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Hi everybody,

I'm wondering what opinions people have for diagnostic testing (other than clinical exam) for nerve entrapments around the tarsal tunnel. From what I've read, electrodiagnostic tests are not very accurate especially for smaller nerve fibers and there is not much research to support using ultrasound. The orthopedists I work with who treat heel pain may do an MRI which often shows involvement of the plantar fascia but I don't know if MRI can show involvement of the nerves. I have several patients whose clinical exams seem very consistent with a neural origin to their pain but in the absence of a diagnostic test, I find the diagnosis from the doc (ortho or DPM) is always plantar fasciitis. Any thoughts?
Thank you!

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It's quite straight forward to assess clinically, and often underdiagnosed.
I would palpate, percuss at the high and low tarsal tunnels (tingling, a positive tinels sign is a signal of axonal regeneration, thus indicating local neural involvement), followed by neurodynamic testing, namely SLR (straight leg raise) where you can sensitise for peroneal nerve would be all I would do. Assuming of course, a full msk assessment had already been done.

Once study found 63% of people with suspected radiculopathy (ie. nueral symptoms of spinal origin) referred to a tertiary centre for electrical studies in fact had peripheral entrapments and problems of msk origin.

Nerve entrapments are very common, I see proabably 2 a week in (but I only do MSK paediatrics, I couldn't say how frequent in adult population)

Hope that helps

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Patient (age 6) "Mum, I know you're pregnant, but why is your bum big too?"

Thanks Sally...I am familiar with the clinical exam. I'm wondering if you or anyone else ever does any other diagnostic testing/ imaging, etc. Any thoughts?

I don't know about others, but I work in a specialist multidiscliplinary MSK team with physios, OT, orthopod, paediatrician etc and we never request testing. we might via neurologist for nerve condution studies for suspected nuerological consditions. I am not sure of the need for electrodiagnostics when clinical assessment is adequate and comprehensive. I have a number of texts on nuerodynamics and assessment and must say I havent come across any mention for the need for any such tests. There may be some but whether or not it is necessary or valid is quite another.

The paper I refer to in my original reply where 63% of people with suspected radiculoopathy didn't but rather had peripheral entrapment did not state how they assessed for the peripheral problem.

I would scan David Butler's publications and texts for any further info. And take a look at the NOI (nuero orthopaedic institute) website as they are the heavy weights in this area. http://www.noigroup.com/

May I ask the reason you want it for?

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Patient (age 6) "Mum, I know you're pregnant, but why is your bum big too?"

Whilst on this subject, what are peoples views that LA is under used as a diagnostics tool?

Hi Sally,

Thank you for the reference to the Neuro Orthopaedic Institute. I am familiar with David Butler's work particularly involving upper and lower extremity nerve tension tests.

I ask my question about diagnostic testing because as you know, a lot is written about differentiating heel pain due to primary involvement of plantar fascia versus other sources such as nerve entrapment. Given the controversy around reliability of clinical exam, including nerve tension testing, to diagnose heel pain of neural origin, I was just wondering how often members of Podiaty Arena used diagnostic testing other than clinical exam to clarify the diagnosis-particularly in recalcitrant cases. I am a Physical Therapist in the USA and therefore can not order tests. DPMs and Orthopedists I have worked with do not typically order tests and will more likely go on to surgery (i.e. plantar fascia release) for patients with heel pain who do not respond to conservative treatment. Although electrodiagnostic tests and ultrasound are certainly not "gold standard" for diagnosis, I wonder if members of Podiatry Arena use these tests (or others) to help clarify the need for surgery in recalcitrant cases and whether the surgery will be a plantar fascia release or nerve decompression.

And if not electrodiagnostic testing, ultrasound or MRI, does anyone use injections to the tarsal tunnel region to assist with diagnosis or treatment?

There's research and then there's what people actually do...I was just wondering what the members of Podiatry Arena actually do...

Thank you for your responses!

Here's a useful paper on the topic

http://www.biblio.physiotek.com/site...nagement_0.pdf

Dave

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Descartes seems to consider here that beliefs formed by pure reasoning are less doubtful than those formed through perception.

Thank you David. I have that paper and refer to it frequently. I'm wondering if people find diagnostic testing helpful despite the research findings that may not support their use. Thank you for your response!

Hi Ann

I cannot make any authoritative comment on this but can suggest that I'm increasingly trying to get my head around the NOI techniques and increasingly use them on a number of low leg, foot and ankle conditions with helpful results. To date, using the NOI assessments and treatment techniques has been useful in dealing with some intractable conditions, to the point where I will often use these techniques as a starting point when these conditions present.

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Ian Linane

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Hi Ann

My approach if suspecting tarsal tunnel syndrome is to do a US exam for space filling lesions within tarsal tunnel, explore tibial nerve for evidence of swelling from proximal to distal to tarsal tunnel and look for possible impingement bony zones around medial malleolus.

If suspecting more proximal nerve injury a guided diagnostic injection with Lidocaine slightly proximal to tarsal tunnel should clarify this.

I think this is often a difficult diagnosis to be sure about since it seems plausible that the degree of nerve injury causing symptoms may be slight and imaging insufficiently sensitive to associated changes, ditto electro conductive tests which are regarded as gold standard for peripheral nerve damage.

Even in absence of any evidence from imaging or other tests I find myself using foot orthoses empirically with belief that mitigating stress within the tarsal tunnel is possible by applying some ground reaction force to counteract pronatory ankle joint complex motion; this often seems to be helpful.

An area which I feel may be rewarding is to use dynamic US exam to view how adequately the tibial nerve is able to glide within tarsal tunnel with passive range of motion; I am unaware that this has been studied properly but may give some insight into theories around nerve tension vs compression injury.

Hope that helps

Martin


Foot and Ankle Clinic
1365 Grant Ave.
Winnipeg Manitoba R3M 1Z8
phone [204] 837 FOOT (3668)
fax [204] 774 9918
www.winnipegfootclinic.com

I would also suggest that a nueral diagnosis would be particularlary indicated where there is an absence of positive symptoms in palpation of plantarfascia and surrounding structures and where the only response is to nuerodynamic testing.

I am quite shocked what you say about the desire to go to surgery, thats very last resort, especially for anyone who wants to remain active in ambulation.

A large number of plantarfasciitis cases are considered to be due to active trigger points and respond very well to accupuncture. So invaluable has this become it is now taught at undergraduate level and very frequently utilised for plantarfasciitis and many previously 'stubborn' cases respond beautifully. This being the case, it makes sense that prior to clinicians awareness of this, how many of their cases they once considered 'failing to respond to any treatment' were simply a misdiagnosis of ORIGIN of the pain, and thus refer onto further more invasive treatment.

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Patient (age 6) "Mum, I know you're pregnant, but why is your bum big too?"

and of course, many cases, even where there is a nuerodynamic issue will have an MSK element as well. Just to state the obvious

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Patient (age 6) "Mum, I know you're pregnant, but why is your bum big too?"

What co morbidities? surely not! May seem obvious but a scenario often overlooked I think.

Dave

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Descartes seems to consider here that beliefs formed by pure reasoning are less doubtful than those formed through perception.

very true Dave

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Patient (age 6) "Mum, I know you're pregnant, but why is your bum big too?"