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Ultrasound of Medial Tarsal Tunnel by Lisa Howell

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Ultrasound of Medial Tarsal Tunnel by Lisa Howell Ultrasound of Medial Tarsal Tunnel by Lisa Howell Medial Tarsal Tunnel Syndrome Medial Tarsal Tunnel Syndrome (Posterior Tibial Neuralgia) is a compression neuropathy Occurs when Posterior Tibial Nerve (PTN) and / or its branches are entrapped within Tarsal Tunnel of Medial ankle Proximal syndrome compression main trunk of PTN, affects entire foot Distal syndrome compression of divisional branches of PTN Medial TTS: -More complex than carpal tunnel syndrome in wrist -Diagnosis and treatment of TTS depends on cause, and severity -Pain typically radiates down medial ankle to heel and/or plantar aspect of foot -Symptoms occur whilst standing, during exercise, and at night when patient is at rest [Ref: 1, 6] Anatomy Medial Ankle Medial Tarsal Tunnel MTT Fibro-osseous tunnel of medial ankle, posterior and inferior to medial malleolus (MM) Tendons of medial ankle Tibialis posterior (PTT), Flexor digitorum longus (FDL), and Flexor hallucis longus (FHL) Ligaments of medial ankle Deltoid ligament is fan shaped, and originates at MM It is divided into a deep and superficial layers Deep layer : Anterior tibiotalar lig, and Posterior tibiotalar lig Superficial layer: Tibionavicular lig, Tibiospring lig, and Tibiocalcaneal lig Neurovascular bundle Posterior tibial nerve (PTN), Posterior tibial artery (PTA), and Posterior tibial veins (PTV) [Ref : 1,6 ] Anatomy of PTN Posterior Tibial Nerve (PTN) branch of Sciatic nerve divides at medial ankle into three branches : ● Medial Calcaneal Nerve ● Medial Plantar Nerve ● Lateral Plantar Nerve Proximal Medial Tarsal Tunnel Flexor Retinaculum (FR) forms the roof of prox MTT Medial Calcaneal nerve (MCN) first branch of PTN MCN superficial to Abductor Hallucis muscle (AHM) Innervates posterior medial part of calcaneus, and posterior fat pad of foot Distal Medial Tarsal Tunnel Lateral Plantar nerve (LPN), and Medial Plantar nerve (MPN) are the terminal branches of PTN [Ref: 1,6] Frank.H.Netter, MD. Atlas of Human Anatomy Anatomy PTN branches LPN and MPN branch beneath Abductor Hallucis muscle Plantar nerves divide into digital nerves at level of metatarsal bases, then continue into web spaces Medial Plantar nerve Innervates plantar aspect of 1st, 2nd, 3rd toes, and medial plantar aspect of 4th toe Lateral plantar nerve Innervates plantar aspect of 5 th and lateral part of 4th toe Inferior calcaneal nerve (Baxter's nerve) first branch of lateral plantar nerve ICN is beneath Abductor Hallucis muscle ICN innervates abductor of 5th toe, and periosteum of large calcaneal tuberosity [Ref: 1,6 ] Medial Ankle / PTN Frank H Netter MD, Atlas of Human Anatomy Anatomy Peripheral nerves Mesoneurium connective tissue that supports nerve trunk Epineurium Outer epineurium is continuous with mesoneurium, and forms outer sheath of nerves Inner epineurium connective tissue intervening b/w outer sheath and fascicles Endoneurium fascicle of nerve Nerve fascicles contain nerve tissue, with collections of axons, myelin sheaths, and schwann cells Perineurium connective sheath surrounds fascicles, and contains intraneural blood vessels [Ref 1,18] Anatomy Peripheral Nerves Vasa nervorum vascular supply of each each nerve -ensures impulse transmission and axonal transport perineural vessels course longitudinally in external epineurium intraneural vessels branch amongst fascicles in perinerium vascular plexuses connect perineural and intraneural vessels Size and number of fascicles vary in each nerve depending on: -distance from the origin -amount of pressure to which nerve is subjected -occurrence of nerve branching Also affected by BMI, Height, Gender, Age, and temperature [Ref:1,18] Pearson education Inc 12 10 8 Column 1 6 Column 2 Column 3 4 2 0 Row 1 Row 2 Row 3 Row 4 Normal U/S appearance PN Peripheral Nerves are more hypoechoic than tendons Run along borders of other structures i.e fascia, blood vessels, or subcutaneous Show sliding movement over tendons and muscles Longitudinal axis: Tubular structures PN appear as multiple hypoechoic parallel lines (fascicles), separated by hyperechoic lines (perineurium) Short axis: Honey comb appearance PN appear as a hyperechoic ovoid area, with multiple hypoechoic dots (fascicles) Epineurium is the hyperechoic rim [Ref: 11,13] Case 1 Normal CSA PTN MM/CL Case 1 PTN Long 3cm above MM Abnormal U/S appearance PN ● Nerve / fascicle enlargement ● Nerve compression within Tunnel, with proximal swelling of nerve ● Loss of normal fascicular architecture of nerve ● Loss of normal nerve sliding movement ● Nerve appears hyperechoic in relation to tendons ● Vas nervorum hyperaemia Additional abnormal U/S PN findings: ● Focal or diffuse thickening of nerve ● Fusiform swelling of the nerve ● Lesion dissecting the fascicles within the nerve ● Dislocation of nerve ● Partial or complete severance of nerve [Ref:1,7,11,13] Peripheral nerve injuries PN injuries classification (Seddon): Sudderland used by surgeons ● Neurapraxia (Grade 1) Mildest injury Endoneurium, perineurium, and epineurium intact eg Nerve contusion, dislocation, or swelling due to pressure *low grade injuries better outcome recovery ● Axonotmesis (Grade 2) Moderate injury disruption of axons and myelin Epineurium, and perineurium intact Motor and sensory function present eg Traction and crush injuries ● Neurotmesis (Grade 3) Severe injury Complete disruption of nerve, partial or complete severance *High grade injuries require surgical intervention [Ref: 1, 11,13] PN Tumours PN Tumours neoplasms derived from schwann cells have entering and exiting nerve often homogenous, and hypoechoic ● Schwannoma defined nerve / tumour transistion, eccentric or central nerve entry, smaller size than neurofibromas Smooth contour, cystic portions, hyperaemia, may have calcifications *Surgery to nerve with preservation of nerve continuity ● Neurofibroma central nerve location, single tumour, fusiform, or lobulated shape *Excision usually comprises affected nerve ● Neurofibromatosis diffuse form, multiple neurofibromas, affects skin and subcutaneous tissues. Also Plexiform type ● Traumatic Neuroma post catherization, post surgical, or amputation ● Neurofibrolipoma [ Ref: 1, 19,20 ] MTTS ● Flexor Retinaculum restricts size of Tunnel ● Increased pressure caused by intrinsic and extrinsic forces within Tunnel causes compression of nerve and / or its branches ● Alterations blood nerve-barrier, oedema and swelling increase ● Slowing of axonal transport ● Thickening of nerve connective tissue ● Vascular compromise causes venous congestion, as pressure increases on nerves ● Nerve more susceptible to compression Initial symptoms: patient has pain, burning, tingling, and numbness Chronic symptoms: Sensory loss of sensations of pain, pressure and temperature Motor muscular weakness,and atrophy Autonomic altered microvascular circulation [Ref: 1,3,4,13] Peripheral Neuropathy Disease or degenerative state of peripheral nerves in which motor, sensory, or vasomotor nerve fibres are affected Symptoms may affect entire nerve, multiple sites of nerve, or multiple nerves within a limb “Peripheral neuropathy contibutes significantly to the neurological burden of disease worldwide” “Prevalence of peripheral neuropathy is increasing.. the growing population affected by Diabetes, and the rising incidence of drug induced neuropathy associated with chemotherapy and antiviral drugs” HRUS provides superior spatial resolution than MRN that has enabled detailed visualisation of even the smallest peripheral nerves” “HRUS allows accurate assessment of different morphological characteristics of the nerve independent of CSA..fascicle diameter, fascicle to connective tissue ratio, epineurial demarcation, and nerve blood flow” E.Gallardo et al 2017 [Ref:13 ] Case 2 MTTS Idiopathic Symptomatic FR MM/CL Case 2 Symptomatic MTTS MM/CL Case 2 Symptomatic MTTS Trifurcation PTN Symptomatic MTTS 3cm prox Case 3 MTTS Pes Planus /Tenosynovitis Case 3 MTTS CSA /FR positive Tinel's sign Case 3 MTTS PTN prox long Case 3 MTTS PTN compression Case 4 Guillain-Barre Syndrome Sural Nerve Case 4 GBS Traumatic Neuroma post biopsy Case 4 GBS Sural nerve post biopsy Ultrasound Technique ● High frequency Transducer 10-15MHz Linear or Hockey stick L8- 18iMHz ● Optimize settings focal zone, B mode, depth, etc ● Patients clinical indications and clinical history ● Patient positioned lying on bed with affected leg in external rotation, knee bent, and a small towel beneath lateral aspect of ankle ● Anatomical landmarks ● Examine Medial ankle tendons, ligaments, and nerves ● U/S CSA measurements inside epineurium as per criteria -level MM/CL, and 3cm, and 10cm prox to MM/CL for MTTS -level MM/CL, and 3cm prox to MM for severity of DPN, & MTNF ● Document pathology ● Static and dynamic study plantar and dorsiflexion, standing view for talus coalition, or dilatation of veins [Ref: 4,5,7,15,17,21,22] Ultrasound Technique ● Short axis and longitudinal (Elevator technique) Image PTN, and its division into its branches ● Comparison to non symptomatic side ● Discrepant size b/w Medial and Lateral Plantar branches ● Minimal pressure with Transducer held perpendicular to nerve ● Laceration measure distance b/w nerve stumps ● Surgical planning relationship of lesion to adjacent neurovascular structures, and tendons or landmarks ● Colour doppler identify neurovascular bundle, and intraneural hyperaemia *Morton's Neuroma or Plantar Fasciitis may present similar symptoms, if study negative, scan PTN *Positive Tinel's sign patient experiences a sharp pain when you Tap over nerve [Ref:6] Technique Causes of MTTS ● Work / sporting
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