TARSAL TUNNEL SYNDROME

• entrapment of tibial nerve beneath the flexor retinaculam

Anatomy and etiology

• flexor retinaculam is the unyielding fibrous roof of the tarsal tunnel that extends from medial malleolus (posteriorly) to medial side of tuberosity of calcaneum ( inferiorly) – 2.5 to 3 cm wide with indistinct borders
• proximal border – continuous with deep fascia of calf
• distally – deep fascial of medial part of sole
• septa from roof to calcaneum separate in order TP, FDL, Tibial N, Post tibial artery, accompanying veins, FHL
• Tibial N – branches to medial and lateral plantar nerves, gives of calcaneal br. In tarsal tunnel

Constrictions related to tarsal tunnel

• bone fragments from displaced distal tibial, talar or calcaneal #
• tenosynovitis or ganglia of adjacent tendon sheath
• bone and soft tissue changes in RA, Ankylosing spondylitis, Varicosities, Neural tumors, Perineural fibrosis
• fixed valgus hind foot ( tarsal coalition) – c/c traction neuropathy

Clinical findings

• burning/ dysthesia/ paraesthesia on plantar aspect of foot – increased by prolonged standing – dec by rest – worsening in night
• Vallix phenomenon – proximal radiation of pain along the medial aspect of leg to mid calf
• subtle sensory difference form other foot, local temp, sweating pattern, skin abnormalities
• Abd hallucis, Abd Dig Minimi, atrophy
• Tinel's sign – tenderness over tibial N at ankle
• Provocative test : dorsiflexion, eversion of ankle, with all MTP maximally dorsiflexed

Diagnosis

• Electro diagnosis
  • NCV of medial and lateral plantar N
  • measurement of motor evoked potentials
  • measurement of sensory conduction velocity
• MRI – to identify the cause – visualize the tarsal tunnel and distal br of tibial N
• X ray, CT

Treatment

• conservative
  • NSAID
  • local steroid injection for tenosynovitis
  • orthotics for flexible foot deformity
• Surgical
  • Tarsal tunnel release

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