Transcript Tarsal Tunnel Syndrome - IMC Podiatry Residency

Tarsal Tunnel Syndrome
Thomas Eddy DPM-PGY2
Intermountain Podiatry Residency
Anatomy
The tarsal tunnel is bordered
by the flexor retinaculum
(formerly called the lacinate
ligament) superficially, the
medial surface of the talus,
sustentaculum tali, and
medial calcaneal wall deep,
the superficial and deep
aponeurotic fascia of the leg
superiorly, and the
abductor hallucis
muscle inferiorly.
The tunnel contains the tibial
nerve and its branches, the
posterior tibial artery and
venous plexus, and the
posterior tibial, flexor
digitorum longus, and flexor
hallucis longus tendons.
Sobotta:Anatomy © Elsevier GmbH Germany
Causes
• Sammarco et al preformed TTSx on 75 feet
Diagnosis
• MRI/CT/US- Space
occupying lesion
• 2 point discrimination
• Sharp dull
• Percussion
• Dorsiflexion eversion
test
• KINOSHITA et al found
that 15 of 20 pt’s with
tarsal tunnel had pain
and numbness induced
or worsened with
Dorsiflexion and
eversion of the foot and
then dorsiflexion of the
hallux
Conservative Management
• NSAIDS
• Physical Therapy
• Injection Therapy
• Biomechanics
– Bracilovic et al found
that The contents of the
tarsal tunnel are lowest
when the STJ is in
neutral position. Thus
recommending posting
the RF to neutral
Surgical management
• Jerosch Preformed TTSx
with external neurolysis
on 75 patients and 43
subjectively stated they
would have the surgery
again.
• Jerosch Preformed TTSx
with both internal and
external neurolysis on
72 patients and found
that pts who had
symptoms the longest
had the poorest
outcomes, and on
average pt’s Maryland
foot score improved by
19 points.
What happens when TTSx fails
• Factors associated with
Tarsal Tunnel Failure
– Older age
– Chronic disease with motor
involvement
– Epineural Scarring of PT
nerve
– Pes Planus
– Inadequate release
• This can include double
crush
Et al Lau
Whats New in Tarsal Tunnel Surgery
• Human amnion wrap
has been shown
histologically to reduce
perineural fibrosis in
rabbits and rats
following nerve surgery.
Et al Kim
• Minimally invasive
techniques are now
being explored however
I could not find
prospective studies.
Ummm et al wooley??
Mt Timpanogos
Credits
• Sammarco, Outcome of Surgical Treatment of Tarsal Tunnel
Syndrome; FAI vol 23 # 2 pp 125-131
• Bracilovic, Effect of Foot and Ankle Position on Tarsal Tunnel
Compartment Volume; FAI, Vol. 27, No. 6 pp 431-437
• Kinoshita, The Dorsiflexion-Eversion Test for Diagnosis of Tarsal
Tunnel Syndrome; JBJS VOL 83-A #12 pp 1835-39
• Jerosch, Results of surgical treatment of tarsal tunnel surgery; JFAS
12 (2006) 205–208
• Lau, Tarsal Tunnel Syndrome: a Review of the Literature; FAI 1999
Vol 20 No 3 pp 201-209
• Kim, USE OF HUMAN AMNIOTIC MEMBRANE WRAP IN REDUCING
PERINEURAL ADHESIONS IN A RABBIT MODEL OF ULNAR NERVE
NEURORRHAPHY; Journal of Hand Surgery (euro) 2010 35E: 3: 214–
219