Tarsal Tunnel Syndrome: Difference between revisions
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There exists a wide variety in clinical outcomes that can be used to evaluate foot conditions. In 2013 Kenneth J. et al. concluded in their 10-year research that most of them were inconsistently used. Out of 139 clinical outcomes the American Orthopaedic Foot & Ankle Society (AOFAS), the visual analog scale (VAS) for pain, the Short Form-36 (SF-36) Health Survey, the Foot Function Index (FFI) and the American Academy of Orthopaedic Surgeons (AAOS) outcomes instruments were the most popular. The study underlined the need for consistent use of a responsive, valid, reliable and clinically meaningful outcome measurement tool.<ref name="32">Hunt KJ, Hurwit D. Use of patient-reported outcome measures in foot and ankle research. J Bone Joint Surg Am. 2013;95(16):e118. (Level of Evidence 1a)</ref><br>One measurement tool that meets the requirements is the Foot and Ankle Abitlity Measure. It was made in 2005 by RobRoy et al. It covers a wide variety of disorders in the lower extremity, namely the lower leg, foot and ankle. Examples are plantar fasciitis<ref name="29">Digiovanni BF, Nawoczenski DA, Malay DP, Graci PA, Williams TT, Wilding GE, Baumhauer JF. Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. J Bone Joint Surg Am. 2006;88(8):1775-81. (Level of Evidence 2b)</ref>, ankle instability<ref name="31">Eechaute et al. The clinimetric qualities of patient-assessed instruments for measuring chronic ankle instability: A systematic review. BMC Musculoskeletal Disorders 2007, 8:6 doi:10.1186/1471-2474-8-6 (Level of evidence: 1a)</ref>, etc. Its clinical relevance was researched by Martin et al. and in the table underneath the validity, reliability and responsiveness of the tool is summerised.<ref name="30">Martin R L, Irrgang JJ. A survey of self-reported outcome instruments for the foot and ankle. Journal of Orthopaedic & Sports Physical Therapy 2007;37(2):72-84. (Level of Evidence 5)</ref><br><br> | There exists a wide variety in clinical outcomes that can be used to evaluate foot conditions. In 2013 Kenneth J. et al. concluded in their 10-year research that most of them were inconsistently used. Out of 139 clinical outcomes the American Orthopaedic Foot & Ankle Society (AOFAS), the visual analog scale (VAS) for pain, the Short Form-36 (SF-36) Health Survey, the Foot Function Index (FFI) and the American Academy of Orthopaedic Surgeons (AAOS) outcomes instruments were the most popular. The study underlined the need for consistent use of a responsive, valid, reliable and clinically meaningful outcome measurement tool.<ref name="32">Hunt KJ, Hurwit D. Use of patient-reported outcome measures in foot and ankle research. J Bone Joint Surg Am. 2013;95(16):e118. (Level of Evidence 1a)</ref><br>One measurement tool that meets the requirements is the Foot and Ankle Abitlity Measure. It was made in 2005 by RobRoy et al. It covers a wide variety of disorders in the lower extremity, namely the lower leg, foot and ankle. Examples are plantar fasciitis<ref name="29">Digiovanni BF, Nawoczenski DA, Malay DP, Graci PA, Williams TT, Wilding GE, Baumhauer JF. Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. J Bone Joint Surg Am. 2006;88(8):1775-81. (Level of Evidence 2b)</ref>, ankle instability<ref name="31">Eechaute et al. The clinimetric qualities of patient-assessed instruments for measuring chronic ankle instability: A systematic review. BMC Musculoskeletal Disorders 2007, 8:6 doi:10.1186/1471-2474-8-6 (Level of evidence: 1a)</ref>, etc. Its clinical relevance was researched by Martin et al. and in the table underneath the validity, reliability and responsiveness of the tool is summerised.<ref name="30">Martin R L, Irrgang JJ. A survey of self-reported outcome instruments for the foot and ankle. Journal of Orthopaedic & Sports Physical Therapy 2007;37(2):72-84. (Level of Evidence 5)</ref><br><br> | ||
== Medical Management | == Medical Management<br> == | ||
The management goes into two directions: a conservative or non-operative management and surgery. The former is used prior to the latter approach, unless signs of muscle atrophy or motor involvement are obvious, according to McSweeney & Cichero. The latter is used when patients haven’t benefitted from the former approach. | The management goes into two directions: a conservative or non-operative management and surgery. The former is used prior to the latter approach, unless signs of muscle atrophy or motor involvement are obvious, according to McSweeney & Cichero. The latter is used when patients haven’t benefitted from the former approach.<ref name="1" /><ref name="21" /><ref name="37">Dr. Karen Hudes, BCs, BS, DC: Conservative management of a case of tarsal tunnel syndrome. (Level of Evidence 4)</ref><ref name="39">Bailie DS, Kelikian AS. Tarsal tunnel syndrome: diagnosis, surgical technique, and functional outcome. Foot & ankle international 1998;19(2):65-72. (Level of Evidence 4)</ref> | ||
<br> | Conservative approach<br>In this approach the following can be included: “physical therapy, non-steroidal anti-inflammatory, analgesic, opioid or GABA analog medications, tri-cyclic antidepressants and vitamin B-complex supplements and corticosteroid injections” (1). In the literature there is unfortunately an absence of RCTs, and in existing case series the efficacy of treatment methods can’t be quantified.<ref name="1" /><ref name="21" /><ref name="37" /><ref name="39" /> | ||
Surgical approach<br>When the non-operative management doesn’t work, surgical management is recommended.<ref name="1" /><ref name="21" /><ref name="37" /><ref name="39" /> This approach can include: “surgical decompression of the tibial nerve and its branches with division of the medial flexor retinaculum; release of the deep fascia of the abductor hallucis muscle and removal of impinging or pathological lesions”.<ref name="1" /> It is stated by McSweeney & Cichero that surgery may improve symptoms of the syndrome but that evidence of the efficacy of the surgery in the literature can conflict itself.<ref name="1" /><ref name="21" /><ref name="37" /><ref name="39" /> Another surgical approach is cryosurgery. McSweeney & Cichero state that there are different advantages of using cryosurgery for this syndrome, but as there is a lack of clinical trials the guideline for the use of this method is still undergoing change.<ref name="1" /><br> | |||
Surgical approach<br>When the non-operative management doesn’t work, surgical management is recommended. | |||
== Physical Therapy Management == | == Physical Therapy Management == | ||
Revision as of 22:46, 9 January 2017
Original Editor - Staci Burns, Jonathan Blondeel
Top Contributors - Admin, Blondeel Jonathan, Dieter Schuddinck, Rani Sileghem, Staci Burns, Kim Jackson, Rachael Lowe, Jesse Lemmens, Vidya Acharya, 127.0.0.1, Tarina van der Stockt, Jenny Wong, Naomi O'Reilly, Kai A. Sigel and WikiSysopSearch Strategy[edit | edit source]
We searched the web using different databases: Pubmed, PEDro, ScienceDirect, Web of Science and Google Scholar. We used one of or a combination of the following keywords.
Keywords: tarsal tunnel syndrome, TTS, tibial nerve entrapment, tibial neuropathy, plantar heel pain, diagnosis, physical therapy, conservative management, surgery, medical management, physical management, etc.
Definition/Description[edit | edit source]
Tarsal tunnel syndrome is a compressive neuropathy of the posterior tibial nerve or one of its associated branches individually or collectively.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleThe tunnel lies posterior to the medial malleolus of the ankle, beneath the flexor retinaculum. Symptoms include pain radiating into the foot, usually this pain is worsened by walking (or weight-bearing acitvities). Examination may reveal Tinel’s sign over the tibial nerve at the ankle, weakness and atrophy of the small foot muscles or loss of sensation in the foot.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Clinically Relevant Anatomy[edit | edit source]
The tarsal tunnel is a fibrous osseus tunnel, it has a proximal floor and a distal floor. The proximal floor is formed by the flexor retinaculum (RET, Fig 1), it contains several flexor tendons (M. Tibialis posterior, M. Flexor digitorum longus, M. Flexor halluces longus), the posterior tibial nerve, the posterior tibial artery and the tibial veins. The distal floor is formed between the abductor hallucis muscle (H ABD, Fig. 1) and the deep quadratus plantae. This contains branches of the plantar vessels and the plantar nerves.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
The posterior tibial nerve (NT, Fig. 1) runs along the M. soleus in the posterior compartment. The nerve exits the compartment and passes deep behind the RET between the calcaneus and the medial malleolus. Before passing behind the flexor retinaculum the nerve branches, one part moves on behind the RET, the other part forms the Medial calcaneal nerve (MCN, Fig 1).
At the distal floor the tibial nerve divides into two terminal branches: Medial plantar nerve (MPN, Fig. 1) and Lateral plantar nerve (LPN, Fig. 1), sometimes this happens at the proximal tunnel. The inferior calcaneal nerve runs branches off from the lateral plantar nerve and is also referred to as the motor nerve for the abductor muscle for the fifth toe (ABD V, Fig. 1)
Compression of the Tibial nerve at the tarsal tunnel leads to plantar heel pain, this condition is called Tarsal Tunnel Syndrome. Other nerves that run in the foot also have risk of compression due to their anatomical situation.
The LPN supplies most of the muscles of the foot, the lateral part of the skin (Fig. 2) and the fourth and fifth toe. This nerve runs between the abductor hallucis and the quadratus plantae, entrapment between these muscles is possible and also the most common. The first branch of the LPN runs close to the calcaneal tuberosity (ICN, Fig. 1), which is also a possible site of entrapment. The MCN supplies sensory innervation to most of the heel (heel fat pad, superficial tissues) (Fig. 2), this nerve is less likely to be compressed between its anatomical sturctures. But can be traumatised and irritated as a result of atrophy of the heel fat pad. The MPN innervates the abductor hallucis, flexor hallucis brevis, flexor digitorum brevis, first lumbrical and also the medial side of the plantar part (Fig. 2) of the foot.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Epidemiology / Etiology[edit | edit source]
Tarsal Tunnel Syndrome is caused by any kind of entrapment or compression of the tibial nerve or its plantar branches. In many cases the cause is idiopathic or posttraumatic. In a literature review, by John T.C. Lau, M.D. et al., was estimated that 20-40 % of cases were idiopathic.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Up to 10% of all cases are the result of the following diseases: arthrosis, tenosynovitis and Rheumatoid_Arthritis. Nearly twice as many cases have convoluted vessels as the origin.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Some other rare causes are Diabetes Mellitus , Hypothyroidism , Gout, mucopolysaccharidoses, and (very rarely) hyperlipidemia.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Some muscles or tendons, medial of the talus bone, can entrap the tibial nerve due to hypertrophy or being accessory. As mentioned in the ‘anatomy’-section the tendon of the flexor hallucis longus muscle passes the tarsal tunnel along with blood vessels, the tibial nerve and other muscles. When enough hypertrophy occurs in one of these muscles the pressure within the tarsal tunnel increases. Sometimes this can even lead up to the muscle belly of the flexor hallucis longus entering the tarsal tunnel. This can cause an overstimulation of the tibial nerve or its branches. Depending on which nerve is being impinged the patient can get different uncomfortable sensations in its foot.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Some persons are born with accessory muscles. These variations from the norm can cause more harm than good. Those muscles are not necessarily helpful, but it is a given that they do occupy space within the foot. Similar to hypertrophy of the muscles in the medial ankle region this can compress the tibial nerve possibly resulting in chronic pain.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Surgery or an overload on the ankle region can cause local inflammation and swelling, yet again causing pressure on the tibial nerve. Sports where sprinting and jumping play a significant role have been proven to be provocative for TTS. People with flat feet, talocalcaneal coalition or bony fragments around the tarsal tunnel are more vulnerable to develop the syndrome.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
People with flat feet, talocalcaneal coalition or bony fragments around the tarsal tunnel are more vulnerable to develop TTS.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
It might be important to mention that because tarsal tunnel syndrome is a relatively uncommon clinical entity, it can often be misdiagnosed in both children and adults due to the clinician’s low index of suspicion.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title McSweeney & Cichero (2015) also state in their review that the incidence of TTS is not known but the prevalence would be greater in females than males, predominately in adults.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title TTS also tends to be more common in athletes and individuals whom are subjected to prolonged weight-baring periods inclusive of standing, walking or intense physical activity.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Pes planus deformity/hyperpronation may compromise the anatomical structures within the tarsal tunnel and thus lead to a physical decrease of space and an increase in tension of the nerve.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title It would be one of the most common extrinsic factors to cause TTS.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Alleviation of pain/complaints could be obtained with restCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title or neutral immobilization of the foot and ankle, and loose-fitting footwear.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title External compression resulting from footwear or tight plaster casts is said to be a most common cause.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Clinical Presentation[edit | edit source]
TTS has the following symptoms: tingling or burning pain (paresthesia), hyperesthesia and sensory impairment (dysesthesia). The symptoms diffuse in the sole and/ or the heel or digits of the forefoot. The Valleix phenomenon, in which the symptoms extend midway to the lower leg due to percussion of the entrapped nerve, may also occur. McSweeney & Cichero (2015) also state in their review that the symptoms are often unilaterally presented and that they may worsen as the day progresses.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title This can also be accompanied by nocturnal awakening.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Furthermore, in some cases muscle the patients may also present weakened, atrophied or paralyzed flexor and digital abductor muscles.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Patients may be unable to move the hallux as a result of local tenderness and swelling. These movements include flexion, extension, abduction and adduction.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Pain becomes worse after or during weight-bearing activities and improves with rest.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Pain is the most prominent symptom, which is localized directly over the medial malleolus with radiation to the longitudinal arch and plantar aspect of the foot including the heel.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Pain begins in the plantar part of the forefoot and extends to the toes. It is usually aggravated in the night due to the modification of foot posture that causes the posterior tibial nerve to be restrained or venous congestion. There is rarely motor weakness or atrophy of intrinsic foot muscles.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Common manifestations of tarsal tunnel syndrome is a positive Tinel’s sign and pain felt on provocation using passively maximally dorsiflexion and eversion of the ankle while all the metatarsophalangeal joints are performing dorsiflexion. Most common and objective symptom is a diminished sensation.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Differential Diagnosis
[edit | edit source]
Most persons have once had sensation of so-called sleeping limbs, usually referred to as paresthesia. This feeling can also rise due to a pathogenic condition such as polyneuropathy. That’s when this numb, tingling feeling can no longer be put under control by the patient. It’s a condition often arises at the hands or feet. Considering one has paresthesia at the foot, the symptoms are very similar to those of the TTS.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
A shortage of oxygen supply to tissue is called ischemia. Permanent damage can occur when this supply is put on hold for extensive time. As nerves start to lack oxygen their functionality slowly decreases. The result of extended ischemia can be devastating. However if a lack of blood flow is the cause, and it is normalized in time, damage can be near to none. Concerning nerves, in some cases permanent ischemic paresthesia can arise. This makes the neurons fire at random which gives the same sensation as the symptoms of TTS.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
A compartment syndrome can mostly be found in the upper arm and lower leg. It can show up after a pressure build-up on or within a muscle compartment with an overload of certain muscle groups or fluid build-up being possible origins of this syndrome. The tibial nerve runs along the deep calf muscles with a compartment. Excessive pressure may trigger this nerve to fire uncontrollably. The TTS can be misdiagnosed for this compartment syndrome if the compression of the nerve mostly takes place near the medial malleolus.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
The former has also proven to be able to produce a distal tibial nerve lesion. A lesion is any damage or abnormal change in tissue. A lesion in or near a nerve can compromise its function. Therefore it can simulate the same symptoms as the TTS when a nerve near the medial malleolus is involved.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
As a tumour is a group of cells which grow uncontrollably and can be benign, precancerous or malignant. Despite these three distinctions they do have in common that they take up space unnecessarily. Pressure caused by tumours rarely induces trouble to its surround tissues. It can however be a differential diagnosis for TTS if it overexcites a nerve at the medial malleolus.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Diagnostic Procedures[edit | edit source]
The diagnosis of TTS is mainly a clinical diagnosis based on detailed medical history and clinical examination. The clinical tests performed by physiotherapists are mostly provocative tests.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title These will be further described in the topic “Examination” (underneath). Adjunctive medical imaging and electrophysiological studies may assist in diagnosingCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title and could provide additional information useful to plan management.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleThis can include electrodiagnostic studies, radiographs, ultrasound, MRI and computed tomography.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title It is, for example, also possible for the digital abductor and flexor muscles of the symptomatic foot to weaken, atrophy or even paralyse in some chronic circumstances.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title This is often difficult to detect clinically and may therefore require subsequent referral for medical imaging or nerve conduction studies.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title We should keep in mind though that these kinds of examinations are not substitutes for the clinical examination but they can play a key role in confirming or excluding the physician’s suspicion.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
As already mentioned, diagnosing the cause of TTS, and actually a lot of other medial ankle and heel pain, by physical examination alone can be challenging for the clinician.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title This is due to the complex anatomy of the medial aspect of the ankle and hindfoot, which makes localizing symptoms to a specific structure difficult.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title For example, plain X-rays of the ankle are useful in demonstrating structural abnormalities such as hind foot varus/valgus. Magnetic resonance imaging (MRI) adds further detail and is highly accurate (83%) when investigating space-occupying lesions.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
MRI is considered the gold standard in identifying suspected compression of the tarsal tunnel caused by the presence of obstructive foreign masses, lesions or tumours.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title This type of imaging not only confirms the presence of a suspected lesion but also defines the depth, extent and margins of the lesion for accurate characterization.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title In a study undertaken by Frey (reviewed by McSweeney & Cichero, 2015), MRI was deemed to have shown significant findings in 88% of symptomatic tarsal tunnel candidates, thus assisting with etiological reasoning and surgical planning if required.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title MRI and high-resolution ultrasound have the diagnostic capability to detect and demonstrate the thickness of the flexor retinaculum, overall depth and contents within the tarsal tunnel, including the posterior tibial nerve cross-sectional area and its terminal branch derivatives.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Ultrasound represents an accessible, portable and relatively inexpensive (less expensive than MRI) imaging tool for the assessment of medial ankle and heel pain.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title In addition, it offers the advantage of comparison with the contralateral side.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Although MRI (above) is considered the gold standard, ultrasound is effective in the diagnosis of pathologic conditions affecting the medial ankle and heel and correlates well with MRI.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Ultrasound is able to demonstrate the complex anatomy of the tarsal tunnel and show the entire course of the tibial nerve and its branches at the medial ankle. It is also effective in the identification of space occupying lesions. Even small changes in the cross sectional area of the nerve can be detected on ultrasound in symptomatic patients.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Electrodiagnostic testing can also assist in the diagnosis of tarsal tunnel syndrome.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title These tests include nerve conduction studies that assess sensory conduction velocities of the tibial nerve or one of its branches, as well as the amplitude and duration of motor-evoked potentials.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title There is limited quality evidence based research that demonstrates high sensitivity and specificity of the electrophysiological techniques in TTS. Reduced amplitude and increased duration of the motor response are the more sensitive indicators of the presence of pathology.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Unfortunately these investigations often yield an unacceptable level of false negative results, and should be utilized as an adjunctive assessment to confirm physical examination findings.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Saeed (reviewed by McSweeney & Cichero, 2015) discusses evidence of false positive readings in his study of 70 asymptomatic subjectsCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title and Ahmad et al (2012) report that false negative tests are not uncommon and therefore do not rule out the diagnosis.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Thus, Abouelela & Zohiery (2012) state that provocative tests remain important in the diagnosis of TTS due to the unaccepted range of false negative results in electrodiagnostic testing.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Last, plain weight-bearing radiographs and/or computed tomography of the foot and ankle should be acquired if suspecting morphological influences or structural anomalies from bony abnormalities, according to McSweeney & Cichero (2012).Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Omoumi et al (2010) state that in practice, the visualization of articular communication with MRI or ultrasonography can be challenging.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Computed tomography (arthrography) with delayed acquisitions has been shown to be a valuable technique for the detection of articular communication between structures and a joint.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Closing, it is recommended that all tests should ideally be performed bilaterally for adequate observation and comparative study of the contralateral joint.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Examination
[edit | edit source]
Tarsal tunnel syndrome may lead to a broad range of symptoms affecting the posteromedial ankle and plantar aspects of the foot.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title This is due to the proximal TTS affecting the tibial nerve in the retromalleolar region, whereas distal TTS tends to affect its branches.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title According to Zheng et al (2016), paresthesia and/or pain in the sole of the foot is the widely accepted primary symptom of tarsal tunnel syndrome.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Ahmad et al (2012) says that the predominant symptom is indeed pain, directly over the tarsal tunnel behind the medial malleolus with radiation to the longitudinal arch and plantar aspect of the foot including the heel.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Tu & Bytomski (2011) talk about medial midfoot heel painCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title and Kavlak & Uygur (2011) about the symptom triad of pain, paresthesia and numbness. Other (sensory) symptoms may include dysesthesia and, as already stated above, paraesthesia (e.g. burning, tingling and numbness) at all or varied sites of the tarsal tunnel including: the posterior compartment, retromalleolar flexor retinaculum coverage, and both the anterior and posterior fibro-osseus tunnels branching to the plantar margins of the foot.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title A varied and specific involvement of the differing nerve branches accounts for the diverse presentation and extent level of symptoms observed with the condition of tarsal tunnel syndrome.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
A very common used clinical test for the diagnosis of tarsal tunnel syndrome is the Hoff-mann-Tinel Sign.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Originally used as a specific test for the carpal tunnel syndrome, it can also be used to examine tibial nerve compression in the ankle.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title During this test, the nerve is percussed or tapped at the suspected site of compression, the area below the medial malleolus.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title A positive diagnosis will cause paresthesia either locally or radiating along the course of the nerve.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title This positive result may be due to the entrapment of the nerve by surrounding tissues.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title When the test delivers a negative result, the patient feels no pain.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title It is furthermore postulated that greater than 50% of patients with compressive neuropathy of the tarsal tunnel will portray a positive Tinel’s sign of the posterior tibial nerve.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Alongside Tinel’s sign, the physiotherapist could also use the SLR (Straight Leg Raise) test to provoke symptoms similar to a nerve problem.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
A second test that could be used (in addition to the Tinel’s sign) for making the symptoms become diagnostically apparent is the dorsiflexion-eversion test.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title To perform this test the clinician both passively maximally everts and dorsiflexes the ankle whilst maximally dorsiflexing the metatarsophalangeal joints.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title This position is held for 5 – 10 s and will display further intensification of the symptoms if positive.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title On occasions pain may also ascend to the thigh following this means of testing (1; LOE: 5), although this would happen rather rarely.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Kinoshita et al (2006) have reported that the dorsiflexion-eversion test reproduced or aggravated symptoms for 82% in symptomatic feet, with no replication evident in the healthy control group.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title In brief, what happens during the dorsiflexion-eversion test is that the distal posterior tibial nerve is stretched and compressed.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Further intensification of symptoms can also be obtained by using the Trepman test or the plantar flexion-inversion test.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title This maneuver also increases pressure on the tibial nerve within the tarsal tunnel confines.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Through intra-operative observation, Hendrix et al (reviewed by McSweeney & Cichero, 2015) acknowledged this combined movement not only reduced the overall width of the tarsal tunnel, but also compressed the lateral-planter nerve.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title So either dorsiflexion-eversion or plantar flexion-inversion can reproduce pain or increase the symptoms of tarsal tunnel syndrome.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Abouelala & Zohiery (2012) investigated a fourth clinical test, called the triple compression stress test (TCST). This provocative test was supposed to be more specific and therefore sensitivity and specificity for diagnosing TTS was investigated. The TCST showed 85,9% sensitivity and 100% specificity. The TCST combines the Tinel’s sign test with the Trepman testCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title by bringing the foot passively in full plantar flexion, inversion and applying an even and constant digital pressure over the posterior tibial nerve for 30s.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title A double compression on the nerve occurs from the plantar flexion and inversion, and along with a simultaneous third compression maneuver by direct digital pressure, the test was hence named triple compression stress test.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title The study found that clinical signs and symptoms of tarsal tunnel syndrome were apparent within a matter of seconds for 93,8% of symptomatic feet.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Pain usually developed within 10 s and numbness within 30 s of the test. All control feet had negative clinical TCST. The researchers also state that the TCST achieves a simple, fast and very reliable provocative maneuver to increase sensitivity of TSS diagnosis, both clinically and electrophysiologically.
Outcome Measures[edit | edit source]
There exists a wide variety in clinical outcomes that can be used to evaluate foot conditions. In 2013 Kenneth J. et al. concluded in their 10-year research that most of them were inconsistently used. Out of 139 clinical outcomes the American Orthopaedic Foot & Ankle Society (AOFAS), the visual analog scale (VAS) for pain, the Short Form-36 (SF-36) Health Survey, the Foot Function Index (FFI) and the American Academy of Orthopaedic Surgeons (AAOS) outcomes instruments were the most popular. The study underlined the need for consistent use of a responsive, valid, reliable and clinically meaningful outcome measurement tool.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
One measurement tool that meets the requirements is the Foot and Ankle Abitlity Measure. It was made in 2005 by RobRoy et al. It covers a wide variety of disorders in the lower extremity, namely the lower leg, foot and ankle. Examples are plantar fasciitisCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, ankle instabilityCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, etc. Its clinical relevance was researched by Martin et al. and in the table underneath the validity, reliability and responsiveness of the tool is summerised.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Medical Management
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The management goes into two directions: a conservative or non-operative management and surgery. The former is used prior to the latter approach, unless signs of muscle atrophy or motor involvement are obvious, according to McSweeney & Cichero. The latter is used when patients haven’t benefitted from the former approach.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Conservative approach
In this approach the following can be included: “physical therapy, non-steroidal anti-inflammatory, analgesic, opioid or GABA analog medications, tri-cyclic antidepressants and vitamin B-complex supplements and corticosteroid injections” (1). In the literature there is unfortunately an absence of RCTs, and in existing case series the efficacy of treatment methods can’t be quantified.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Surgical approach
When the non-operative management doesn’t work, surgical management is recommended.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title This approach can include: “surgical decompression of the tibial nerve and its branches with division of the medial flexor retinaculum; release of the deep fascia of the abductor hallucis muscle and removal of impinging or pathological lesions”.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title It is stated by McSweeney & Cichero that surgery may improve symptoms of the syndrome but that evidence of the efficacy of the surgery in the literature can conflict itself.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Another surgical approach is cryosurgery. McSweeney & Cichero state that there are different advantages of using cryosurgery for this syndrome, but as there is a lack of clinical trials the guideline for the use of this method is still undergoing change.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Physical Therapy Management[edit | edit source]
There is a lack of evidence in literature on treatment approaches (4; LOE: 5). Small RCT’s would help to find succesfull rehabilitation excersices or other treatments for patients with tarsal tunnel syndrome (1; LOE: 5). Published papers have reported case studies, but empirical evidence of their efficacy is lacking (1; LOE: 5)
At the time patients who do not respond to physical therapy or other conservative treatment are reffered to a clinician for a surgical approach (e.g. decompression of the tarsal tunnel).
Conservative treatment
There are three stages (33; LOE: 5, 34; LOE: 5) in the development of TTS, in every stage there are different aspect that may be adressed in the management of the symptoms.
Key Research[edit | edit source]
add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)
The following source was key research for this page:
28. Kavlak, Y., & Uygur, F. (2011). Effects of nerve mobilization exercise as an adjunct to the conservative treatment for patients with tarsal tunnel syndrome. Journal of manipulative and physiological therapeutics, 34(7), 441-448 (Level of evidence 1b)
Resources
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http://sportspodiatry.co.uk
http://www.footlogics.co.za/achilles-tendonitis-pain-treatment.html
http://www.aofas.org/footcaremd/conditions/ailments-of-the-heel/pages/plantar-fasciitis.aspx
https://www.youtube.com/watch?v=5Z2XlqsuQSY
https://www.youtube.com/watch?v=zJ56EjnQ3Ok
https://www.youtube.com/watch?v=aDyr2wAOIhM
Clinical Bottom Line[edit | edit source]
Tarsal tunnel syndrome is a rare condition and often underdiagnosed (1; LOE: 5). A variety of symptoms are possible, such as: tingling or burning pain (paresthesia), hyperesthesia and sensory impairment (dysesthesia). These are felt on the plantar face of the ankel and foot.
There are a few test to identify tarsal tunnel syndrome or rule out other possibilities, these tests include: MRI, Ultrasound, Hoffman-tinels test, dorsiflexion-eversion test, trepman test and the triple compression stress test. (4; LOE: 5)
Treatment of a tarsal tunnel syndrom should be attemted conservatively at first (see “Physical therapy management”). If conservative treatment fails a surgical aproach can be taken.
Recent Related Research (from Pubmed)[edit | edit source]
