TARSAL TUNNEL

SYNDROME

HERLAMBANG B MULYONO, MD
 Student Learning Outcomes
 Identify common midfoot & forefoot injuries
based on their presenting history, symptoms,
visual signs (inspection), & palpation findings
 Identify special tests that might be used to
evaluate these injuries
 Discuss basic management strategies for
dealing with these injuries
 Discuss anatomical or biomechanical
predisposing factors associated with these
common midfoot & forefoot injuries
 Location of Pain: Medial
Calcaneus/Medial Arch
 Injuries to consider
(continued from Ch. 4 Part 1)
 tarsal tunnel syndrome
 impingement &
inflammation of the
posterior tibial nerve
within the tarsal tunnel
History

 Tarsal tunnel syndrome

 Symptoms
 pain, numbness, or
parasthesia along
medial or plantar aspect
of foot
 may mimic plantar
fasciitis
 Onset
 Acute or chronic
History

 Tarsal tunnel syndrome

 MOI
 EV or PF/EV ankle
injury (acute)
 Forced PF (acute)
 Repetitive stress
associated with pes
planus foot
 Previous history of
tarsal fx
History

 Tarsal tunnel syndrome

 Possible related factors
 Training surface
 Distance
 Shoes
Inspection

 Tarsal tunnel syndrome

 pes planus foot
 typically no swelling,
discoloration, or
deformity
Palpation

 Tarsal tunnel syndrome

 Point tenderness
proximal, over, and
distal to the flexor
retinaculum
ROM
 Tarsal tunnel syndrome

 EV may reproduce
symptoms
 PF & EV may reproduce
symptoms
 may demonstrate
weakness of toe flexors
Stress Tests/Special Tests

 Tarsal Tunnel Syndrome

 n/a
Neurological Tests

 Tarsal Tunnel Syndrome

 Tinel’s sign
 Decreased sensation
over nerve distribution
Management

 Tarsal Tunnel Syndrome

 Ice
 NSAIDs
 Orthotics
 Surgical release (in
severe cases)
 SEKIAN TERIMA KASIH
 Location of Pain: Midfoot

 Injuries to consider
 fx/dislocation
 sprain
 strain/inflammation of tendon
insertion sites
 tarsal coalition
 Location of Pain: Midfoot

 Injuries to consider
 fx/dislocation
 Lisfranc injury
 navicular stress fx

Lisfranc injury
 Location of Pain: Midfoot

 Injuries to consider:
 sprain
 midtarsal joints
 tarsometatarsal joints
 Location of Pain: Midfoot

 Injuries to consider:
 strain/inflammation of muscle/tendon at
insertion sites
 tibialis posterior
 tibialis anterior
 peroneal longus
 peroneal brevis
 Location of Pain: Midfoot

 Injuries to consider:
 Tarsal coalition
 abnormal union between two or more tarsals
 bony
 fibrous
 Cartilaginous
 Location of Pain: Midfoot

 Injuries to consider:
 Tarsal coalition
 typically presents between 3 – 16 yrs of age
 3 – 5 yrs: talonavicular coalition jt.
 8 – 12 yrs: calcaneonavicular jt.
 12 – 16 yrs: talocalcaneal jt.
 Location of Pain: Midfoot

 Injuries to consider:
 Tarsal coalition
 will present clinically as a rigid pes planus
 limitations in subtalar joint
 History

Location of pain
Symptoms Onset MOI
(midfoot)
Dropping something on the foot;
Acute;
Fx/dislocation stepping in hole or on uneven
trauma ground - twisting the foot

Dropping something on the foot;

Acute;
Lisfranc fx** stepping in hole or on uneven
trauma ground - twisting the foot**

Acute;
Sprain Twisting the foot
trauma

Strain/inflammation of Acute or Forceful contraction;

tendon insertion site(s) chronic repetitive stress

Tarsal coalition congenital n/a

**often mistaken for midfoot sprain

Inspection/Observation
Signs
Location of pain
Deformity? Swelling? Discoloration?
(midfoot)
Fx/dislocation
Possible Possible Possible

Lisfranc fx Possible Common Possible

Sprain No Common Possible

Strain/inflammation of
tendon insertion site(s)
No Minimal if at all Typically not

Rigid pes planus;

ABD of forefoot,
medial
Tarsal coalition displacement of No No
talus; navicular
drop
Palpation

Location of pain Point

tenderness? Deformity? Swelling? Crepitus?
(midfoot)
Directly over
Fx/dislocation 1 or more Possible Possible Possible
tarsals

Over
Sprain involved No Possible Possible
joint
Over
Possible,
Strain/inflammation of tendon or
tendon insertion site(s)
Usually not would be Possible
insertion
minimal
site
Over
Typically
Tarsal coalition involved Typically not No
not
joint
Physical Exam

Location of pain
Special Neurological
ROM? Stress Tests?
(midfoot) Tests? ?

Fx/dislocation n/a n/a n/a n/a

Intermetatarsal glide
test
n/a
Sprain n/a Midtarsal joint glides n/a
Tarsometatarsal joint
glides
Pain w/passive
stretching of
Strain/inflammation of muscle/tendon;
tendon insertion site(s) n/a n/a Pain w/resisted
n/a
action of muscle
tendon

May have
Tarsal coalition limitation in n/a n/a n/a
IN/EV
Management

 Midfoot fx/dislocations
 Ice
 Walking boot or NWB
 Spring steel innersole
 Surgery (when severely displaced)
 Management

 Lisfranc fx/dislocation
 Cast
 NWB
 Rigid orthotic
 Surgery when necessary to
stabilize
Management

 Midfoot sprain
 Ice
 NSAIDs
 Spring steel innersole or rigid
orthotic
 Strengthening of intrinsic foot
muscles
Management

 Inflammation at tendon insertion

sites
 Ice
 NSAIDs
 Stretching
 Strengthening of involved muscle
with emphasis on eccentrics
 Management

 Tarsal coalition
 referral to orthopedist
 Location of Pain: Forefoot

 Injuries to consider
 Fx
 midshaft
 avulsion
 Jones’ fx
 Intermetatarsal (Morton’s)
neuroma
 metatarsalgia
 History
Location of pain
Symptoms Onset MOI
(forefoot)
Acute: Getting stepped on or
having something dropped onto
Acute or
Pain directly over MT; stepping in hole or onto
Midshaft fx chronic uneven surface;
metatarsal
(stress fx) Chronic: repetitive stress,
weakness of toe flexors
Most common site: styloid
Base of 5th MT: forceful
process of 5th MT
Avulsion fx Acute contraction of peroneal
Pain over fracture site; may
have heard/felt pop brevis

Force inversion with ankle

Pain over distal styloid of
Jones’ fx Acute in PF; landing on lateral
5th metatarsal
aspect of foot

Morton’s neuroma Pain, burning

Pain under head(s) of

Metatarsalgia metatarsals; may feel like Acute/chronic
“stepping on pebble”
Inspection/Observation
Signs
Location of pain
Deformity? Swelling? Discoloration?
(forefoot)
Midshaft fx   
Avulsion fx   
Jones’ fx   
Morton’s neuroma -- Possible --

Metatarsalgia -- Possible --
Palpation

Location of pain Point

tenderness? Deformity? Swelling? Crepitus?
(forefoot)
Midshaft fx    
Avulsion fx    
Jones’ fx    
Over
Morton’s neuroma n/a n/a n/a
neuroma

Involved head
Over head of Minimal if
Metatarsalgia may feel lower n/a
involved MT present
than others
Physical Exam

Location of pain
Stress Neurological
ROM? Special Tests?
(forefoot) Tests? ?

Toe flex/ext
Tap test;
Midshaft fx may increase -- --
pain Morton’s test
May have
limitation if
Avulsion fx motion -- -- --
stresses fx
site
May be
Jones’ fx
limited in EV -- Morton’s test --
Toe ext. may
Morton’s neuroma increase -- Morton’s test --
symptoms
Toe ext. may
Metatarsalgia increase -- -- --
symptoms
Management

 Midshaft fx/dislocation
 Ice
 NSAIDs
 Boot/cast
 Spring steel innersole
 Surgery with comminuted or
displaced fx
Management

 avulsion fx
 Boot/cast
 Surgery when necessary to
stabilize
Management

 Jones’ fx
 Boot/cast – NWB
 Known for nonunions
 Surgery when necessary to
stabilize
History

 Location of pain
Symptoms
 Forefoot •Burning pain
 between metatarsals •Electric shock
•Dull ache
 neuroma
 intrinsic muscles

MOI
•Gradual onset
•Improper shoes
•Forceful contraction
•Stretching beyond
normal limits of ROM
 Inspection/Palpation

 Forefoot injuries
Signs
 between metatarsals •swelling?
 neuroma
 intrinsic muscles

Palpation
•Point tenderness
•Compression of
neuroma reproduces
pain
 Stress/Special Tests

 Forefoot injuries
Tests
 between metatarsals •Morton’s Test
 neuroma •Abd/add of toes

 intrinsic muscles
 Management

 Forefoot injuries
Treatment
 between metatarsals •Ice
 neuroma •Anti-inflammatories
 intrinsic muscles •Orthotics
Questions?