The accessory soleus and recurrent tarsal tunnel syndrome: case report of a new surgical approach.

The accessory soleus muscle is a rare anatomic variant, which presents as a mass in the posteromedial aspect of the ankle. This anomaly has been linked with compression neuropathy of the posterior tibial nerve. The authors present a case of tarsal tunnel syndrome in which the presence of an accessory soleus was unrecognized at the time of the original procedure, but was utilized during the revisional operation to provide safe coverage of the posterior tibial nerve.     

Soft tissue chondroma compression—A unique cause of tarsal tunnel syndrome: A case report and review of the literature

Posterior tibial nerve entrapment can be caused by extrinsic compression in the tarsal tunnel. We report a nerve compression due to a chondroma in the tarsal tunnel. To our knowledge it is a very rare cause of tarsal tunnel syndrome.     

Tarsal tunnel syndrome associated with an accessory muscle

Between 1986 and 1999, we surgically treated 41 patients (49 feet) with Tarsal Tunnel Syndrome (TTS) in whom seven (eight feet) were associated with an accessory muscle. An accessory flexor digitorum longus muscle was present in six patients, and an accessory soleus muscle was in one patient (both feet). Three of them were males and four females, with the mean age of 33.1 years (12 to 59 years). The mean interval from the onset of symptoms to operation was 7.5 months (range, six to nine months). All patients with an accessory muscle had a history of trauma or strenuous sporting activity. The diagnosis of TTS was made based on physical findings in all the patients (eight feet) and confirmed in five patients (six feet) by electrophysiological examination. Imaging examinations (radiography, ultrasonography, MRI) revealed abnormal bone and soft tissue lesions in and around the tarsal tunnel. Preoperative signs and symptoms disappeared average 4.1 months after decompression of the tibial nerve in addition to excision of the muscle. No functional deficit was observed at final follow-up (24 to 88 months).     

Venous malformation as source of a tarsal tunnel syndrome: treat the source or the cause of the complaints? A case report

Painful tarsal tunnel syndrome is a compression neuropathy with a variety of possible sources. As it presents a challenging differential diagnostic problem, it is often under-diagnosed. Among the intrinsic and extrinsic factors, varicose veins are the main source in case of a venous etiology.

We report a case of a 39-year old male patient who presented with complaints of paresthesia and excessive pain of the right foot, especially the medial side. Further work up by ultrasonography, magnetic resonance imaging and electromyography revealed an extensive congenital venous malformation of the right lower limb with subsequent compression of the tibial nerve in the tarsal tunnel. We did not treat the source, but the cause by open tarsal tunnel release. Excellent result with immediate full relieve of the patients complaints was achieved.     

Tibial nerve decompression: Reliable exposure using shorter incisions

Background: Patients and surgeons recognize the value of procedures that minimize scarring and tissue dissection, but technical standards do not exist with regards to incision lengths needed for tibial nerve decompression. This article introduces reproducible techniques that reliably provide exposure for release of known anatomical compression points of the tibial nerve, while minimizing the length of required skin incisions. Methods: The senior author's approach to decompression of the tibial nerve at the soleus arch and the tarsal tunnel is presented. Typical incision lengths and surgical exposure are demonstrated photographically. The safety of using this technique is examined by review of the medical records of all patients undergoing this procedure from 2003 to 2011, looking for technical complications such as unintentional damage to nerves or adjacent structures. Results: 224 consecutive patients undergoing 252 total procedures underwent release of known anatomical compression points of the tibial nerve at either the tarsal tunnel, inner ankle, or the soleus arch. Typical incision lengths used for these procedures were 5 cm for the proximal calf and 4.5 cm for the tarsal tunnel. Review of medical records revealed no incidences of unintentional injury to nerves or adjacent important structures. Functional and neurological outcomes were not assessed. Conclusions: Tibial nerve decompression by release of known anatomical compression points can be accomplished safely and effectively via minimized skin incisions using the presented techniques. With appropriate knowledge of anatomy, this can be performed without additional risk of injury to the patient, making classically‐described longer incisions unnecessarily morbid. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

A GANGLION CAUSING THE TARSAL TUNNEL SYNDROME: REPORT OF A CASE

The tarsal tunnel syndrome is a complex of symptoms affecting the foot produced by compression neuropathy of the posterior tibial nerve on the medial aspect of the ankle, within the fibrous osseous “tunnel” that has the posteromedial aspect of the tibia as its floor and the flexor retinaculum as its roof. Keck first drew attention to this entity in 1962, and was followed by Lam in the same year. Despite sporadic reports following these documentations, the clinical recognition of the syndrome is often delayed. It is still frequently misdiagnosed as acute foot strain or plantar fasciitis at its initial presentation (Kopell and Thompson, 1963; Lam, 1962, 1967). In this paper we report a case of tarsal tunnel syndrome caused by compression of the posterior tibial nerve by a ganglion at the ankle.     

A ganglion causing the tarsal tunnel syndrome: report of a case.

The tarsal tunnel syndrome is a complex of symptoms affecting the foot produced by compression neuropathy of the posterior tibial nerve on the medial aspect of the ankle, within the fibrous osseous "tunnel" that has the posteromedial aspect of the tibia as its floor and the flexor retinaculum as its roof. Keck first drew attention to this entity in 1962, and was followed by Lam in the same year. Despite sporadic reports following these documentations, the clinical recognition of the syndrome is often delayed. It is still frequently misdiagnosed as acute foot strain or plantar fasciitis at its initial presentation (Kopell and Thompson, 1963; Lam, 1962, 1967). In this paper we report a case of tarsal tunnel syndrome caused by compression of the posterior tibial nerve by a ganglion at the ankle.     

Acute tarsal tunnel syndrome following partial avulsion of the flexor hallucis longus muscle: a case report.

An acute posterior tibial nerve compression from a partially ruptured flexor hallucis longus (FHL) muscle is reported. This etiology for acute tarsal tunnel syndrome has not been previously described. A 17-year-old male sustained multiple injuries in a motor vehicle accident, including a tibial shaft fracture and a posterior medial right ankle laceration of the same limb. The injured limb had no sensation on the plantar aspect of the foot and heel, decreased active great toe flexion, and associated leg pain. Exploration of the posterior tibial nerve for presumed laceration revealed the nerve to be intact, but compressed in a tense tarsal tunnel from a retracted partially ruptured flexor hallucis longus tendon. Decompression of the tunnel and resection of the devascularized muscle resulted in complete neurologic recovery.     

A rare case of an accessory flexor hallucis longus causing tarsal tunnel syndrome

Tarsal tunnel syndrome (TTS) is a rare entrapment neuropathy of the tibial nerve within the fibro-osseous tarsal tunnel for which multiple etiologies, including trauma, congenital foot abnormalities and space occupying lesions, have been described. We present an unusual case of TTS caused by an accessory Flexor Hallucis Longus (FHL) tendon. Surgical excision led to a complete resolution of symptoms and improved the quality of life of our patient.     

Tarsal tunnel syndrome: a compression neuropathy involving four distinct tunnels

Tarsal tunnel syndrome is a complex and often under-diagnosed or misdiagnosed condition that affects the foot and ankle. It is a compression neuropathy of the posterior tibial nerve as it passes in the anatomic tarsal tunnel in the medial ankle under flexor retinaculum. This article reviews diagnosis, conservative treatment, and surgical outcomes, which have dramatically improved with more comprehensive release of the foot nerves in addition to the tibial nerve. Internal neurolysis facilitates a second level of nerve decompression in needed cases. Physical therapy protocols have made it possible for patients to return to ambulation with limited long-term down time.     

Tarsal tunnel syndrome. A case report and review of the literature

An illustrative case report and a review of the literature are presented. The tarsal tunnel syndrome is a relatively rare syndrome consisting of pain, paresthesias, and varying degrees of motor and vasomotor changes in any or all three branches of the posterior tibial nerve at the ankle. It represents a pressure neuropathy secondary to intrinsic or extrinsic stenosis of the tarsal tunnel, with a wide variety of underlying causes. The clinical suspicion may be confirmed by electromyography and nerve conduction studies, comparing motor and sensory action potential latency, amplitude and duration to that of the uninvolved foot. Surgical decompression affords the only consistent good results with an 80% to 90% cure rate.     

Tibial osteochondroma causing foot pain mimicking tarsal tunnel syndrome: A case report

Nerve entrapment syndromes of the lower extremity are relatively rare in patients with multiple hereditary osteochondromatosis. A case of tarsal tunnel like symptoms in a 52-year-old woman with a distal tibial osteochondroma is presented. This case emphasizes that the possibility of nerve compression needs to be considered in a patient with multiple hereditary osteochondromatosis and that tibial osteochondromas can be a cause of tarsal tunnel-like symptoms.     

Median and ulnar nerve compression at the wrist caused by anomalous muscles

Compression of the median and ulnar nerves at the wrist is frequently encountered. Carpal tunnel syndrome usually occurs without any obvious extrinsic cause; several cases have however been reported caused by anomalous or hypertrophic muscles. A survey of the literature shows that compression neuropathy of the median nerve has been reported in relation with anomalies affecting three muscles: the first (or second) lumbrical, the palmaris longus and its anatomic variants and the superficial flexor of the index finger. In the ulnar tunnel the situation is thoroughly different: so-called idiopathic ulnar tunnel syndrome is rare and an extrinsic compressing structure can usually be disclosed. Anomalous muscles belong to the palmaris longus/abductor digiti minimi group; the flexor carpi ulnaris is sometimes involved. One can suspect the presence of such an anomalous muscle when the compression syndrome concerns a patient who is not within the "usual" age group with symptoms initiated or aggravated by physical exercise.     

Iatrogenic posterior tibial neurothlipsis: a tarsal tunnel syndrome

Posterior tibial neurothlipsis in the retromalleolar space, secondary to internal fixation of a prior ankle fracture, is presented in the following report. The possibility of a tarsal tunnel syndrome cannot be ruled out. No apparent similar reference is made in the medical literature concerning the above etiology of posterior tibial compression/neurothlipsis/tarsal tunnel syndrome. Electrodiagnosis with sensory nerve conduction velocities is reviewed for more accurate diagnosis of tarsal tunnel syndrome.     

Medial tarsal tunnel syndrome: a review

The medial tarsal tunnel syndrome is a compression neuropathy involving the tibial nerve or its branches as they pass through the tarsal tunnel under the flexor retinaculum. Medial tarsal tunnel syndrome is not recognized as readily as its counterpart in the wrist. This syndrome can lead to a painful burning sensation in the medial border of the foot and into the great toe. In its fullest extent medial tarsal tunnel syndrome can involve sensory changes in the heel and the lateral part of the sole of the foot as well as the remaining toes. In addition, it may lead to weakness of the intrinsic muscles of the foot. This syndrome often goes unrecognized or misdiagnosed particularly in the athlete. While medial tarsal tunnel syndrome may respond initially to nonoperative techniques of ultrasound and modification of footwear, as it progresses surgical release of the nerve in the tunnel will be required for optimal results. This paper reviews the anatomy, etiology, pathology, clinical presentation, and treatment of the medial tarsal tunnel syndrome. In order to bring more attention to this condition, our clinical experience is presented.J Orthop Sports Phys Ther 1984;6(1):39-45.     

The proximal and distal tarsal tunnel syndromes

Summary Clinical and electromyographic studies in the tarsal tunnel syndrome may suggest compression of only one of the two terminal branches of the posterior tibial nerve.This anatomical study demonstrates the structures which may cause isolated damage to either the medial plantar or the lateral plantar nerves.A surgical approach to the tarsal tunnel is described.

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Résumé Certaines observations cliniques et électromyographiques de syndromes du tunnel tarsien permettent de penser qu'une seule des deux branches terminales du nerf tibial postérieur est comprimée. Dans cette étude anatomique les auteurs montrent quelles sont les structures qui peuvent entraîner l'atteinte isolée du nerf plantaire interne ou externe. Ils décrivent une voie d'abord chirurgical du tunnel tarsien.

     

Effect of foot and ankle position on tarsal tunnel compartment volume

BACKGROUND: Tarsal tunnel pressure is increased when the foot and ankle are positioned in eversion or inversion from neutral, aggravating symptoms of tarsal tunnel syndrome in some patients. Space-occupying lesions may cause tarsal tunnel syndrome. We hypothesized that positional change of the foot and ankle from neutral to eversion or inversion causes decreased tarsal tunnel compartment volume that may aggravate symptoms of posterior tibial nerve entrapment. METHODS: MRI of 13 ankles in nine healthy subjects in three positions (neutral, eversion, inversion) were obtained with respect to the malleolar-calcaneal plane; this plane was defined by the distal tip of the anterior colliculus of the medial malleolus, the medial tubercle of the posterior calcaneal tuberosity, and the lateral tubercle of the posterior calcaneal tuberosity. The borders of the tarsal tunnel noted on the MRI were traced with a computer digitizing apparatus to determine the cross-sectional area of the tarsal tunnel on each image, and the slice thickness and interspace distance for the seven central images were used to calculate tarsal tunnel volume. RESULTS: The mean tarsal tunnel volume was significantly greater when the foot and ankle were in neutral position (21.5 +/- 0.9 cm(3)) than in either full eversion (18.0 +/- 0.9 cm(3); p = or < 0.001) or inversion (20.3 +/- 1.0 cm(3); p = or < 0.001). CONCLUSIONS: The results support the hypothesis that eversion and inversion of the foot and ankle cause decreased compartment volume of the tarsal tunnel and increased tarsal tunnel pressure that may contribute to symptoms of posterior tibial nerve entrapment in tarsal tunnel syndrome. CLINICAL RELEVANCE: Neutral immobilization of the foot and ankle may relieve symptoms of posterior tibial nerve entrapment in tarsal tunnel syndrome by minimizing pressure on the nerve and maximizing tarsal tunnel compartment volume available for the nerve.     

Combined peroneal and proximal tibial nerve palsies

Combined compression of both the common peroneal nerve and the proximal tibial nerve at the level of the popliteal fossa is rare. Recently, an anatomic site of compression of the proximal tibial nerve at the soleal sling (originating arch for the soleus muscle) has been described in cadavers. The present report includes three patients who had a combined compression of the common peroneal nerve at the fibular neck (fibular tunnel syndrome) and compression of the proximal tibial nerve at the soleal sling (soleal sling syndrome). In each case, blunt trauma was the precipitating event. Neurolysis of both nerves resulted in restoration of motor and sensory function in each ofthese three patients. This is the first clinical report illustrating combined neurolysis of the common peroneal at the knee and the proximal tibial nerve in the soleal sling. © 2009 Wiley‐Liss, Inc. Microsurgery, 2009.     

Results of decompression of four medial ankle tunnels in the treatment of tarsal tunnels syndrome

Controversy surrounds the surgical approach and efficacy for tibial nerve compression at the ankle. The hypotheses tested are that the poor published results are due to failure to recognize that the tarsal tunnel is analogous to the forearm, not the carpal tunnel, and that postoperative ankle immobilization contributes to poor results by permitting fibrosis of the tibial nerve branches. From January of 1987 through December of 1994, a consecutive series of 77 patients with tarsal tunnel syndrome was accrued, 10 of whom had the condition bilaterally. The surgical approach included a neurolysis of the tibial nerve in the tarsal tunnel and the medial, lateral plantar, calcaneal nerves in their own tunnels. Postoperatively, immediate weight bearing and ambulation were permitted in a bulky cotton dressing. The dressing was removed at 1 week. For the 87 legs, mean follow-up after surgery was 3.6 years. Utilizing the traditional postoperative assessment, there were 82% excellent, 11% good, 5% fair, and 2% poor results. Utilizing a numerical grading scale, there was a statistically significant improvement at the P<0.001 level for sensory and also for motor impairment. Recognition that decompression of four medial ankle tunnels and immediate postoperative mobilization of the tibial nerve through ambulation is necessary results in a high level of success for patients with tarsal tunnels syndrome.     

The surgical treatment of tarsal tunnel syndrome

Tarsal tunnel syndrome is an entrapment neuropathy involving the posterior tibial nerve within the tarsal canal. Typical symptoms include burning pain and paraesthesia along the medial ankle and plantar aspect of the foot. Although potential causes of tarsal tunnel syndrome include trauma, varicosities, tenosynovitis, space-occupying lesions, and hindfoot deformity, in most cases the aetiology is idiopathic. Surgical release of the posterior tibial nerve and its terminal branches is indicated if symptoms persist despite non-operative treatment. In this article, we discuss the pre-operative evaluation of these patients and illustrate in detail our preferred technique for surgical release.