Archive for March, 2011

Tarsal Tunnel Syndrome and Treatment

March 20, 2011

Symptoms of Tarsal Tunnel Syndrome

Tarsal tunnel syndrome refers to the irritation and/or compression of a nerve called the posterior tibial nerve. This nerve is found behind the anklebone on the inner side of the foot.  (Same side as the big toe) As the nerve travels in this area it runs through small canal called the Tarsal Tunnel.

Symptoms of tarsal tunnel include:

1. Radiation, burning, or shooting pain on the bottom of the foot, along the arch and/or up into the leg

2. “Pins and needles” sensation to the bottom of the foot and into the toes

3. Disturbances in the perception of temperature (feelings of coldness)

4. Feeling like there is a tight band around the foot

5. Loss of sensation to the sole of the foot and/or heel

6. Pain getting worse with prolonged standing or walking

7. Rest and leg elevation can relieve symptoms

Causes of Tarsal Tunnel Syndrome

The main culprit of tarsal tunnel syndrome is the decrease in space in the tarsal tunnel, which results in compression of the posterior tibial nerve. There are multiple reasons that can cause narrowing of the tarsal tunnel.

1. As the tibial nerve travels behind the anklebone, it goes through the tarsal tunnel, which is a narrow canal bordered by a sheath of tissue and the heel bone.  As the tibial nerve goes through the tarsal tunnel, it usually splits into two nerves, the medial and lateral plantar nerves. If the tibial nerve splits into two nerves before entering the tarsal tunnel, it increases the number of structures going through the tarsal tunnel. This results in a relative decrease of space in the tunnel and compression of the nerve.

2. Several tendons and veins course through the tarsal tunnel with the tibial nerve. If these structures are enlarged or swollen the tibial nerve can be compressed.

3. Compression of the tibial nerve can also occur from bony prominences, spurs or fragments of bone in the tarsal tunnel.

4. Abnormal heel position with the heel positioned more inward or outward can stretch the tibial nerve or narrow tube of the tarsal tunnel again resulting in excessive pressure on the nerve.

Physical Examination in Tarsal Tunnel Syndrome

Tarsal tunnel syndrome can mirror other foot conditions, such as heel pain, arch pain, or neuropathy therefore, the podiatrist may need to utilize various examination techniques, imaging modalities and electro diagnostic studies to diagnosis tarsal tunnel and syndrome. The podiatrist will tap along the course of tibial nerve to reproduce the shooting sensation often associated with tarsal tunnel syndrome. The podiatrist will also examine if there is any swelling along the tarsal tunnel and the medial arch because this may indicate a mass that may be in the tunnel. The podiatrist may also try to increase the pressure on the tibial nerve by turning the foot outward and up and holding this position for 5-10 seconds. This exam produces a narrowing the space of the tarsal tunnel and can recreate the patient’s symptoms. Heel and foot position may also be examined to determine if that may be the cause of tarsal tunnel compression. In order to determine which nerve branches are involved, a pin prick test may be applied to the sole of the foot to determine which areas of the foot has decreased sensation.

Diagnostic Studies in Tarsal Tunnel Syndrome

If a bony prominence is suspected as the cause of tarsal tunnel syndrome, the podiatrist may request X-ray imaging of the foot and ankle. For soft tissue masses or increase tendon size/swelling, MRIs may be requested as well. Ultrasound may also be utilized to determine the tibial nerve split or tendon pathology. If vein enlargement is suspected, the podiatrist may use a tourniquet wrapped above the tarsal tunnel to increase fluid accumulation in the veins.  Other studies that may be ordered to study the function of the tibial nerve are nerve conduction studies or electromyography.

Non-Surgical Treatment of Tarsal Tunnel Syndrome

The podiatrist may recommend taping, bracing, orthotics, or shoe modifications to provide support to the feet and correct the heel position.  Correcting the abnormal foot movement that may cause stretching and pressure in the tarsal tunnel may prove to relieve the symptoms of Tarsal Tunnel Syndrome. Icing and oral anti-inflammatory may be suggested to decrease swelling in the area.

Surgical Treatment of Tarsal Tunnel Syndrome

The main purpose of tarsal tunnel surgery is to release structures that may be putting pressure on the posterior tibial nerve or removing bone or soft tissue masses that may cause narrowing in the tarsal tunnel. The incision is made behind the anklebone and in front of the Achilles tendon. During surgery, blunt surgical instruments are utilized in order to avoid damage to the nerves. The sheath of the tarsal tunnel is opened and the course of the tibial nerve and its branches are followed in order to remove any thickened structures and release any tight structures around the nerves. Following surgery, a bulky dressing is applied to the foot in order to decrease swelling. One week after surgery, simple motions of the ankle for 10-20 minutes twice a day may be recommended to prevent adhesions. After 2-3 weeks, sutures are removed and ambulation with tennis shoe may be allowed.  The average time for most patients to begin exercise and full activity is 2-3 months after surgery.  It is also important to note that tingling and pain may increase after surgery, and the pain and numbness may take up to one year or more to resolve


Ankle Sprains and Ruptures

March 12, 2011

Anatomy of the Ankle

Ankle sprains, if not treated early, can create chronic ankle instability; (weak ankle) which leads to difficulty in sports activities and frequent recurrent ankle sprains. The ankle is composed of the joint, formed by three bones called the tibia (lower leg bone) and the talus as well as the fibula and ligaments that surround the joint.  The ankle ligaments support the joint and prevent excessive motion that may cause instability. There are two sets of ligaments in the ankle joint, the deltoid ligaments (found on the inside of the ankle joint on the same side as the big toe) and the lateral collateral ligaments (found on the outside of the ankle joint on the same side of the little toe).  The weakest of the fore mentioned and most commonly injured ankle ligaments are the lateral collateral ligaments. It is commonly injured by “rolling the ankle” or turning the foot inward, which stretches the ligament and results in tearing or rupturing of the ligament.

Causes of Ankle Sprains

Stretching the ankle ligaments beyond their maximum ability causes ankle sprains. This results in tearing or rupturing. Stretching of the ankle ligaments can occur when missing a step on a curb or physical activity that results in turning the foot inward or outward. Certain factors can increase the likelihood that ankle sprains occur.  Skeletal deformities of the foot where the heel is turned inward places the foot in a position that encourages the ankle to roll. Increased laxity and flimsiness of the ligaments will create a situation in some people where the supporting ligaments cannot stop the twisting motion, which leads to the ankle injury.  Impaired proprioception, a condition where the body has difficulty sensing the position of the ankle and impaired muscular control of the ankle joint, can also lead to more frequent sprains. Additionally, the incidence of ankle sprains can also increase if there are loose bone fragments found in the ankle joint associated with arthritis.

Symptoms of Ankle Sprains

Ankle ligament injures are classified by grades from grade I to grade III. Each grade is treated differently and the classification enables the podiatrist to provide the best treatment for the patient. Grade I ankle ligament injuries do not involve ligament rupture and only have minor swelling and tenderness. Grade II injuries have partial rupture of the ligaments, with moderate tenderness, swelling and loss of motion. Grade III injuries include a complete rupture of the ligament, severe bruising, swelling, pain, and major loss of function and motion of the ankle joint. Patients with ankle instability complain of persistent pain, recurrent sprains, and repeated instances of the ankle giving way.

Diagnosing Ankle Sprains:

When visiting a podiatrist for evaluation of an ankle sprain, the doctor will ask if the patient can recall the position the foot was in when the injury occurred. This will allow the podiatrist to determine which ligament was most likely injured. Additionally, the podiatrist will perform a physical exam. The exam will include pushing along both sides of the ankle where the ligaments attach, as well as distracting and moving the ankle to determine which ligaments have been injured. The podiatrist will perform X-rays of the foot and ankle in order to determine if the ankle sprain is accompanied by a fracture.  This may occur when the ligament has pulled off a bone fragment from the ankle and/or foot. Diagnostic ultrasound may be done to visualize the extent of the soft tissue injury.

Non-surgical Treatment for Ankle Sprains

Simple sprains can be treated non-surgically with: resting the foot and ankle, ice, compression, and elevation— especially during the first few days. Early weight bearing without crutches is encouraged if possible to prevent stiffness of the ankle joint.  It is usually recommended to start range-of-motion exercises of the ankle followed by coordination training with balance boards and trampoline, as well as strengthening exercises. An external ankle brace or ankle taping may be used to control the motion of the joint to reduce symptoms of the sprain and to prevent additional injury during the healing phase. With more severe ligament injuries, treatment can consist of cast immobilization, rehabilitation and possible surgical repair.

Platelet Rich Plasma Treatment:

Also known as PRP, is another treatment method that can be used to treat this condition. The procedure can be performed in the office and takes about 45 minutes. This is performed by taking a small sample of blood from the patient. This blood is then processed and a concentrated smaller amount of blood is produced with a very high quantity of platelets. Then, using ultrasound to guide the needle to the exact location of the injury the platelet-rich compound is injected. When the platelets are placed at the injured area they release a growth factor that attracts the patients stem cells. These stem cells then infiltrate the area and form new tissue to aid in healing the injured tissue.

Surgical Treatment for Ankle Sprains

When nonsurgical treatment does not resolve the ankle sprain, surgical treatment is the next option. There are three main types of surgical repair of ankle ligaments:

1. Tendon reconstruction: uses tendons to function similarly to the ligaments and since the long-term outcome is not as successful as other procedures, it is commonly used as secondary procedures in repairing ankle injuries.

2. Anatomic repair of the ligaments: restores the original ligament attachment and length by shortening and stitching the rupture ligaments.

3. Anatomic reconstruction: uses tissue flaps and grafts to reinforce and strengthen the ankle ligaments. This type of procedure is commonly used if anatomic repair of the ligament cannot be performed due to weakness and damage to the ends of the original ligament, failure from previous repair, increased ligament slack, or longstanding ankle stability of greater than 10 years.

After surgery, it is usually expected that the patient will be in a weight-bearing cast for about 6 weeks, followed by physical therapy and range-of-motion exercises.