Botulinum Toxin Injection for the Treatment of Compression of Lateral Plantar Nerve by Flexor Digitorum Accessorius Longus.

ABSTRACT: The flexor digitorum accessorius longus is an anomalous muscle with a reported prevalence of 1.6%-12.2% in cadaveric studies. Flexor digitorum accessorius longus courses through the tarsal tunnel and has been reported as an etiology of tarsal tunnel syndrome in previous case reports. The flexor digitorum accessorius longus is intimately related to the neurovascular bundle and may impinge on the lateral plantar nerves. However, very few cases of lateral plantar nerve compression by the flexor digitorum accessorius longus have been reported. Herein, we report a case of lateral plantar nerve compression caused by the flexor digitorum accessorius longus muscle in a 51-year-old man who complained of insidious pain at the lateral sole and hypoesthesia at the left third-fifth toe and lateral sole, and the pain improved after treatment of botulinum toxin injection into the flexor digitorum accessorius longus muscle.

Tarsal tunnel syndrome: a still challenge condition / Síndrome do túnel do tarso: uma condição ainda desafiadora

Tarsal tunnel syndrome is a rare, under diagnosed and often confused neuropathy with other clinical entities. There is a lack of population studies on this disease. Herein, we performed a non-systematic review of articles between January 1992 and February 2018. Although with a less complex anatomy comparing to the carpal tunnel, the tarsal tunnel is source of pain and some other conditions. Treatment involves conservative measures such as analgesics and physical therapy rehabilitation or surgical procedures in case of conservative treatment failure. Randomized control studies are lack and mandatory for uncover the best modality of treatment for this condition.

A Síndrome do túnel do tarso é uma rara e subdiagnosticada neuropatia geralmente confundida com outras entidades clínicas. Há falta de estudos populacionais sobre a doença. Assim sendo, realizamos uma revisão da literatura de artigos entre Janeiro de 1992 e fevereiro de 2018. Apesar de possuir uma anatomia de menor complexidade comparada ao túnel do carpo, o túnel do tarso é origem de dor e algumas outras condições. O tratamento envolve medidas conservadoras como analgésicos e terapia de reabilitação ou procedimentos cirúrgicos, em caso de falha do tratamento conservador. Estudos randomizados são escassos e necessários para descoberta da melhor modalidade de tratamento desta condição.

Recurrence of Extranodal Natural Killer/T-cell Lymphoma Presenting as Tarsal Tunnel Syndrome.

This case report is a rare form of lymphoma recurrence which presented as tarsal tunnel syndrome. The patient had been previously treated for the malignancy and was presumed to be in remission; however, standard radiology imaging protocols failed to include the distal extremities on these scans. The patient presented to the orthopedic clinic with tarsal tunnel symptoms and a mass in the tarsal tunnel. A complete evaluation resulted in a diagnosis of recurrence of the malignancy. This case illustrates the importance of a thorough medical history and personal review of imaging studies, and how a systematic approach can produce the correct diagnosis for any unknown lesion. Furthermore, this case may prompt oncologists to consider obtaining whole-body fluorodeoxyglucose positron emission tomography computed tomography when evaluating for recurrence in patients.

Uridine monophosphate, folic acid and vitamin B12 in patients with symptomatic peripheral entrapment neuropathies.

BACKGROUND: Carpal tunnel syndrome is the most common type of peripheral entrapment neuropathy. PATIENTS & METHODS: We performed an exploratory, open-label, multicenter, observational study of 48 patients with peripheral entrapment neuropathy. Patients received a daily capsule of uridine monophosphate, folic acid + vitamin B12 for 2 months and were evaluated using the Pain DETECT questionnaire. RESULTS: The global score for pain decreased from 17.3 ± 5.9 at baseline to 10.3 ± 6.1 at the final evaluation (p < 0.001). Concomitant analgesic and anti-inflammatory treatment was stopped or the dose reduced in 77.4% of patients. CONCLUSION: Uridine monophosphate + folic acid + vitamin B12 reduced total pain score, intensity and characterization of pain and associated symptoms. These results should be tested in a well-designed, adequately powered randomized controlled trial.

Acetazolamide as an adjunct to CPAP treatment: a case of complex sleep apnea in a patient on long-acting opioid therapy.

A 41-year-old white woman on long-acting opioid therapy was diagnosed with moderate obstructive sleep apnea. On initiation of continuous positive airway pressure (CPAP), she manifested severe central apnea that was unresponsive to supplemental oxygen and interfered with CPAP titration. Acetazolamide, 250 mg, nightly at bedtime was initiated, and CPAP titration was repeated. On acetazolamide, optimal CPAP pressure was obtained with no manifestation of clinically significant central respiratory disturbance. This case suggests that acetazolamide may be an effective adjunct to positive airway pressure therapy in patients on long-acting opioids. A need exists for examination of acetazolamide in this capacity.

Clinical and electrophysiological findings and follow-up in tarsal tunnel syndrome.

The authors report clinical and electrophysiological findings in 59 patients with tarsal tunnel syndrome (TTS) and follow-up in 23 of them. The entrapment was prevalent in females; was bilateral in 6 patients and involved medial plantar in 7 and lateral plantar nerves in two cases. Eleven presented with other nerve entrapment syndromes or focal mononeuropathies, due to hereditary neuropathy with liability to pressure palsy or systemic diseases. The other 48 subjects had TTS without any other related entrapment syndromes: 23 were idiopathic cases, 13 had a history of local trauma, 3 had systemic diseases and the others had external or intrinsic compressions. The most frequent symptoms were paraesthesia or dysaesthesia (86% of feet) and pain (55%). Hypoaesthesia of the sole and weakness of toe flexion were evident in 74% and 22% of feet, respectively. Absence of sensory action potential or slowing of sensory conduction velocity (SCV) of the plantar nerves were present in 77% of feet; significant differences of SCV between affected and unaffected plantar nerves and/or between distal sural and plantar nerves were evident in 14%. Abnormalities of plantar SCV were therefore absent in only 9% of feet. Distal motor latency was delayed in 55% and electromyography showed neurogenic changes in 45% of sole muscles. Five cases (6 feet) underwent surgery with excellent or good results in 5, 4 of them also showing improvement in distal conduction of the plantar nerves. Nine were treated with local steroid injections, with good results shown in 6 patients. Nine other patients who did not receive any therapy showed a disappearance of symptoms or good outcome in 6 cases. The subjects with poor therapeutic results had S1 radiculopathy or systemic diseases. The authors underline that patients with connective tissue diseases should not be treated by surgical decompression because they may have subclinical neuropathy. Some subjects with idiopathic or trauma-induced TTS recover spontaneously. Surgical release should be limited to cases with space-occupying lesions and when conservative treatments fail.