AANEM PRACTICE TOPIC

American Association of Neuromuscular & Electrodiagnostic Medicine

421 First Avenue S.W., Suite 300 East, Rochester, MN 55902 (507/288-0100)

ABSTRACT: This evidence-based review was performed to evaluate the

utility of nerve conduction studies (NCSs) and needle electromyography
(EMG) in the diagnosis of tibial neuropathy at the ankle (tarsal tunnel
syndrome, TTS). A total of 317 articles on TTS were identified that were
published in English from 1965 through April 2002, from the National Library
of Medicine MEDLINE database. All articles were reviewed on the basis of
six selection criteria. The results of this search revealed that four articles met
five or more criteria. All four articles examined the use of electrodiagnostic
(EDX) techniques for the evaluation of patients with clinically suspected
TTS, and were included in this practice parameter. Each of these four
studies was considered to meet Class III level of evidence. NCSs were
abnormal in some patients with suspected TTS. Sensory NCSs were more
likely to be abnormal than motor NCSs but the actual sensitivity and spec-
ificity could not be determined. The sensitivity of needle EMG abnormalities
could not be determined. NCSs may be useful for confirming the diagnosis
of tibial neuropathy at the ankle, recommendation Level C. Well-designed
studies are needed to evaluate more definitively EDX techniques in TTS.
Muscle Nerve 32: 236 –240, 2005

U S EF U L NES S OF EL ECTROD IAG NOS TIC TECH NIQ U ES

IN TH E EV AL U ATION OF S U S PECTED TARS AL TU NNEL
S Y ND ROME: AN EV ID ENCE-B AS ED REV IEW
A T U L T . P A T E L , M D , K E N N E T H G A IN E S , M D , R IC H A R D M A L A M U T , M D ,
T R A C Y A . P A R K , M D , D A V ID R . D E L T O R O , M D , a n d N E IL H O L L A N D , M B , B S

Am erican Association of Neurom uscular & Electrod iag nostic Med icine, 421 First Avenue SW,
Suite 300E, Rochester, Minnesota 55902, U SA

This p ractice p aram eter is an ed ucational effort
sp onsored b y the Am erican Association of Neuro-
m uscular and Electrod iag nostic Med icine (AANEM,
form erly AAEM), and is b ased on a sy stem atic review
of the p ub lished scientifi c literature to assess the
usefulness of electrod iag nostic (ED X ) techniq ues in
A v a ila b le fo r C a te g o r y 1 C M E c r e d it th r o u g h th e A A N E M
a a n e m .o r g
T h is a r tic le w a s p r e p a r e d a n d r e v ie w e d b y th e A A N E M a n d d id n o t
u n d e r g o th e s e p a r a te r e v ie w p r o c e s s o f M u s c le & N e r v e .
A b b r e v ia tio n s : AANEM, American Association of Neuromuscular and Elec-
trodiagnostic Medicine; EDX, electrodiagnostic; EMG, electromyography;
NCS, nerve conduction study; TTS, tarsal tunnel syndrome
K e y w o r d s : electrodiagnosis; electromyography; entrapment neuropathies;
nerve conduction studies; tarsal tunnel syndrome; tibial nerve
C o r r e s p o n d e n c e to : American Association of Neuromuscular & Electrodi-
agnostic Medicine, 421 First Avenue SW, Suite 300E, Rochester, MN 55902,
USA; e-mail: aanem@aanem.org
© 2005 American Association of Neuromuscular & Electrodiagnostic Medi-
cine. Published by Wiley Periodicals, Inc.
Published online 7 July 2005 in Wiley InterScience (www.interscience.wiley.
com). DOI 10.1002/mus.20393
the d iag nosis of p atients w ith involvem ent of the
tib ial nerve at the level of the m ed ial ank le (i.e.,
tarsal tunnel sy nd rom e, T T S). T he T T S T ask Force
of the AANEM w as charg ed b y the AANEM B oard to
d evelop this p ractice p aram eter to p rovid e recom -
m end ations for the ap p rop riate use of ED X stud ies
in T T S and to p rovid e recom m end ations for future
research.
at w w w .
J U S TIF ICATION
T he m ost com m on site of tib ial m ononeurop athy is
at the level of the tarsal tunnel. T he constellation of
sy m p tom s of p ain and num b ness in the sole of the
foot, sensation of tig htness, cram p ing p ain, and
w orsening of sy m p tom s w ith p rolong ed stand ing or
w alk ing has b een associated w ith T T S.5– 7,9 T he term
w as fi rst coined b y K eck and L am in sep arate arti-
cles.14,16 H ow ever, the fi rst d escrip tion of the clinical
features of T T S is attrib uted to von Malaisé in
1918.18,24 T he tib ial nerve is rep orted to b e com -

236 AANEM P ractice Topic MU SCLE & NERV E August 2005

p ressed in the tarsal tunnel, p osterior and inferior to
the m ed ial m alleolus. No p op ulation-b ased stud ies
ex ist to d eterm ine the incid ence or p revalence of
T T S.
ED X stud ies have b een used in an effort to d iag -
nose the cond ition m ore accurately . U nfortunately ,
the techniq ues used for these stud ies vary consid er-
ab ly and are not alw ay s clearly d escrib ed in the lit-
erature. T o d eterm ine the usefulness of ED X tech-
niq ues in the evaluation of p atients w ith susp ected
T T S, sy stem atic review and analy sis w ere cond ucted
of the relevant literature to answ er the follow ing
clinical q uestions: (1) I n p atients clinically susp ected
of having T T S, w hat are the b est electrod iag nostic
(ED X ) stud ies to confi rm the d iag nosis? and (2)
H ow can future clinical research stud ies b e im -
p roved to evaluate the usefulness of lab oratory stud -
ies, includ ing ED X stud ies, to confi rm the d iag nosis
of T T S?
PROCES S
T he task force ag reed up on a set of six criteria to
evaluate the literature in the electrod iag nosis of T T S
(ad ap ted from AAEM C arp al T unnel Sy nd rom e cri-
teria, 2002).2 P ub lished articles that m et at least fi ve
of the follow ing six criteria w ere includ ed for further
review :
1. T he stud y w as p rosp ective.
2. T he d iag nosis of T T S w as b ased on clinical crite-
ria ind ep end ent of the ED X p roced ures und er
evaluation.
3. T he ED X p roced ure w as d efi ned , or the refer-
ence to a p ub lished techniq ue w as p rovid ed , suf-
fi cient to p erm it d up lication of the p roced ure.
4. T he lim b tem p erature w as m onitored .
5. T he reference values w ere rep orted .
6 . T he criteria for ab norm ality of results of the ED X
p roced ures w ere clearly stated and d efi ned .
D ES CRIPTION OF TH E REV IEW PROCES S
A MED L I NE search w as cond ucted from January
196 5 throug h Ap ril 2002. T he follow ing d escrip tions
and k ey head ing s w ere utiliz ed : electrod iag nosis;
electrom y og rap hy ; entrap m ent neurop athies; nerve
cond uction stud ies; tarsal tunnel sy nd rom e; and tib -
ial nerve. T he search id entifi ed a total of 319 articles,
2 of w hich could not b e ob tained . T he articles and
their b ib liog rap hies w ere review ed for ad d itional ref-
erences and none w ere found . Articles that m et the
inclusion criteria w ere includ ed for a second review
p rocess b y all the task force m em b ers.
AANEM P ractice Topic
T he follow ing m ethod olog ical characteristics
w ere ab stracted from each article: ty p e of stud y ;
num b er of p atients stud ied w ith T T S; d em og rap hic
inform ation (ag e, g end er); m ethod of p atient assem -
b ly ; clinical criteria for the d iag nosis of T T S; assess-
m ent tim e relative to onset of sy m p tom s; and the
ty p e of ED X p roced ures utiliz ed . B ased on the re-
sults of this d ata ab straction, the articles w ere rated
using the d iag nostic test streng th-of-evid ence
schem e ad op ted b y the AANEM. T his inform ation is
located in Ap p end ix 7 of Am erican Acad em y of Neu-
rolog y ’s (AAN) d ocum ent on the P rocess for D evel-
op ing P ractice P aram eters.1
ANAL Y S IS OF EV ID ENCE
S tudy Ch aracteristics. Four stud ies ex am ined ED X
techniq ues in the evaluation of p atients w ith clini-
cally susp ected T T S. T hree m et six of the literature
inclusion criteria w hile one m et fi ve criteria (this
stud y d id not m eet criterion num b er 6 ). T he m eth-
od olog ical characteristics of these stud ies are listed
in T ab les 1 and 2, availab le electronically (http ://
w w w .aanem .org /p racticeissues/p racticeP aram eters/
ttsT ab les.cfm .).
Clinical D iagnosis of Tarsal Tunnel S y ndrome. T he
four stud ies d escrib ed the clinical d iag nosis of T T S
in d ifferent w ay s. T ab le 1 sum m ariz es the clinical
sy m p tom s noted in the articles. T he m ost com m on
asp ects includ ed sy m p tom s of b urning or ting ling
(or b oth) on the sole of the foot. T hree stud ies also
noted nocturnal ex acerb ation of sy m p tom s. O b jec-
tive fi nd ing s consisted of a T inel’s sig n, altered sen-
sation, and w eak ness of foot m uscles.
In Patients w ith S usp ected Tarsal Tunnel S y ndrome,
Are Electrodiagnostic S tudies U seful to Confi rm th e D i-
agnosis? Nerve Conduction Studies. A variety of
nerve cond uction techniq ues w ere used in the four stud -
ies review ed (T ab le 2). All rep orted m otor NC S, three
includ ed sensory NC Ss, and one includ ed m ix ed nerve
stud ies.
In a case series rep ort, G alard i and colleag ues
noted that only 3 of 13 p atients had ab norm al m otor
stud ies and those p atients w ho had m otor stud y ab -
norm alities alw ay s had ab norm alities of m ix ed and
sensory nerves.8 L ateral p lantar nerve sensory con-
d uction ab norm alities w ere ob served in all lim b s.
Ab sence of the sensory nerve action p otential w as
the m ost freq uent ab norm ality , rep resenting 92.8%
of the ab norm alities in the lateral p lantar nerve and
76 .9% in the m ed ial p lantar nerve. Sensory nerve
action p otentials w ere also ab sent from tw o unaf-
MU SCLE & NERV E August 2005 237
fected lim b s. Mix ed NC Ss w ere ab norm al in 85.7%
of T T S lim b s, b ut norm al in all asy m p tom atic lim b s
and control sub jects. Mix ed NC S ab norm alities w ere
alw ay s associated w ith ab norm al sensory NC Ss. O nly
21.5% of T T S lim b s had sig nifi cantly p rolong ed d is-
tal m otor latencies to the ab d uctor hallucis.
I n a case series stud y , O h and colleag ues d e-
scrib ed the use of near-nerve sensory nerve cond uc-
tion in the m ed ial and p lantar nerves in 25 cases in
w hich T T S w as susp ected .20 T hey found ab norm al
sensory nerve cond uctions in 24 cases (96 % ). T he
m ost com m on ab norm alities w ere slow nerve con-
d uction velocities and d isp ersion p henom ena. T hey
noted that these fi nd ing s d isp lay ed the m ost p rom i-
nent ab norm alities in sensory NC Ss for T T S evalua-
tion.
In a case control stud y , K ap lan and colleag ues d e-
scrib ed a stud y using m otor NC Ss in the assessm ent of
T T S.12 No d ifferences in nerve cond uction p aram eters
w ere noted b etw een the control g roup and the nond i-
ag nostic g roup or b etw een the control g roup and the
uninvolved sid e of the p atients w ith T T S. T he involved
sid e show ed p rolong ed d istal latencies b oth to the
ab d uctor hallucis as w ell as the ab d uctor d ig iti m inim i.
Am p litud e and d uration w ere m ore lik ely to b e af-
fected than the d istal latency .
I n another case series stud y , O h and colleag ues
d escrib ed the use of sensory NC Ss assessing 17 p a-
tients (21 nerves) w ith T T S.21 Resp onses w ere ob -
tained b y averag ing any w here from 32 to 256 stim uli.
T hey found that, com p ared w ith the m ed ial p lantar
nerve, the lateral p lantar sensory nerve cond uction
velocity w as slow er and the resp onse am p litud e
sm aller. T hey also noted that p rolong ed d istal m otor
latency (11 of 21 cases, 52.4% ) w as less sensitive than
ab norm al sensory nerve cond uction velocity or am -
p litud e (19 of 21 cases, 90.5% ). Sensory nerve con-
d uction w as ab norm al in all nerves in w hich the
d istal m otor latency w as p rolong ed .
Needle Electromy ograp h y . None of the stud ies used
need le electrom y og rap hy (EMG ) in the assessm ent
of p atients w ith T T S. B ased on this inform ation,
further com m ents w ith reg ard to the utility of need le
EMG in T T S cannot b e m ad e.
Can Electrodiagnostic Tech niq ues B e U sed to Assess
th e Prognosis in Patients w ith Clinically S usp ected
Tarsal Tunnel S y ndrome? No stud ies w ere found
that evaluated the im p act of ED X testing on the
outcom es or treatm ent in the T T S p atient p op ula-
tion.
238 AANEM P ractice Topic
S U MMARY OF EV ID ENCE
T he review of these articles show s som e association
b etw een ab norm al nerve cond uction p aram eters in
p atients w ho p resent w ith clinical sy m p tom s sug g es-
tive of T T S. It ap p ears that sensory NC Ss are m ore
sensitive than m otor NC Ss b ut at the ex p ense of
sp ecifi city . H ow ever, there are sig nifi cant m ethod -
olog ical fl aw s in the stud ies. T he lim itations of these
stud ies includ e: (1) the ab sence of b lind ing p roce-
d ures; (2) the ab sence of a reference stand ard clin-
ical d efi nition of T T S; and (3) the variab ility in the
tim ing of assessm ents relative to sy m p tom onset.
CONCL U S IONS
Sy m p tom s and sig ns, op erative fi nd ing s, and re-
sp onse to therap y d efi ne m ost cases of T T S rep orted
in the literature. T he p recise clinical criteria used in
the ind ivid ual stud ies are inconsistent. I t is im p ossi-
b le to com p are the sensitivity and sp ecifi city of ind i-
vid ual ED X tests for T T S in the ab sence of ind ep en-
d ent stand ard iz ed clinical d iag nostic criteria.
Moreover, all of the stud ies have b een unb lind ed
stud ies or retrosp ective. B ecause of these lim itations,
the b est evid ence reg ard ing ED X stud ies for the
evaluation of T T S are consid ered C lass I I I .
T he current lack of d efi nitive recom m end ations
is not d ue to the p resence of research that refutes
the value of ED X stud ies in T T S, b ut rather b ecause
of the ab sence of hig h-q uality evid ence-b ased re-
search on the valid ity and usefulness of the electro-
p hy siolog ic techniq ues in T T S. When the d ata w ere
insuffi cient to reach a conclusion, consensus w as
soug ht b y the author p anel and the P ractice I ssues
Review P anel of the AANEM to form ulate recom -
m end ations.
B efore m ak ing the recom m end ations reg ard ing
the use of NC Ss in the assessm ent of T T S, the p anel
of investig ators further stud ied the issue of sp ecifi city
of m ed ial and lateral p lantar NC Ss. A sep arate liter-
ature review w as carried out and 10 articles w ere
id entifi ed . T hese stud ies assessed p lantar NC Ss in
norm al or asy m p tom atic sub jects. Eig ht of these
stud ies used surface record ing s and tw o used near-
nerve record ing of the resp onse at the ank le. T ab le
3, availab le electronically (http ://w w w .aanem .org /
p racticeissues/p racticeP aram eters/ttsT ab les.cfm .),
sum m ariz es the NC S fi nd ing s in nine of these stud -
ies. O ne of the stud ies d id not p rovid e the ex act
num b er of ab sent resp onses from each of the nerves
and hence w as not used in the d eterm ination of the
sp ecifi city of m ed ial and lateral p lantar NC Ss.4 T he
investig ators rep orted that m ost of the sub jects had
b oth a m ed ial p lantar and lateral p lantar sensory
MU SCLE & NERV E August 2005
resp onse, and that all the sub jects had at least one
resp onse. B ased on the other stud ies, the sp ecifi ci-
ties of m ed ial and lateral p lantar NC Ss using surface
record ing are as follow s: m ed ial p lantar sensory ,
98% ; m ed ial p lantar m ix ed , 99% ; lateral p lantar sen-
sory , 92% ; and lateral p lantar m ix ed , 91% . T he sp ec-
ifi city of m ed ial p lantar sensory NC Ss using near-
nerve record ing is 99% .
RECOMMEND ATIONS
T he recom m end ations are b ased up on the assum p -
tion that the clinical situation, as evaluated throug h
the history and p hy sical ex am ination and testing ,
includ ing other NC Ss and need le EMG ex am ination,
has ex clud ed the p ossib ility of p oly neurop athy , ra-
d iculop athy , and other cond itions that m ig ht b e re-
sp onsib le for the p atient’s sy m p tom s. T he follow ing
ED X tests are recom m end ed for confi rm ing the
p resence of tib ial m ononeurop athy at the level of
the tarsal tunnel in the ank le/foot in p atients w ith
clinically susp ected T T S:
1. T ib ial m otor NC Ss, w ith resp onses record ed over
the ab d uctor hallucis and ab d uctor d ig iti m inim i
p ed is m uscles, d em onstrating p rolong ed d istal
onset latency (L evel C , C lass I I I ).
2. Med ial and lateral p lantar m ix ed NC Ss, d em on-
strating p rolong ed p eak latency or slow ed con-
d uction velocity across the tarsal tunnel (L evel C ,
C lass I I I ).
3. Med ial and lateral p lantar sensory NC Ss, d em on-
strating slow ed cond uction velocities across the
tarsal tunnel and /or sm all am p litud e or ab sent
resp onses (L evel C , C lass I I I ).
4. T he utility of need le EMG in the assessm ent of
T T S is unclear (L evel U , d ata insuffi cient).
RECOMMEND ATION F OR F U TU RE RES EARCH
S TU D IES
T he AANEM recom m end s that future clinical re-
search stud ies evaluating the usefulness of ED X test-
ing to confi rm the d iag nosis of clinically susp ected
T T S m eet all of the criteria that w ere used to evalu-
ate the literature in the d iag nosis of T T S. I n ad d i-
tion, it is recom m end ed that the stud ies b e p er-
form ed in a b lind ed fashion and that ED X
d eterm ination b e ob tained in a m ix ed p op ulation of
those m eeting a case d efi nition, norm al control sub -
jects, and those w ith sim ilar com p laints b ut not
m eeting the case d efi nition of T T S.
I n ad d ition, it is recom m end ed that: (1) consen-
sus criteria b e d evelop ed and tested to form a stan-
AANEM P ractice Topic
d ard case d efi nition of T T S; (2) future clinical re-
search stud ies includ e need le EMG to d eterm ine its
utility in the assessm ent of p atients w ith clinically
susp ected T T S; and (3) outcom e stud ies b e p er-
form ed to assess the risk s, b enefi ts, and cost of NC Ss
and need le EMG in p atients w ith clinically susp ected
T T S.
D IS CL AIMER
T his rep ort is p rovid ed as an ed ucational service of
the AANEM. I t is b ased on an assessm ent of the
current scientifi c and clinical inform ation. I t is not
intend ed to includ e all p ossib le m ethod s of care
for a p articular clinical p rob lem , or all leg itim ate
criteria for choosing to use a sp ecifi c p roced ure. I t
is not intend ed to ex clud e any reasonab le alterna-
tive m ethod olog ies. T his statem ent is not intend ed
to ad d ress all p ossib le uses of, or issues reg ard ing ,
the evaluation of tarsal tunnel sy nd rom e and in no
w ay refl ects up on the usefulness of electrod iag nos-
tic stud ies in those areas not ad d ressed . T he AA-
NEM recog niz es that sp ecifi c p atient-care d eci-
sions are the p rerog ative of the p atient and their
p hy sician and are b ased on all of the circum -
stances involved . T hese g uid elines are not a sub -
stitute for the ex p erience and jud g m ent of a p hy -
sician. T his review w as not w ritten w ith the intent
that it b e used as a b asis for reim b ursem ent d eci-
sions.
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