Posterior Tarsal Tunnel Syndrome Research Articles

Rare nerve compression neuropathies

In regard to the complex anatomical relationship of peripheral nerves and muscles, tendons, fasciae as well as their long course within those anatomical structures and additional close contact to bony structures, they are prone to suffer from local compression syndromes. Hence creating a vast majority of entrapment syndromes - well described in literature for almost every single nerve. The purpose of this article is to give an overview of symptoms, signs, diagnostic studies and treatment options, addressing especially the less known syndromes. Compression syndromes of the upper arm and shoulder region include the suprascapular nerve syndrome the compression of the axillary nerve within the spatium quadrilaterale and the compression of the long thoracic nerve at the chest wall. The upper extremity offers a variety of infrequent entrapment syndromes, as the pronator teres syndrome and anterior interosseus syndrome, both resulting from pressure to the median nerve in the forearm. Compression neuropathy in the course of the radial nerve in the distal upper extremity is also known as supinator syndrome. Guyon's canal syndrome is the ulnar side equivalent to the well-known carpal tunnel syndrome. In the case of a Cheiralgia paresthetica, a compression of a sensory branch of the superficial radial nerve can be seen. In the lower extremities, a variety of nerves especially in the groin and thigh area can be compressed as they pass through the narrow spaces between the abdominal muscles or underneath the inguinal ligament. Compression of the lateral femoral cutaneous nerve is the most common syndrome. Compression syndromes of the femoral and obturator nerves are most often iatrogenic. Pain around the knee, especially the lateral part and following orthopedic procedures of the knee, can arise from a compression or a lesion of a small infrapatellar branch of the saphenous nerve. Another probably underdiagnosed syndrome is piriformis syndrome, resulting from an entrapment of the sciatic nerve as it passes through certain muscular structures. In the distal lower extremity, the peroneal and tibial nerves can be compressed at multple sites, clinically known as peroneal nerve paralysis resulting from nerve compression around the fibular head, the anterior and posterior tarsal tunnel syndrome, and Morton's metatarsalgia.

Clinical Results Following Conservative Management of Tarsal Tunnel Syndrome Compared With Surgical Treatment: A Systematic Review.

Posterior tarsal tunnel syndrome involves entrapment of the posterior tibial nerve as it travels in the groove posterior to the medial malleolus. Conventional wisdom dictates that patients with tarsal tunnel syndrome be treated with conservative treatment and medical management, with surgical options available for patients with refractory symptoms and good candidacy. Minimally invasive options for neuropathic entrapment syndromes have developed in recent years and may provide a therapeutic role in tarsal tunnel syndrome. The present investigation provides a summary of the current state of knowledge on tarsal tunnel syndrome and a comparison between minimally invasive and surgical treatment options. The literature search was performed in Mendeley. Search fields were varied until redundant. All articles were screened by title and abstract and a preliminary decision to include an article was made. A full-text screening was performed on the selected articles. Any question regarding the inclusion of an article was discussed by 3 authors until an agreement was reached. Most commonly tarsal tunnel syndrome is idiopathic. Other reported causes include post-traumatic, lipomas, cysts, ganglia, schwannomas, ganglia, varicose plantar veins, anatomic anomalies, and systematic inflammatory conditions. Several risk factors have been described including female gender, athletic participation, hypothyroidism, diabetes mellitus, systemic sclerosis, chronic renal failure, and hemodialysis use. A few recent studies demonstrate anatomic variants that have not previously been summarized. Three articles describe clinical outcomes after conservative treatment with acceptable results for first line treatment. Two primary articles report on the use of minimally invasive treatment for tarsal tunnel syndrome. Fourteen articles report on the clinical outcomes after surgical management. Clinical understanding of tarsal tunnel syndrome has evolved significantly, particularly with regards to the pathoanatomy of the tarsal canal over the past twelve years. A few novel anatomic studies shed light on variants that can be helpful in diagnosis. Conservative management remains a good option that can resolve the symptoms of many patients. As more prospective cohorts and clinical trials are performed on minimally invasive options, pulsed radiofrequency and neuromodulation may evolve to play a larger role in the treatment of this condition. Currently, surgical treatment is only pursued in a very select group of patients with refractory symptoms that do not respond to medical or minimally invasive options. Surgical outcomes in the literature are good and current evidence is stronger than that for minimally invasive options.

An Update on Posterior Tarsal Tunnel Syndrome.

Posterior tarsal tunnel syndrome (PTTS) is an entrapment neuropathy due to compression of the tibial nerve or one of its terminal branches within the tarsal tunnel in the medial ankle. The tarsal tunnel is formed by the flexor retinaculum, while the floor is composed of the distal tibia, talus, and calcaneal bones. The tarsal tunnel contains a number of significant structures, including the tendons of 3 muscles as well as the posterior tibial artery, vein, and nerve. Focal compressive neuropathy of PTTS can originate from anything that physically restricts the volume of the tarsal tunnel. The variety of etiologies includes distinct movements of the foot, trauma, vascular disorders, soft tissue inflammation, diabetes mellitus, compression lesions, bony lesions, masses, lower extremity edema, and postoperative injury. Generally, compression of the posterior tibial nerve results in clinical findings consisting of numbness, burning, and painful paresthesia in the heel, medial ankle, and plantar surface of the foot. Diagnosis of PTTS can be made with the presence of a positive Tinel sign in combination with the physical symptoms of pain and numbness along the plantar and medial surfaces of the foot. Initially, patients are treated conservatively unless there are signs of muscle atrophy or motor nerve involvement. Conservative treatment includes activity modification, heat, cryotherapy, non-steroidal anti-inflammatory drugs, corticosteroid injections, opioids, GABA analog medications, tricyclic antidepressants, vitamin B-complex supplements, physical therapy, and custom orthotics. If PTTS is recalcitrant to conservative treatment, standard open surgical decompression of the flexor retinaculum is indicated. In recent years, a number of alternative minimally invasive treatment options have been investigated, but these studies have small sample sizes or were conducted on cadaveric models.

Endoscopic Ganglionectomy of the Tarsal Tunnel: A Medial Approach

A ganglion inside the tarsal tunnel can compress the tibial nerve, leading to posterior tarsal tunnel syndrome. Classically, the ganglion is resected with an open approach. This requires release of the flexor retinaculum and dissection around the tibial neurovascular bundle, which may induce fibrosis around the tibial nerve. Endoscopic resection of a tarsal tunnel ganglion via a posterior approach has been reported. The purpose of this Technical Note is to describe the medial approach of endoscopic ganglionectomy of the tarsal tunnel. This is indicated for tarsal tunnel ganglia compressing the tibial nerve and extending to the flexor retinaculum. It is contraindicated if there is other pathology of the tarsal tunnel that demands open surgery; the ganglion compresses the tibial nerve from its deep side and does not extend to the flexor retinaculum; or in the presence of intraneural ganglion of the tibial nerve.

Endoscopic Resection of the Tarsal Tunnel Ganglion

The tarsal tunnel ganglion is a cause of posterior tarsal tunnel syndrome. Open resection of the ganglion calls for release of the flexor retinaculum and dissection around the tibial neurovascular bundle. This can induce fibrosis around the tibial nerve. We report the technique of endoscopic resection of the tarsal tunnel ganglion. It is indicated for tarsal tunnel ganglia arising from the adjacent joints or tendon sheaths and compressing the tibial nerve from its deep side. It is contraindicated if there is other pathology of the tarsal tunnel that demands open surgery; if the ganglion compresses the tibial nerve from its superficial side, which calls for a different endoscopic approach using the ganglion portal; or if an intraneural ganglion of the tibial nerve is present. The purpose of this technical note is to describe a minimally invasive approach for endoscopic resection of the tarsal tunnel ganglion.

Foot neuropathy in rheumatoid arthritis patients: clinical, electrophysiological, and ultrasound studies

This study aimed to evaluate neuropathic foot pain in patients with rheumatoid arthritis (RA) using electrophysiological studies and musculoskeletal ultrasound (MSUS) to address the association between these findings and disease activity. Evaluation of the usefulness of this combination was undertaken. The present study was designed as a cross-sectional study. A total of 50 RA patients underwent a complete history-taking and rheumatologic examination. According to the cut-off point of Disease Activity Score in 28 joints, patients were divided into two equal groups (25 patients each): active and inactive. In total, 25 healthy individuals were included as controls. Routine tibial and peroneal nerve conduction studies, as well as electromyography of tibialis anterior and abductor hallucis muscles, were carried out. MSUS assessment of the ankle joint and extra-articular portion of the foot complex was also performed. Electrophysiological findings of foot neuropathy were observed in 78% of the patients, irrespective of the disease activity level. In total, 48% of the patients had mononeuropathies of a demyelinating pattern (entrapment neuropathies), whereas the other 30% had symmetrical polyneuropathy with axonal degeneration. Combined distal tibial and peroneal nerve entrapments were reported in 16% of the patients. A positive power Doppler signal and joint erosions showed a highly statistical significant prevalence among the active group in comparison with patients in remission (P ≤ 0.001). Peripheral nerve affection is common in the rheumatoid foot, irrespective of the disease activity status. The most common neuropathies were posterior tarsal tunnel syndrome, peroneal nerve entrapment at the fibular neck, and pure sensory axonal neuropathy. A positive power Doppler signal and bone erosions of the ankle joint, detected by MSUS, were associated with RA disease activity. Electrophysiology was superior to MSUS for the diagnosis of posterior tarsal tunnel syndrome.

TIBIAL NERVE PERINEURAL INJECTIONS AT THE POSTERIOR TARSAL TUNNEL

Introduction: Posterior tarsal tunnel syndrome (PostTTS) refers to compression of the tibial nerve (TN) within this tunnel. PostTTS is most commonly secondary to entrapment with subsequent inflammation. As it is true with other entrapment-type neuropathies, corticosteroids could provide therapeutic relief. To the authors' knowledge, the feasibility of such injections using ultrasound guidance has not been described in the literature. We hypothesize that one can inject the TN perineural space immediately proximal to the posterior tarsal tunnel utilizing ultrasonography US-guidance. Methods: This research was a pilot study using four cadaveric models. US was utilized to image the proximal posterior tarsal tunnel. Perineural injections of methylene blue were performed with subsequent dissection. Injections were designated as accurate (referring to nerve staining) and precise (referring to dye localization). Results: One cadaver was precluded due to pronounced musculoskeletal abnormality. 5-of-6 (83%) injections were accurate and 6-of-6 (100%) precise. Conclusion: Initial attempt was inaccurate and precise, while later injections were both accurate and precise. The most apparent source of error was from one cadaver's pronounced musculoskeletal deformity, which precluded successful injections bilaterally. Of the three cadavers unaffected by musculoskeletal deformity, accuracy was 5-of-6 (83%) and precision was 6-of-6 (100%). While surgery is the definitive treatment for refractory PostTTS, therapeutic effect of corticosteroid injections has not been evaluated in this patient population. Such injections could provide symptomatic relief and postpone surgical intervention. Small sample size not withstanding the results suggest that TN perineural injections are feasible under US-guidance. This study suggests that US-guidance can increase accuracy and precision and is a potential adjunct to the treatment. Future study will expand the initial data set and categorize consistent protocol. Subsequent translational research will then be sought to evaluate therapeutic efficacy in this patient population.

Clinical utility of tibial motor and sensory nerve conduction studies with motor recording from the flexor hallucis brevis: a methodological and reliability study

BackgroundStandard tibial motor nerve conduction measures are established with recording from the abductor hallucis. This technique is often technically challenging and clinicians have difficulty interpreting the information particularly in the short segment needed to assess focal tibial nerve entrapment at the medial ankle as occurs in posterior tarsal tunnel syndrome. The flexor hallucis brevis (FHB) has been described as an alternative site for recording tibial nerve function in those with posterior tarsal tunnel syndrome. Normative data has not been established for this technique. This pilot study describes the technique in detail. In addition we provide reference values for medial and lateral plantar orthodromic sensory measures and assessed intrarater reliability for all measures.MethodsEighty healthy female participants took part, and 39 returned for serial testing at 4 time points. Mean values ± SD were recorded for nerve conduction measures, and coefficient of variation as well as intraclass correlation coefficients (ICC) were calculated.ResultsMotor latency, amplitude and velocity values for the FHB were 4.1 ± 0.9 msec, 8.0 ± 3.0 mV and 45.6 ± 3.4 m/s, respectively. Sensory latencies, amplitudes, and velocities, respectively, were 2.8 ± 0.3 msec, 26.7 ± 10.1 μV, and 41.4 ± 3.5 m/s for the medial plantar nerve and 3.2 ± 0.5 msec, 13.3 ± 4.7 μV, and 44.3 ± 4.0 msec for the lateral plantar nerve. All values demonstrated significant ICC values (P ≤ 0.007).ConclusionMotor recording from the FHB provides technically clear waveforms that allow for an improved ability to assess tibial nerve function in the short segments used to assess tarsal tunnel syndrome. The reported means will begin to establish normal values for this technique.

Posterior Tarsal Tunnel Syndrome

Posterior tarsal tunnel syndrome is an uncommon clinical entity which is sometimes misdiagnosed in patients with pain of the retromalleolar region and the plantar aspect of the foot. Surgical intervention is recommended for correctly diagnosed posterior tarsal tunnel syndrome. Selective literature review. Surgical treatment is indicated in the presence of dysesthesias refractory to conservative treatment or of neurological deficits. If a neural tumor or tarsal tunnel ganglion is suspected, diagnostic imaging (MRI, neurosonography) should precede surgery. Division of the flexor retinaculum (ligamentum laciniatum) in the tarsal tunnel must always include distal decompression of the end branches of the tibial nerve posterior to the fascia of the abductor hallucis muscle. Only extensive exposure of the nerve guarantees adequate release. Accurate diagnosis requires the evaluation of relevant clinical, neurological, and neurophysiological findings along with the careful consideration of other possible diagnoses. High success rates of 44% to 91% are reported after operative treatment. The results are better in idiopathic than in posttraumatic cases. If surgery fails, re-operation is indicated only in patients with inadequate release.

Posterior tarsal tunnel syndrome: an unusual unrelated cause of late pain after lumbar spine surgery

Posterior tarsal tunnel syndrome: an unusual unrelated cause of late pain after lumbar spine surgery

Surgical Management of Lower Extremity Entrapment Neuropathies

Learning Objectives: After reading this article, the participant should be able to: 1. Describe the anatomy, clinical findings, and treatment options of posterior tarsal tunnel syndrome. 2. Describe the anatomy, clinical findings, and treatment options of saphenous nerve entrapment. 3. Describe the anatomy, clinical findings, and treatment options of sciatic nerve entrapment (piriformis syndrome).