Tarsal Tunnel Syndrome, causes and treatment.
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- čas přidán 20. 01. 2023
- Educational animated video describes tarsal tunnel syndrome - medial ankle.
The tarsal tunnel is a fibro-osseous tunnel posterior and inferior to the medial malleolus. The tunnel is covered by the flexor retinaculum, which protects the structures contained within the tunnel. The flexor retinaculum is a thick ligament that runs between the medial malleolus and the calcaneus.
The structures which pass through the tunnel include the Tibialis posterior, the flexor Digitorum longus, posterior tibial artery, the tibial Nerve, and the flexor Hallucis longus. We are interested in the tibial nerve which lies between the posterior tibial artery and the flexor Hallucis longus.
Tarsal tunnel syndrome is a compression neuropathy caused by compression of the posterior tibial nerve within the tarsal tunnel. Tarsal tunnel syndrome is the most common compression neuropathy in the ankle and foot. Thickening of the flexor retinaculum may cause compression of the posterior tibial nerve.
Causes
80% of the cases are associated with a specific cause.
•Space-occupying lesion as lipoma or ganglia
•Varicose veins
•Muscle anomalies
•History of trauma
•Tenosynovitis
•Rheumatoid arthritis
•Diabetes
•Misaligned foot.
Symptoms of tarsal tunnel syndrome include burning pain, numbness, tingling, electric shock sensation typically around ankle or at the bottom of the foot (plantar aspect of the foot). Symptoms are worse with activity such as walking, standing or running. Tarsal tunnel symptoms are relieved with rest and elevation. Pain associated with tarsal tunnel syndrome may be worse at night. There may be swelling around the ankle and the foot.
Patient will have a positive compression test and a positive tinel’s sign. Tapping on the nerve posterior to the medial malleolus causes radiating pain into the medial side of the ankle and possibly to the foot.
Pressure within the tarsal tunnel increases with ankle dorsiflexion and foot eversion. This may reproduce the symptoms. Pain associated with tarsal tunnel syndrome radiates proximally and distally.
Tarsal tunnel may present as part of the heel pain triad which occurs in adults. The heel pain triad includes tarsal tunnel syndrome, plantar fasciitis and acquired flat foot deformity.
Diagnosis is by combination of history, examination, EMG and nerve studies that can lead you to the diagnosis (history is the most useful examination, EMG is accurate in about 80-90%). The dorsiflexion-eversion test is described to be helpful in the diagnosis of tarsal tunnel. Sensory nerve conduction studies are more helpful than motor studies (EMG). Always rule out radiculopathy.
Radiographs and CT scan may show osseous impingement or posteromedial process fracture of the talus. MRI may show a space occupying lesion such as a ganglion cyst or lipoma.
Differential diagnosis includes Peripheral neuropathy that involves all the nerves, not just the tibial nerve. Sural nerve and saphenous nerve are also involved and there will be an absent ankle jerk.
Treatment is immobilization, anti-inflammatory medications, and steroid injections. Patient may have orthotic with medial posting if the patient has a valgus hindfoot.
Surgical release of the tarsal tunnel if non-operative treatments fails after a trail of 3-6 months.
•Release the fascia proximal to the flexor retinaculum.
•Release the flexor retinaculum.
•Identify the tibial nerve proximal to the tunnel and decompress the nerve and its three branches.
•Decompress the entire tunnel 5 cm proximal to the flexor retinaculum and distally to the deep fascia of the abductor hallucis.
•Distal release of the Baxter’s nerve is usually done if the patient has chronic plantar medial heel pain (heel pain is uncommon in tarsal tunnel).
•Decompress the Baxter’s nerve by release of the deep fascia of the abductor hallucis.
•Remove any space occupying mass.
Best results occur if symptoms occurred in less than one year. A successful outcome occurs in about 50-90% of the cases. The best result occurs if the patient has space occupying lesion with a positive physical examination and EMG findings. The suboptimal results can occur from inadequate release traction neuritis and repeat tarsal tunnel release. In these situations, the patient will not respond well to surgery (always rule out double crush syndrome).
Revision surgery has a less successful outcome unless the patient has an inadequate release.
Recurrence of tarsal tunnel syndrome is usually caused by inadequate release and repeat tarsal tunnel release is usually not advisable. In general, tarsal tunnel decompression may not produce a good long-term outcome.
special thanks for NATHAN ELKINS FOR HIS CONTRIBUTION TO THIS VIDEO - Jak na to + styl
You sound just like the stereotypical doctor I always have in my head when I think of doctors. It must come from something I watched on TV when I was a small child. This is not an insult. It's a very good thing. I got a chuckle as I learned about TTS. Thank you so much for the information! 😃
Thank you
Keep watching and making comments
Thanks for sharing this with us.
Thank you very much Sir🙏
Nicely explained as usual 👏💝
Thank you doc!
Thanks
Thank you for such details. I know for certain that this is what I have.
Hello. I am having numbness in my left big toe. What could be the reason. I hv lower back pain since 2 year. Is it curable or not please help me doctor . Is this numbness is permanent?
Much thanks
This is a very helpful review for something I don't see very often in my current clinical practice. I've just recently found your channel and really appreciate your thorough videos and the visual images you provide. Thank you so very much!!
Thank you
I hope you share it
Merci beaucoup ci vous faite le sous-titre merci en francais.
Saad du maroc
Awesome CZcams channel thanks 🙏
Thank you, I hope you share it
@@nabilebraheim Doc, always! Rain or shine! 🫂👍👏👏👏👏🙏
@@universeusa thanks
hi my teacher I live in Turkey , there was a sacroiliac fracture in the neural foramen six months ago. Along with this, trendelenburg syndrome and 1/5 drop foot occurred. Do you think it will be like before? Can you help with the treatment method? Please , Thank you very much, regards
I feel relief when I press on my tibial nerve and hold it. Is this a sign of TTS?
Read this please.
After years of going back and forth to the podiatrist (multiple). This was finally confirmed after a year of telling everyone this is what I have. None of the doctors believed me.
I’m losing my life over TTS. I’m 33 and I can’t stand for than 15 minutes without the pain starting to radiate under my calf to big toe.
I am currently looking for a doctor in the USA to do the surgery. All the doctors I’ve seen say I am the first or second patient with TTS. My current podiatrist has a surgery success rate of one failed surgery that made the condition worse.
If podiatry is your career or going to school for it. Please keep this in mind. My quality of health (mental and physically) are at its end and I don’t know what to do.
عالمي
Thanks, but sensory conduction study in TTS, is technically very difficult, Do you have any solution?
Use clinical diagnosis
@@nabilebraheim Of course, but you have to confirm!!