Tarsal Tunnel Syndrome

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Clinically Relevant Anatomy

The tarsal tunnel is a fibro-osseous tunnel formed by the flexor retinaclum behind and below the medial malleolus. It is through this tunnel that the distal posterior tibial nerve and its branches, which include the calcaneal nerve and the medial and lateral plantar nerves, pass through as the curve around the medial malleolus into the foot. The structures that pass through this tunnel (from anterior to posterior) include the tibialis posterior tendon, the flexor digitorum longus tendon, the posterior neurovasulcar bundle, and the flexor hallicus longus tendon.

Mechanism of Injury / Pathological Process

Tarsal Tunnel Syndrome occurs when there is an entrapment neuropathy of the tibial nerve. This entrapment could be caused by trauma that would cause inflammation or bleeding, hypertrophy of the flexor hallicus longus, space occupying lesions, or foot deformity. Space occupying lesions include tumors, talocalcaneal coalition, ganglion cyst, or an accessory muscle and/or bone. Flatfoot deformity in particular is also another causitive factor.

Clinical Presentation

Clinical features are burning pain at the medial malleolus radiating into the toes and sole and heel,along with paraethesia in the distrubution of the posterior tibial nerve that is aggravated by weight bearing. Sensory impairment may develop, though motor deficits are often uncommon. The symptoms may vary according to the nerves affected: the calcaneal nerves are purely sensory and supply the heel; the medial plantar nerve innervates the medial aspect of the sole and the medial 3 or 4 toes and their associated muscles; and the lateral plantar nerve supplies the remainder of the skin on the plantar aspect of the sole and toes, and the small muscles that control the lateral toes.

Diagnostic Procedures

Diagnosis of tarsal tunnel syndrome includes subjective information, diagnostic testing including MRI, CT scans or x-rays and electrodiagnostic studies, a (+) tinel sign.

There is also a rating scale for tarsal tunnel syndrome to determine the severity of the syndrome.

The Rating Scale for the Severity of Tarsal Tunnel Syndrome

Symptom:                                                 Absent                Some              Definite

Pain, spontaneous or on movement              2                          1                       0
Burning pain                                               2                          1                       0
Tinel sign                                                   2                          1                       0
Sensory disturbance                                   2                          1                       0
Muscle atrophy or weakness                       2                          1                       0

(A normal foot scores 10 points)

Outcome Measures

Outcome measures for Tarsal Tunnel Syndrome could include the FAAM or the Rating Scale for the Severity of Tarsal Tunnel Syndrome (as above).

Management / Interventions

Nonoperative interventions include non-steriodal anti-inflammatory agents, local steriod injections, physical therapy, and foot orthosis. However, if the patient does not respond to non-operative treatment, then posterior tibial nerve decompression is performed.
Outcomes after surgical removal of space occupying lesions, such are ganglion cysts, are usually good, although a 17% recurrence during long-term follow-up despite complete surgical resection has been reported.

Differential Diagnosis

When evaluating for Tarsal Tunnel Syndrome, in general you want to differential diagnosis between tarsal tunnel syndrome and lumbar radiculopathies and/or peripheral nerve injuries.

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References 

Kinoshita M, Okuda R, Yasuda T and Abe M. Tarsal Tunnel Syndrome in Athletes. Am J Sport Med. 2006;34:1307-1312.

Takakura Y, Kitada C, Sugimoto K, Tanaka Y, Tamai S. Tarsal Tunnel Syndrome: Causes and Results of operative treatment. J Bone Joint Surg [Br]. 1991;73-B:125-8.

Erikson SJ, Quinn SF, Kneeland JB et al. MRI Imaging of the Tarsal Tunnel and Related Spaces: Normal and Abnormal Findings with Anatomical Correlation. AJR. 1990;155:323-328.

Low HL and Stephenson G. These boots weren't made for walking: Tarsal Tunnel Syndrome. CMAJ. 2007;176 (10):1415-1416.