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The tarsal tunnel syndrome

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DOI: 10.1016/j.fuspru.2015.09.001

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FUSPRU 30695 1—10 ARTICLE IN PRESS
1 Fuß & Sprunggelenk xxx (2015) xxx—xxx

Online verfügbar unter www.sciencedirect.com

ScienceDirect
Q1 Nervenengpasssyndrome

2 The tarsal tunnel syndrome

3 Q2 Mariano De Prado a, Manuel Cuervas-Mons b,c,∗, Pau Golanó d,1,
4 E. Rabat e, Javier Vaquero b,c

5 Q3 a Department of Orthopaedics and Trauma Surgery, ‘Quirón’ Hospital, Murcia, Spain

b
6 Department of Orthopaedics and Trauma Surgery, ‘Gregorio Marañón’ University Hospital, Madrid, Spain
c
7 Complutense University of Madrid, Madrid, Spain
d
8 Human Anatomy & Embriology Unit. University of Barcelona, Barcelona, Spain
e
9 Departament of Orthopaedics an Trauma Surgery, ‘‘Quirón’’ Hospital, Barcelona, Spain

10 Received 16 June 2015; accepted 14 September 2015

11 KEYWORDS Summary
12
Tarsal tunnel; Background: Tarsal tunnel syndrome is a common compressive neuropathy of the
13
review; foot, but is a significantly misunderstood clinical entity.
14
tibial nerve Material and Methods: We performed a narrative review of the tarsal tunnel trough
15 the published literature.
16 Results: The accurate diagnosis is the most important part for success in the treat-
17 ment, made by clinical and physical examination. Complementary test, such MRI or
18 electromyography, help us to accurate the diagnosis and surgical planning.
19 Conclusion: Initial treatment should be non-operative, although is of limited value
20 in some cases, where surgery should be considered from the start. Open surgery
21 should be recommended for releasing all the potential nerve entrapment sites,
23
22 Q4 although new techniques appears to offer hopeful results.
Level of clinical evidence: IV.

24 Background This clinical condition, manifested as hyperesthe- 32

sia, dysesthesia o paresthesia along the course of 33

25 The tarsal tunnel syndrome (TTS) is the most com- the nerve, radiating into the plantar aspect of the 34

26 mon compressive neuropathy of the foot [31], foot [16] was first described in 1960 by Kopell and 35

27 produced by an entrapment of the tibial nerve Thompson [18], and lately coined by Keck [17] and 36

28 within the tarsal canal behind the medial malleo- Lam [20] in independent publications, although the 37

29 lus [20]. But unlike its similar sounding counterpart first clinical features are attributed to Von Malisé 38

30 in the hand, the carpal tunnel syndrome, the TTS in 1918 [27]. No population-based studies exist to 39

31 is a significantly misunderstood clinical entity [14]. determinate the incidence or prevalence of TTS

∗ Corresponding author: Manuel Cuervas-Mons, c/ Jesús, 2 4◦ D, 28014, Madrid (Spain). Tel.: +0034 649818463.
E-Mail: manuel.cuervasmons@gmail.com (M. Cuervas-Mons).
1 Deceased
http://dx.doi.org/10.1016/j.fuspru.2015.09.001

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40 [27] and the terminology involved in various diag-

41 noses for chronic heel pain, which is a hodgepodge
42 of poorly understood entities [14].

43 Anatomy
44 There is a poor understanding of the detailed
45 anatomy and potential sites of nerve compression
46 in the tarsal tunnel syndrome [35].

47 Tibial nerve

48 The tibial nerve (TN) is a branch of the sciatic

49 nerve, passing through the popliteal fossa to pass
50 below the arch of soleus. Below the soleus muscle,
51 the nerve lies close to the tibia and supplies the tib-
52 ialis posterior, the flexor digitorum longus and the
53 flexor hallucis longus.
54 In the foot, the nerve divides into three
55 branches: medial, lateral and calcaneal branch
56 (Figs. 1 and 2). It gives off its medial and lat-
57 eral plantar nerve branches in the tarsal tunnel,
58 however the branching occurs prior to entry to
59 the tunnel up to 7% of the time [21]. The cal-
60 caneal branch is highly variable, originated above
61 the tarsal tunnel in 35% of the population, within
62 the tunnel 34% of the time, and as a lateral plantar
63 nerve branch 16% of the time [37]. Figure 1. Tarsal tunnel: anatomic view
◦ 1: Lateral plantar nerve
64 The tarsal tunnel ◦ 2: Medial plantar nerve
◦ 3: Laciniate ligament (flexor retinaculum)
65 The tibial nerve passes into the foot running poste- ◦ 4: Abductor hallucis longus
◦ 5: Calcaneal branch
66 rior to the medial malleolus in a fibro-osseous space
◦ 6: Superior retinaculum.
67 named tarsal tunnel or TT. The TT is a continuation
68 of the deep posterior compartment of the leg [21],
69 created by different structures: the laciniate lig-
70 ament (flexor retinaculum) forming the roof, the
71 medial malleolus as the anterior wall, and the cal-
72 caneus and the sustentacullum tali composing the
73 lateral wall [10].
74 This tunnel is a space 2.5 to 3.0 cm wide where
75 different structures lay in close relationship [22]
76 (Fig. 3). From medial to lateral, we can find the tib-
77 ialis posterior tendon, the flexor digitorum longus
78 tendon, the posterior tibial artery and vein, the tib-
79 ial nerve and the flexor hallucis longus tendon [22].
80 The different tendons are in three separates fibro-
81 osseous compartments [21], and the tibial nerve
82 and artery are often attached to these septa via a
83 surrounding layer of dense areolar tissue [8], con-
84 forming four canals inside the TT [26]: first canal Figure 2. Tibial nerve branches into the tarsal tunnel
85 for the tibialis posterior tendon, second canal for ◦ 1: Lateral plantar nerve
86 the flexor digitorum longus tendon, third canal for ◦ 2: Medial plantar nerve
87 the tibial nerve, artery and vein, and fourth canal ◦ 3: Calcaneal branch
88 for the flexor hallucis longus tendon. ◦ 4: Abductor hallucis muscle aponeurosis.

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Figure 4. Space-occupying lesion in tarsal tunnel: gan-

glion.
Photograph courtesy of Dr Leal.

Figure 3. Tarsal tunnel: anatomy dissection have been explored [29], and in about 80% of 114

◦ 1: Tibial nerve patients, a specific cause can be identified for TTS 115

◦ 2: Flexor hallucis longus tendon [38]. The most common etiologies can be classified 116

◦ 3: Posterior tibial vessels into: space-occupying lesions, foot deformities and 117

◦ 4: Posterior tibial tendon traumatic lesions. 118

◦ 5: Flexor digitorum longus tendon.

Space-occupying lesions 119

89 The TN could be entrapped behind the medial

90 malleolus under the tough flexor retinaculum [35], The flexor retinaculum has a limited ability to 120

91 but there other points where the entrapping can stretch, so any space-occupying lesion lead to an 121

92 be developed. An extension of the TTS involves increased pressure, which will eventually cause 122

93 entrapment of the plantar nerves at the level of the compression on the nerve within the tunnel [34], 123

94 abductor hallucis on entering the foot [24]. There producing the clinical symptoms. Specific lesions 124

95 are three tough fascial septae in the sole of the include [21,31]: ganglion (Fig. 4), lipoma, nerve 125

96 foot [35], representing potential nerve entrapment tumors (Fig. 5), exostosis (Fig. 6), talocalcaneal 126

97 sites, due to the TN and its branches run in close bar (Fig. 7), accessory muscle (abductor hallucis 127

98 relationship to these septae. The septae are: (a) or flexor digitorum longus) or venous varicosities 128

99 medial septum, the deep fascia of abductor hallu- (Fig. 8). Space-occupying lesion is an uncommon 129

100 cis, (b) intermediate septum, the dorsal extension etiology of TTS [40], nevertheless it offers the best 130

101 of lateral border of plantar aponeurosis, and (c) lat- results after surgery. 131

102 eral septum, the dorsal extension of lateral border

103 of the lateral band of plantar aponeurosis [35]. In Foot deformities 132
104 addition to the flexor retinaculum and the abductor
105 hallucis, two of these septae represented poten- Varus and valgus heel are an identifiable cause of 133

106 tial sites of compression of the tibial nerve and its TTS [21]. A tarsal tunnel syndrome can be devel- 134

107 branches [35]. oped by increasing the tibial nerve pressure in 135

valgus heel with associated flat foot [23] (Fig. 9), 136

demonstrated by Daniels et al [5] in his in vitro 137

108 Etiology of tarsal tunnel syndrome study with cadaveric feet, where the tension on the 138

tibial nerve was significantly increased in a surgi- 139

109 The tarsal tunnel syndrome is thought to be an cally created flat foot. 140

110 entrapment neuropathy, defined as entrapment of Failure of static and dynamic longitudinal arch 141

111 the TN at the level of the ankle [4]. The syndrome support may result in traction injury to the TN 142

112 has been associated with traumatic and inflamma- [19], producing a clinical condition named ‘Heel 143

113 tory etiologies [4], however other causative factors pain triad’ [19,40], involving plantar fasciitis, 144

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Figure 6. Hypertrophic sustentaculum tali causing a

tarsal tunnel.
Photograph courtesy of Dr Leal.

Traumatic lesions 152

Trauma is the most common cause of TTS [4]. Trau- 153

matic neuropathies are the result of either closed 154

Figure 5. Space-occupying lesion in tarsal tunnel: nerve

tumours.
◦ Fig. 5a: Schwannoma in tarsal tunnel
◦ Fig. 5b: Surgical exeresis
◦ Fig. 5c: Tibial post after schwannoma exeresis.
Photographs courtesy of Dr Álvarez.

145 posterior tibial tendon dysfunction and tarsal

146 tunnel syndrome.
147 There have been described also dynamic defor-
148 mities leading to a TTS. Jackson el al [15] in his
149 study of TTS in runners, concludes that running
150 with excessive pronation stretch the tibial nerve
151 and may lead to a tunnel tarsal syndrome. Figure 7. Talocalcaneal bar.

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Clinical presentation and physical 173

examination 174

Symptoms are often insidious, aggravated by activ- 175

ity and usually relieved by rest with elevation of 176

the lower extremity [31]. Tarsal tunnel syndrome 177

can lead to numbness in the foot, pain, burning, 178

electrical sensations, big toe and tingling over the 179

base of foot and heel. Nevertheless, the most com- 180

mon symptoms are burning, tingling, or both, on 181

the sole of the foot, and nocturnal exacerbation of 182

symptoms [27]. 183

Commonly the patients will have their pain 184

reproduced by percussion along the tibial nerve, 185

indicating a Tinel’s positive sign if paraesthesia are 186

reproduced [39], while proximal and distal radia- 187

tion indicates a positive Valleix phenomenon [24]. 188

Figure 8. Venous varicosities in the tarsal tunnel. When varicosities may be the contributing factor to 189

Photograph courtesy of Dr Leal. the TTS, symptoms are reproducible with the Turks 190

test [26], realised by placing a tourniquet above 191

the malleolus at a pressure between systolic and 192

diastolic. 193

Other commonly objective finding is the impair- 194

ment in the sensory distribution of the plantar 195

nerve terminal branches [31]. Digital compression 196

of the nerve and sustained inversion of the hind- 197

foot can also reproduce symptoms distally, or even 198

radiating proximally [4]. 199

It is important separate examination of the tib- 200

ial nerve, the medial and lateral plantar nerves, in 201

order to ascertain whether either or both might be 202

Figure 9. Valgus heel with associated flat foot.
affected [42]. 203

Nerve conduction studies 204

155 or open injuries, and later attention is directed
156 toward painful neuroma or nerve entrapment [24]. Electrophysiological studies have generally been 205

157 Any bone fracture surrounding the ankle (tibia, viewed as the gold standard for TTS [39], per- 206

158 tarsal bones, calcaneus) or even ankle sprains formed to identify motor and sensory latencies. 207

159 involving deltoid ligament, can reduce the cross- In sensory nerves we can find slow or absent 208

160 sectional area of the tunnel, which may lead to conduction, in motor nerves increased latency and 209

161 a compression of the TN [29]. Traumatic flexor decreased amplitude of motor evoked potentials 210

162 tenosynovitis can also compress the tibial nerve, [13,16]. Understanding nerve conduction studies in 211

163 due to tibialis posterior, flexor digitorum longus and TTS requires knowing that TN and their branches 212

164 flexor hallucis longus are in close proximity to the are mixed nerves [40]. 213

165 tibial nerve [15]. Electromyography often demonstrate abnormal 214

fibrillation potential within the intrinsic muscles 215

[24], although normal findings do not rule out 216

impingement [24]. 217

166 Diagnosis Nowadays nerve conduction velocity and elec- 218

tromyography are the most reliable objective 219

167 The diagnosis is made primarily through history and quantitative test used in TTS [4,31], and the most 220
168 physical examination [10], but a variety of spe- advanced conduction problems usually involve the 221
169 cial diagnostic test can be performed, although the lateral plantar nerve [2]. However, there is no cor- 222
170 appropriateness and significance of various diag- relation between the clinical outcome after surgery 223
171 nostic tests intervention attests to the lack of at and the results of preoperative electrodiagnos- 224
172 consensus surrounding this condition [14]. tic studies [28]. Skelley et al [36] concludes that 225

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Doppler mode [22]. Alshami et al [1] states that 261

high-resolution US is reliable to measure the cross- 262

sectional area of a peripheral nerve. 263

Treatment 264

We can classify the TTS treatment into non- 265

operative and operative. 266

Non-operative treatment 267

Non-operative treatment is a hodgepodge of 268

treatments (physiotherapy, injections, nonste- 269

roidal anti-inflammatory drugs, immobilization, 270

orthotics,. . .) with variable results. Physiotherapy 271

Figure 10. Soft tissue tumor into the tarsal tunnel (MRI has been recommended, including stretching exer- 272

image). cises for extrinsic and intrinsic muscles of the foot 273

[32]. Nonsteroidal anti-inflammatory drugs, should 274

226 clinical history and physical examination are more be considered for a short brief of time, mainly in 275

227 helpful than electrodiagnostic studies in determin- cases with associated tenosynovitis [21]. 276

228 ing the extent and location of the tibial nerve Injections into the third canal of the TT may 277

229 irritation following previous tarsal tunnel release be helpful [24]. Selectively anesthetizing the TN 278

230 surgery. Ward et al [41] were unable to predict with lidocaine or bupivacaine will result in dra- 279

231 which cases would respond to decompression using matic relief, also helping identifying and localizing 280

232 electrophysiological methods, and they question the nerve branches to further isolate the problem 281

233 the use of nerve conduction studies in the diagnosis [24]. Corticosteroid injection may be performed in 282

234 of TTS. rebel situations, remarkably decreasing symptoms 283

235 Compression neuropathy in the lower extremity [24], must care should be taken avoiding injection 284

236 is common, but the occurrence of more than one into tibialis posterior tendon [21]. Rigid ankle- 285

237 lesion of the nerve in the same limb is less fre- foot orthotics and walking cast has been proposed, 286

238 quent [30]. Nevertheless, in the presence of these which may be effective in flexible deformities [9]. 287

239 lesions we must rule out more proximally nerve Orthopaedic insoles with medial longitudinal arch 288

240 entrapment sites [21], referred as ‘double crush supports controlling the excess pronation [24] has 289

241 syndrome’[3,30,33], where the TTS is associated been used as well in flexible valgus heel [9] with 290

242 with one or more additional lesions of the sciatic successful results. 291

243 nerve or its branches of the same lower extremity. When TTS appears in the sports context, res- 292

olution is achieved typically with conservative 293

244 Imaging methodologies treatment, including an occasional injection of 294

local anaesthetic with and without corticosteroid 295

245 We can support our clinical findings in patients with [32]. Conservative treatment is generally successful 296

246 TTS with different imaging methods, helping us in in dynamic and/or flexible deformities, such as the 297

247 the accuracy of the diagnosis and the preoperative presented in runners. Jackson et al [15] thinks that 298

248 planning if necessary. successful treatment of TTS requires an accurate 299

249 Radiographs or computed tomography may be diagnosis by differentiating it from other clinical 300

250 helpful in evaluating bony deformities [31]. Mag- entities, such plantar fasciitis or Achilles tendinitis, 301

251 netic resonance imaging (MRI) can pinpoint the soft and then making proper biomechanical and training 302

252 tissue content within the tunnel [11], localize the changes in the runner [15]. 303

253 etiology responsible for the compression (Fig. 10), Nevertheless, most authors suggest surgical 304

254 its extension and the relationship with the TN [22], decompression for the treatment of tarsal tunnel 305

255 characteristics that becomes the MRI a very useful syndrome [4], and authors such Sammarco et al [30] 306

256 tool for surgical planning. had no improvement in symptoms in their unopera- 307

257 Ultrasound [27] can identify the complex tarsal ted patients during the period of his study. 308

258 tunnel anatomy and its components, offering Despite the variable results in TTS treatment, in 309

259 information about the nature of the compres- our opinion physical therapy should be performed 310

260 sion and even about nerve vascularity with the before surgical therapy is considered in most of 311

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Figure 12. Superior retinaculum release.

◦ 1: Inferior retinaculum
Figure 11. Surgical approach for tarsal tunnel.
◦ 2: Opening superior retinaculum
◦ 3: Tibial nerve
312 the cases, but TTS etiologies such space-occupying ◦ 4: Abductor hallucis muscle.
313 lesions or traumatic ones are really difficult to
314 manage, case scenario where surgery should be
the plantar fascia. Before closure, release of tourni- 347
315 considered.
quet will ensure adequate hemostasis [2], then the 348

superficial fascia and skin incision are sutured, leav- 349

316 Operative treatment
ing the laciniate ligament open [24]. 350

317 Indications Miller [24] plead that in cases where plantar 351

318 Surgery is indicated after non-operative treat- nerves are entrapped, surgery must not only free 352

319 ment failure [24] and in acute TTS cases with the nerve tissue, but create some form of arch 353

320 space-occupying lesions [21], but there have been architecture through arthrodesing procedures to 354

321 controversy concerning its efficacy [31], and the get the weight bearing pressure off the nerve. 355

322 role of surgery in the management of TTS it has There are another surgical techniques; an alter- 356

323 been question [41]. In cases that fail to respond native to ‘classic surgery’, which may be useful in 357

324 to conservative treatment and have well-localized TT release. 358

325 neurologic findings, surgery may be indicated. Endoscopic TT release offers the surgeon an 359

alternative procedure, presumably resulting in less 360

326 Surgery patient trauma and faster recovery time [7]. This 361

327 The most common site of tibial mononeuropathy

328 is at the level of tarsal tunnel [27], posterior and
329 inferior to the medial malleolus.
330 The procedure can be performed with general
331 or regional anesthesia, and the use of tourniquet
332 is recommend [2]. An extensile approach is rec-
333 ommended [2], beginning 4 cm above the medial
334 malleolus and extending in a curvilineal fashion pos-
335 terior to the tendons (Fig. 11), extended across the
336 arch at the level of the navicular [2]. Surgical inter-
337 vention involves division of the flexor retinaculum
338 overlying the nerve behind the medial malleo-
339 lus [20] (Fig. 12). The laciniate ligament must be
340 incised over the third canal [24], and the nerve
341 should be minimally manipulated [32] by careful
342 neurolysis [24] (Fig. 13), first proximally, where the
Figure 13. Laciniate ligament release
343 TN is readily identified, and then distally, where the ◦ 1: Opening laciniate ligament (flexor retinaculum)
344 porta pedis is dilated as the nerve passes beneath ◦ 2: Superior retinaculum
345 the abductor hallucis muscle into the plantar vault ◦ 3: Tibial nerve
346 (Figs. 14—16), releasing the plantar nerves beneath ◦ 4: Abductor hallucis muscle.

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Figure 14. Abductor hallucis muscle release

◦ 1: Inferior retinaculum opened Figure 16. Distal release
◦ 2: Opening abductor hallucis muscle superficial aponeu- ◦ 1: Distal release
rosis ◦ 2: Abductor hallucis muscle deep aponeurosis
◦ 3: Abductor hallucis muscle. ◦ 3: Abductor hallucis muscle.

362 technique was described by Day and Naples in 1994 exposure of the operative field, which may result in 376

363 [6], performing a small incision immediately supe- faster recovery of the patient, but it cannot be per- 377

364 rior to the abductor hallucis muscle and introducing formed in all TTS etiologies, such space-occupying 378

365 a cannulated sleeve into the TT from distal to lesions o foot deformities. 379

366 proximal, cutting the laciniate ligament under

367 endoscopic vision [7]. Outcome 380

368 Minimally invasive TT release also can be per- The success rate after surgery have been reported 381

369 formed. Described by Kobak in 1992 [26], in this between 75 to 91% [31], recognizing improvement 382

370 procedure a small skin incision is performed 1 cm in nerve function within 6 weeks [2]. But some 383

371 below the tibial malleolus and immediately poste- authors conclude recently that the results of sur- 384

372 rior to the laciniate ligament, performing a blunt gical treatment are suboptimal, especially in the 385

373 dissection and opening the laciniate ligament with absence of space-occupying lesions [35]. 386

374 a Halsted forceps. This procedure is carried out Pfeiffer et al [28] reviewed the clinical symp- 387

375 through extremely small incisions without direct toms after decompression of TN, and 38% of their 388

patients were clearly dissatisfied with the result 389

and had no long-term relief of the pain, having a 390

successful outcome in only 44% of cases. Gondring 391

et al [12] had only an improvement of quality of life 392

in 51% of their patients, with a clinical dichotomy 393

between the objective pain relief measurement in 394

contrast to the subjective patient’s assessment. 395

Ward et al [41] reported satisfactory outcome in 396

42% of their patients. 397

Mullick et al [25] thinks that the poor published 398

results are due to failure to recognize that the TT 399

is analogous to the forearm, not the carpal tunnel, 400

and postoperative ankle immobilization contributes 401

to poor results by permitting fibrosis of the tib- 402

ial nerve branches [25]. Decompression of four 403

medial ankle tunnels and postoperative mobiliza- 404

Figure 15. Abductor hallucis muscle release
tion results in a high level of success for patients 405
◦ 1: Tibial nerve
◦ 2: Opening abductor hallucis muscle superficial aponeu-
with TTS [25]. Failure of TT release has been also 406

rosis associated with post-traumatic epineural scarring 407

◦ 3: Abductor hallucis muscle of the tibial nerve resulting from haemorrhage 408

◦ 4: Abductor hallucis muscle deep aponeurosis. within the TT [36]. 409

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410 Summary [6] F.N. Day 3rd, J.J. Naples, Tarsal tunnel syndrome: an 460

endoscopic approach with 4- to 28-month follow-up, 461

411 The tarsal tunnel syndrome is a common compres- J Foot Ankle Surg. 33 (3) (1994) 244—248. 462

[7] J.J. Day FNrN, Endoscopic tarsal tunnel release: 463

412 sive neuropathy, where the accurate diagnosis is
update 96, J Foot Ankle Surg. 35 (3) (1996) 464
413 the most important part for success in the treat-
225—229. 465
414 ment. Diagnosis is made by clinical and physical [8] D.D. Denny-Brown, M.M. Doherty, EFfects of tran- 466
415 examination. Complementary test, such MRI or sient stretching of peripheral nerve, Archives of 467
416 electromyography help us to accurate the diagno- Neurology & Psychiatry. 54 (2) (1945) 116—129. 468
417 sis and offer the best treatment for our patients. [9] V. DiStefano, J.T. Sack, R. Whittaker, J.E. Nixon, 469

418 Electrophysiological studies are considered the gold Tarsal-tunnel syndrome. Review of the literature and 470

419 standard diagnosis test, and often demonstrate two case reports, Clin Orthop Relat Res. 88 (1972) 471

420 abnormalities, although normal findings do not 76—79. 472

421 rule out impingement, and there is no correlation [10] D.L. Downey MSS, Tarsal tunnel syndrome, in: 473

422 between the clinical outcome after surgery at and A.S.D.M. Banks, D.E. Martin (Eds.), McGlamry’s com- 474

prehensive textbook of foot and ankle surgery, 475

423 the results of preoperative electrodiagnostic stud-
Lippincot \Williams & Tilkins, Philadelphia, 2001, 476
424 ies. MRI is a valuable tool, for its application to
pp. 1266—1278. 477
425 diagnosis and surgical planning. [11] C. Frey, R. Kerr, Magnetic resonance imaging and the 478
426 Initial treatment should be non-operative, evaluation of tarsal tunnel syndrome, Foot Ankle. 14 479
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