Tarsal Tunnel Syndrome Research Articles

Clinical anatomical study on the treatment of tarsal tunnel syndrome with four-point vertical acupotomy

To explore safety and accuracy of four-point acupotomy for the treatment of tarsal tunnel syndrome regarding release of ankle tunnel flexor retinaculum to provide an anatomical basis of clinical treatment. Twenty-nine adult specimens (15 males and 14 females) fixed with 10% formalin, aged from 47 to 98 years old with an average age of (81.10±11.14) years old, 29 on the right side and 29 on the left side, which were selected for the study from September 2020 to October 2020. Simulate the operation of loosening flexor retinaculumt with a needle knife on the human specimen, and place the specimen on the frog position of lower limbs with medial malleolus upward to determine the center of medial malleolus. Choose 4 different positions near the flexor retinaculum to insert the needle so that the needle body was perpendicular to skin and cutting edge direction was perpendicular to the running direction of the flexor retinaculum. The needle knife penetrates the skin and explores slowly. When the flexor retinaculum was reached, the needle tip may touch the tough tissue. At this time, the cutting is loosened for 4 times. After acupotomy release operation was completed, make a lateral incision on the skin surface along acupotomy direction, open the area of the exposed flexor retinaculum, dissecting layer by layer, observe and record the needle knife and its surrounding anatomical structure. The length of acupotomy cutting marks of flexor retinaculum was measured by electronic vernier caliper. The safety and accuracy of acupotomy loosening of ankle canal flexor retinaculum were evaluated by observing the number and degree of ankle canal contents such as tendons and nerves injured by needle knife. The safety is to count the number of cases of acupotomy injury to the contents of the ankle canal, and to calculate the injury rate, that is, the number of injury cases/total cases × 100%. The effective release was defined as the release length L ≥ W/2(W is the width of the flexor retinaculum, defined as 20 mm). For safety, there were no acupotomy injuries to nerves or blood vessels in 58 cases, 26 cases injuried to posterior tibial tendon which 17 of these tendon injury cases, the tendon was penetrated and severely injured, and flexor digitorum longus tendon was injured in 12 cases. Among these cases, tendon was penetrated and severely injured in 4 cases, and total injury rate was 32.14%. No nerve and vessel injury on c3 and c4 point. For accuracy, 58 specimens were successfully released. The length Lc of releasing trace for acupotomy was (10.40±1.36) cm, and length range 6.38 to 12.88 cm. Among all cases, the length of releasing trace was ≥10 mm in 37 cases. The overall success rate of release was 100.00%. Layered structure of ankle tube flexor retinaculumt:fiber diaphragm from flexor retinaculum divides contents of ankle tube into different chambers inward, and fiber diaphragm meets here to synthesize a complete flexor retinaculum at the midpoint of the line between the medial malleolus tip and calcaneal tubercle(above the neurovascular course). Four-point needle-knife method of releasing flexor retinaculum for the treatment of tarsal tunnel syndrome is performed at the attachment of the two ends of flexor retinaculum;the tendon, but not the nerves and blood vessels, is easily damaged. It is safe to insert needle on the side of calcaneus. The extent of release is relatively complete, but due to the "layered" structure of the flexor retinaculum, classic surgical technique could only release one layer of flexor retinaculum when a needle is inserted at the edge of the bone and cannot achieve complete release of the full thickness of the flexor. Therefore, it remains to be determined whether the desired effect can be achieved clinically.

An unusual cause of tarsal tunnel syndrome: Schwannoma of the posterior tibial nerve; a rare cause and rare localization.

IntroductionSchwannoma of the posterior tibial nerve is extremely rare.Case presentationA 25-year-old female with a one-year history of left foot pain is presented. Clinical and radiological findings were in favor of a tarsal tunnel syndrome caused by a schwannoma of the posterior tibial nerve, prompting the patient to undergo surgery. We performed a complete excision of the tumor with the aid of a loupe magnification. At the last follow-up, the patient did well, with no recurrent pain and no neurological squeals.DiscussionThe diagnosis of a tibial nerve schwannoma can often be difficult as, in the early stages, a mass may not be palpable and symptoms are often non-specific because of the slow-growing soft tissue mass.ConclusionAlthough schwannoma is a rare cause of tarsal tunnel syndrome, it should be kept in mind by physicians, especially in cases of chronic unexplained foot pain with a positive Tinel's test.

Iatrogenic nerve injury and foot drop: Surgical results in 28 patients

Background: Most peroneal nerve injuries resulting in foot drop are secondary to trauma or iatrogenic. Foot drop can occur due to potential complications from the hip, lumbosacral spine, and knee surgeries, which are critical to diagnose and manage.Methods: We reviewed our foot drop patients’ data to determine the incidence and iatrogenic causes of the injury and managed surgically by neurolysis of the peroneal nerve and transfer of functional fascicles of either the superficial peroneal or the tibial nerve to the deep peroneal nerve.Results: We found 28 iatrogenic foot drop patients who have had surgery and postoperative follow-up evaluations with us. Before the onset of foot drop, all except one (27 of 28) patient have had surgeries in other clinics before presenting to our institution. Foot drop in one patient was due to infection and hip wound after he was intubated and stayed in ICU for 4 weeks. Thirteen of the 28 patients have had lumbosacral (L3-4, L4-L5, and L5-S1) fusion or laminectomy, eight have had hip surgery, and five have had knee surgery. One patient had a fasciotomy due to compartment syndrome and another patient had two previous surgeries for posterior tibial entrapment and tarsal tunnel syndrome at other institutions. NCS and EMG reports showed that these patients had injuries to the peroneal or tibial nerve after their prior surgeries. One patient had a femoral nerve injury. Preoperatively, 10 patients had severe foot drop with muscle weakness and a functional grade of 0/5; 16 patients had grades ranging from 1 to 2/5; and two patients had 3/5. Overall, 23 of the 28 patients (83%) had improvement in their ankle dorsiflexion with anti-gravity and regained a healthier gait after the decompression, neurolysis, and nerve transfer at our clinic.Conclusion: Twenty-three of the 28 (83%) iatrogenic foot drop patients in this report regained a healthier gait with improved ankle dorsiflexion and anti-gravity after the neurolysis, and nerve transfer of the peroneal or tibial nerve and transfer of functional fascicles of either the superficial peroneal or the tibial nerve to the deep peroneal nerve at our clinic.

Radiofrequency Plantar Fascia Coblation With and Without Gastrocnemius Recession in the Management of Recalcitrant Plantar Fasciitis.

Plantar fasciitis is the most common cause of plantar heel pain. Although most are self-limiting, recalcitrant conditions can be debilitating, significantly reducing patient's quality of life. A myriad of surgical procedures are available for the treatment of recalcitrant plantar fasciitis (RPF) with little consensus on best practice. This purpose of this study was to assess the efficacy of radiofrequency coblation with and without gastrocnemius release on the surgical management of RPF. Between June 2013 and June 2019, a total of 128 patients with RPF and tight gastrocnemius were treated surgically. Presence of tight gastrocnemius was assessed clinically by a positive Silfverskiold test. Group A (n = 73) consisted of patients who underwent radiofrequency coblation alone; group B (n = 55) consisted of patients who underwent radiofrequency coblation and endoscopic gastrocnemius recession. The primary outcome measure was visual analog scale (VAS) score. Secondary outcome measures included (1) American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score; (2) physical (PCS) and mental component summaries (MCS) of the 36-Item Short Form Health Survey; (3) overall assessment of improvement, expectation fulfilment, and satisfaction; and (4) complication rates. Both groups reported significant improvement in VAS, AOFAS, and PCS scores postoperatively at 6 and 24 months. Group B (radiofrequency coblation with gastrocnemius recession) was associated with better VAS at both 6 months (3.0 ± 2.9 vs 1.7 ± 2.6, P < .05) and 24 months postoperatively (1.9 ± 3.1 vs 0.8 ± 2.0, P < .05) compared with group A (radiofrequency coblation without gastrocnemius recession). At 24 months postoperatively, no differences were found in AOFAS, PCS, MCS scores, expectation fulfilment, or overall satisfaction. No wound complications were reported in either group. One patient (group B) has persistent symptoms consistent with tarsal tunnel syndrome. In this retrospective cohort comparative study, treatment of RPF with radiofrequency coblation alone was associated with slightly inferior results than radiofrequency coblation combined with endoscopic gastrocnemius recession in terms of pain relief without an increase in complication rates. However, at 2 years, we did not find a significant difference in other measures of outcome. Level III, retrospective cohort study.

The Course of Tarsal Tunnel Syndrome after Ultrasound-Guided Injections.

Local ultrasound (US)-guided injections of anesthetics with corticosteroids are commonly performed for the conservative treatment of tarsal tunnel syndrome (TTS). This retrospective study aimed to investigate the outcomes of TTS after US-guided injections. The study included patients who were diagnosed with TTS and received US-guided injections as part of their initial treatment. The pain levels were noted on a scale between zero and ten before and after each injection. The patients were divided into non-surgical and surgical groups. The nonsurgical group included patients who had received US-guided injections and did not proceed to surgical treatment, and the surgical group included those who received US-guided injections and ultimately underwent tarsal tunnel release (TTR). The two groups were compared in terms of age, post-injection follow-up time, and the amount of pain reduction immediately after injection (ΔPN). In the surgical group, outcomes of surgical treatment were also assessed. A total of 218 patients were diagnosed with TTS and received US-guided injections. After the injections, 169 patients (77.5%) did not go on to TTR (nonsurgical group) and 49 patients (22.5%) underwent TTR (surgical group). The average ages for the nonsurgical and surgical groups were 53.8 and 48.9 years (P = 0.03). The average time between the injection and final follow-up for the nonsurgical group was 339 days. The average time between the injection and TTR for the surgical group was 145 days. There were no differences in pain relief after the injections between the nonsurgical and surgical groups (mean ΔPN: 3.6 and 3.8, respectively). The average post-surgical follow-up time was 117 days. At final follow-up, 41 patients (84%) in the surgical group had complete resolution of pain and neurological symptoms. US-guided injection can be an effective conservative treatment option for patients with TTS. Younger patients may be more likely to proceed to TTR. Level III.

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.

An update on imaging of tarsal tunnel syndrome.

Tarsal tunnel syndrome (TTS) is an entrapment neuropathy of the tibial nerve (TN) within the tarsal tunnel (TT) at the level of the tibio-talar and/or talo-calcaneal joints. Making a diagnosis of TTS can be challenging, especially when symptoms overlap with other conditions and electrophysiological studies lack specificity. Imaging, in particular MRI, can help identify causative factors in individuals with suspected TTS and help aid surgical management. In this article, we review the anatomy of the TT, the diagnosis of TTS, aetiological factors implicated in TTS and imaging findings, with an emphasis on MRI.

Verifying the Insertion of the Fibulocalcaneus (Peroneocalcaneus) Internus Muscle – A Rare Variant Leg Muscle

The fibulocalcaneus (peroneocalcaneus) internus (PCI) muscle is a rare variant leg muscle with a low prevalence of &lt;1%‐3% in cadaveric dissection and imaging studies. The PCI arises from the medial aspect of the distal third of the fibula, descends posterior and lateral to the flexor hallucis longus (FHL) muscle, traverses the tarsal tunnel inferior to the sustentaculum tali of the calcaneus, and inserts into the plantar surface of the calcaneus. However, controversy exists concerning the exact location of the insertion site of the PCI muscle. The insertion of the PCI muscle was recently described as being located distal to the coronoid fossa, a small depression between the anterior tuberosity and the anterior apex of the sustentaculum tali of the calcaneus. However, historical descriptions described the PCI as inserting into either the sustentaculum tali itself or a small tubercle on the medical surface of the calcaneus distal to the sustentaculum tali. During routine dissection of a 53‐year‐old Caucasian male, a PCI muscle was identified, and it inserted into distal to the coronoid fossa on the plantar surface of the calcaneus. More specifically, it inserted into the plantar surface of the calcaneus in the space between the origin of the plantar talonavicular (spring) ligament and the plantar calcaneocuboid ligament. Knowledge of the PCI muscle is important due its involvement with various ankle pathologies, including predisposing individuals to tarsal tunnel syndrome, FHL tenosynovitis, and posterior ankle impingement and pain.

Avoidance of injury to the posterior neurovascular bundle during total ankle arthroplasty – A simple technical tip

Iatrogenic nerve injury to the tibial nerve is a serious but avoidable complication of total ankle replacements and may be under-reported as it may go unrecognised or thought to be due to tarsal tunnel syndrome. The tibial nerve is particularly vulnerable during the saw cuts at the posteromedial corner without appropriate protection. Prior to drilling the tibial and talar pins of the adjustment block for the Infinity ankle replacement we perform a 2 cm incision behind the medial malleolus. The tibialis posterior tendon sheath is identified and incised. A periosteal elevator is used to develop a plane between the back of the tibia and the tibialis posterior tendon and then exchanged for a mini Hohmann retractor protecting the neurovascular bundle. This allows us to drill the pins and saw cuts safely. The Hohmann retractor can be felt at the tip of the saw blade providing reassurance that the blade is not too deep. Our technique has not previously been reported in the literature. It acts as a simple reproducible way of avoiding injury to structures at the back of the ankle joint.

A retrospective magnetic resonance imaging analysis of bone and soft tissue changes associated with the spectrum of tarsal coalitions.

We aimed to investigate the bone and soft tissue changes accompanying tarsal coalition (TC) and aimed to evaluate their association with the location and type of coalition. Ankle magnetic resonance imagings of 65 patients with TC were included. The relationship between the location and type of coalition and bone marrow edema, subchondral cysts, sinus tarsi syndrome, tarsal tunnel syndrome, posterior impingement syndrome, accessory bone, tibiotalar effusion, talar osteochondritis dissecans, ganglion cysts, and calcaneal spur were evaluated. Twenty-nine patients without coalition were selected as the control group, and the distribution of these variables between the two groups was analyzed. There were 33 females and 32 males in the coalition group (mean age: 42.0 ± 15.63 years), and 22 females and seven males in the control group (mean age: 44.79 ± 12.33 years). Coalition was most common in the talocalcaneal joint (n=33, 50.8%), and the most common coalition type was non-osseous (n=57, 87.6%). We find no significant difference between the pathologies defined in terms of coalition location and type. Sinus tarsi syndrome, tarsal tunnel syndrome, subchondral cysts, and tibiotalar effusion were found to be more common in the coalition group (p=0.028, p=0.010, p=0.023, and p=0.006, respectively). The presence of coalition increased the probability of developing tarsal tunnel syndrome 9.91 times (95% CI: [1.25-78.59]; p=0.029), and sinus tarsi syndrome 3.66 times (95% CI: [1.14-11.78]; p=0.029). Tarsal coalition may predispose bone and soft tissue changes. In this study, sinus tarsi syndrome, tarsal tunnel syndrome, subchondral cysts and tibiotalar effusion were found to be more common in the coalition group.

Patient reported outcomes following revision neurectomy through a dorsal approach for recurrent interdigital neuroma

Interdigital neuroma is one of the commonest causes of metatarsalgia. The reported success rate after excision of a primary neuroma is 74%. Recurrent symptoms after neurectomy can be due to a recurrent interdigital neuroma. Recurrent interdigital neuromas can be diagnosed using sound clinical examination and ultrasonography. Surgical excision is the best treatment modality with varying success reported in the literature. We report on the clinical outcome following surgical excision of recurrent interdigital neuromas through a dorsal approach. All patients who had undergone excision of a recurrent interdigital neuroma by a single surgeon between 01/2010 and 12/2019 were identified. Inclusion criteria included patients having a preoperative ultrasound and postoperative histology report. The exclusion criteria were preexisting neuropathy or tarsal tunnel syndrome. Demographic data was collected, and a self-reported foot and ankle score questionnaire (SEFAS) was completed by the patient at their most recent follow-up. Twenty-three patients (25 feet) were included in the study. Mean time of follow-up was 75 (range 14–189) months. The mean age was 49 (range 15–71) years. Eleven (44%) recurrent neuromas were excised from the second webspace and 14 (56%) were excised from the third webspace. All excised masses were confirmed as recurrent neuromas histologically. Regarding the SEFAS score, 17 (73.93%) patients scored as excellent, one (4.34%) as good, three (13.04%) as fair, and two (8.69%) as poor. This long term follow-up study on outcomes after surgery for recurrent interdigital neuroma suggests that excision through a dorsal approach is an effective treatment option with a high patient satisfaction.

Tarsal tunnel syndrome secondary to accessory or variant muscles: a clinical and anatomical systematic review.

Many etiologies are known to lead to a tarsal tunnel syndrome (TTS). One rare cause is mass-occupying lesions, and particularly accessory or variant muscles (AVM). This study aimed to systematically collect published clinical cases of TTS caused by AVM. An electronic literature search was conducted from inception to April 2021. The diagnosis of AVM should be reported in one of the following methods: ultrasonography, magnetic resonance imaging (MRI), or per-operatively. Data extraction included types and prevalence of accessory muscles, clinical presentation and diagnosis, and treatment modalities. Twenty-five studies were identified with a total 39 patients (47 ankles). The prevalence of TTS was reported in only two studies (9%). Forty-nine AVM were identified with the accessory flexor digitorum longus being the most common (52%). The most common sign/symptoms were tenderness (78.7%), pain (82.9%), dysesthesia (57.4%), Tinel sign (44.6%), and a swelling (25.5%). Decompression and excision were the most commonly performed procedures. Four accessory/variant muscles in the ankle have the potential to induce a tarsal tunnel syndrome. This review highlights the clinical and imagery specificities of TTS secondary to accessory or variant muscles. Mass-occupying etiology should be included in the list of differential diagnoses whenever a posterior tibial nerve compression is suspected.

Surgical Treatment Compared to Conservative Treatment in Remission of Pain and Hyposthesia in Tarsal Tunnel Syndrome – Systematic Review

Abstract Introduction Tarsal tunnel syndrome (TTS) is caused by compression of the posterior tibial nerve. Objective To evaluate the effectiveness of surgical treatments compared to conservative treatments in reducing the symptoms of the syndrome. Methods The PubMed, Lilacs, Cochrane Library, and PEDro databases were used for this review. Results Only 11 articles were selected. Conclusion The most common causes of TTS identified were presence of ganglia, bone prominence causing a talocalcaneal collision, trauma, varicose and idiopathic veins. The main symptom was pain in the medial plantar region and paresthesia that can radiate to the fingers or to the calf. Most patients have a positive Tinel sign upon physical examination. Electrodiagnostic test usually shows the presence of latency in sensory nerve conduction. There is no consensus suggesting that a longer time between diagnosis and surgical treatment leads to worse prognosis. In the group of operated patients, the ones who benefited most from the procedure were those who had a structure such as ganglion, cysts, or varicosities causing compression. The most cited surgical complications were postsurgical wound infection, wound dehiscence, and calcaneus hypoesthesia. Regarding surgical techniques, the release of the posterior tibial nerve via endoscopy had a favorable outcome in relation to the symptoms of pain and hypoesthesia, with no reports of infection of the operative site in the articles identified in this review. We observed a rate of good or excellent pain control of 68% (n = 204) for open surgery (n = 299), 100% (n = 8) for endoscopic surgery (n = 8), and 7% (n = 2) for conservative treatment (n = 28).

Tarsal Tunnel Syndrome Following Medializing Calcaneal Osteotomy

Category:HindfootIntroduction/Purpose:The tarsal tunnel syndrome is a compressive neuropathy that affects either the posterior tibial nerve, within the tarsal tunnel, or one of its terminal branches. It can be caused by extrinsic or intrinsic factors. Even though the tarsal tunnel syndrome has been reported as a complication of lateralizing calcaneal osteotomy, we have not identified in the literature reports of this syndrome associated to medializing calcaneal osteotomy. We report the case of a 60-year-old female who developed a tarsal tunnel syndrome, on the third postoperative week, following a medializing calcaneal osteotomy for flatfoot correction with stage IIB posterior tibial tendon dysfunction.Methods:We reviewed and obtained the information from the medical records of this patient: clinical examination, radiographs, computed tomography, magnetic resonance imaging, and outcome. Pain was assessed with visual analog scale (VAS).Results:The patient is a 60-year-old female with left stage II posterior tibial tendon dysfunction who failed to respond to conservative treatment. Medializing and lengthening (Evans) osteotomies of the calcaneus were performed, together with posterior tibial tendon repair and spring ligament reconstruction. In the postoperative, after a cast replacement into a more plantigrade position, the patient developed symptoms that suggested a compressive neuropathy of posterior tibial nerve within the tarsal tunnel associated to calcaneal medializing osteotomy. Initial conservative treatment failed and the posterior tibial nerve was explored under loupe magnification and the tarsal tunnel was released. Figure 1. An immediate improvement in pain was observed postoperatively and almost full recovery occurred within 6 months.Conclusion:In our case report, the tarsal tunnel syndrome was a consequence of the osteotomy fragment displacement that generated a reduction of the tarsal tunnel volume. It has been described that the tarsal tunnel syndrome symptoms become more evident with ankle dorsiflexion and eversion, in our patient this can be associated with the symptom exacerbation presented when the cast was placed into plantigrade position. We conclude that even though in the literature the tarsal tunnel syndrome has been mainly associated to lateralizing osteotomies, it is important to take this complication into account when performing a medializing osteotomy.

The Course of Tarsal Tunnel Syndrome after Ultrasound-Guided Injections

Category:Other; Ankle; Hindfoot; Midfoot/Forefoot; SportsIntroduction/Purpose:Local ultrasound (US)-guided injections of anesthetics with corticosteroids are commonly performed for the conservative treatment of tarsal tunnel syndrome (TTS). This retrospective study aimed to investigate the course of TTS after US-guided injections.Methods:The study included patients who were diagnosed with TTS and received US-guided injections as their initial conservative treatment. The patients' pain levels were noted on a scale between zero and ten before and after each injection. The patients were divided into two groups: nonsurgical and surgical groups. The nonsurgical group included patients who had received US-guided injections and were not treated surgically, and the surgical group included those who received US-guided injections and ultimately underwent surgical tarsal tunnel release (TTR). The two groups were compared in terms of age, gender, post-injection follow-up time, and the amount of pain reduction immediately after injection (ΔPN). In the surgical group, the presence or absence of additional foot and ankle pathologies requiring operative treatment during TTR, and outcomes of surgical treatment were also assessed.Results:218 patients were diagnosed with TTS and received US-guided injections as their initial treatment. After the injections, 169 patients (77.5%) required no TTR (nonsurgical group) and 49 patients (22.5%) underwent TTR (surgical group). The average ages for the nonsurgical and surgical groups were 53.8 and 48.9 years (P = 0.03). The average time between the injection and final follow-up for the nonsurgical group was 339 days. The average time between the injection and TTR for the surgical group was 145 days. There were no differences in pain relief after the injections between the nonsurgical and surgical groups (mean ΔPN: 3.6 and 3.8, respectively). In the surgical group, 16 patients (32%) presented with additional foot and ankle pathologies that were surgically treated during TTR. The average post-surgical follow up time was 117 days. At final follow up, 41 patients (84%) in the surgical group had no pain or functional impairment.Conclusion:US-guided injection can be an effective conservative treatment option for patients with TTS. Surgical release of tarsal tunnel may improve and resolve the overall symtoms of TTS in majority of the patients who do not respond to nonsurgical treatment. Younger age and additional foot and ankle pathologies appear to be associated with greater likelihood of undergoing TTR.

A Rare Case of Flexor Digitorum Accessorius Longus Muscle Presenting as Tarsal Tunnel Syndrome.

Tarsal tunnel syndrome (TTS) is a relatively uncommon nerve entrapment neuropathy. Many pathologies are reported as possible causes for TTS. The diagnosis of TTS can be difficult and often missed. We present a rare case of TTS due to an accessory flexor digitorum longus muscle. Together with a high index of suspicion, MRI is the investigation of choice in making the diagnosis. These patients are best managed with excision or transposition of the flexor digitorum accessorius longus (FDAL) and neurolysis of the posterior tibial nerve and its branches.

The Effects of Tibial Nerve Mobilization in Patients with Tarsal Tunnel Syndrome: A Randomized Controlled Trial

The Effects of Tibial Nerve Mobilization in Patients with Tarsal Tunnel Syndrome: A Randomized Controlled Trial

Translated article] Tarsal tunnel syndrome: Clinical-imaging analysis of a case series

BackgroundRetrospective review of patients with a diagnosis of Tarsal Tunnel Syndrome (TTS) treated surgically. MethodsRetrospective series of patients with diagnosis of TTS operated between 2005 and 2020 in the same center. Variables such as age, sex, side, affected nerve or branch, classification, type of imaging study, biopsy result, infection rate, recurrence rate, sequelae, among others, were analyzed. ResultsWe included 8 men and 2 women with an average age of 47 years (range 34−67) and an average follow-up of 62.2 months (range 2–149). All cases were related to intrinsic compression. The most frequent cause was the presence of cyst (40%) followed by perineural adhesions (20%). The posterior tibial nerve was the most affected (50%) and 30% the medial plantar branch. Ultrasound (70%) and MRI (50%) were the most requested studies. There were no cases of postoperative infection. There were 3 patients who presented recurrence of the lesion requiring a new surgery. ConclusionsTTS is a neuropathy involving the posterior tibial nerve or some of its branches. In general, it is caused by compression of the nerve by different structures such as accessory muscles and ganglions, among others. The diagnosis is eminently clinical, supported by imaging studies. Surgical treatment presents better results when the cause is an intrinsic compression, although variable recurrence rates are described.

Novel Minimally Invasive Sliding Calcaneal Osteotomy: A Case Series

Category:Hindfoot; AnkleIntroduction/Purpose:Sliding calcaneal displacement osteotomy is a mainstay in the treatment of hindfoot deformity. A lateral oblique or L shaped incision and direct visualization of the calcaneus is the traditional open approach to this osteotomy.Complications of this approach are not common and include wound dehiscence, delayed union, neurovascular damage, tarsal tunnel syndrome, symptomatic bony overhang and peroneal fibrosis. Several techniques have been developed to address the limitations of the open approach including osteotomy with a Gigli saw, percutaneous endoscopic assisted osteotomy, and most recently minimally invasive osteotomy (MICO) with a low speed, high torque burr. Each of these techniques has limitations. This report presents a simple minimally invasive technique that may help mitigate wound issues without the technical hurdles of a steep learning curve.Methods:Patients undergoing MICO procedures with the senior author from February 2019 - June 2020 who had not undergone previous foot/ankle surgery were retrospectively enrolled. Patients underwent clinical and radiographic assessment preoperatively as well as at 2, 6, 12, and 24 weeks postoperatively. The technique utilizes a 1.5cm incision along the plane of osteotomy, centered about a K-wire placed through both cortices of the calcaneus at the midpoint of the osteotomy plane. The plane and K-wire placement are determined under radiographic guidance. A micro-sagittal saw is rested on the K-wire and used as a cutting block in the coronal plane. After the osteotomy is created and mobility of the calcaneus confirmed, the K-wire is removed. The mobile segment is adjusted as needed, held in placed by dorsiflexing the ankle, and fixed using two posterior-to-anterior 6.5 cannulated screws, one 1cm superior to the other. The wounds can then be irrigated and closed.Results:37 patients were treated using this technique. 24 (65%) patients were female, with average age 56.9 years. Osteotomies were performed concomitantly with procedures including flexor digitorum longus transfer, subtalar fusion, triple arthrodesis, talonavicular fusion, hallux valgus corrective osteotomy, and Strayer gastrocnemius recession. Thirty-five (95%) patients achieved radiographic fusion within 1 year postoperatively with 28 (76%) fusing by 3-month follow up. Two (5%) patients developed a radiographic non-union without instability and opted to be managed expectantly. Of note, one patient is a diabetic current smoker with Rheumatoid Arthritis, while the other is a non-diabetic former smoker. A single patient was readmitted within 90 days for incision and debridement of a dehisced wound from subtalar fusion performed concomitantly. One patient underwent eventual removal of the screw compressing the calcaneal osteotomy site due to hardware prominence. No patients reported peroneal symptoms postoperatively. No patients reported any other complications related to the osteotomy.Conclusion:Sliding calcaneal displacement osteotomy is a well-established component in the treatment of hindfoot deformity. Although larger lateral oblique and L shaped incisions allow direct visualization of the osteotomy, more minimally invasive approaches have been used. The proposed technique in the current report offers a low non-union rate, minimal surgical footprint, easily available surgical instruments, reliable osteotomy plane, and short surgical time.

Tarsal tunnel syndrome: current rationale, indications and results.

Tarsal tunnel syndrome (TTS) is a neuropathy due to compression of the posterior tibial nerve and its branches.It is usually underdiagnosed and its aetiology is very diverse. In 20% of cases it is idiopathic.There is no test that diagnoses it with certainty. The diagnosis is usually made by correlating clinical history, imaging tests, nerve conduction studies (NCSs) and electromyography (EMG).A differential diagnosis should be made with plantar fasciitis, lumbosacral radiculopathy (especially S1 radiculopathy), rheumatologic diseases, metatarsal stress fractures and Morton’s neuroma.Conservative management usually gives good results. It includes activity modification, administration of pain relief drugs, physical and rehabilitation medicine, and corticosteroid injections into the tarsal tunnel (to reduce oedema).Abnormally slow nerve conduction through the posterior tibial nerve usually predicts failure of conservative treatment.Indications for surgical treatment are failure of conservative treatment and clear identification of the cause of the entrapment. In these circumstances, the results are usually satisfactory. Surgical success rates vary from 44% to 96%.Surgical treatment involves releasing the flexor retinaculum from its proximal attachment near the medial malleolus down to the sustentaculum tali. Ultrasound-guided tarsal tunnel release is possible.A positive Tinel’s sign before surgery is a strong predictor of surgical relief after decompression.Surgical treatment achieves the best results in young patients, those with a clear aetiology, a positive Tinel’s sign prior to surgery, a short history of symptoms, an early diagnosis and no previous ankle pathology. Cite this article: EFORT Open Rev 2021;6:1140-1147. DOI: 10.1302/2058-5241.6.210031