Tarsal Tunnel

Syndrome
Better - vulnerabilities of distal
tibial & plantar nerves at the ankle
and foot
objectives

 Understand the ‘tarsal tunnel concept’

 Know the EDX for TTS
 To appreciate the realities of RRS
Tarsal tunnel syndrome
(TTS)
 TTS – “ a complex of symptoms resulting
from compression of the tibial nerve or of
the plantar nerves in the tarsal tunnel,
with pain, numbness and tingling
paresthesias of the sole of the foot”

 From: Dorland’s Medical Dictionary 28th

edition
Tarsal tunnel Syndrome
 This is a RARE condition
 Most reports – local trauma to distal tibial
nerve rather than ‘idiopathic TTS’
 If truly an ‘idiopathic’
 Must be compromised under laciniatum
ligament (retinaculum musculorumm flexorum
pedis)
Or entrapment in abductor hallucis
ligament

 laciniate ligament
 Or Lacinatum
 Or retinaculum muscculum flexorum
pedis

 This is ‘tarsal tunnel syndrome’

CMAP AMPLITUDE AND
DURATION – IMPORTANT!
 Compare amplitude when stimulating
proximal and distal to TT
 Side-to-side amplitudes = 20%
 Latency is helpful –but not the only
parameter for diagnosis
Foot – locate intrinsic
muscles
 Abductor hallicus – 1 cm below navicular
tubercle
 Abductor dig V pedis – below the lateral
malleolus at junction of normal and sole
skin
Note best placement of recording
electrode
Stimulate distal to tarsal ligament
Ankle entrapments
 Tarsal tunnel Syndrome - idiopathic
 This is overdiagnosed!
 Could be lateral plantar nerve in abd hallicus
 Or distal tibial nerve under lanciniatum ligament
 Frequently present as compromise in diabetic
peripheral neuropathy
EDX
 Motor latency – medial plantar n <5.5 ms; lat pl n - <6 ms
 Trans-tarsal amplitude and latency similar to sural –
amplitude reduced and latency prolonged
Lateral plantar nerve
entrapment
 More frequently seen in diabetic peripheral neuropathy
CNAP will be reduced or absent with
stimulation at sole of foot (Lat Pl N)
CMAP of abd dig min pedis will be smaller
 Needle EMG abnormalities in abd dig V ped and lateral
interosseus muscles. Do not accept notion that
abnormal irritability is present in normal foot
intrinsic muscles
 (In 45% of patients lateral Plantar nerve will give
branch to anterior plantar fascia ergo. Resistent plantar
fasciitis
Tarsal tunnel values

 Medial plantar nerve - >6 ms

 Lateral plantar nerve - >7 ms

 NB. Amplitudes and trans-tarsal latencies

are critical for diagnosis

 Compare contralateral values (nl = +/- 20%

Trans-tarsal technique

 Medial plantar nerve

Amplitudes similar to sural
 Lateral plantar nerve
 Amplitudes similar to sural

 NB. This is a MIXED nerve action potential

Duration is the key
Trans tarsal mixed N
values
 Note the amplitude and duration
 Latency can be converted to CV (nl >35
M/sec)
 NB. Comparable to sural nerve values
Tarsal tunnel is a syndrome!

 Definition – comparable with CTS if

compromise is under lancinatum
ligament – this is rare!
 Could occur if underlying nerve is ‘sick’
as in peripheral neuropathy

 Many cases are 2d to trauma at ankle

 Ergo. NOT really tarsal tunnel syndrome
Tarsal tunnel –bottom line
 This is a rare disorder but it can be DX
 ‘Idiopathic’ is rare
 Must verify with mixed – trans-tarsal
abnormal values – best test (consensus)
 Must do needle EMG on intrinsic foot
muscles (caution!- end plate areas)
 It is common – only – in patients with
underlying diabetic polyneuropathy
references
 Kerr & Frey: MR imaging in tarsal tunnel. J Computer
Assisted Tomography. 1991. 15:280
 Kinoshita, M et al: The dorsiflexion-eversion test for
diagnosis of tarsal tunnel syndrome.2001.83A:1835.
 Mondelli, M et al: an electrophysiologic severity scale in
tarsal tunnel syndrome.Acta. Neurologica
Scandinavica.2004.109:284
 Oh, S et al: Electrophysiologic improvement following
decrompression surgery in tarsal tunnel syndrome.
Muscle & Nerve 1991.14:407
 Ward,P & Porter, M: Tarsal tunnel: a study of the
clinical and neurophysiologic results of decompression.
J Royal Coll of Surg of Edinburgh.1998.43:35.
references
 Dellon A et al: Variations in origin of medial calcaneal
nerve. J Am Podiatric Med Assn. 2002.92:97
 Dumitru, D et al: SSEP of medial & lateral plantar &
calcaneal nerves. Muscle & Nerve.1991.14:665
 Felsenthal, G et al: Across tarsal tunnel motor nerve
consuction technique. Arch PM&R 1992.73:64
 Galardi, G et al: Electrophysiologic studies in Tarsal
tunnel syndrome – diagnostic reliability of motor, mixed
and sensory nerve conduction studies. Am J PM&R
1994.73:193.
 Gumasalum & Kalaycioglu: Bilateral accessory flexor
digitorum longus muscle in man.Annals of
Annatomy.2000. 182:573.
References
 Lee,C & Dellon,A: Diagnostic ability of Tinel sign in determining outcome
for decompression surgery in diabetic and nondiabetic neuropathy.Ann
Plastic Surg. 2004. 53:523.
 Azsmann,O et al: Incidence of ulcer/amputation in the contralateral limb of
patients with a unilateral nerve decompression procedure. Ann Plastic
Surg.2004. 53:517
 Kim,D et al: Surgical management and results of 135 tibial nerve lesions
at the Louisiana State University Health Sciences Center. Neurosurgery.
2003. 53:lll4
 Sammarco,G & Chang,L: Outcome of surgical treatment of tarsal tunnel
syndrome. Foot & Ankle International.2003.24:125
 Labib,S et al: The combination of plantar fasciitis, posterior tibial tendon
dysfunction and tarsal tunnel syndrome. Foot & Ankle Internation.
2002.23:212.
 Watson, T et al: Distal tarsal tunnel release with 0artial plntar fasciotomy
for chronic heel pain: an outcome analysis. Foot & Ankle International.
2002. 23:530
references

 Watson, B et al: An unusual presentation

of tarsal tunnel syndrome caused by an
inflatable ice hockey skate. Canadian J
Neurologic Sciences.2002.29:386

references
 Kim, J & Dellon, A: Pain at the site of tarsal tunnel incision due to
neuroma of sural nerve. J Am Podiatric Med Assoc. 2001. 81:109
 Kohno, M et al: Neurovascular decompression for idiopathic tarsal tunnel
syndrome: technical note. J Neurol Neurosurg Psychiatry. 2000.69:87
 Bailie, D & Kelikian A: Tarsal tunnel syndrome: Diagnosis, surgical
technique and functional outcome.. Foot & Ankle International1998.19:65
 Herbsthofer, B et al: Tarsal tunnel syndrome: diagnostic and longgterm
follow-up after operative treatment.Zieitschrift fur Ortholpadie und Ihre
Grenzgebiete. 1998. 136:77.
 Pfeiffer, W & Cracchiolo, A: Clinical results after tarsal tunnel
decompression. J Bone & Joint Surg. (A) 1994. 76A:1222
 Mondelli,M & Cioni, R: EDX evidence of a relationship between idiopathic
carpal and tarsal tunnel syndromes. Clinical
Neurophysiology.1998.28:391
 Lau, T & Daniels, T: Tarsal tunnel syndrome: A review of the literature.
Foot & Ankle International.1999. 20:201
Usefulness of EDX in DX of
TTS
 AANEM PRACTICE TOPIC
 Patel, A et al: Muscle & Nerve. 2005. 236
 Recommendations:
 Tibial motor CV with responses abd hall & abd
dig min ped with prolonged latencies
 Medial and Lateral Plantar prolonged latencies
 Medial and Lateral Plantar slowed CV across TT
or reduced or absent SNAP
 Needle exam of foot intrinsic muscles – no data