Management of Tarsal Tunnel Syndrome

CHAPTER 20 Management of Tarsal Tunnel Syndrome


A tarsal tunnel release is performed for intractable refractory pain, burning, tingling, and numbness on the plantar and medial aspect of the foot. These symptoms can be associated with aching in the foot or leg, cramping, and vague sensations of soreness, fatigue, and burning, with or without activities. The common recognized causes of tarsal tunnel syndrome include hyperpronation of the foot, a valgus hindfoot, stress or pressure on the tibial nerve from a mass effect, varicosities, and trauma; in many patients, however, no identifiable cause for their symptoms can be found.


Before starting an operation for tarsal tunnel release, I routinely perform electrophysiologic testing. Although a normal test result does not contraindicate the performance of surgery, having confirmation of the clinical condition from an electromyogram (EMG) and nerve conduction studies is certainly useful. The problem arises when the patient has vague symptoms suggestive of a tarsal tunnel syndrome but not confirmed on EMG. The results of tarsal tunnel release are not that predictable; probably approximately 80% of well-selected patients improve satisfactorily. Therefore it is imperative to approach this condition with caution, and certainly to avoid operating on the patient with chronic pain or recurrent tarsal tunnel syndrome. In the latter condition, improvement is extremely difficult to obtain. Patients who have been previously operated on through a short incision over the tarsal canal and who continue to have more distal symptoms may constitute an exception: Perhaps the repeat surgery is indicated in this group of patients, for whom an inadequate release was initially performed.


The approach to tarsal tunnel release must include an incision that extends distally over the abductor hallucis muscle. The most frequent error in performing a tarsal tunnel release is to ignore the compression that occurs deep to the abductor hallucis muscle. The more proximal portion of the tibial nerve under the laciniate ligament (the flexor reticulum) is rarely the source of compression other than in patients who have lesions, masses, or varicosities in the tarsal tunnel immediately behind the medial malleolus.


The incision is deepened through subcutaneous tissue, and in the more proximal area of the tarsal tunnel the flexor retinaculum is perforated and opened proximally. Rarely, an entrapment is found in the more proximal aspect of the tarsal tunnel behind the malleolus. The flexor retinaculum (the laciniate ligament) is inspected and released slightly more distally to the level of the medial malleolus, and the nerve is inspected (Figures 20-1 and 20-2

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Mar 6, 2016 | Posted by in Reconstructive surgery | Comments Off on Management of Tarsal Tunnel Syndrome

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