Tarsal Tunnel Syndrome

Patients with tibial nerve compression neuropathy, in addition to pain, may experience numbness, pins and needles, or a burning sensation on the bottom of their foot.  The tibial nerve, after it branches off the sciatic nerve behind the knee, descends in the posterior compartment of the leg on its way to the bottom of the foot. It is responsible for supplying feeling over the posterior calf, heel, bottom of the foot, and toes.  It also provides motor innervation controlling the toe flexion and foot plantar flexion. In cases of advanced tibial neuropathy or severe tibial nerve injury, patients can not press the foot downwards or feel the bottom of their foot and toes. The clinical presentation and severity of the tibial nerve neuropathy, due to excessive pressure on or injury to the nerve varies based on the duration of the neuropathy and compression site location:


Proximal tibial nerve compression (soleus arch in the proximal posterior calf) is an uncommon compression site, caused by excessive pressure of the soleus muscle fibrous arch and surrounding tissues on the tibial nerve. Pain in the posterior upper calf may be present with activities or be constant, it is reproduced by pushing on the nerve. In addition, these patients can have varying degrees of tibial nerve dysfunction distally; such as pain, numbness or muscle weakness. This can be a result of abnormal anatomy, underlying medical conditions, traction-stretch injury, trauma or surgery in a nearby area.


Tarsal tunnel syndrome is due to distal tibial nerve compression that can be present alone or in combination with the aforementioned proximal tibial nerve compression. The tarsal tunnel is the most common compression site for the tibial nerve. Patients may report numbness, pins and needles or a burning sensation on the bottom of the foot.  This often interferes with ambulation and overall quality of life. Balance in patients with tibial nerve neuropathy can be affected due to abnormal plantar proprioception, exposing them to a higher risk of falls. This condition is common in people who have had lower extremity trauma, especially in the calf and ankle area, but can also follow surgery or be a complication of an underlying medical condition, such as diabetes.


Diabetic patients, due to abnormal glucose metabolism, over time, may develop swelling of the nerve, as well as narrowing of the tunnel. This alters the normally perfect relationship between the nerve and its tunnel, making it now too narrow for the more swollen and stiffer nerve, resulting in tibial nerve compression neuropathy. (Tarsal tunnel syndrome is about three times more common in diabetics than in the general population.)  Therefore, numbness, pins and needles or burning sensation in the toes and bottom of the foot in diabetics, despite good blood glucose control, requires evaluation by a peripheral nerve surgeon, and early surgical treatment before the nerve is irreversibly damaged.


You should see Dr. Ducic for tibial nerve neuropathy if your symptoms persist:

•Despite the medical care prescribed to you by your physician

•Despite supportive medical care, such as activity and work adjustments

•After three months of prescribed medical and conservative care

•Despite good medical diabetic care

•If you had surgery for a different, non-nerve related problem that was complicated by an acute tibial nerve functional loss (numbness, weakness or pain), timely evaluation and intervention within 6 or (at the most) 12 weeks after its onset is critical to maximize the likelihood of a positive outcome. Restoration of nerve function may be significantly reduced if decompression is done after 3 months from neuropathy onset. This is unfortunately often overlooked by many who instead choose physical therapy and a “let’s wait and see” approach.



Surgery for Tibial Nerve Neuropathy

If symptoms continue to be present despite reasonable observation period (>6-12 weeks) and conservative, supportive care, then you can see me for evaluation for possible surgical treatment. The success of the surgery depends on how long the nerve has been compressed, the severity of the compression, extent of nerve damage due to injury and possible presence of underlying medical or spine problems. I use advanced, minimally invasive techniques that I described, with the advantages of a quicker recovery, reduced possibility of infection and faster return to full function of the affected extremity. In addition, the shorter scar is aesthetically more appealing to all.


Based on which of the two aforementioned compression sites or their combination is identified; surgical treatment is aimed towards your symptomatic sites (anatomical cause of the neuropathy).


I often perform revision surgeries, which address continued neuropathy following previous surgery in patients who failed to get relief after procedures performed elsewhere.


During Tibial Nerve / Tarsal Tunnel Surgery:

1.You will receive anesthesia so you won’t feel any pain during the surgery.

2.For proximal tibial nerve compression at the soleus arch, a small incision is made over the proximal posterior calf. Unless dealing with a very large calf, instead of making large incisions, special instruments are used to conduct a minimally invasive approach. Fibrous tissues of the soleus arch and bands squeezing the nerves are released to ease the pressure on the tibial nerve; sometimes tissue around the nerve is removed if found abnormal.  The skin is then closed in anatomical layers.

3.Tarsal tunnel decompression is performed at the inner ankle to decompress the tibial nerve at this site. Again, a minimally invasive approach is utilized to control incision length. At the same time, the medial plantar, lateral plantar and calcaneal nerves are also decompressed after the incision is modified inferiorly, so that these distal branches / compression sites would not remain symptomatic. The skin is then closed in anatomical layers.

4.Tibial nerve / tarsal tunnel surgery is an outpatient procedure. Ambulation is allowed immediately following the surgery, with crutches or a walker. Your dressing will stay on for about a week, while the sutures are removed three weeks later.


Unless already evaluated by me, if you are not sure about your eligibility for surgery, and if you are not in the Washington, D.C. area, you can send me your records so I can determine if you are a good candidate for treatment. Visit my patient forms page for a downloadable form.

 

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