EXPLAIN IN DETAIL THE CLINICAL FEATURES , DIAGNOSIS AND MANAGEMENT OF TARSAL TUNNEL SYNDROME ?
A 15 INTRODUCTION
1 Tarsal tunnel syndrome (TTS), also known as posterior tibial neuralgia, is a compression neuropathy and painful foot condition in which the tibial nerve is compressed as it travels through the tarsal tunnel.
2 This tunnel is found along the inner leg behind the medial malleolus
3 The flexor retinaculum has a limited ability to stretch, so increased pressure will eventually cause compression on the nerve within the tunnel.
A ) As pressure increases on the nerves, the blood flow decreases.
B ) Nerves respond with altered sensations like tingling and numbness.
C ) Fluid collects in the foot when standing and walking and this makes the condition worse.
D ) As small muscles lose their nerve supply they can create a cramping feeling
COMPONENTS OF TARSAL TUNNEL **
A ) The posterior tibial artery
B ) tibial nerve
C ) tendons of the tibialis posterior, flexor digitorum longus, and flexor hallucis longus muscles travel in a bundle through the tarsal tunnel.
D ) vv imp Inside the tunnel, the nerve splits into three different segments -
1 One nerve (calcaneal) continues to the heel
2 the other two (medial and lateral plantar nerves) continue on to the bottom of the foot.
E ) The tarsal tunnel is delineated by bone on the inside and the flexor retinaculum on the outside.
CLINICAL FEATURES *
1 numbness in the foot radiating to the big toe and the first 3 toes
2 pain, burning, electrical sensations, and tingling over the base of the foot and the heel.
3 Swelling of the feet
4 Hot and cold sensations in the feet
5 Pain radiating up into the leg,and down into the arch, heel, and toes
6 A feeling as though the feet do not have enough padding
7 Pain while operating automobiles
8 Pain along the Posterior Tibial nerve pathway
9 Burning sensation on the bottom of foot that radiates upward reaching the knee"
10 Pins and needles"-type feeling and increased sensation on the feet
11 A positive Tinel’s sign
ETIOPATHOGENESIS
1 Idiopathic ( Primary )
2 Secondary to -
A ) benign tumors or cysts
B ) bone spurs
C ) inflammation of the tendon sheath
D ) nerve ganglions
E ) swelling from a broken or sprained ankle.
F ) * Varicose veins (that may or may not be visible) can also cause compression of the nerve.
G ) TTS is more common in athletes and other active people. These people put more stress on the tarsal tunnel area v imp
H ) * Flat feet may cause an increase in pressure in the tunnel region and this can cause nerve compression.
I ) Those with lower back problems may have symptoms.
J ) vv imp Back problems with the L4, L5 and S1 regions are suspect and might suggest a “Double Crush” issue: one “crush” (nerve pinch or entrapment) in the lower back, and the second in the tunnel area.
3 Associated with -
A ) Rheumatoid arthritis
B ) Neurofibromatosis -
1 a disease that results in the formation of pigmented, cutaneousneurofibromas.
2 These masses, in a specific case, were shown to have the ability to invade the tarsal tunnel causing pressure, therefore resulting in TTS
C ) Diabetes -
1 makes the peripheral nerve susceptible to nerve compression, as part of the double crush hypothesis.
2 vv imp In contrast to carpal tunnel syndrome due to one tunnel at the wrist for the median nerve, there are four tunnels in the medial ankle for tarsal tunnels syndrome **
3 If there is a positive Tinel sign when you tap over the inside of the ankle, such that tingling is felt into the foot, then there is an 80% chance that decompressing the tarsal tunnel will relieve the symptoms of pain and numbness in a diabetic with tarsal tunnel syndrome.
DIAGNOSIS
1 is based upon physical examination findings. Patients’ pain history and a positive Tinel’s sign are the first steps in evaluating the possibility of tarsal tunnel syndrome.
2 X-ray can rule out fracture.
3 MRI can assess for space occupying lesions or other causes of nerve compression.
4 Ultrasound can assess for synovitis or ganglia.
5 Nerve conduction studiesalone are not, but they may be used to confirm the suspected clinical diagnosis.
6 Common causes include trauma, varicose veins, neuropathy and space-occupying anomalies within the tarsal tunnel.
7 EMG / NCV ANALYSIS
A ) During this test, electrodes are placed at various spots along the nerves in the legs and feet.
B ) Both sensory and motor nerves are tested at different locations.
C ) Electrical impulses are sent through the nerve and the speed and intensity at which they travel is measured.
D ) If there is compression in the tunnel, this can be confirmed and pinpointed with this test.
MANAGEMENT
A - CONSERVATIVE
1 One being immobilization, by placing the foot in a neutral position with a brace, pressure is relieved from the tibial nerve thus reducing patients pain.
2 Activity Modification - Eversion, inversion, and plantarflexion all can cause compression of the tibial nerve therefore in the neutral position the tibial nerve is less agitate and is recommended in early cases
3 Use of appropriate footwear
4 A ) Strengthening exercises of tibialis anterior, tibialis posterior, peroneus and short toe flexors
B ) Tibial nerve Mobilisation exercises - In this , patients are instructed to sit on the edge of a table in a slumped position, have their ankle taken into dorsiflexion and ankle eversion then the knee was extended and flexed to obtain the optimal tibial nerve mobilization vv imp
5 use of casting with a walker boot
B ) SURGICAL -
Is recommended if non-invasive treatment measures fail, tarsal tunnel release surgery may be recommended to decompress the area.
1 The incision is made behind the ankle bone and then down towards but not as far as the bottom of foot.
2 The Posterior Tibial nerve is identified above the ankle.
3 It is separated from the accompanying artery and vein and then followed into the tunnel.
The nerves are released.
4 Cysts or other space-occupying problems may be corrected at this time.
5 If there is scarring within the nerve or branches, this is relieved by internal neurolysis.
A ) Neurolysis is when the outer layer of nerve wrapping is opened and the scar tissue is removed from within nerve.
6 Following surgery, a large bulky cotton wrapping immobilizes the ankle joint without plaster.
7 The dressing may be removed at the one-week point and sutures at about three weeks.