Clinical Results Following Conservative Management of Tarsal Tunnel Syndrome Compared With Surgical Treatment: A Systematic Review

Abstract

Introduction Posterior tarsal tunnel syndrome involves entrapment of the posterior tibial nerve as it travels in the groove posterior to the medial malleolus. Conventional wisdom dictates that patients with tarsal tunnel syndrome be treated with conservative treatment and medical management, with surgical options available for patients with refractory symptoms and good candidacy. Minimally invasive options for neuropathic entrapment syndromes have developed in recent years and may provide a therapeutic role in tarsal tunnel syndrome. Objective The present investigation provides a summary of the current state of knowledge on tarsal tunnel syndrome and a comparison between minimally invasive and surgical treatment options. Methods The literature search was performed in Mendeley. Search fields were varied until redundant. All articles were screened by title and abstract and a preliminary decision to include an article was made. A full-text screening was performed on the selected articles. Any question regarding the inclusion of an article was discussed by 3 authors until an agreement was reached. Results Most commonly tarsal tunnel syndrome is idiopathic. Other reported causes include post-traumatic, lipomas, cysts, ganglia, schwannomas, ganglia, varicose plantar veins, anatomic anomalies, and systematic inflammatory conditions. Several risk factors have been described including female gender, athletic participation, hypothyroidism, diabetes mellitus, systemic sclerosis, chronic renal failure, and hemodialysis use. A few recent studies demonstrate anatomic variants that have not previously been summarized. Three articles describe clinical outcomes after conservative treatment with acceptable results for first line treatment. Two primary articles report on the use of minimally invasive treatment for tarsal tunnel syndrome. Fourteen articles report on the clinical outcomes after surgical management. Conclusion Clinical understanding of tarsal tunnel syndrome has evolved significantly, particularly with regards to the pathoanatomy of the tarsal canal over the past twelve years. A few novel anatomic studies shed light on variants that can be helpful in diagnosis. Conservative management remains a good option that can resolve the symptoms of many patients. As more prospective cohorts and clinical trials are performed on minimally invasive options, pulsed radiofrequency and neuromodulation may evolve to play a larger role in the treatment of this condition. Currently, surgical treatment is only pursued in a very select group of patients with refractory symptoms that do not respond to medical or minimally invasive options. Surgical outcomes in the literature are good and current evidence is stronger than that for minimally invasive options.

Postoperative Outcomes Between Positive and Negative Electrodiagnosis in Patients With Tarsal Tunnel Syndrome: A Retrospective Comparative Study

“…Establishing a diagnosis of tarsal tunnel syndrome is known to be challenging because there is currently no definitive criteria and no gold standard test or investigation for this condition. 1,10,14,23,29 Based on the literature reviews and previously recent studies of TTS, the diagnosis of this condition is mainly relied on the triad including detailed history, physical examination, and electrodiagnostic study. 1,5,10,[12][13][14]22,23,29 First, the patients usually present with paresthesia, dysesthesia, or hyperesthesia from posterior part of medial malleolus radiated distally to the heel, plantar surface of the foot or toes, often described as a burning or tingling pain.…”

“…1,10,14,23,29 Based on the literature reviews and previously recent studies of TTS, the diagnosis of this condition is mainly relied on the triad including detailed history, physical examination, and electrodiagnostic study. 1,5,10,[12][13][14]22,23,29 First, the patients usually present with paresthesia, dysesthesia, or hyperesthesia from posterior part of medial malleolus radiated distally to the heel, plantar surface of the foot or toes, often described as a burning or tingling pain. 17,24,29 However, the pain sometimes radiated proximally to the middle part of the calf, this is known as the Valleix phenomenon and the pain or paresthesia is usually relieved with rest or elevation of the foot.…”

“…1,5,10,[12][13][14]22,23,29 First, the patients usually present with paresthesia, dysesthesia, or hyperesthesia from posterior part of medial malleolus radiated distally to the heel, plantar surface of the foot or toes, often described as a burning or tingling pain. 17,24,29 However, the pain sometimes radiated proximally to the middle part of the calf, this is known as the Valleix phenomenon and the pain or paresthesia is usually relieved with rest or elevation of the foot. 24 Second, on physical examination, percussion over the PTN posterior to the medial malleolus will reproduce a tingling sensation, indicating a positive Tinel sign.…”

“…Lastly, the most commonly used adjunctive investigation is an electrodiagnostic study because this can confirm the TTS as well as exclude other pathologies such as L5-S1 radiculopathy or sensory peripheral neuropathy. 4,10,14,16,[21][22][23]26,29 An electrodiagnostic study (NCS and needle EMG) and physical examination are commonly used in tandem to detect the characteristic abnormalities demonstrated by a compressed posterior tibial nerve. However, recent literature has scrutinized the usefulness of an electrodiagnostic study in the diagnosis of TTS, and the consensus of its efficacy remains controversial.…”

“…Lastly, the most commonly used adjunctive investigation is an electrodiagnostic study because this can confirm the TTS as well as exclude other pathologies such as L5-S1 radiculopathy or sensory peripheral neuropathy. 4,10,14,16,21-23,26,29…”