Tarsal Tunnel Syndrome

1. Tarsal Tunnel Syndrome
ADE WIJAYA MD
SEPTEMBER 2017

2. Outline:
• Introduction
• Anatomy
• Etiology
• Clinical Manifestation
• Differential Diagnosis
• Diagnosis (Electrodiagnostic Studies, MRI, Ultrasound)
• Treatment
• Summary

3. Introduction
most common compressive neuropathy of the foot
entrapment of the tibial nerve within the tarsal canal (under flexor retinaculum) behind the
medial malleolus
first described in 1960 by Kopell and Thompson
H.P. Kopell, W.A. Thompson, [Peripheral entrapment neuropathies of the lower extremity], N Engl J Med. 262 (1960) 56—60.
S.J. Lam, A tarsal-tunnel syndrome, Lancet. 2 (7270) (1962) 1354—1355.
G.J. Sammarco, L. Chang, Outcome of surgical treatment of tarsal tunnel syndrome, Foot Ankle Int. 24(2) (2003) 125—131.

4. Anatomy
M. De Prado, et al., The tarsal tunnel syndrome, Fuß & Sprunggelenk (2015)
Electromyography and Neuromuscular Disorders 3rd Edition. Preston

5. Anatomy
M. De Prado, et al., The tarsal tunnel syndrome, Fuß & Sprunggelenk (2015)

6. Etiology
Space Occupying Lesions (SOL)
• Ganglion
• Lipoma
• Nerve tumors
• Exostosis
• Talocalcaneal bar
• Accessory muscle (abductor halluces or flexor
digitorum longus)
• Venous varicosities
M. De Prado, et al., The tarsal tunnel syndrome, Fuß & Sprunggelenk (2015)

7. Etiology
 Food deformities (varus and valgus heel)
 Trauma
 Degenerative bone or connective tissue disorders
 Hypertrophy of flexor retinaculum from repetitive use
W.R. Cimino, Tarsal tunnel syndrome: review of the literature, Foot Ankle. 11 (1) (1990) 47—52.
J.T. Lau, T.R. Daniels, Tarsal tunnel syndrome: a review of the literature, Foot Ankle Int. 20 (3) (1999) 201—209.
Electromyography and Neuromuscular Disorders 3rd Edition. Preston

8. Clinical Manifestation
SYMPTOMS
 insidious, aggravated by activity, relieved by rest with
elevation of lower extremity
 numbness
 pain
 burning
 electrical sensation
 tingling sensation over the base of food and heel
 big toe sensation
 nocturnal exacerbation
SIGNS
Tarsal Tinnel’s sign
 Valleix phenomenon; Proximal radiation of
pain and paresthesia along the neuraxis on
percussion at the point of nerve injury.
 Turks test; realised by placing a tourniquet
above the malleolus at a pressure between
systolic and diastolic.
 impairment in the sensory distribution of the
plantar nerve terminal branches
M. De Prado, et al., The tarsal tunnel syndrome, Fuß & Sprunggelenk (2015)

9. Differential Diagnosis
 tendinitis
 fasciitis
 proximal tibial neuropathy
 S1 radiculopathy
 lumbosacral plexopathy
M. De Prado, et al., The tarsal tunnel syndrome, Fuß & Sprunggelenk (2015)

10. Electrodiagnostic Studies
Electromyography and Neuromuscular Disorders 3rd Edition. Preston

11. Electrodiagnostic Studies
Electromyography and Neuromuscular Disorders 3rd Edition. Preston

12. MRI
o evaluating bony deformities
o pinpoint soft tissue content within the tunnel
o find the etiology
Ultrasound
M. De Prado, et al., The tarsal tunnel syndrome, Fuß & Sprunggelenk (2015)

13. Treatment
Physiotherapy (stretching exercises for extrinsic and intrinsic muscles)
Injections (steroid and lidocaine/bupivacaine)
NSAIDs (only for brief period of time)
Orthotics
Immobilization
J.T. Lau, T.R. Daniels, Tarsal tunnel syndrome: a review of the literature, Foot Ankle Int. 20 (3) (1999) 201—209
S.J. Miller, Entrapment Neuropathies, in: V. Hetherington (Ed.), Hallux Valgus and Forefoot Surgery, Churchill Livingstone, 1994, pp. 401—428
L.C. Schon, Nerve entrapment, neuropathy, and nerve dysfunction in athletes, Orthop Clin North Am. 25 (1) (1994) 47—59.

14. Treatment
Surgical indication:
- Non-operative treatment failure
- Space Occupying Lesions
The success rate after surgery have been reported between 75 to 91%, recognizing improvement
in nerve function within 6 weeks. But some authors conclude recently that the results of surgical
treatment are suboptimal, especially in the absence of space-occupying lesions.
M. De Prado, et al., The tarsal tunnel syndrome, Fuß & Sprunggelenk (2015)

15. Summary:
1. Tarsal tunnel syndrome is the most common compressive neuropathy of the foot due to
entrapment of the tibial nerve within the tarsal canal (under flexor retinaculum) behind the
medial malleolus.
2. The most common symptoms are burning, tingling, or both, on the sole of the foot, and
nocturnal exacerbation of symptoms
3. Electrodiagnostic studies is the gold standard for diagnostic
4. Treatment includes non-surgical and surgical approaches

16. THANK YOU