Tarsal tunnel ganglion cyst: intraneural or extraneural site?

Intraneural ganglion cysts are very uncommon lesions, whose diagnosis has increased since the articular theory and the description of the MRI findings were established. We present a case report of a 59-year-old man with symptoms of tarsal tunnel syndrome. Foot and ankle MRI demonstrated the presence of an intraneural cystic lesion in the posterior tibial neve and its connection with the subtalar joint through an articular branch. The identification of the specific radiological signs like the «signet ring sign¼ allowed establishing an adequate preoperative diagnosis, differentiating it from an extraneural lesion and facilitating the articular disconnection of the nerve branch during surgery.

Mapeo sonográfico de los nervios de la cara medial del tobillo y del pie / Sonographic mapping of the nerves of the medial side of the ankle and foot

El uso de los ultrasonidos en el examen, la identificación y el intervencionismo de las diferentes ramas nerviosas del tobillo y del pie son una herramienta de gran apoyo en el ámbito clínico. En la actualidad, la ecografía es un método que se ha ido universalizando en el mundo de la podología, bien por su mayor accesibilidad debido al abaratamiento de los costes, a los avances tecnológicos y a sus beneficios de inocuidad, fácil disponibilidad para el examen inmediato y su aplicación dinámica en la evaluación de las diferentes estructuras anatómicas. El presente trabajo trata de presentar a la comunidad podológica una descripción detallada del mapeo mediante ecografía de los nervios en cara medial del pie. Entendemos que esta descripción puede ayudar a los profesionales en el diagnóstico de las patologías de atrapamiento nervioso a dicho nivel, así como en procedimientos mínimamente invasivos guiados ecográficamente en dicha área anatómica.(AU)

The use of ultrasound in clinical practice is a great tool for the examination, identification and intervention of the different nerve branches in the foot and ankle. Nowadays, sonography is an exploratory method that has been universally expanded in podiatry because of lowering of costs associated to its use, technological progresses and its benefits of safety, disposal for the inmediate clinical exam and its dynamic application in the evaluation of different structures. The aim of the present paper is to present to the podiatry community a detailed description of sonographic mapping of the nerves in the medial side of the ankle. It is intended to help professionals involved in the management of foot ankle disorders regarding the diagnosis of entrapment neuropathies at this level and also to help with minimally invasive treatments sonographically guided.(AU)

Síndrome del túnel del tarso: análisis clínico-imagenológico de una serie de casos / Tarsal tunnel syndrome: Clinical-imaging analysis of a case series

Antecedentes: Revisión retrospectiva de pacientes con diagnóstico de síndrome del túnel del tarso (STT) tratados quirúrgicamente. Método: Serie retrospectiva de pacientes con diagnóstico de STT operados entre los años 2005 y 2020 en un mismo centro. Se analizan variables como edad, género, lado, nervio o rama afectada, clasificación, tipo de estudio imagenológico, resultado biopsia, tasa de infección, tasa recurrencia, secuelas, entre otras. Resultados: Se incluyen ocho hombres y dos mujeres con edad promedio de 47 años (rango 34-67) y seguimiento promedio de 62,2 meses (rango 2-149). Todos los casos se relacionan con una compresión intrínseca. La causa más frecuente fue la presencia de quiste (40%), seguida de adherencias perineurales (20%). El nervio tibial posterior fue el más afectado (50%) y 30% la rama plantar medial. La ecografía (70%) y resonancia magnética (50%) fueron los estudios más solicitados. No hubo casos de infección postoperatoria. Hubo tres pacientes que presentaron recurrencia de la lesión requiriendo una nueva cirugía. Conclusiones: El STT es una neuropatía que compromete al nervio tibial posterior o a algunas de sus ramas. En general su causa es la compresión del nervio por distintas estructuras como músculos accesorios, gangliones, entre otras. El diagnóstico es eminentemente clínico apoyándose en estudio por imágenes. El tratamiento quirúrgico presenta mejores resultados cuando la causa es una compresión intrínseca, aunque se describen tasas variables de recurrencia.(AU)

Background: Retrospective review of patients with a diagnosis of Tarsal Tunnel Syndrome (TTS) treated surgically. Methods: Retrospective series of patients with diagnosis of TTS operated between 2005 and 2020 in the same center. Variables such as age, sex, side, affected nerve or branch, classification, type of imaging study, biopsy result, infection rate, recurrence rate, sequelae, among others, were analyzed. Results: We included 8 men and 2 women with an average age of 47 years (range 34-67) and an average follow-up of 62.2 months (range 2-149). All cases were related to intrinsic compression. The most frequent cause was the presence of cyst (40%) followed by perineural adhesions (20%). The Posterior Tibial Nerve was the most affected (50%) and 30% the Medial Plantar Branch. Ultrasound (70%) and MRI (50%) were the most requested studies. There were no cases of postoperative infection. There were 3 patients who presented recurrence of the lesion requiring a new surgery. Conclusions: TTS is a neuropathy involving the posterior tibial nerve or some of its branches. In general, it is caused by compression of the nerve by different structures such as accessory muscles and ganglions, among others. The diagnosis is eminently clinical, supported by imaging studies. Surgical treatment presents better results when the cause is an intrinsic compression, although variable recurrence rates are described.(AU)

Tarsal tunnel syndrome: Clinical-imaging analysis of a case series / Síndrome del túnel del tarso: análisis clínico-imagenológico de una serie de casos

Background: Retrospective review of patients with a diagnosis of Tarsal Tunnel Syndrome (TTS) treated surgically. Methods: Retrospective series of patients with diagnosis of TTS operated between 2005 and 2020 in the same center. Variables such as age, sex, side, affected nerve or branch, classification, type of imaging study, biopsy result, infection rate, recurrence rate, sequelae, among others, were analyzed. Results We included 8 men and 2 women with an average age of 47 years (range 34-67) and an average follow-up of 62.2 months (range 2-149). All cases were related to intrinsic compression. The most frequent cause was the presence of cyst (40%) followed by perineural adhesions (20%). The Posterior Tibial Nerve was the most affected (50%) and 30% the Medial Plantar Branch. Ultrasound (70%) and MRI (50%) were the most requested studies. There were no cases of postoperative infection. There were 3 patients who presented recurrence of the lesion requiring a new surgery. Conclusions: TTS is a neuropathy involving the posterior tibial nerve or some of its branches. In general, it is caused by compression of the nerve by different structures such as accessory muscles and ganglions, among others. The diagnosis is eminently clinical, supported by imaging studies. Surgical treatment presents better results when the cause is an intrinsic compression, although variable recurrence rates are described.(AU)

Antecedentes: Revisión retrospectiva de pacientes con diagnóstico de síndrome del túnel del tarso (STT) tratados quirúrgicamente. Método: Serie retrospectiva de pacientes con diagnóstico de STT operados entre los años 2005 y 2020 en un mismo centro. Se analizan variables como edad, género, lado, nervio o rama afectada, clasificación, tipo de estudio imagenológico, resultado biopsia, tasa de infección, tasa recurrencia, secuelas, entre otras. Resultados: Se incluyen ocho hombres y dos mujeres con edad promedio de 47 años (rango 34-67) y seguimiento promedio de 62,2 meses (rango 2-149). Todos los casos se relacionan con una compresión intrínseca. La causa más frecuente fue la presencia de quiste (40%), seguida de adherencias perineurales (20%). El nervio tibial posterior fue el más afectado (50%) y 30% la rama plantar medial. La ecografía (70%) y resonancia magnética (50%) fueron los estudios más solicitados. No hubo casos de infección postoperatoria. Hubo tres pacientes que presentaron recurrencia de la lesión requiriendo una nueva cirugía. Conclusiones: El STT es una neuropatía que compromete al nervio tibial posterior o a algunas de sus ramas. En general su causa es la compresión del nervio por distintas estructuras como músculos accesorios, gangliones, entre otras. El diagnóstico es eminentemente clínico apoyándose en estudio por imágenes. El tratamiento quirúrgico presenta mejores resultados cuando la causa es una compresión intrínseca, aunque se describen tasas variables de recurrencia.(AU)

Tarsal tunnel syndrome: Clinical-imaging analysis of a case series. / Síndrome del túnel del tarso: análisis clínico-imagenológico de una serie de casos.

BACKGROUND: Retrospective review of patients with a diagnosis of Tarsal Tunnel Syndrome (TTS) treated surgically. METHODS: Retrospective series of patients with diagnosis of TTS operated between 2005 and 2020 in the same center. Variables such as age, sex, side, affected nerve or branch, classification, type of imaging study, biopsy result, infection rate, recurrence rate, sequelae, among others, were analyzed. RESULTS: We included 8 men and 2 women with an average age of 47 years (range 34-67) and an average follow-up of 62.2 months (range 2-149). All cases were related to intrinsic compression. The most frequent cause was the presence of cyst (40%) followed by perineural adhesions (20%). The Posterior Tibial Nerve was the most affected (50%) and 30% the Medial Plantar Branch. Ultrasound (70%) and MRI (50%) were the most requested studies. There were no cases of postoperative infection. There were 3 patients who presented recurrence of the lesion requiring a new surgery. CONCLUSIONS: TTS is a neuropathy involving the posterior tibial nerve or some of its branches. In general, it is caused by compression of the nerve by different structures such as accessory muscles and ganglions, among others. The diagnosis is eminently clinical, supported by imaging studies. Surgical treatment presents better results when the cause is an intrinsic compression, although variable recurrence rates are described.

Bilateral posterior tarsal tunnel syndrome caused by accessory flexor digitorum longus; case report and surgical technique. / Síndrome del túnel del tarso posterior bilateral por músculo flexor digitorum longus accesorio; reporte de un caso y descripción de técnica quirúrgica.

OBJECTIVE: To present a case report of bilateral posterior tarsal tunnel syndrome (PTTS) caused by an accessory flexor digitorum longus (AFDL), including the surgical technique and a review of the literature. MATERIALS AND METHODS: Twenty-nine year old male diagnosed with bilateral PTTS, refractory to conservative management, with 53 points on the preoperative AOFAS score. MR of both ankles showed an AFDL within the tarsal tunnel, in close relationship to the posterior tibial nerve. Bilateral tarsal tunnel decompression and AFDL resection was performed. RESULTS: There were no post-operative complications. At 6 months after surgery, the patient had no pain and had 87 points on the AOFAS score. DISCUSSION: The PTTS is an entrapment neuropathy of the posterior tibial nerve or one of its terminal branches. A rare cause is the presence of an AFDL, and its resection is associated with good clinical results. Careful scar tissue resection and neurolysis is recommended. Knowing the normal pathway and anatomical variability of the posterior tibial nerve and its branches is essential to avoid iatrogenic injury. In our case report, MR and intraoperative findings identified a bilateral FDLA in close relationship to the common flexor digitorum, an unusual finding, with few reports in current literature. CONCLUSIONS: Careful tarsal tunnel decompression and AFDL resection in our patient with bilateral symptomatic PTTS has good clinical results and no complications, particularly when diagnosed and treated early.

Síndrome del túnel del tarso: Revisión del tema / Tarsal tunnel syndrome: Review of the topic as a result of one case

La primera descripción del túnel del tarso se le atribuye a Richter, en 1897; en 1932 Pollock y Davis describen por primera vez el síndrome, en 1960 Kopell y Thompson describen la clínica del síndrome de túnel del tarso y en 1962 Charles Keck describió el síndrome del túnel del tarso en forma detallada con casos clínicos. Se presenta el caso de un paciente femenino de 61 años que inició su padecimiento en 2010, al presentar talalgia intermitente que se incrementa de forma gradual, seis meses después el dolor es constante y limita la marcha, EVA de 6/10, se diagnostica fascitis plantar, y se envía a fisioterapia sin mejoría a los dos meses de tratamiento. El ultrasonido de fascia plantar, reporta engrosamiento de la misma, con microdesgarros en su inserción en calcáneo, se realiza infiltración de plasma rico en plaquetas en fascia plantar sin mejoría, dos meses después es enviada a sesiones de ondas de choque sin cambios, se revalora caso y se realiza el diagnóstico de síndrome del túnel del tarso en forma clínica y por electromiografía y en 2011 se infiltran esteroide con anestésico local con mejoría temporal. En 2012, encontramos EVA de 7/10 y AOFAS de 54 puntos, se interviene quirúrgicamente y como hallazgo transoperatorio se encuentra trayecto varicoso que disminuía el calibre del túnel del tarso oprimiendo a las estructuras adyacentes. Se presenta el caso clínico y la revisión en la literatura del síndrome del túnel del tarso.

The first description of tarsal tunnel is attributed to Richter in 1897, in 1932 Pollock and Davis described the syndrome for the first time, in 1960 Kopell and Thompson described the clinical features of tarsal tunnel syndrome; and in 1962 Charles Keck described tarsal tunnel syndrome in a detailed manner with clinical cases. We present the case of a 61 year old female patient who presented symptoms in 2010, she had intermittent talalgia that increased gradually, six months later pain is constant and limiting gait, EVA is 6/10, she is diagnosed with plantar fasciitis and is referred to physiotherapy with no improvement after two months of treatment. The plantar fascia ultrasound reports thickening with micro tears in the heel bone attachment, we infiltrated the plantar fascia with platelet rich plasma with no improvement, two months later she has shock wave sessions with no changes observed. We reassess the case and make the diagnosis of tarsal tunnel syndrome clinically and with electromyography and in 2011 we infiltrate a steroid with local anesthesia with temporary improvement. In 2012, we found an EVA of 7/10 and an AOFAS of 54 points, we perform surgery and the intraoperative finding is a varicose vein that decreased the caliber of the tarsal tunnel compressing adjacent structures. The clinical case is presented and we reviewed tarsal tunnel syndrome in the literature.