1. Tarsal Tunnel Syndrome Outcomes
Mr M Aly,
Mr P Dearden,
Mr S Sturdee, Mr G Wells, Mr A Shenolikar

2. Overview Background Audit standards Methodology Results Conclusions
Anatomy
Diagnosis
Management
Audit standards
Methodology
Results
Conclusions
Recommendations

3. Background
Post traumatic compression of the posterior tibial nerve described by Pollock and Davis as early as 1933
The expression "tarsal tunnel syndrome" was coined by Keck in a case report 1962
Tarsal tunnel compression syndrome recommended in differential diagnosis of pain and paraesthesia in the sole of the foot by Keck and Lam independently 1,2

4. Background Tibial nerve divides within tarsal tunnel
Compressive neuropathy of the tibial nerve within the fibro osseous tibial tunnel
Located posterior and inferior to the medial malleolus
Tibial nerve divides
within tarsal tunnel
Medial/lateral plantar
Calcaneal branch

5. Anatomy Boundaries Contents Tib post, FHL, and FDL tendons
Superficially Flexor retinaculum (laciniate ligament)
Deep Medial talus, medial calcaneus, and Sustentaculum tali
Inferiorly Abductor hallucis
Numerous septa subdivide the tunnel
Contents Tib post, FHL, and FDL tendons
Posterior tibial artery, Post tibial nerve
Venae comitantes (tortuous veins)

6. Background Potential causes of tarsal tunnel syndrome 3 include:
Trauma (17% - 43%)
Varicosities (17%)
Arthosis
Tenosynovitis
Rheumatoid
Hindfoot deformity
Ganglia (8%)
Space-occupying lesions (Rare)
Idiopathic
(10%)

7. Background Rare condition Frequently under diagnosed
Accurate diagnosis difficult as similar symptoms to other lower limb conditions
Surgical treatment may benefit patients with definite nerve entrapment
Diagnosis aided by thorough history, examination and investigation 4

8. Diagnosis
History
Pain over tarsal tunnel + radiation to medial longitudinal arch, plantar surface and heel
Often exacerbated by foot position, walking or prolonged standing
Relieved by rest / elevation
Night symptoms not uncommon

9. Diagnosis Examination Pain on deep palpation over tarsal tunnel
Positive Tinel’s sign often present
Sensory changes in distribution of terminal branches of posterior tibial nerve
Palpable masses representing extrinsic compression
Toe contractures and weak foot intrinsics are chronic signs

10. Diagnosis Investigation
Plain X-ray useful identifying structural abnormality / deformity
USS used to identify ganglia, varicosities, lipoma, tenosynovitis
NCS and EMG essential adjuvant to history + examination
False –ve studies not uncommon and do not rule out tarsal tunnel syndrome 3

11. Treatment
In patients with confirmed compression of nerve surgery is recommended if no response to 3/12 non-operative treatment
Surgical outcomes are variable
Reported good outcomes in 44% -91% 4-6
No prospective analysis of non-operative treatment

12. Audit Standards
All patients should have nerve conduction studies as ‘Gold standard’ investigation
Those with atypical symptoms / presentation should have further imaging (USS/MRI)
Outcomes of surgery should be comparable to with low complication rate

13. Methodology Retrospective case note review
Patient group identified from AS2/WLS/SS surgical logbook
Notes reviewed using standardised data collection proforma
Patients contacted by telephone and outcome scores calculated using AFAOS score

14. Results Demographics Surgery April 2008 to April 2012
34 ankles in 30 patients
14 Female : 16 Male
18 Left : 15 Right
Surgery April 2008 to April 2012
Follow up of months (mean 36)

15. Results Duration of symptoms (34 ankles) Tinel’s sign
18 with symptoms for >12 month duration
Remaining 16 cases average symptom duration of 4.6 months
Tinel’s sign
+ ve 18 pts
- ve / not documented 15

16. Results 100 % cases pre-operative NCS Further diagnostic imaging
94% positive suggestive Tarsal tunnel syndrome
53% positive EMG study
Further diagnostic imaging
4 MRI
2 USS
1 Isotope bone scan

17. Results Operative findings – 33 op notes
7 cases tight flexor retinaculum
2 cases engorged veins in tarsal tunnel
1 ganglion within tarsal tunnel
1 subtalar OA with osteophytes
1 nerve entrapment in scar of prev ankle athrodesis
1 incidental Mortons neuroma on MRI
excised at time of tarsal tunnel surgery

18. Results Clinic letter reported outcomes 24 cases good outcome 79%
3 cases slight improvement
7 cases no improvement in symptoms %

19. Results Association of Foot and Ankle Surgery Outcome Survey (midfoot)
Patients contacted by telephone
Asked to report current symptoms
24/30 patients contactable

20. Results – Outcome Survey

21. Results

22. Results

23. Results Nil or mild pain in 63% patients
No or mild limitations in recreational activities in 63% patients
54% could walk more than 6 blocks
(1/3 mile)
No difficulty with uneven terrain (stairs, hills, etc.) reported in 41%

24. Results 7 patients not satisfied: 2 had 12+ months symptoms
1 had 12+ months symptoms and a negative NCS
3 had pathology within the tarsal tunnel
(2 x engorged veins / 1 x ganglion)
Final 1 patient had concurrent L4-5 radiculopathy

25. Results - Complications
Superficial wound infection
4 cases (12%) - (3 diagnosed and treated by GP)
All resolved with PO Abx
Wound dehiscence
1 case (3%)
Resolved + healed with dressings only
Recurrance
2 cases
Revision surgery planned in 1 but never undertaken

26. Conclusions
All patients underwent pre-op NCS as per recommendation in literature
Results of surgical treatment at HRI/CRH comparable with that reported in the literature (79% good outcome)

27. Recommendations Review of current outcomes of non-operative treatment
Pre-operative scoring to allow more accurate analysis of outcomes
Patient advice leaflets explaining condition and its treatment

28. References
Keck C: The tarsal-tunnel syndrome. J. Bone Joint Surg 1962, 44A:180–2.
Lam SJS: A tarsal-tunnel syndrome. Lancet 1962; 2: 1354–5.
Antoniadis G, Scheglmann K. Posterior tarsal tunnel syndrome: diagnosis and treatment. Dtsch Arztebl Int Nov;105(45):
Ahmad M, Tsang K, Mackenney PJ, Adedapo AO. Tarsal tunnel syndrome: A literature review. Foot Ankle Surg Sep;18(3):
Singh S, Wilson M, Chiodo: The surgical treatment of tarsal tunnel syndrome: Review. The Foot 15 (2005) 212–216.
Ballie DS, Kelinkian AS: Tarsal tunnel syndrome: Diagnosis, surgical technique, and functional outcome. Foot Ankle Int 1998; 19: 65–72.