Вы находитесь на странице: 1из 38

m  m

V   - vulnerabilities of distal
tibial & plantar nerves at the ankle
and foot

Ú nderstand the µtarsal tunnel concept¶

Ú Know the EDX for TTS
Ú To appreciate the realities of RRS
Ú TTS ± 3   





Ú ¦rom: Dorland¶s Medical Dictionary 28th


Ú This is a RARE condition

Ú Most reports ± local trauma to distal tibial
nerve rather than µidiopathic TTS¶
Ú If truly an µidiopathic¶
Ú Must be compromised under laciniatum
ligament (retinaculum musculorumm flexorum
Or entrapment in abductor hallucis

Ú laciniate ligament
Ú Or Lacinatum
Ú Or retinaculum muscculum flexorum

Ú This is µtarsal tunnel syndrome¶

×  m
m  mm
Ú ×ompare amplitude when stimulating
proximal and distal to TT
Ú Side
to--side amplitudes = 20%
Ú Latency is helpful ±but not the only
parameter for diagnosis

Ú Abductor hallicus ± 1 cm below navicular
Ú Abductor dig V pedis ± below the lateral
malleolus at junction of normal and sole

Ú Tarsal tunnel Syndrome - idiopathic

Ú This is   


Ú ¦requently present as compromise in
diabetic peripheral neuropathy
Ú Motor latency ± medial plantar n <5.5 ms; lat pl n
- <6 ms
Ú Trans
Trans--tarsal amplitude and latency similar to
Ú More frequently seen in diabetic peripheral neuropathy
× AP will be reduced or absent with
stimulation at sole of foot (Lat Pl )
×MAP of abd dig min pedis will be smaller
Ú eedle EMG abnormalities in abd dig V ped and lateral
interosseus muscles.     


Ú ¬     



Ú Medial plantar nerve - >6 ms

Ú Lateral plantar nerve - >7 ms

Ú . Amplitudes and trans-

trans-tarsal latencies
are critical for diagnosis

Ú ×ompare contralateral values (nl = +/-

+/- 20%

Ú Medial plantar nerve

Amplitudes similar to sural
Ú Lateral plantar nerve
Ú Amplitudes similar to sural

Ú . This is a MIXED nerve action potential


m    !

Ú ote the amplitude and duration
Ú Latency can be converted to ×V (nl >35
Ú . ×omparable to sural nerve values

Ú Definition ± comparable with ×TS if

compromise is under lancinatum
ligament ± this is rare!
Ú ×ould occur if underlying nerve is µsick¶
as in peripheral neuropathy

Ú Many cases are 2d to trauma at ankle

Ú Ergo. ^ 

Ú This is a  disorder but it can be DX

Ú µIdiopathic¶ is rare
Ú Must verify with mixed ± trans
abnormal values ± best test (consensus)
Ú Must do needle EMG on intrinsic foot
muscles (caution!-
(caution!- end plate areas)
Ú It is common ± only ± in patients with
underlying diabetic polyneuropathy
Ú Kerr & ¦rey: MR imaging in tarsal tunnel. J ×omputer
Assisted Tomography. 1991. 15:280
Ú Kinoshita, M et al: The dorsiflexion-
dorsiflexion-eversion test for
diagnosis of tarsal tunnel syndrome.2001.83A:1835.
Ú Mondelli, M et al: an electrophysiologic severity scale
in tarsal tunnel syndrome.Acta. eurologica
Ú Oh, S et al: Electrophysiologic improvement following
decrompression surgery in tarsal tunnel syndrome.
Muscle & erve 1991.14:407
Ú Ward,P & Porter, M: Tarsal tunnel: a study of the
clinical and neurophysiologic results of decompression.
J Royal ×oll of Surg of Edinburgh.1998.43:35.
Ú Dellon A et al: Variations in origin of medial calcaneal
nerve. J Am Podiatric Med Assn. 2002.92:97
Ú Dumitru, D et al: SSEP of medial & lateral plantar &
calcaneal nerves. Muscle & erve.1991.14:665
Ú ¦elsenthal, G et al: Across tarsal tunnel motor nerve
consuction technique. Arch PM&R 1992.73:64
Ú Galardi, G et al: Electrophysiologic studies in Tarsal
tunnel syndrome ± diagnostic reliability of motor, mixed
and sensory nerve conduction studies. Am J PM&R
Ú Gumasalum & Kalaycioglu: ilateral accessory flexor
digitorum longus muscle in man.Annals of
Annatomy.2000. 182:573.
Ú Lee,× & Dellon,A: Diagnostic ability of Tinel sign in determining outcome
for decompression surgery in diabetic and nondiabetic neuropathy.Ann
Plastic Surg. 2004. 53:523.
Ú Azsmann,O et al: Incidence of ulcer/amputation in the contralateral limb of
patients with a unilateral nerve decompression procedure. Ann Plastic
Surg.2004. 53:517
Ú Kim,D et al: Surgical management and results of 135 tibial nerve lesions
at the Louisiana State niversity Health Sciences ×enter. eurosurgery.
2003. 53:lll4
Ú Sammarco,G & ×hang,L: Outcome of surgical treatment of tarsal tunnel
syndrome. ¦oot & Ankle International.2003.24:125
Ú Labib,S et al: The combination of plantar fasciitis, posterior tibial tendon
dysfunction and tarsal tunnel syndrome. ¦oot & Ankle Internation.
Ú Watson, T et al: Distal tarsal tunnel release with 0artial plntar fasciotomy
for chronic heel pain: an outcome analysis. ¦oot & Ankle International.
2002. 23:530

Ú Watson,  et al: An unusual presentation

of tarsal tunnel syndrome caused by an
inflatable ice hockey skate. ×anadian J
eurologic Sciences.2002.29:386
Ú Kim, J & Dellon, A: Pain at the site of tarsal tunnel incision due to
neuroma of sural nerve. J Am Podiatric Med Assoc. 2001. 81:109
Ú Kohno, M et al: eurovascular decompression for idiopathic tarsal tunnel
syndrome: technical note. J eurol eurosurg Psychiatry. 2000.69:87
Ú ailie, D & Kelikian A: Tarsal tunnel syndrome: Diagnosis, surgical
technique and functional outcome.. ¦oot & Ankle International1998.19:65
Ú Herbsthofer,  et al: Tarsal tunnel syndrome: diagnostic and longgterm
follow--up after operative treatment.Zieitschrift fur Ortholpadie und Ihre
Grenzgebiete. 1998. 136:77.
Ú Pfeiffer, W & ×racchiolo, A: ×linical results after tarsal tunnel
decompression. J one & Joint Surg. (A) 1994. 76A:1222
Ú Mondelli,M & ×ioni, R: EDX evidence of a relationship between idiopathic
carpal and tarsal tunnel syndromes. ×linical
Ú Lau, T & Daniels, T: Tarsal tunnel syndrome: A review of the literature.
¦oot & Ankle International.1999. 20:201
" "## "
Ú Patel, A et al: Muscle & erve. 2005. 236
Ú Recommendations:
Ú Tibial motor ×V with responses abd hall & abd
dig min ped with prolonged latencies
Ú Medial and Lateral Plantar prolonged latencies
Ú Medial and Lateral Plantar slowed ×V across TT
or reduced or absent S AP
Ú eedle exam of foot intrinsic muscles ± no data