TARSAL TUNNEL SYNDROME

Dr.PRASHANTH KUMAR
Junior resident of orthopaedics
• A compressive neuropathy caused by
compression of the tibial nerve

•may be subdivided into anterior or

posterior tarsal tunnel syndrome
• Tarsal tunnel syndrome is analogous to carpal
tunnel syndrome,
• but instead of median nerve entrapment beneath
the transverse carpal ligament, the tibial nerve is
constricted beneath the flexor retinaculum
(laciniate ligament).
• Release of the flexor retinaculum is not as
effective in tarsal tunnel syndrome as release of
the transverse carpal ligament in carpal tunnel
syndrome.
 Anatomy
• Posterior tarsal tunnel an anatomic structure
defined by
– flexor retinaculum (laciniate ligament)
– calcaneus (medial)
– talus (medial)
– abductor hallucis (inferior)
• contents include
• tibial nerve
• posterior tibial artery
• FHL tendon
• FDL tendon
• tibialis posterior tendon
• Tibial nerve has 3 distal branches
– medial plantar
– lateral plantar
– medial calcaneal
– the medial and lateral plantar nerves can be
compressed in their own sheath distal to tarsal
tunnel
– bifurcation of nerves occurs proximal to tarsal
tunnel in 5% of cases
 Mechanism
• types of impingment
• intrinsic
– ganglion cyst
– tendonopathy
– tenosynovitis
– lipoma/tumor
– peri-neural fibrosis
– osteophytes
• Extrinsic
• shoes
• trauma
• anatomic deformity (tarsal coalition, valgus
hindfoot)
• post-surgical scaring
• systemic inflammatory disease
• edema of the lower extremity
• cause of impingement able to be identified in
80% of cases
• Prognosis results vary between 50-90%
success
• worse results with 'double crush' injuries and
post-operative scarring
• revision surgery less successful than index
operation
 Presentation
• History may have previous trauma or surgery
• Symptoms
– pain with prolonged standing or walking
– often vague and misleading medial foot pain

– sharp, burning pains in the foot

• numbness
– intermittent paresthesias and numbness in the plantar
foot
• Physical exam tenderness of tibial nerve (tinel's sign)
• sensory exam equivocal
• pes planus
• muscle wasting of foot intrinsics
– abductor digiti quinti or abductor hallucis
• pain with dorsiflexion and eversion of the ankle
• compression test
– plantar flexion and inversion of ankle
– digital pressure over tarsal tunnel
• highly senstitive and specific
• Imaging Radiographs
– weight-bearing radiographs provide osseous
structure
• MRI
– may be helpful to rule out accessory
muscle or soft-tissue tumor
• Studies EMG
– positive finding include
• distal motor latencies of 7.0 msec or more
• prolonged SENSORY latencies of more than 2.3 msec
– sensory (SAP) more likely to be abnormal than motor
• decreased amplitude of motor action potentials of
– abductor hallucis
– or abductor digiti minimi
• Diagnosis
– history is often most useful diagnostic aid
• It is important to attempt to determine the
source of the problem.
• Trauma
• Space occupying lesion: ganglion cyst, benign
tumors, swollen tendon, varicose veins
• Ankle deformities: pes planus (flat foot)
• Peripheral neuropathy: diabetes (if pain follows
"stocking distribution")
• .
• Herniated lumbar disk: back pain in L4, L5, S1
regions, leg/thigh pain, "double crush"–one
nerve pinch in the lower back, and the second in
the tarsal tunnel.
• Complex regional pain syndrome: if regional
discoloration, swelling, temperature changes,
allodynia, hyperesthesia
• Neurofibromatosis: formation of pigmented,
cutaneous neurofibromas can invade tarsal
tunnel and create pressure
 Red flags
• It is important to rule out nerve compression
in the low back area.
• There is a fairly high correlation between
nerve compression in the spine region (ex
from a disk or spinal stenosis) and tarsal
tunnel-type symptoms.
• If this is the case, then local treatments may
not be effective if the real problem is at the
level of the low back.
 Non-operative treatment

• The vast majority of patients with tarsal tunnel

syndrome can (and should) be treated
nonoperatively.
• The primary approach to treating this condition
is to attempt to decrease the repetitive traction
injury across the nerve and the other structures
in this area of the foot.
• In this regard, treatment is quite similar to that
for acquired adult flatfoot deformity and plantar
fasciitis.
• In fact, these three conditions (tarsal tunnel,
acquired adult flatfoot, and plantar fasciitis)
together have been labeled as the terrible
triad and it is not uncommon to see them all
together in one patient.
• This patient is typically someone with a
flattened arch of the foot who is overweight.
• Comfort shoes designed to disperse the force
more evenly across the foot can be very helpful.
• A prefabricated orthotic with a supportive arch
will help to disperse the force more evenly across
the foot may also be helpful.
• Stretching exercises designed to stretch the calf
muscle and thereby indirectly decrease the load
through this area of the foot may also be helpful.
• Weight loss will often end up being a critically
important component of non-operative
treatment, as this will serve to decrease the
repetitive forces through this area of the foot.
• Activity modification to limit the amount of
standing and walking and thereby the amount of
repetitive injury to this area is also an important
component of nonoperative management.
• .
• Physical therapy to establish exercise program
characterized by appropriate fitness and stretching
exercises, as well as some localized massage to help
desensitize the area and perhaps breakdown scar may
be of some benefit.
• Corticosteroid injections may help to decrease the
swelling around the nerve in the short and
intermediate term.
• However, it is unclear what effect they have in the long
term.
• In addition it is possible to injure the nerve during the
injection process
•medications
–anti-inflammatory
medications
–SSRIs have been used
 Operative
• surgical release of tarsal tunnel
– indications
• after 3-6 months of failed conservative
management and
–compressive mass (ganglion cyst) identified
–positive EMG
–reproducible physical findings
–outcomes
• best results following surgery are in cases
where a compressing anatomic
structure (ganglion cyst) is identified and
removed
• traction neuritis does not respond as well
to surgery
 TARSAL TUNNEL RELEASE
• Extend the incision from 1 cm plantar to the
navicular tuberosity in a proximal direction,
bisecting the area between the medial
malleolus and the medial aspect of the
tuberosity of the calcaneus, ending 1 cm
anterior to the Achilles tendon.
• With the foot in gravity equinus, this is almost
a straight line .
• Do not undermine the incision.
• Coagulate or tie the superficial veins connecting
the plantar and saphenous systems, and deepen
the incision through the investing fascia of the
calf proximally and the medial side of the foot
distally.
• This allows identification of the proximal and
distal (posterior and anterior)borders of the
flexor retinaculum and the neurovascular bundle
before the bundle disappears beneath the
retinaculum
• Occasionally, the nerve is enlarged at the upper
border of the retinaculum. Release the
retinaculum from a proximal to a distal direction
until the muscle fibers of the abductor hallucis
are reached.
• ■ Sometimes a medial calcaneal branch
penetrates the retinaculum,and care must be
taken to avoid severing one or more branches of
this nerve (medial calcaneal) to avoid a painful
neuroma
• The tibial nerve divides beneath the flexor retinaculum
into the medial and lateral plantar branches.
• The medial calcaneal branch may arise from the main
tibial nerve or its lateral plantar branch .
• An anatomical study by Havel et al. showed the tibial
nerve to bifurcate into its medial and lateral
components beneath the laciniate ligament in 93% of
68 foot dissections.
• When the medial and lateral plantar nerves reach the
medial border of the abductor hallucis, they turn
plantarward and lateral deep to this muscle
• Trace each nerve well distal to the inferior edge
of the flexor retinaculum until it is certain that no
tethering by the fascial origin of the abductor
hallucis exists.
• This is made easier by releasing part of the origin
of the abductor hallucis.
• ■ If the epineurium appears unequally thickened,
it should be incised.
• ■ Remove a section of the flexor retinaculum
over the neurovascular bundle .
• Remove the tourniquet and secure hemostasis
before closing the wound (skin and
subcutaneous tissue only).
• Apply a sterile compression dressing.
• ■ Apply a short-leg posterior splint to “rest”
the wound while the incision is in the initial
stages of healing (10-14 days).
 POSTOPERATIVE CARE

• A bulky compression dressing and a short-leg

plaster splint with the foot in mild equinovarus
are applied and are worn for 7 to 10 days.
• The sutures are removed, and adhesive strips are
applied.
• The foot is brought to a neutral position, and a
fiberglass prefabricated short-leg cast-brace is
worn for an additional 10 to 14 days while the
wound matures
• Ankle edema persisting for many weeks is
common if the dissection has been extensive,
and complete recovery may require 6 to 12
months.
 Risk factors and prevention

• Tarsal tunnel syndrome is known to affect

both athletes and individuals that stand a lot.
• Strenuous activities involved in athletic
activities put extra strain on the ankle and
therefore can lead to the compression of the
tibial nerve.
• Activities that especially involve sprinting and
jumping have a greater risk of developing TTS.
• This is due to the ankle being put in eversion,
inversion, and plantarflexion at high velocities.
• Examples of sports that can lead to TTS include
basketball, track, soccer, lacrosse, and volleyball.
• Neuropathy can occur in the lower limb through
many modalities, some of which include obesity
and inflammation around the joints. By
association, this includes risk factors such as RA,
compressed shoes, pregnancy, diabetes and
thyroid diseases
• Complications
• Recurrence
– usually caused by inadequate release
– repeat tarsal tunnel release not recommended
 ANTERIOR TARSAL TUNNEL
SYNDROME (DEEP PERONEAL
NERVE ENTRAPMENT)

• The anterior tarsal tunnel syndrome, denoting

entrapment of the deep peroneal nerve
beneath the inferior extensor retinaculum
 Anatomy
• Anterior Tarsal Tunnel
– borders
• superficial
– inferior extensor retinaculum
• deep
– capsule of talonavicular joint
• lateral
– lateral malleolus
• medial
– medial malleolus
 contents of anterior tarsal tunnel
• EDL
• EHL
• Tibialis anterior
• peroneus tertius
• Deep peroneal nerve
– within tunnel division of nerve between mixed
(lateral) and sensory only (medial) occurs
• dorsalis pedis artery and vein
• Epidemiology incidence
– rare
• demographics
– adults of all ages and genders
• risk factors
– high heel use
– compressive show wear
– previous fracture
• Pathophysiology site of compression
– anterior leg/ankle/foot from 1 cm proximal to
ankle joint proximally to talonavicular joint distally
• position of compression
– ankle inversion and plantar flexion (when
traumatic)
 pathoanatomy
-intrinsic impingement
• dorsal osteophytes over tibiotalar or talonavicular joints
• other bony deformity (pes cavus, post-fracture)
• ganglion cyst
• tumor
• tendinitis or hypertrophic muscle belly of EHL, EDL or
TA
• peripheral edema
–extrinsic impingement
• tight laces or ski boots
• high heels (induces plantar flexion)
• trauma (including recurrent ankle instability)
• Associated conditions pes cavus
• fracture
– navicular nonunion
• talonavicular arthritis
• systemic conditions causing peripheral edema
• Prognosis recalcitrant cases may require
surgery, which may yield 80% good to
excellent results
 Presentation
• Symptoms
– dysesthesia and paresthesias on dorsal foot
• lateral hallux, medial second toe and first web space
are most common locations
– vague pain on dorsum of foot
• Physical exam
– motor
• weakness or atrophy of EDB
– sensory
• decreased two-point discrimination
– provocative tests
• Tinel sign over course of DPN with possible radiation to
first web space
• exacerbation with plantar flexion and inversion (puts
nerve on stretch)
• relief of symptoms with injection of lidocaine (DPN
nerve block)
• Imaging Radiographs
– recommended views
• lateral view of foot and ankle
– findings
• dorsal osteophytes
• sequelae of prior fracture
• CT
– to define bony anatomy of canal
• MRI
– best for evaluation of mass lesions
 Treatment
• Nonoperative
– shoe modifications
• indications
– first line of treatment
• techniques
– well padded tongue on shoe
– alternative lacing configurations
– full length rocker-sole steel shank
– night splint (to prevent natural tendency for ankle to assume
plantar flexion)
–NSAIDs
–PT (if ankle instability contributing)
–injection
diuretic if chronic
--

peripheral edema
is implicated
 Operative
• surgical release of DPN by releasing inferior
extensor retinaculum and osteophyte /
ganglion resection
– indications
• failure of nonoperative treatment
• symptoms of RSD are a contraindication to release
– outcomes
• 80% satisfactory
 ANTERIOR TARSAL TUNNEL RELEASE
• Before surgery, locate the area of compression at
the anterior ankle joint or the dorsal talonavicular
joint.
• ■ Make a longitudinal incision 5 to 7 cm long over
the dorsum of the foot from the talonavicular
joint to the first intermetatarsal space.
• ■ Identify the deep peroneal nerve and dorsalis
pedis artery.
• .
• Identify the deep peroneal nerve as it courses
beneath the extensor hallucis brevis, and
release the constricting portion of the inferior
extensor retinaculum.
• ■ Mann and Baxter recommend releasing only
the portion of the retinaculum that seems to
be constricting the nerve.
• ■ Remove any underlying lesion, such as a
ganglion cyst or osteophyte
 POSTOPERATIVE CARE
• The patient is placed in a cast or removable
walking boot and begins weight bearing to
tolerance.
• The sutures are removed at 2 weeks, and
immobilization is discontinued unless
tenderness persists.
• If the patient is an athlete, training can
resume 4 to 6 weeks after surgery
• Complications Persistent symptoms following
decompression
– warn patient that recovery is prolonged