Tarsal Tunnel Syndrome

Tarsal tunnel syndrome is a condition that is caused by compression of the tibial nerve or its branches.

Tarsal tunnel syndrome is analogous to carpal tunnel syndrome of the wrist.

The tarsal tunnel is a narrow space that lies on the inside of the ankle.

The tunnel is covered with a thick ligament called the flexor retinaculum.

Structures within the tarsal tunnel include:

-Arteries
-Veins
-Tendons
-Nerves

Tarsal tunnel syndrome is a compression on the posterior tibial nerve.

This syndrome produces symptoms anywhere along the path of the nerve.

Possible symptoms include:

-Tingling
-Burning
-Numbness
-Shooting pain
-Paresthesias

Contribute Factors to Tarsal Tunnel:

-Soft tissue masses:
Lipomas-is a benign tumor composed of fatty tissue
-Tendon Sheath Ganglia:
Neoplasms- is an abnormal mass of tissue as a result abnormal proliferation of cells
-Nerve tumors
-Varicose Veins

Work up:

Tinel sign- Percussion of a nerve with radiation of pain along the course of the nerve.

The doctor may order any of the following tests to help with the diagnosis:

-Electromyography (EMG) - A technique for evaluating and recording the electrical activity produced by skeletal muscles
-Nerve conduction velocity (NCV)
-Magnetic resonance imaging (MRI)- In cases of suspected soft-tissue masses and other space-occupying lesions
-Ultrasonography
-Radiography

Conservative Treatment:

-Rest
-Ice
-Non steroidal anti-inflammatory drugs-to help reduce pain and inflammation
-Immobilization- Restricting movement of the foot by wearing a cast or cam boot
-Physical therapy
-Injection therapy
-Orthotic devices. To control any abnormal bio mechanics of the foot









-Surgical Therapy

Tarsal tunnel release surgical intervention may be needed if conservative therapy fails to alleviate pain and symptoms. This procedure is used to decrease pressure on the posterior tibial nerve. Any space occupying lesions may also be excised.

Plantar Fasciitis

Plantar fasciitis is one of the most common problems treated in a foot and ankle practice.

Approximately 10% of the United States population experiences bouts of heel pain.

The plantar fascia acts like a windlass mechanism.

The plantar fascia is made up of 3 distinct parts: medial, central, and lateral bands.

It extends from the heel bone to the metatarsal heads.

The plantar fascia is a thick band of tissue in the arch of the foot.

Etiology

Biomechanical dysfunction of the foot is the most common origin of plantar fasciitis.

The pathology is believed to be secondary to the development of microtears in the fascia

There is an inflammation at the fascia at its origin due to repetitive strain of the arch with weight bearing.

Symptoms
Most common complaint is pain in the bottom of the heel. Patients will typically present with post–static dyskinesia. Pain with the first steps out of bed or periods of rest so it is usually worst in the morning and may improve throughout the day or with more activity.

By the end of the day the pain may be replaced by a dull aching that improves with rest.

Most people complain of increased heel pain after walking for long periods of time.

Generally the most common pain is that elicited upon palpation of the plantar-medial calcaneus

This is at the site of plantar fascial insertion to the heel bone. Pain can occur also at the central and sometimes at the lateral insertion as well.

A tight Achilles tendon can be an adjunctive finding and can contribute to the heel pain. This is known as an Equinus.


Diagnosis
Generally the diagnosis can be made with a good history.

X rays , MRI, and ultrasonography are important modalities to the diagnosis of plantar fasciitis.

X rays may reveal a plantar heel spur, which show the presence of abnormal stresses across the plantar fascia

A heel spur forms in a manner consistent with Wolff’s law. It should be noted that the heel spur is not the cause of the symptoms and therefore does not need specific treatment or removal.

MRI and ultrasonography shows the thickness of the fascia and helps rule out other problems that are not visible with x rays .

Treatment

Nonsurgical treatment include/ Conservative:

• Rest
• Icing
• Stretching
• Nonsteroidal anti-inflammatory medication such as Ibuprofen
  
• Taping/Strapping
• Orthoses (pre molded or custom-made)
  

• Physical Therapy
• Weight Loss
• Corticosteroid Injections
• Night Splints
  

These treatments should be used in combination.

Walking, running, and jumping sports are associated with plantar fasciitis; restriction of these activities may be necessary.

Surgical:

Severe cases may require surgical intervention if conservative therapy does not improve symptoms.

Extracorporeal shockwave therapy (ESWT) is an alternative treatment for chronic heel pain using acoustic-energy shockwaves

Plantar fascia release—performed by transecting part of the fascia - This is performed through an open incision or performed endoscopically

Another relatively new percutaneous technique is Topaz bipolar radiofrequency microdebridement, which applies a bipolar radiofrequency pulse to the plantar fascia.

Giant Hobbled by Heel Pain

Eli Manning, quarterback of the New York Giants, was recently diagnosed with plantar fasciitis. Plantar fasciitis is caused when the thick band of tissue running along the bottom of the foot, the plantar fascia, becomes inflamed. Symptoms include severe stabbing, burning, or aching sensations in the bottom of the foot and/or in the heel. These symptoms usually occur during weight bearing movements but may be present even when just standing. It’s obvious to see how this would cause difficulty for a quarterback to do his job. The QB sought council after he was diagnosed and immediately started treatment. He is hoping to practice with his team on Wednesday but for now his pain and ability to play is being judged day to day.

Being a quarterback for a professional football team is not the only profession where plantar fasciitis can cause problems. Almost any job or activity where frequent walking or standing on hard surfaces can cause this ailment. Pregnancy, obesity, and several other sports tend to make people prone to this injury as well.

Luckily for Eli and anyone who may suffer from plantar fasciitis, there is hope. There are several treatment options offered by podiatrists to correct this problem. Foot and heel pain does not have to be part of everyday life when correct council is available. Treatment can take anywhere from 6 to 18 months. When plantar fasciitis is caught in its early stages the recovery rate is dramatically reduced. Pain in the foot during the first few steps of the day (especially when first getting out of bed) is an early warning to call a podiatrist and get the feet checked out.

Take care of your feet today… so they can continue to take you the places you need to go tomorrow!