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Tarsal Tunnel Syndrome
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Tarsal Tunnel Syndrome - April 26, 2002 4:48:00 PM
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sarty
Posts: 65
Joined: April 22, 2001
From: Florida, USA
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Anyone have any tips on this diagnosis? Or links to protocols?
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Re: Tarsal Tunnel Syndrome - April 28, 2002 6:20:00 PM
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mcap
Posts: 652
Joined: February 8, 2000
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Sarty:
I am not sure about links for this one. As I understand it, it presents very similarly to plantar facsitis. I think there would be clues in the history. PF is usually much more painful during the first few steps of the day and worse after weight bearing. TTS might appear at different times. Try having the patient flex the C-Spine and see if it increases the pain significantly.
Not sure about treatment options. There is some information in Management of Common Musculoskeletal disorders. Don't have it home for the weekend.
If I come up with anything useful.....I will post.
mcap
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Re: Tarsal Tunnel Syndrome - May 5, 2002 5:38:00 PM
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PTupdate.com
Posts: 1490
Joined: October 8, 2001
From: Pittsburgh, PA USA
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Here is an article I recently abstracted from The American Journal of Sports Medicine, Vol. 19, No. 1, 1991:
ABSTRACT
The tarsal tunnel is a fibroosseous tunnel, with the floor consisting of the talus and calcaneus, along with the FDL, FHL and posterior tibialis tendons. The flexor retinaculum, also known as the lancinate ligament, forms the roof as it runs from the medial malleolus to the calcaneus and proximal border of the abductor hallicus muscle. The tibial nerve runs through this inelastic fixed space, and branches into the medial calcaneal branch and lateral plantar nerve either at the end of the tunnel, or just after it exits the tunnel. Occasionally, the medial branch actually pierces the retinaculum as it exists. As the tunnel is inelastic, anything that causes compression or inflammation may result in tarsal tunnel syndrome. Entrapment may also occur, and is most common at the anterior inferior region where the nerves run around the medial malleolus. It has been found the lateral plantar branch is more commonly affected than the medial branch. Forced PF, lipoma, acute/chronic foot eversion, post-trauma fibrosis, spurs, DJD, RA, synovial hypertrophy, edema, rapid weight gain, fluid retention, gout and overuse are all causes of the condition. Athletes with excessive pronation will present with the condition, known as “joggers foot”, as the stretch placed on the abductor hallicus causes the compression.
Clinical presentation can be simple, focal heel pain, or more widespread symptoms. Unlike plantar fasciitis, which this condition may mimic, the TTS patient reports more medial heel pain and arch pain (the abductor hallicus muscle), pain that worsens with running and activity, and nocturnal parasthesias that may radiate into the calf. Loss of two-point discrimination is an early sign, along with weakness to the foot intrinsics. Tinel’s sign may be positive over the tunnel, and is referred to as the Valleix sign. Forced dorsiflexion with valgus stress may cause pain, and there may be tenderness along the length of the nerve. Manual sensory testing along the courses of the medial and lateral plantar nerves must be assessed. Radiographs may be necessary to rule out any bony deformity, and definitive diagnosis is accomplished via EMG/NCV tests. However, the entire foot and ankle musculature must be tested to rule out any proximal neural entrapment. Treatment consists of stretching, NSAID therapy, injection of a corticosteroid into the tunnel, physical therapy, orthotic intervention where biomechanics may be the cause, ice and rest. Often, symptoms resolve on their own in 6-9 months, but some nerve atrophy may occur due to the constant compression. When conservative treatment fails, surgical release of the flexor retinaculum and resection of the connective tissue branches is recommended.
The authors present two case studies. One patient had pain that was diminishing, but persistent numbness along the plantar aspect of the foot. New ski boots may have been the cause of the problem, and physical exam was unremarkable except for diminished sharp/dull and two point discrimination in the region supplied by the medial and lateral plantar nerves. Tinel’s was positive over the tarsal tunnel, radiographs were normal, and EMG revealed a problem. Treatment was via injection, NSAID’s, ultrasound/stretching/strengthening/coordination in PT and resolved the problem. The second patient was a 42 year-old runner with persistent pain and numbness that radiated into the calf in the evening. She had been diagnosed with Achilles tendonitis and plantar fasciitis, received PT and no resolution. The patient presented with plano-valgus, high Q-angles, and signs of increased heel valgus but normal wear patterns. She had decreased sharp/dull discrimination, positive Tinel’s, and slowed sensory nerve conduction. Treatment was with NSAID’s, injection, ice and ultrasound at therapy, and orthotics.
mcap is correct in assessment of neural adhesion via cervical flexion. Plus, the condition can mimic entrapment of Baxter's nerve.
Regards,
John Duffy, PT OCS
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