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Tarsal Tunnel Syndrome: a Still Challenge Condition

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Tarsal Tunnel Syndrome: a Still Challenge Condition Rev Bras Neurol. 55(1):12-17, 2019 TARSAL TUNNEL SYNDROME: A STILL CHALLENGE CONDITION SÍNDROME DO TÚNEL DO TARSO: UMA CONDIÇÃO AINDA DESAFIADORA Celmir de Oliveira Vilaça1,2, Bruno Pessoa3, Janaína de Moraes Silva4, Victor Hugo Bastos5, Diandra Martins5, Silmar Teixeira6, Victor Marinho6, Rossano Fiorelli7, Vanessa de Albuquerque Dinoa8; Marco Orsini7, 9 ABSTRACT RESUMO Tarsal tunnel syndrome is a rare, under diagnosed and often confu- A Síndrome do túnel do tarso é uma rara e subdiagnosticada neuro- sed neuropathy with other clinical entities. There is a lack of popula- patia geralmente confundida com outras entidades clínicas. Há falta tion studies on this disease. Herein, we performed a non-systematic de estudos populacionais sobre a doença. Assim sendo, realizamos review of articles between January 1992 and February 2018. Althou- uma revisão da literatura de artigos entre Janeiro de 1992 e fevereiro gh with a less complex anatomy comparing to the carpal tunnel, the de 2018. Apesar de possuir uma anatomia de menor complexidade tarsal tunnel is source of pain and some other conditions. Treatment comparada ao túnel do carpo, o túnel do tarso é origem de dor e involves conservative measures such as analgesics and physical the- algumas outras condições. O tratamento envolve medidas conserva- rapy rehabilitation or surgical procedures in case of conservative doras como analgésicos e terapia de reabilitação ou procedimentos treatment failure. Randomized control studies are lack and manda- cirúrgicos, em caso de falha do tratamento conservador. Estudos ran- tory for uncover the best modality of treatment for this condition. domizados são escassos e necessários para descoberta da melhor modalidade de tratamento desta condição. Keywords: Tarsal Tunnel Syndrome, Tibial Neuropathy, Nerve Com- pression Syndromes Palavras-chaves: Síndrome do Túnel do Tarso, Neuropatia Tibial, Síndromes de Compressão Nervosa 1Institute of Traumatology and Orthopedics (INTO), Rio de Janeiro-RJ, Brazil. 2Federal Fluminense University (UFF); MMC / Division of Neurology; Postgraduate Program in Neurology / Neurosciences, UFF, Niterói-RJ, Brazil. 3Federal Fluminense University (UFF); Assistant professor, Division of Neurosurgery; Niterói-RJ, Brazil. 4State University of Piauí (UESPI); Assistant professor, Health Sciences Center; Teresina-PI, Brazil 5Federal University of Piauí (UFPI); Brain Mapping and Functionality Laboratory; Parnaíba-PI, Brazil. 6Federal University of Piauí (UFPI); Neuro-innovation Technology & Brain Mapping Laboratory; Parnaíba-PI, Brazil. 7University of Vassouras; Applied Science to Health Masters Program; 8Rio de Janeiro Federal University - Radiology Service - UFRJ - Brazil 9Federal University of Piauí (UFPI); Brain Mapping and Functionality Laboratory; Parnaíba-PI, Brazil. Endereço para correspondência: Marco Antonio Orsini Neves. University of Vassouras, Brazil. Email: [email protected]. +5521980049832 12 Revista Brasileira de Neurologia » Volume 55 » Nº 1 » JAN/FEV/MAR 2019 Síndrome do túnel do tarso INTRODUCTION gion and the calcaneus. This mistake, in turn, may increase Pain in the plantar and calcaneal region occurs in the risks of incorrect treatments associated with unneces- up to 15% of adult subjects. Among these causes Tarsal sary tibial nerve decompression surgeries. Tunnel Syndrome (TTS) is often an under diagnosed con- dition.1 The first clinical description of TTS was in 1918 METHODS AND RESULTS by Von Malisé.2 Later, Pollock and Davis described the We did a non-systematic review of articles on the compression of the posterior tibial nerve by post-trauma- Google Scholar and PubMed platform between January tic fibrous tissue in 1932.3 Finally Keck and Lam in 1962 1992 and February 2018. Papers in English with the title were the first to describe the tarsal tunnel syndrome as we “Tunnel Tarsal Syndrome” in the title of the journal were know it nowadays.4,5,6 preferred. We obtained a total of 434 articles addressing TTS can be defined as the compression of the tibial the theme. We have included trial articles, review articles, nerve or its branches in the ankle tarsal tunnel.7 The tibial case reports or expert opinions without any specific crite- nerve corresponds to the greater division of the sciatic ner- ria for disregarding them except to be written in English ve and is derived from the ventral branches of the roots of language. Some references were chosen from periodicals L5, S1 and S2.8 The TTS represents the most frequent cau- of the initial search. At the end, we used a total of 39 refe- se of compressive foot neuropathy and the most frequent rences to perform this review. site of compression of the tibial nerve.9 There is a predo- minance of females compared to males, but with a less DISCUSSION pronounced difference compared to carpal tunnel syndro- me (CTS).10 It can affect people of varying ages, with cases Anatomy of the Tarsus Tunnel 11 from the second to ninth decade of life. Some authors Anatomically the tarsal tunnel is a fibro-osseous divide the tarsal tunnel syndrome into two types: anterior space located in the medial area of the​​ ankle (Figure 1). and posterior. The posterior one (TTSP) compromises Laterally it is formed by the posterior wall of the talus, with compression of the tibial nerve is used as a synonym medial part of the talocalcaneal joint and medial wall of of TTS by most specialists being the most frequently diag- the calcaneus. Medially the tunnel is formed by the retina- nosed and is the one addressed in this manuscript. Anterior culum of the flexors and its fibrous expansion to the ten- tarsal tunnel syndrome (TTSA) indicates a less common don of the posterior tibial muscle and long abductor of the form of compression affecting the deep fibular nerve in the hallucis.15 The tunica of the tarsus is located posterior and 12 ankle and will not be addressed here. Unfortunately, no inferior to the medial malleolus and has the dimension of epidemiological studies address the prevalence and inci- approximately 10 cm proximal of the medial malleolus.16 9 dence of TTSP or simply TTS in the general population. Inwardly, a neurovascular component crosses the tarsal In electrophysiological studies, the rate of TTS is 0.4% to tunnel. This tunnel is composed of the tibial nerve, tendon 10 0.5% of the total number of exams. Patients with TTS of the posterior tibialis muscles, flexor digitorum of the may have an identifiable factor in up to 80% of the ca- fingers, long flexor of the hallucis, the posterior tibial -ar 13 ses. The causes of TTS can be divided into intrinsic or tery and vein.4 Unlike the carpal tunnel, the components of extrinsic injuries. Intrinsic ones are related to the presence the tarsal tunnel are separated by a septum, making it more of space-occupying lesions within the tarsal tunnel while difficult to differentiate these structures.17 On the other 11 the extrinsic lesions external to the canal. The most com- hand, the thickness of the flexor retinaculum is smaller mon cause of TTS is the extrinsic compression of the tibial in the tarsus tunnel when compared to the carpal tunnel 2 nerve due to trauma. External compression may affect the making the dissection of the first easier during the surgical vasa nervorum of the tibial nerve provoking ischemia with procedure.18 This is one of the possible explanations of the difficulty of the axonal transport. Compression above 40 frequency of the TTS be much smaller in comparison to mmHg is capable of causing axonal ischemia, and above CTS.19 Another explanation for the greater occurrence of 14 80 mmHg these lesions may become irreversible. CTS in comparison to TTS would be the fact that in the The discussion herein about TTS becomes rele- first beyond the median nerve, there is the passage of nine vant due to its challenging diagnosis, being often confused tendons, all susceptible to the most diverse inflammatory with other more frequent states of pain in the plantar re- Revista Brasileira de Neurologia » Volume 55 » Nº 1 » JAN/FEV/MAR 2019 13 Neves MAO, et al. conditions. There are also a greater number of bones and cramps. The symptoms worse with ambulation or standing joints in the carpus concerning the tarsus. Each of these upright for long periods. There may be a nocturnal worse- joints is subject to the occurrence of displacements and ning of symptoms.9 Rarely, in chronic and advanced con- synovitis with greater potential of compression of the me- ditions, there is a loss of strength and atrophy of the foot dian nerve in comparison to the tibial nerve.20 muscles.4 Some sports activities present a higher risk of The tibial nerve in the tarsal tunnel is divided into TTS. Of note are sports activities where it is fundamental three branches: lateral plantar, medial plantar and calca- to use lower limbs as martial arts judo variants, running neal.4 More often, the calcaneal branch originates from the and jumping.22 tibial nerve. However, it can also originate from its medial During the anamnesis, the patient usually presen- plantar branch.21 Compression may occur either proximal ts difficulty in pointing out exactly where the pain in the in the tunnel, affecting the tibial nerve, or more distally, plantar region is located. At the clinical examination, there affecting only one or more of its branches.3 Compression may be a presence of the Tinel’s sign or irradiated pain of the lateral plantar nerve is more frequent when compa- during percussion of the nerve.14 The presence of the Ti- red to compression of the medial plantar one.1 The sepa- nel’s sign is associated with a better outcome of the sur- ration of the tibial nerve in its medial branches and lateral gical treatment and occurs in about 50% of the patients.23 approach occurs proximal to the flexor retinaculum in 5% This sign possibly has origin in the firing of axon terminals of people.
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