Tarsal tunnel syndrome: still more opinions than evidence. Status of the art

Abstract

Tarsal tunnel syndrome is an entrapment neuropathy of the posterior tibial nerve or its terminal branches within its fibro-osseous tunnel beneath the flexor retinaculum on the medial side of the ankle. The condition is frequently underdiagnosed leading to controversies regarding its epidemiology and to an intense debate in the literature. With the advent of nerve imaging techniques, the diagnostic confirmation and the etiological identification have become more accurate. However, management of this entrapment neuropathy remains challenging because of many intervention strategies but limited robust evidence. Uncertainties still exist about the best conservative treatment, timing of surgical intervention, and best surgical approach. In the attempt to clarify these aspects and to provide the reader some understanding of the status of the art, we have reviewed the published literature on this controversial condition.

Results of ultrasound-guided release of tarsal tunnel syndrome: a review of 81 cases with a minimum follow-up of 18 months

“…The causes include tarsal tunnel syndrome, which may be an underdiagnosed condition [1,16]. Doneddu et al [17] refer to a literature review that found that TTS was the fifth most commonly published nerve compression syndrome in the scientific literature from 1 January 2016 to 1 June 2016, with 134 articles, compared to 2450 indexed articles for carpal tunnel syndrome.…”

Tarsal tunnel syndrome in the mucopolysaccharidoses: A case series and literature review

“…15 Patients may describe vague symptoms of foot pain, and paraesthesia, often described as worst at night or during prolonged standing. 7,16 Examination may reveal sensory changes over terminal branches of the posterior tibial nerve and tenderness on deep palpation, 16 atrophy of the intrinsic foot muscles and a positive Tinel's sign, which in CTS has a sensitivity and specificity of 82.2% and 88.9%, respectively. 17 The dorsiflexion-eversion test may assist in TTS diagnosis and is performed by passively maximally everting and dorsiflexing the ankle, while all of the metatarsophalangeal joints are maximally dorsiflexed.…”

“…We have not used injection with corticosteroid and local anaesthetic as a diagnostic or treatment modality for TTS in MPS, but this is described in the non-MPS population and could be considered. 7,16,24 Ultrasound has been used in the non-MPS population to identify space occupying lesions within the TTS and sensitivities of up to 74% have been reported for diagnosis of idiopathic TTS. 25,26 There is no literature regarding ultrasound for assessment of TTS in MPS and we have not used this modality for this purpose.…”

“…In non-MPS patients, initial management of TTS usually involves non-surgical treatments with anti-inflammatory medication, physiotherapy and shoe modification. 7,16,24 Success rates following surgical decompression vary from 44% to 96%. 16 A narrative review of TTS in non-MPS patients recommends early decompression in selected patients in order to prevent nerve fibrosis.…”

“…4 Routine neurophysiological CTS screening is recommended to allow early surgical decompression and prevent permanent impairment. 5 Other nerve entrapment syndromes occur less commonly in MPS, 6 including tarsal tunnel syndrome (TTS): compression of the posterior tibial nerve as it passes inferiorly to the flexor-retinaculum within its fibro-osseous tunnel 7 (Figure 1).…”