Orthopedics Book


Posterior Tarsal Tunnel Syndrome

Aka: Posterior Tarsal Tunnel Syndrome, Tarsal Tunnel Syndrome, Tarsal Tunnel, Tibial Neuropathy, Posterior Tibial Nerve Entrapment
  1. Anatomy (See Ankle Anatomy)
    1. Posterior Tibial Nerve
      1. Behind medial malleolus and under flexor Retinaculum
    2. Flexor Retinaculum
      1. Arises from medial malleolus
      2. Insertion into medial Calcaneus
      3. Neurovascular encasement in combination with medial Calcaneus, distal tibia, posterior talus, medial malleolus
        1. Posterior tibial nerve
        2. Tibialis posterior tendon
        3. Flexor digitorum longus tendon
        4. Flexor hallucis longus tendon
        5. Posterior tibial artery
        6. Posterior tibial vein
  2. Epidemiology
    1. Uncommon
  3. Pathophysiology
    1. Posterior Tibial Nerve compressed in flexor Retinaculum and Tarsal Tunnel
  4. Associated Conditions
    1. Phlebitis
    2. Rheumatoid Arthritis
    3. Pes Planus
    4. Foot Fracture
    5. Foot traction injury
    6. Heel or foot deformity
    7. Foot or ankle mass lesion
  5. Symptoms
    1. Burning, numbness, or tingling Sensation
      1. Starts at posteromedial ankle and plantar heel
      2. May radiate into distal sole of foot to toes
      3. May radiate up into calf
      4. May result in cramping of medial longitudinal arch
    2. Provocative
      1. Worse with ambulation, standing or Running
      2. Worse at night
    3. Palliative
      1. Better with rest, foot elevation
      2. Better with loose fitting footwear
  6. Signs
    1. Sensory loss in posterior tibial nerve distribution
    2. Pes Planus may be associated
    3. Motor function usually intact
      1. Intrinsic Muscle Weakness and atrophy may be present
    4. Provocative maneuvers may elicit symptoms
      1. Tinel's sign
        1. Percussion over Tarsal Tunnel (Flexor Retinaculum)
        2. Identify posterior tibial tendon
          1. Lies behind medial malleolus
          2. Find tendon by inverting foot against resistance
        3. Posterior tibial nerve lies behind tibial tendon
      2. Stretch, compress posterior tibial nerve
        1. Simultaneous dorsiflexion and eversion of foot
        2. Simultaneous plantar flexion and inversion of foot
  7. Imaging
    1. Foot MRI (most diagnostic modality)
    2. Ultrasound
    3. Electromyography and Nerve Conduction Studies
  8. Differential Diagnosis
    1. Complex Regional Pain Syndrome
    2. Plantar Fasciitis
    3. Diabetic Neuropathy
    4. Lumbar Disc Disease (Lumbosacral Radiculopathy)
    5. Peripheral Neuropathy
    6. Posterior tibial dysfunction
    7. Exertional Compartment Syndrome
  9. Management
    1. General measures
      1. Modify activities
      2. Stretching Program
      3. Medications
        1. NSAIDs
        2. Tricyclic Antidepressants (e.g. Amitriptyline)
        3. Gabapentin or Pregabalin
    2. Medial Heel wedge or Heel Seat
      1. Inverts heel
      2. Removes traction from tibial nerve
    3. Orthotics to correct foot Posture (e.g. Pes Planus)
    4. Tarsal Tunnel Injection (Corticosteroid Injection)
    5. Surgical release of entrapment
      1. Indicated for persistent symptoms
  10. References
    1. Del Toro in Frontera (2002) Essentials PMR, p. 453-6
    2. Mann in DeLee (2003) Orthopedic Sports Med, p. 2474-6
    3. Shapiro (2003) Med Clin North Am 87(3):663-96 [PubMed]
    4. Tu (2018) Am Fam Physician 97(2):86-93 [PubMed]

Tarsal Tunnel Syndrome (C0039319)

Definition (NCI) A syndrome resulting from the entrapment and compression of the tibial nerve. Signs and symptoms include burning sensation, tingling, and pain in the foot sole.
Definition (MSH) Entrapment of the distal branches of the posterior TIBIAL NERVE (which divides into the medial plantar, lateral plantar, and calcanial nerves) in the tarsal tunnel, which lies posterior to the internal malleolus and beneath the retinaculum of the flexor muscles of the foot. Symptoms include ankle pain radiating into the foot which tends to be aggravated by walking. Examination may reveal Tinel's sign (radiating pain following nerve percussion) over the tibial nerve at the ankle, weakness and atrophy of the small foot muscles, or loss of sensation in the foot. (From Foot Ankle 1990;11(1):47-52)
Concepts Disease or Syndrome (T047)
MSH D013641
ICD9 355.5
ICD10 G57.5, G57.50
SnomedCT 155077008, 47374004
English Syndromes, Tarsal Tunnel, Tarsal Tunnel Syndrome, Tarsal Tunnel Syndromes, Tunnel Syndrome, Tarsal, Tunnel Syndromes, Tarsal, Syndrome, Tarsal Tunnel, tarsal tunnel syndrome, tarsal tunnel syndrome (diagnosis), Entrapment Neuropathy, Tarsal Tunnel, Tarsal Tunnel Entrapment Neuropathy, Tarsal Tunnel Tibial Neuropathy, Tibial Neuropathy, Tarsal Tunnel, Tarsal Tunnel Syndrome [Disease/Finding], Posterior Tibial Nerve Neuralgia, syndrome tarsal tunnel, Tarsal tunnel syndrome, unspecified lower limb, Tarsal tunnel syndrome (ankle condition), Tarsal tunnel syndrome, TTS - Tarsal tunnel syndrome, Tarsal tunnel syndrome (disorder), compression; posterior tibial nerve (in tarsal tunnel), entrapment; neuropathic, nerve, posterior tibial, syndrome; tarsal tunnel, tarsal tunnel; syndrome
Swedish Tarsaltunnelsyndrom
Japanese ソクコンカンショウコウグン, ソッコンカンショウコウグン, 足根管症候群, 足根トンネル症候群
Czech tarzální tunelový syndrom, Syndrom tarzálního tunelu
Finnish Nilkkakanavaoireyhtymä
German Tarsaltunnel-Syndrom, Tarsaltunnelsyndrom, Tibialis-Neuropathie, Tarsaltunnel, Engpaßneuropathie, Tarsaltunnel, Tarsaltunnelneuropathie durch Engpaß
Italian Neuropatia da intrappolamento nel tunnel tarsale, Neuropatia tibiale, Sindrome del tunnel tarsale
Korean 발목 터널 증후군
Spanish síndrome del túnel tarsiano, síndrome del túnel tarsal, síndrome del túnel tarsiano (trastorno), síndrome del túnel tarsal (trastorno), Síndrome del túnel tarsiano, Neuropatía por Atrapamiento del Túnel Tarsiano, Neuropatía Tibial del Túnel Tarsiano, Síndrome del Túnel Tarsiano
Polish Zespół cieśni stępu, Zespół ciasnoty kanału stępu, Zespół kanału stępu, Zespół tunelowy stępu, Zespół cieśni kanału stępu
Hungarian Tarsalis alagút syndroma
Norwegian Tarsaltunnelsyndrom, Tarsaltunnelsyndromet
Portuguese Neuropatia de Compressão do Túnel do Tarso, Síndrome do canal társico, Neuropatia de Aprisionamento do Túnel do Tarso, Neuropatia de Encarceramento do Túnel do Tarso, Neuropatia Tibial do Túnel do Tarso, Síndrome do Túnel do Tarso
Dutch compressie; nervus tibialis posterior (in tarsale tunnel), inklemming; neuropathie, nervus, tibialis posterior, syndroom; tarsale tunnel, tarsale tunnel; syndroom, tarsaletunnelsyndroom, Compressieneuropathie, tarsale tunnel, Syndroom, tarsale-tunnel-, Tarsale-tunnelsyndroom, Tibiale neuropathie, tarsale tunnel
French Syndrome du canal tarsien, Compression du nerf tibial postérieur, Neuropathie de compression du nerf tibial postérieur
Derived from the NIH UMLS (Unified Medical Language System)

Structure of tarsal canal (C0225150)

Concepts Body Space or Junction (T030)
SnomedCT 19567005
Spanish estructura del canal tarsiano (estructura corporal), estructura del canal tarsiano, canal tarsiano, conducto tarsiano, estructura de conducto del tarso (estructura corporal), estructura de conducto tarsiano (estructura corporal), estructura de conducto del tarso, estructura de conducto tarsiano, túnel tarsiano
English tarsal tunnel, Tarsal canal, Tarsal tunnel, Structure of tarsal canal (body structure), Structure of tarsal canal
Derived from the NIH UMLS (Unified Medical Language System)

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