Tarsal Tunnel Syndrome 355.5

 

synonyms: TTS

Tarsal Tunnel Syndrome ICD-9

  • 355.5 (tarsal tunnel syndrome)

Tarsal Tunnel Syndrome Etiology / Epidemiology / Natural History

  • Tarsal tunnel syndrome = symptomatic entrapment of the tibial nerve and/or its branches within the confines of the tarsal tunnel or distally. (Wukich DK, JBJS 2010;92A:2002)
  • Causes: Often idiopathic can be from tendon sheath ganglion, subtalar ganglion, tenosyonvitis, perineural fibrosis, bony encroachment, accessory muscles (accessory FDL, soleus), middle facet tarsal coalition, nerve sheath tumor, ganglion cysts, lipomas, varicose veins, synovitis, hypertrophic tarsal coalition, nonunion of a sustentaculum tali fracture, Pathologic hindfoot valgus.
  • "Heel pain triad" includes adult-acquired flatfoot, plantar fasciitis, and tarsal tunnel syndrome,

Tarsal Tunnel Syndrome Anatomy

  • Borders: [1]distal part of the tibia anteriorly, [2]posterior border of the talus and calcaneus posteriorly, [3]roof of the tunnel is formed by the flexor retinaculum.
  • Contents of the tarsal tunnel: [1]posterior tibial artery and vein, [2]posterior tibial tendon, [3]flexor hallucis and flexor digitorum longus tendons, [4]posterior tibial nerve.
  • Flexor retinaculum runs from medial malleolus to adjacent surface of calcaneous covering contents of the tarsal tunnel; begins 10 cm proximal to the medial malleolus.
  • Posterior tibial nerve has three terminal branches: the medial plantar, lateral plantar, and medial calcaneal nerves. The three terminal nerve branches typically arise in the tarsal tunnel. (Dellon AL. Neurosurg Clin N Am. 2008;19:629).

Tarsal Tunnel Syndrome Clinical Evaluation

  • Vague symptoms; pain proximal or distal to flexor retinaculum, medial or lateral foot, rest/activity related/night pain
  • Tenderness over post tibial nerve
  • Burning or tingling sensation along the plantar aspect of the foot
  • Pain radiating proximally into the distal part of the medial aspect of the leg
  • Symptoms exacerbated by activity: walking, prolonged standing.
  • Reproduction of paresthesias with percussion over the posterior tibial nerve (i.e., Tinel sign).
  • Exacerbation of symptoms with dorsiflexion and eversion
  • Inspect for soft-tissue masses, varicosities, hindfoot malalignment.

Tarsal Tunnel Syndrome Xray / Diagnositc Tests

  • Ankle/foot films
  • EMG/NCV indicated if TTS suspected: distal motor latency >7.0msec, sensory latency >2.3msec, decreased amplitude of motor action potentials in abductor hallucis or abductor digiti minimi
  • MRI r/o accessory muscle of soft-tissue tumor

Tarsal Tunnel Syndrome Classification / Treatment

  • Nonop=medial sole, heel wedge or both, immobilization in walking cast, NSAIDS>>all generally ineffective. Injections risk injury to posterior tibial nerve. May consider PT (ice, heat, ultrasound)
  • Operative=release flexor retinaculum and deep investing fascia of leg proximally 3/4cm and superficial and deep fascia of abductor hallucis where PTN passes beneath.  Release MPN and LPN branches. Remove any mass lesions.

Tarsal Tunnel Syndrome Associated Injuries / Differential Diagnosis

  • Lumbar radiculopathy
  • Neuropathy (diabetes, alcoholism)

Tarsal Tunnel Syndrome Complications

  • Recurrence-usually inadequate release; repeat release generally not recommended unless space occupying lesion recurs or develops because additional fibrous reaction after repeat surgery often reproduces or increases symptoms.
  • Infection
  • Dehiscence
  • Hematoma formation
  • Incomplete release of the tarsal tunnel
  • Complex regional pain syndrome.

Tarsal Tunnel Syndrome Follow-up Care

Tarsal Tunnel Syndrome Review References

  1. Wukich DK, JBJS 2010;92A:2002
  2. Pfeiffer WH, Cracchiolo A III: Clinical results after tarsal tunnel decompression.  J Bone Joint Surg 1994;76A:1222-1230.
  3. Beskin JL: Nerve entrapment syndromes of the foot and ankle.  J Am Acad Orthop Surg 1997;5:262-263. 
  4. Bailie DS, Kelikian AS: Tarsal tunnel syndrome: Diagnosis, surgical technique, and functional outcome.  Foot Ankle Int 1998;19:65-72.
  5. Pfeiffer WH, Cracchiolo A III: Clinical results after tarsal tunnel decompression.  J Bone Joint Surg 1994;76A:1222-1230. 
  6. Skalley TC, Schon LC, Hinton RY, et al: Clinical results following revision tibial nerve release.  Foot Ankle Int 1994;15:360-367.

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