your name will be carved upon the gates of the Arena and there it shall live as a legend, forever.

    Why am I encouraging a well respected surgeon to stick a comedy nose and glasses on a patients foot during surgery.....? Very odd. Seriously though... go on. Challarnge.......

    Attached Files:

  8. Lee

    Lee Active Member

    Hello Steve,
    What sort of pre-operative imaging do you usually do prior to your tarsal tunnel surgery (if any)? I have a patient listed for tarsal tunnel decompression at the moment with either an MR scan or Ultrasound scan (can't remember which and I'm not in work to check the full details at the moment) sign of a probable gangion plus all the usual symptoms and clinical signs (she's already tried drainage, etc...). I can find out more details and attempt to post them up if you like (or if I remember)? What's your usual work up to surgery/ tarsal tunnel decompression?
  9. drsarbes

    drsarbes Well-Known Member

    Hi Lee:
    TT is a clinical Dx. keeping with this, I no longer order nerve conduction, EMGs since I put no value on the results.

    If I feel there is a mass, which in my experience is not very common, I'll do a MSK US or order an MRI if I don't have time to do the US.
    Masses, when present, are usually not masses but ganglion cysts and I like to know where they are before surgery (i.e., in relation to the nerve and hopefully where it is coming off of)
    Ganglions are usually aspirated first, obviously, to determine if surgery is indicated.

    For most TTs that give me no reason to believe there is a mass/cyst present, my Dx is determined historically and clinically and by the results of a plain decadron injection.

    These patients have severe, penetrating, radiating pain with positive tinel's and pain on palpation of the TT. They frequently have concomitant fasciitis (and often have been treated for it)

    It's my opinion that TT is far more common then most of us appreciate; we just don't look for it enough. When I get a new patient and I read the CC that the nurse has recorded - I start thinking TT when I see things like "severe pain" "can't walk" "want to cut my foot off" "Burns" and "shoots" etc...etc.....

    hope that helps


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