Tarsal Tunnel Syndrome

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SYMPTOMS There is aching or sharp pain around the medial part of the foot and ankle joint, often radiating along the medial or the lateral part of the foot, or towards the plantar fascia insertion. AETIOLOGY This syndrome is caused by trapping of the posterior tibia nerve or any of its branches in the tarsal tunnel, most often after scarring from trauma. Other non-traumatic aetiology, such as varicose veins, neuroma or tumours, may also trap the nerve.

CLINICAL FINDINGS There is tenderness on palpation over the tarsal tunnel and a positive Tinel's sign is typical. Dysaestesia along the nerve branch distribution is also a common finding. INVESTIGATIONS X-ray is usually normal. MRI may show localised oedema in or around the tarsal tunnel and may, if present, identify some causes for the entrapment such as varicose veins or tumours. Nerve conduction tests can show decreased nerve conduction in chronic cases but can be normal in early cases.

Fig. 47 Tarsal tunnel syndrome, medial view

TREATMENT Direct friction over the tarsal tunnel should be minimised by using well-fitting shoes or soft padding. NSAID or a local injection of cortisone may decrease symptoms in mild cases. In chronic cases surgery may be necessary to release the nerve. REFERRALS Refer to orthopaedic foot surgeon if the pain is persistent or is getting worse, to investigate the underlying cause of entrapment and for consideration of surgery. In mild cases, the surgeon may suggest orthotics to start with. EXERCISE PRESCRIPTION Even though exercise often worsens the symptoms, rest will not help, so allow all kinds of sporting activities using well-fitting shoes but avoiding unnecessary impact. EVALUATION OF TREATMENT OUTCOMES Monitor clinical symptoms, which should disappear. Tinel's sign should be normal. Note that even after successful surgery it can take a very long time (months to a year) before nerve function is normal. DIFFERENTIAL DIAGNOSES Plantar fasciitis (entrapped nerve branch may cause radiating pain to insertion of plantar fascia); Deltoid ligament tear (acute injury); OCD of the talus dome (ache, no radiating pain, joint effusion). Note! Tarsal tunnel syndrome may be associated with metabolic diseases such as diabetes or malignant tumours. PROGNOSIS Usually good-fair. If symptoms persist over several months, surgery may be indicated. Again the underlying cause of the nerve compression is more important for outcome than the syndrome itself. Even after successful surgery symptoms may persist over one to two years.

Fig. 47 Tarsal tunnel syndrome, medial view

Fig. 48 The posterior tibial tendon is most often injured between the position posterior to the medial malleoli and the distal insertion

SYMPTOMS Gradually increasing exercise-induced pain around the posterior medial part of the ankle joint, often after previous sprain. It is common in middle-aged or elderly athletes. AETIOLOGY This is a tenosynovitis and or partial rupture of the posterior tibial tendon. If the tendon ruptures completely, a fairly discrete acquired

Fig. 49 Tenderness on palpation over the tendon during a weak-resisted plantar flexion and inversion may indicate injury to this tendon flat foot can result after a long time of diffuse symptoms.

CLINICAL FINDINGS There is tenderness on palpation over the posterior tibial tendon. INVESTIGATIONS MRI or ultrasound may show localised oedema or swelling around the tendon. Sometimes a rupture can be seen. TREATMENT Early proprioceptive training and weight-bearing exercises are usually recommended. Rehabilitation is usually curative and the athlete can resume occasional sport within six to twelve weeks, using well-fitting shoes, with or without orthotics.

REFERRALS Refer to physiotherapist for mild symptoms and to orthopaedic surgeon if pain is unclear or severe.

EXERCISE PRESCRIPTION Rest will not help so allow all kinds of sporting activities using well-fitting shoes and avoiding impact. Suggest low-impact activities such as cycling and swimming. EVALUATION OF TREATMENT OUTCOMES Monitor decrease of clinical symptoms and signs. DIFFERENTIAL DIAGNOSES Stress fracture of the navicular bone (X-ray or MRI will differentiate). PROGNOSIS Excellent-Good but in rare cases an acquired flat foot can occur, requiring permanent orthotics in shoes.

Fig. 49 Tenderness on palpation over the tendon during a weak-resisted plantar flexion and inversion may indicate injury to this tendon

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