Tarsal tunnel syndrome caused by coalition associated with a ganglion

Ganglia-Induced Tarsal Tunnel Syndrome

BACKGROUND

Tarsal tunnel syndrome (TTS) is a common entrapment neuropathy that is sometimes elicited by ganglia in the tarsal tunnel.

METHODS

Between August 2020 and July 2022, we operated on 117 sides with TTS. This retrospective study examined data from 8 consecutive patients (8 sides: 5 men, 3 women; average age 67.8 years) with an extraneural ganglion in the tarsal tunnel. We investigated the clinical characteristics and surgical outcomes for these patients.

RESULTS

The mass was palpable through the skin in 1 patient, detected intraoperatively in 1 patient, and visualized on MRI scanning in the other 6 patients. Symptoms involved the medial plantar nerve area (n = 5), lateral plantar nerve area (n = 1), and medial and lateral plantar nerve areas (n = 2). The interval between symptom onset and surgery ranged from 4 to 168 months. Adhesion between large (≥20 mm) ganglia and surrounding tissue and nerves was observed intraoperatively in 4 patients. Of the 8 patients, 7 underwent total ganglion resection. There were no surgery-related complications. On their last postoperative visit, 3 patients with a duration of symptoms not exceeding 10 months reported favorable outcomes.

CONCLUSIONS

Because ganglia eliciting TTS are often undetectable by skin palpation, imaging studies may be necessary. Early surgical intervention appears to yield favorable outcomes.

A retrospective magnetic resonance imaging analysis of bone and soft tissue changes associated with the spectrum of tarsal coalitions

We aimed to investigate the bone and soft tissue changes accompanying tarsal coalition (TC) and aimed to evaluate their association with the location and type of coalition. Ankle magnetic resonance imagings of 65 patients with TC were included. The relationship between the location and type of coalition and bone marrow edema, subchondral cysts, sinus tarsi syndrome, tarsal tunnel syndrome, posterior impingement syndrome, accessory bone, tibiotalar effusion, talar osteochondritis dissecans, ganglion cysts, and calcaneal spur were evaluated. Twenty-nine patients without coalition were selected as the control group, and the distribution of these variables between the two groups was analyzed. There were 33 females and 32 males in the coalition group (mean age: 42.0 ± 15.63 years), and 22 females and seven males in the control group (mean age: 44.79 ± 12.33 years). Coalition was most common in the talocalcaneal joint (n = 33, 50.8%), and the most common coalition type was non-osseous (n = 57, 87.6%). We find no significant difference between the pathologies defined in terms of coalition location and type. Sinus tarsi syndrome, tarsal tunnel syndrome, subchondral cysts, and tibiotalar effusion were found to be more common in the coalition group (p = 0.028, p = 0.010, p = 0.023, and p = 0.006, respectively). The presence of coalition increased the probability of developing tarsal tunnel syndrome 9.91 times (95% CI: [1.25-78.59]; p = 0.029), and sinus tarsi syndrome 3.66 times (95% CI: [1.14-11.78]; p = 0.029). Tarsal coalition may predispose bone and soft tissue changes. In this study, sinus tarsi syndrome, tarsal tunnel syndrome, subchondral cysts and tibiotalar effusion were found to be more common in the coalition group.

Tarsal tunnel disease and talocalcaneal coalition: MRI features

OBJECTIVE

To assess, utilizing MRI, tarsal tunnel disease in patients with talocalcaneal coalitions. To the best of our knowledge, this has only anecdotally been described before.

MATERIALS AND METHODS

Sixty-seven ankle MRIs with talocalcaneal coalition were retrospectively reviewed for disease of tendons and nerves of the tarsal tunnel. Interobserver variability in diagnosing tendon disease was performed in 30 of the 67 cases. Tarsal tunnel nerves were also evaluated in a control group of 20 consecutive ankle MRIs.

RESULTS

Entrapment of the flexor hallucis longus tendon (FHL) by osseous excrescences was seen in 14 of 67 cases (21 %). Attenuation, split tearing, tenosynovitis, or tendinosis of the FHL was present in 26 cases (39 %). Attenuation or tenosynovitis was seen in the flexor digitorum longus tendon (FDL) in 18 cases (27 %). Tenosynovitis or split tearing of the posterior tibial tendon (PT) was present in nine cases (13 %). Interobserver variability ranged from 100 % to slight depending on the tendon and type of disease. Intense increased signal and caliber of the medial plantar nerve (MPN), indicative of neuritis, was seen in 6 of the 67 cases (9 %). Mildly increased T2 signal of the MPN was seen in 15 (22 %) and in 14 (70 %) of the control group.

CONCLUSIONS

Talocalcaneal coalitions may be associated with tarsal tunnel soft tissue abnormalities affecting, in decreasing order, the FHL, FDL, and PT tendons, as well as the MPN. This information should be provided to the referring physician in order to guide treatment and improve post-surgical outcome.

Supramalleolar Osteotomies for the Treatment of Ankle Arthritis

Supramalleolar osteotomy is a joint-preserving surgical treatment for patients with asymmetric valgus or varus ankle arthritis. The primary goal of the procedure is to realign the spatial relationship between the talus and tibia and thereby normalize joint loading within the ankle. Procedures to balance the soft tissues, as well as hindfoot osteotomy and arthrodesis, may also be necessary. Clinical studies of supramalleolar osteotomy demonstrate that correction of the altered biomechanics associated with asymmetric arthritis improves functional outcomes.

Arthroscopic evaluation of persistent pain following supramalleolar osteotomy for varus ankle osteoarthritis

PURPOSE

The purposes of this study were to investigate pain experienced by patients after supramalleolar osteotomy for varus ankle osteoarthritis and to analyse correlations between this pain and arthroscopic findings.

METHODS

Twenty-nine patients (31 ankles) who underwent arthroscopic evaluation after supramalleolar osteotomy were reviewed retrospectively. The visual analog scale (VAS) was used to assess pain, and the patients were instructed to record the time point, location, and character of the pain. The tibial-ankle surface angle, talar tilt, and tibial-lateral surface angle were measured on radiographs.

RESULTS

The location, time point, and character of the pain experienced by the patients changed after supramalleolar osteotomy. The mean VAS score was significantly improved after supramalleolar osteotomy at the time of the arthroscopic evaluation (P < 0.001) and improved further after the arthroscopic procedures (P = 0.026). During arthroscopy, pathologic lesions such as adhesions, synovitis, and soft-tissue impingement were identified. A significant correlation was found between adhesions and dull pain and pain at rest (P = 0.016 and P = 0.005, respectively). In addition, soft-tissue impingement in the lateral gutter was significantly correlated with dull pain, pain at rest, and clicking pain (P = 0.001, P = 0.035, and P = 0.042, respectively). No significant correlations were found between post-operative radiographic measurements and development of pathologic lesions.

CONCLUSIONS

With the use of arthroscopy, persistent pain experienced after supramalleolar osteotomy was found to be associated with adhesions, synovitis, and soft-tissue impingement in medial and lateral gutters of the ankle. Arthroscopy can be helpful in identifying and treating painful lesions commonly seen after supramalleolar osteotomy. An understanding of these painful lesions will help patients have more realistic expectations regarding the supramalleolar osteotomy.

LEVEL OF EVIDENCE

Case series study, Level IV.

Entrapment neuropathies of the lower extremity

Neuropathies that affect the lower limbs are often encountered after trauma or iatrogenic injury or by entrapment at areas of anatomic restriction. Symptoms may initially be masked by concomitant trauma or recovery from surgical procedures. The nerves that serve the lower extremities arise from the lumbosacral plexus, formed by the L2-S2 nerve roots. The major nerves that supply the lower extremities are the femoral, obturator, lateral femoral cutaneous, and the peroneal (fibular) and tibial, which arise from the sciatic nerve, and the superior and inferior gluteal nerves. An understanding of the motor and sensory functions of these nerves is critical in recognizing and localizing nerve injury. Electrodiagnostic studies are an important diagnostic tool. A well-designed electromyography study can help confirm and localize a nerve lesion, assess severity, and evaluate for other peripheral nerve lesions, such as plexopathy or radiculopathy.

Malunited calcaneal fracture fragments causing tarsal tunnel syndrome: a rare cause

This is a report of tarsal tunnel syndrome (TTS) due to a specific malunited calcaneal fracture fragment in a 46-year-old man. He was treated non-operatively for extra-articular calcaneal fracture. Four months later he presented with pain, tingling and hypoaesthesia over the medial aspect of the heel. He had a positive Tinel's sign and a positive dorsiflexion-eversion test. Radiography revealed malunited calcaneal fracture along medial wall producing bony prominence. The tarsal tunnel was surgically decompressed by excising the malunited fragments. The branches of the posterior tibial nerve were stretched over these fragments intra-operatively. There was symptomatic improvement with surgical excision of the fragment, however, the hypoesthesia did not resolve completely. Appropriate initial treatment will help to prevent this complication.

Measuring hindfoot alignment radiographically: the long axial view is more reliable than the hindfoot alignment view

BACKGROUND

Hindfoot malalignment is a recognized cause of foot and ankle disability. For preoperative planning and clinical follow-up, reliable radiographic assessment of hindfoot alignment is important. The long axial radiographic view and the hindfoot alignment view are commonly used for this purpose. However, their comparative reliabilities are unknown. As hindfoot varus or valgus malalignment is most pronounced during mid-stance of gait, a unilateral weight-bearing stance, in comparison with a bilateral stance, could increase measurement reliability. The purpose of this study was to compare the intra- and interobserver reliability of hindfoot alignment measurements of both radiographic views in bilateral and unilateral stance.

MATERIALS AND METHODS

A hindfoot alignment view and a long axial view were acquired from 18 healthy volunteers in bilateral and unilateral weight-bearing stances. Hindfoot alignment was defined as the angular deviation between the tibial anatomical axis and the calcaneus longitudinal axis from the radiographs. Repeat measurements of hindfoot alignment were performed by nine orthopaedic examiners.

RESULTS

Measurements from the hindfoot alignment view gave intra- and interclass correlation coefficients (CCs) of 0.72 and 0.58, respectively, for bilateral stance and 0.91 and 0.49, respectively, for unilateral stance. The long axial view showed, respectively, intra- and interclass CCs of 0.93 and 0.79 for bilateral stance and 0.91 and 0.58 for unilateral stance.

CONCLUSION

The long axial view is more reliable than the hindfoot alignment view or the angular measurement of hindfoot alignment. Although intra-observer reliability is good/excellent for both methods, only the long axial view leads to good interobserver reliability. A unilateral weight-bearing stance does not lead to greater reliability of measurement.

Anatomy of the subtalar joint and imaging of talo-calcaneal coalition

Talo-calcaneal coalitions may be intra-articular or extra-articular in position and may be classified as fibrous, cartilaginous or osseous in morphology. Fibrous coalitions, particularly extra-articular talo-calcaneal coalitions, may have cross-sectional imaging findings that resemble normal anatomic variants, particularly the medial talo-calcaneal ligament and to a lesser extent the presence of an accessory articular facet between the posterior margin of the sustentaculum and postero-medial process of the talus. Typically, in the adult fibrous coalition, there will be some osseous deformity at the entheses, allowing differentiation from a medial talo-calcaneal ligament. The anatomy of the subtalar joint and its ligamentous supports, normal anatomic variations and their corresponding imaging appearance are reviewed in the first part of this article. In the second part, the various forms of talo-calcaneal coalition and their imaging appearance are reviewed.

Tricortical bone grafts for treatment of malaligned tibias and fibulas

Malunions and malaligned nonunions of the tibia and fibula after fracture alter limb function and can be corrected only with surgical intervention. We sought to determine whether using tricortical portions of the iliac crest in conjunction with osteotomy and internal fixation could successfully treat malunions and malaligned nonunions of the tibia and fibula. Seventeen patients with either a malunion or a malaligned nonunion of the tibia or fibula were treated with an osteotomy, deformity correction, and placement of an autogenous iliac crest tricortical bone graft with open reduction and internal fixation (ORIF). The minimum followup was 3 months (average, 32 months; range, 3-118 months). Sixteen patients (94%) had clinical and radiographic evidence of healing at an average of 99 days (range, 43-229 days). Major complications occurred in four patients; one had a persistent nonunion, two had wound infections, and one underwent resection of the distal fibula for subsequent development of fibulotalar arthrosis after ankle arthrodesis. Minor complications occurred in two patients, one tendinitis and one persistent malunion. There were no complications at the iliac crest bone graft site. Autogenous iliac crest tricortical bone grafts, when used in conjunction with correction of alignment and stable internal fixation, are a reasonable option for treatment of nonunions and malaligned nonunions of the tibia and fibula.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Ultrasonography in tarsal tunnel syndrome

OBJECTIVE

The purpose of this study was to clarify the diagnostic value of ultrasonography in tarsal tunnel syndrome.

METHODS

Seventeen patients (17 feet) with tarsal tunnel syndrome were treated between 1988 and 2003. Preoperative ultrasonography was performed, and the cause of the syndrome was confirmed intraoperatively in all cases. Long and short axes of the tarsal tunnel were scanned to ascertain the presence of any space-occupying lesion.

RESULTS

The causes of tarsal tunnel syndrome, as confirmed by surgery, were ganglia (n = 10), talocalcaneal coalition (n = 1), talocalcaneal coalition associated with ganglia (n = 3), and varicose veins (n = 3). Among the cases involving ganglia, hypoechoic or anechoic regions were observed. The mean sizes +/- SD of these regions were 19.4 +/- 8.8 mm in the long axis, 15.2 +/- 6.3 mm in the short axis, and 10.4 +/- 3.8 mm in depth. Of these, 3 ganglia were not clearly palpable before surgery and were small: 10 x 10 x 7, 13 x 11 x 9, and 9 x 8 x 7 mm. Among the cases involving talocalcaneal coalition, ultrasonography indicated a beak-shaped bony process on the short axis images. Although these 3 cases were associated with ganglia, this could not be determined by preoperative palpation.

CONCLUSIONS

As a diagnostic imaging technique for tarsal tunnel syndrome, ultrasonography is extremely useful for identifying space-occupying lesions. Ultrasonography should be performed routinely in patients with suspected tarsal tunnel syndrome.

Ergonomic Pain--Part 2: Differential Diagnosis and Management Considerations

Work-related musculoskeletal disorders (MSDs) can produce ergonomic pain in several different regions of the body, including the shoulder, elbow, wrist and hand, lumbar spine, knee, and ankle/foot. Each family of disorders is distinctive in presentation and requires diagnosis-specific interventions. Because of the complex nature of these disorders, management approaches may not always eliminate symptoms and or completely restore patient function to a level found prior to symptom onset. As a consequence, ergonomic measures should be implemented to reduce the overload on tissue and contribute to patient recovery. However, functional limits may persist and the clinician must make further decisions regarding a person's functional status in the chronic stages of the patient's care.

Nerves in a pinch: imaging of nerve compression syndromes

Nerve compression is a common entity that can result in considerable disability. Early diagnosis is important to institute prompt treatment and to minimize potential injury. Although the appropriate diagnosis is often determined by clinical examination, the diagnosis may be more difficult when the presentation is atypical, or when anatomic and technical limitations intervene. In these instances, imaging can have an important role in helping to define the site and etiology of nerve compression or in establishing an alternative diagnosis. MR imaging and ultrasound provide direct visualization of the nerve and surrounding abnormalities. For both modalities, the use of high-resolution techniques is important. Bony abnormalities contributing to nerve compression are best assessed by radiographs or CT. For the radiologist, knowledge of the anatomy of the fibro-osseous tunnels, familiarity with the causes of nerve compression, and an understanding of specialized imaging techniques are important for successful diagnosis of nerve compression.

Diagnosis and Management of the Painful Ankle/Foot. Part 2: Examination, Interpretation, and Management

Diagnosis, interpretation, and subsequent management of ankle/foot pathology can be challenging to clinicians. A sensitive and specific physical examination is the strategy of choice for diagnosing selected ankle/foot injuries and additional diagnostic procedures, at considerable cost, may not provide additional information for clinical diagnosis and management. Because of a distal location in the sclerotome and the reduced convergence of afferent signals from this region to the dorsal horn of the spinal cord, pain reference patterns are low and the localization of symptoms is trustworthy. Effective management of the painful ankle/foot is closely linked to a tissue-specific clinical examination. The examination of the ankle/foot should include passive and resistive tests that provide information regarding movement limitations and pain provocation. Special tests can augment the findings from the examination, suggesting compromises in the structural and functional integrity of the ankle/foot complex. The weight bearing function of the ankle/foot compounds the clinician's diagnostic picture, as limits and pain provocation are frequently produced only when the patient attempts to function in weight bearing. As a consequence, clinicians should consider this feature by implementing numerous weightbearing components in the diagnosis and management of ankle/foot afflictions. Limits in passive motion can be classified as either capsular or non-capsular patterns. Conversely, patients can present with ankle/foot pain that demonstrates no limitation of motion. Bursitis, tendopathy, compression neuropathy, and instability can produce ankle/foot pain that is challenging to diagnose, especially when they are the consequence of functional weight bearing. Numerous non-surgical measures can be implemented in treating the painful ankle/foot, reserving surgical interventions for those patients who are resistant to conservative care.

C sign for diagnosis of talocalcaneal coalition

PURPOSE

To reevaluate the relevance of the C sign for diagnosis of talocalcaneal coalition.

MATERIALS AND METHODS

Weight-bearing lateral radiographs of 55 feet with talocalcaneal coalition (patient group) and 55 feet without coalition (control group) were reviewed retrospectively. In the patient group, 36 cases of talocalcaneal coalition were confirmed histologically, and 19 cases that did not require surgery were diagnosed at computed tomography (CT). At CT, absence of talocalcaneal coalition in control subjects was confirmed, and control subjects were individually matched with patients according to sex, age, and the calendar year of the clinic visit. Two observers who were blinded to personal information regarding the subjects assessed the presence of the C sign on randomly presented radiographs. When judgments differed, a third observer made the final judgment. Affected feet were classified according to location (ie, medial, posterior, or diffuse) of the coalition and age (ie, <12, 13-20, >21 years). Sensitivity, specificity, and likelihood ratios of the C sign were calculated, and a second radiologic sign, posterior joint surface irregularity, was also evaluated. Differences in occurrence of the C sign among groups according to age and type of coalition were evaluated with the Fisher exact probability test.

RESULTS

Sensitivity and specificity of the C sign for diagnosis of talocalcaneal coalition were 49% and 91%. The positive and negative likelihood ratios were 5.44 and 0.56, respectively. Corresponding sensitivity, specificity, and positive and negative likelihood ratios for the irregularity of the posterior talocalcaneal joint were 71%, 93%, 10.14, and 0.31, respectively. C-sign false-negative findings were more frequent in patients younger than 12 years and in those with posterior coalition.

CONCLUSION

C sign sensitivity obtained in our study was low, which indicated that an absence of the C sign does not negate a diagnosis of coalition.

Outcome of surgical treatment of tarsal tunnel syndrome

One hundred and eight ankles in 72 patients were evaluated from July 1986 to July 1997 with clinical findings and positive electrodiagnostic studies of tarsal tunnel syndrome. Clinical data included physical findings, subjective complaints, duration of symptoms, trauma history, steroid injections, nonsteroidal use and workman's compensation involvement. Associated medical conditions included diabetes, back pain and arthritis. Sixty-two patients underwent tarsal tunnel release, with 13 of them bilateral. There were 44 females and 18 males, 35 right feet and 40 left feet. The average age was 49 years. Preoperative symptom duration was 31 months. Average length of follow-up was 58 months. Average time for return to usual activity was nine months. All patients had at least a 12-month follow-up, and compared with both (Maryland Foot Score) MFS and AOFAS postoperative scores. Preoperative MFS scores obtained prior to 1994, were 61/100 (average), and postoperative MFS scores were 80/100 (average). Postoperative AOFAS scores were 80/100 (average). Patients with symptoms less than one year had postoperative MFS/AOFAS scores significantly higher than those with symptoms greater than one year. The most common surgical findings included arterial vascular leashes indenting the nerve and scarring about the nerve. Varicosities and space occupying lesions were present also. The outcome of surgery was not affected by the presence or absence of trauma. Patients with tarsal tunnel syndrome warrant surgery when significant symptoms do not respond to conservative management. Meticulous surgical technique must be followed. Improvement in foot scores is predictable even when a discrete space-occupying lesion is not present and when symptoms have been present for periods of greater than one year.

Serpiginous ganglion cyst of the foot mimicking cutaneous larva migrans

A patient had a serpiginous lesion on the foot that turned out to be a ganglion cyst. This lesion is more common on the hands. On the lower extremity, ganglion cysts tend to have a misleading clinical appearance. Histologic examination shows pseudocysts formed by mucoid degeneration of collagen structures. The pathogenesis is unclear. Many ganglions are asymptomatic, but pain occurs in 50% of cases. Management of symptomatic lesions is surgical excision. Recurrence is possible.