Tarsal tunnel syndrome ( TTS ), also known as posterior tibial neuralgia , is a compression neuropathy and a painful leg condition in which the tibial nerves are compressed on walking through the tarsal tunnel. This tunnel is found along the inner legs behind the medial malleolus (a lump on the inside of the ankle). The posterior tibial artery, the tibial nerve, and the posterior tendon of the tibialis, flexor digitorum longus, and the smooth muscles of the flexor run in the bundle through the tarsal tunnel. Inside the tunnel, the nerve is divided into three distinct segments. One nerve (calcaneal) continues to the heel, the other two (medial and lateral plantar nerves) continue to the bottom of the foot. The tarsal tunnel is represented by the inner bone and the flexor retinaculum on the outside.
Patients with TTS usually complain of numbness in the foot that spreads to the big toe and the first 3 toes, pain, burning sensations, electrical sensations, and tingling at the base of the feet and heels. Depending on the trap area, other areas may be affected. If entrapment is high, the entire foot may be affected because different branches of the tibial nerve may be involved. Ankle pain is also present in patients who have high levels of traps. Inflammation or swelling may occur in this tunnel for a number of reasons. The flexor retinaculum has limited ability to stretch, so that increased pressure will eventually lead to compression of the nerves in the tunnel. When the pressure increases on the nerves, blood flow decreases. The nerves respond with an altered sensation such as tingling and numbness. Fluids collect in the legs when standing and walking and this makes the condition worse. When small muscles lose their nerve supply, they can create a feeling of cramp.
Video Tarsal tunnel syndrome
Symptoms
Some of the symptoms are:
- Pain and tingling around the ankle and occasionally the toes
- Swelling of the foot and ankle area.
- Pain burning, tingling, or numbness in the lower leg. Pain worsens and spread after standing for long; the pain is worse with activity and relief with rest.
- Electric shock sensation
- Pain spreads to the foot, behind the shin, and down to the arch, heel, and toes
- Hot and cold sensation in feet
- Feeling as if the foot does not have enough padding
- Pain when operating the car
- Pain along the Posterior Tibial nerve line
- The burning sensation at the bottom of the foot that radiates upward reaches the knee
- "Pin and needle" -types of feeling and increased sensation in feet
- Tinel positive sign
The Tinel Sign is a shock shock sensation that occurs when you hit the affected nerve. The sensation usually moves to the feet but can also travel to the inner legs as well.
Maps Tarsal tunnel syndrome
Cause
It is difficult to determine the exact cause of Tarsal Tunnel Syndrome. It is important to try to determine the source of the problem. Treatment and potential outcome of treatment may depend on the cause. Anything that creates pressure in the Tarsal Tunnel can cause TTS. These include benign tumors or cysts, bone spurs, tendon shear, nerve ganglion, or swelling of a broken or sprained ankle. Varicose veins (which may or may not be seen) may also cause nerve compression. TTS is more common in athletes and other active people. These people put more emphasis on the tarsal tunnel area. Flat feet can cause increased pressure in the tunnel region and this can lead to nerve compression. Those with lower back problems may have symptoms. Back problems with the L4, L5 and S1 areas are suspect and may suggest the problem of "Double Crush": a "crush" (pinched or nerve trap) in the lower back, and the second in the tunnel area. In some cases, TTS can be very idiopathic.
Rheumatoid arthritis is also associated with TTS.
Neurofibromatosis
Another mechanism that can cause this TTS is neurofibromatosis. It is a disease that results in the formation of pigment, skin neurofibromas. This mass, in certain cases, proved to have the ability to attack the tarsal tunnel causing pressure, resulting in TTS.
Diabetes makes peripheral nerves susceptible to nerve compression, as part of a double crush hypothesis. Unlike carpal tunnel syndrome due to a tunnel on the wrist for the median nerve, there are four tunnels in the medial ankle for tarsal tunnel syndrome s . If there is a positive Tinel sign when you press on the inside of the ankle, such as a tingling feeling to the feet, then there is a 80% chance that tarsal tunnel decompression will relieve pain and numbness symptoms in diabetics. Tarsal Tunnel Syndrome.
Diagnosis
The diagnosis is based on the physical examination findings. A patient history of pain and a positive Tinel sign is the first step in evaluating the possibility of tarsal tunnel syndrome. X-rays can rule out fractures. MRI can assess lesions that occupy space or other causes of nerve compression. Ultrasound may be assessed for synovitis or ganglia. Neural conduction studies alone are not, but they can be used to confirm a suspected clinical diagnosis. Common causes include trauma, varicose veins, neuropathy and spatial anomalies within the tarsal tunnel. Tarsal tunnel syndrome is also known to affect both athletes and individuals who stand a lot.
A neurologist or physiotherapist usually performs a neural conduction test or supervises a trained technologist. During this test, the electrodes are placed at various points along the nerves in the legs and feet. Both sensory and motor nerves are tested in different locations. The electrical impulse is sent through the nerve and the speed and intensity of the trip are measured. If there is compression in the tunnel, this can be confirmed and marked with this test. Some doctors do not feel that this test is a reliable way to get rid of TTS. Several studies have shown that nerve conduction tests will be normal at least 50% of cases.
Given the unclear role of electrodiagnostics in the diagnosis of tarsal tunnel syndrome, efforts have been made in the medical literature to determine the most sensitive and specific nerve conduction studies for mononeuropathy tibia at the tarsal tunnel level. An evidence-based practice topic put forward by professional organizations, the American Association of Neuromuscular & amp; Electrodiagnostic drugs have determined that Level C, Class III evidence exists for the use of tibial nerve conduction motor studies, a lateral and lateral mixed cord conduction study, and lateral and lateral plantar conduction studies. The role of needle electromyography is still poorly defined.
Tarsal Tunnel Syndrome (TTS) is closest to Carpal Tunnel Syndrome (CTS). However, the similarity to a much fewer or even sparser partner in a prevalence study has found that patients with rheumatoid arthritis (RA) show signs of distal limb neuropathy. The posterior tibial nerve serves the victim of peripheral neuropathy and often shows signs of TTS among RA patients. Therefore, TTS is a common finding found in autoimmune disorders of rheumatoid arthritis
Risk factors
Anything that sacrifices the posterior tibial nerve tunnel proves significant in the risk of causing TTS. Neuropathy can occur in the lower limb through many modalities, some of which include obesity and inflammation around the joint. By association, these include risk factors such as RA, compressed shoes, pregnancy, diabetes and thyroid disease
Cost
As stated earlier, musculoskeletal disorders can cost up to $ 15- $ 20 billion in direct costs or $ 45- $ 55 billion in indirect spending. This is about $ 135 million per day. Tests that confirm or improve TTS require expensive treatment options such as x-rays, CT-scans, MRI and surgery. 3 previous options for detecting and finding TTS, while the latter is a form of treatment for decompression of tibial nerve pressure Because surgery is the most common form of TTS treatment, a high financial burden is placed on those diagnosed with rare syndrome.
Prevention
The exact cause of Tarsal Tunnel Syndrome (TTS) may vary from patient to patient. But the same end result applies to all patients, compression of the posterior and branched tibial nerve while moving around the medial malleolus causes pain and irritation for the patient. There are many possible causes of tibial nerve compression therefore there are various prevention strategies. One is immobilization, by placing the foot in a neutral position with a clamp, the pressure is released from the tibial nerve thereby reducing the patient's pain. Eversion, inversion, and plantarflexion can all cause compression of the tibial nerve therefore in the neutral position of the tibial nerves less restless. Usually this is recommended for patients to do while sleeping. Another common problem is improper footwear, because shoes that damage the legs because they are too tight can cause increased pressure on the tibial nerve. Having footwear that tightens the legs for a long time will even lead to the TTS. Therefore, just by having the right shoes, TTS can be prevented.
Treatment
Treatment usually includes rest, manipulation, anterior tibialis reinforcement, posterior tibialis, peroneus and short-foot flexor, foundry with boot walker, corticosteroid injections and anesthesia, hot wax bath, wrapping, compression hoses, and orthotics. Drugs may include various anti-inflammatories such as Anaprox, or other drugs such as Ultracet, Neurontin, and Lyrica. Lidocaine patch is also a treatment that helps some patients.
Conservative care (nonsurgical)
There are several ways that the tarsal tunnel can be treated and the pain can be reduced. Initial treatment, whether conservative or surgical, depends on the severity of the tarsal tunnel and how much pain the patient has. There have been studies conducted that treated patients were diagnosed with tarsal tunnel syndrome with a conservative approach. This means that this patient program participates in consisting of physiotherapy exercises and orthopedic shoe inserts in addition to the program. There were fourteen patients who had additional tibial nerve mobilization exercises. They are instructed to sit on the edge of the table in a degenerate position, their ankles brought to dorsiflexion and ankle and then the knee is extended and flexed to obtain optimal tibial nerve mobilization. Patients in both groups showed positive progress from both programs. The medial calcaneal, medial plantar and lateral plantar areas have pain relief after successful nonoperative or conservative treatment. There is also a choice of local steroid or cortisone injections that can reduce inflammation in the area, thereby relieving the pain. Or just a simple reduction in the patient's weight to reduce the pressure in the area.
Surgical treatment
If non-invasive treatment measures fail, a tarsal tunnel release operation may be recommended for decompression of the area. The incision is made behind the ankle bone and then descends in direction but not as far as the bottom of the foot. Posterior Tibial Tibia is identified above the ankle. It is separated from the accompanying arteries and veins and then followed into the tunnel. The nerves are released. Cysts or other spatial problems can be fixed at this time. If there is scarring in the nerves or branches, this is reduced by internal neurolysis. Neurolysis is when the outer layer of the neural membrane is opened and scar tissue is removed from within the nerve. After surgery, large cotton wrap paralyze the ankle joint without plaster. Dressing can be removed at the point of one week and stitches about three weeks.
Complications may include bleeding, infection, and unpredictable healing. The incision can open from the swelling. There may be considerable pain and cramps. Regeneration of nerve fibers can cause pain. The patient may have a hot or cold sensation and may feel worse than before surgery. Crutches are usually recommended for the first two weeks, as well as elevations to minimize swelling. The nerves will grow about an inch per month. One can expect to continue the healing process for about a year.
Many patients report good results. Some, however, do not experience improvement or worsening of symptoms. In the Pfeiffer article (Los Angeles, 1996), fewer than 50% of patients reported an increase, and there was a 13% complication rate. This is a surprising percentage of complications for what is a fairly shallow and small surgical procedure.
The tarsal tunnel can greatly affect the quality of life of the patient. Depending on the severity, the ability to walk away people usually takes it for granted (like grocery shopping) can be compromised. Proper pain management and counseling are often required.
Operating results can be maximized if all four medial ankle tunnels are released and you walk with a walker a day after surgery. Success can be increased to 80%.
Incident
Although TTS is uncommon, the cause can be determined in 70% of cases reported. In the workplace TTS is considered a musculoskeletal disorder and accounts for 1.8 million cases per year, which accumulates to around $ 15- $ 20 billion per year. The new study shows the occurrence of TTS in sports that puts a high load on the ankle joint (3). This can be seen in Figure 1. TTS occurs more predominantly in active adults, with higher pervasiveness among women. Active adults who experience more leaps and landing in the ankle joint are more susceptible (see figure 2). Although athletics and sport are correlations, the cases are assessed individually for their peculiarities.
Athletic activity
Athletic populations tend to place themselves at greater risk of TTS due to participation in sports involving the lower extremities. The heavy activity involved in athletic activity adds strain to the ankle and therefore can lead to compression of the tibial nerve. Activities that mainly involve sprinting and jumping have a greater risk of developing TTS. This is caused by an ankle that is inserted into eversion, inversion, and plantarflexion at high speed. Examples of sports that can cause TTS include basketball, tracks, soccer, lacrosse, snowboarding, and volleyball. Participation in this sport should be done with caution because of the high risk of developing TTS. However athletes will tend to continue to participate in these activities because proper stretching, especially in lower extremities, before participation can help in the prevention of TTS development.
Famous case
According to South Korea's National Intelligence Service, North Korean leader Kim Jong Un underwent an operation to repair the TTS on his right ankle, a source that looked limp. Kim's loss from the public for six weeks around a suspected operation creates speculation around the world about Kim's and North Korea's future.
See also
- Carpal tunnel syndrome
- Cube-shaped syndrome
References
External links
Source of the article : Wikipedia
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