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Background: The details of the occurrence of tarsal tunnel syndrome in athletes have not been well documented in the literature, and more data on tarsal tunnel syndrome related to sporting activity are necessary to enable better recognition of this condition.
Hypothesis: Sporting activities make athletes vulnerable to the occurrence of tarsal tunnel syndrome under specific conditions.
Study Design: Case series; Level of evidence, 4.
Methods: Between 1986 and 2002, 18 patients with tarsal tunnel syndrome related to sporting activities were surgically treated, of whom 15 patients (21 feet; mean age, 17.8 years) were competitive athletes and 3 were recreational sports amateurs (4 feet; mean age, 52.7 years). To assess the role of physical factors and sporting activities in making athletes vulnerable to the occurrence of tarsal tunnel syndrome, the authors reviewed the medical charts and evaluated the results of treatment. The mean duration of follow-up was 58.6 months.
Results: Activities that triggered tarsal tunnel syndrome were those that applied a heavy burden on the ankle joint such as sprinting, jumping, and performing ashibarai in judo under specific physical conditions. Predisposing underlying physical factors were flatfoot deformity and an existence of talocalcaneal coalition, accessory muscles, and bony fragments around the tarsal tunnel. The majority of patients were able to return to the same sport after treatment.
Conclusion: Tarsal tunnel syndrome occurs in athletes involved in strenuous sporting activities, especially when predisposing physical factors are present.
In relation to its counter-part in the upper-limb (carpal tunnel syndrome), the signs and symptoms are classical. Patients often c/o symptoms, relating to median nerve compromise, that are worse in the morning. Nerve conduction tests are quite conclusive. Jamar dynamometer strength testing is consistently poor.
How is TTS diagnosed? What are the signs and symptoms?
These are my notes I used to handout when I used to teach the neurology:
Quote:
Tarsal tunnel syndrome is an entrapment or compression neuropathy of the tibial nerve or its branches as it courses in the fibro-osseous tunnel under the flexor retinaculum, posterior to the medial malleolus.
Clinical Features
Symptoms and signs vary (depends on exact location and cause; also the nerve has sensory, motor and autonomic innervations), but the most common features are gradual onset of tenderness, intermittent burning, tingling, shooting, numbness or radiating pain along the course of the tibial nerve or one of its branches – pain may be in heel, sole, metatarsal heads or toes or a combination of these sites (should be consider in differential diagnosis of metatarsalgia and heel pain). Forced pronation of foot may exacerbate symptoms. Less common features a decreased sensation on the plantar surface, a weakness of the intrinsic muscles, feelings of a “fullness” in the arch and a swelling over the tarsal tunnel. May get cramp in arch that awakens from sleep. In severe cases --> parathesias or anaesthesia. Tarsal tunnel syndrome is usually unilateral. The symptoms tend to be exacerbated by prolonged standing or walking. With progression, the pain is commonly present at night. ‘Tapping’ lightly over the tarsal tunnel may produce symptoms distally (Tinel’s sign) or proximally (Valliex sign). Sensory disturbances may be noted in distribution of nerve – especially vibration. Later get motor signs (atrophy of intrinsic muscles).
Nerve conduction studies have been widely used to support the diagnosis in the presence of a positive history – usually a delayed distal latency. Sensitivity of nerve conduction is 70-90% - 10%+ false negatives. MRI can show lesions in the tarsal tunnel.
Aetiology
The aetiology may be multifactorial, with a large number of cases having no identifiable aetiology (most due to overuse/repetitive microtrauma).
1) Trauma:
This may result from direct trauma, fracture, ankle sprains. The nerve may also be compressed by tight footwear (eg ski boots) or plaster casts. Traumatic events may lead to tarsal tunnel syndrome as a result of:
1. Post traumatic fibrosis of the flexor retinaculum or intracanal fibrosis
2. Fracture or dislocation causing a spatial alteration or direct impingement on the nerve
3. Tenosynovitis
4. Post traumatic oedema and haematoma formation
5. Cysts, osteophytes or ganglions
2) Systemic disease:
Inflammatory diseases such as rheumatoid arthritis, can cause a swelling around the flexor retinaculum or a tenosynovitis, raising pressure in the tarsal tunnel. Oloff et al (1983) found systemic disease in 35% (diabetes – 20%, inflammatory arthritis – 12%, hypothyroidism – 2%).
3) Biomechanical:
It is thought that feet that excessively pronation of the foot may tighten structures in the tarsal tunnel, compressing the tibial nerve or directly overstretching the tibial nerve. Tarsal tunnel compartment pressure has been shown to be significant higher when the foot is held in an inverted or everted position. Daniel et al (1998) showed an increase in tension on the tibial nerve in an unstable foot during eversion.
4) Soft tissue masses:
Space occupying lesions, such as ganglioneuromas, lipomas, schwanomas, neural lesions, haemangiomas, neurilemoma have been reported as causing compression on the tarsal tunnel.
5) Other:
Tarsal tunnel syndrome has been associated with an accessory flexor digitorum longus muscle which originated from the tendon of the flexor hallucis longus. It is assumed that the presence of the muscle increased pressure in the tarsal tunnel.
Other reported causes include accessory ossicles, hypertrophy of abductor hallucis, rapid weight gain and connective tissue changes associated aging.
6) Idiopathic
Could be most common – up to 30% may have no identifiable cause.
Management:
Will depend on aetiology - important that it is determined. Orthoses and/or heel raises to invert foot (reduces neural tension and inflammation/tension on other tarsal tunnel structures); local injection of corticosteroids; anti-inflammatory medication; activity modification/relative rest - conservative treatment often unsuccessful, but will depend on aetiology. Elastic stockings if oedema present. Neural tension stretching. Definitive treatment is surgical release of tarsal tunnel (reports of symptom relief in 85%-90%).
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
I was speaking to a nerve-conduction-test-technician at the Epworth last year while he was assessing my CTS, and when questioning him about TTS, he said "I don't think it exists as much as 'they' think". I don't know who is 'they'. 'They' might be 'us'.
I hope I am not confusing myself with SinusTarsiSyndrome. I must contact the tech again to find out for sure.
I find a few of my TTS patients will complain of heaviness or fatigue in the foot.Is that common? As for cause,it seems to me like the tarsal tunnel is a crowded place.It has 4 compartments.There are muscles,nerves and blod vessels here.It could be a case of overcrowding.Of course,either ankle instability or sports that put pressure on the ankle are a major cause of it.
Background
Assessment of treatment outcomes for tarsal tunnel syndrome may be improved with a standardized pain rating scale using a descriptive anatomical foot model for pretreatment and post-treatment plantar foot pain analysis.
Methods
Prospective evaluation of 46 consecutive patients (56 feet) who had non-operative and surgical treatment for tarsal tunnel syndrome. Pain intensity was documented before and after treatment with the Wong-Baker FACES Pain Rating Scale applied to the anatomic nerve regions of the plantar aspect of the foot.
Results
In patients who had successful non-operative treatment, overall pain intensity was significantly improved in the medial calcaneal, medial plantar, and lateral plantar nerve regions. In patients who had ongoing symptoms despite non-operative treatment, surgical treatment resulted in significant pain improvement in the medial calcaneal and medial plantar, but not lateral plantar, nerve regions. Pretreatment motor nerve conduction latency was significantly greater in patients who had surgical treatment than those who had only non-operative treatment.
Conclusions
Anatomic pain intensity rating models may be useful in the pretreatment and follow-up evaluation of tarsal tunnel syndrome. Predictors of failed non-operative treatment included longer motor nerve conduction latency and greater predominance of foot comorbidities.
Tibial Nerve Decompression in Patients with Tarsal Tunnel Syndrome: Pressures in the Tarsal, Medial Plantar, and Lateral Plantar Tunnels.
Rosson GD, Larson AR, Williams EH, Dellon AL. Plast Reconstr Surg. 2009 Oct;124(4):1202-1210.
Quote:
BACKGROUND:: The anatomical basis for the surgical techniques used to treat tarsal tunnel syndrome is not well studied. The authors sought to evaluate their hypotheses that (1) pronation and pronation with plantar flexion of the intact foot would have higher pressures than the intact foot in other positions; (2) decompression surgery would significantly lower the pressure in all three tunnels in all foot positions, and roof incision plus septum excision would lower the pressure further in some positions; and (3) the pressures in symptomatic patients would be significantly higher than those in an analogous cadaver study.
METHODS:: In 10 patients with tarsal tunnel syndrome, the authors intraoperatively measured pressures in the tarsal, medial plantar, and lateral plantar tunnels in multiple foot positions before and after excision of the tunnel roofs and intertunnel septum.
RESULTS:: The authors found that (1) pronation and plantar flexion significantly increased pressures in the medial and lateral plantar tunnels, to levels sufficient to cause chronic nerve compression; (2) tunnel release and septum excision significantly decreased those pressures; and (3) compared with cadaver pressures, patients had similar tarsal tunnel pressures but higher lateral plantar tunnel pressures in some positions.
CONCLUSIONS:: Many surgeons operating on patients with tarsal tunnel syndrome do not decompress the respective medial plantar and lateral plantar nerves and excise the septum. The authors' study validates the hypotheses that patients who are clinically suspected of having chronic compression of the tibial nerve and its branches at the ankle have higher tunnel pressures and that releasing these structures decreases the pressures.
Tarsal Tunnel Syndrome
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