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 Bracilovic, Effect of Foot and Ankle Position on Tarsal Tunnel Compartment Volume; FAI, Vol. 27, No. 6 pp Kinoshita, The Dorsiflexion-Eversion Test for Diagnosis of Tarsal Tunnel Syndrome; JBJS VOL 83-A #12 pp 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 Kim, USE OF HUMAN AMNIOTIC MEMBRANE WRAP IN REDUCING PERINEURAL ADHESIONS IN A RABBIT MODEL OF ULNAR NERVE NEURORRHAPHY; Journal of Hand Surgery (euro) E: 3: 214– 219