Anterior Tarsal Tunnel Syndrome

THE CLINICAL SYNDROME

Anterior tarsal tunnel syndrome is caused by compression of the deep peroneal nerve as it passes beneath the superficial fascia of the ankle. The most common cause of compression of the deep peroneal nerve at this anatomic location is trauma to the dorsum of the foot. Severe, acute plantar flexion of the foot has been implicated in anterior tarsal tunnel syndrome, as has the wearing of overly tight shoes or squatting and bending forward, as when planting flowers. Anterior tarsal tunnel syndrome is much less common than posterior tarsal tunnel syndrome.

Anterior tarsal tunnel syndrome will present as deep, aching pain in the dorsum of the foot, weakness of the exterior digitorum brevls, and numbness in the distibution of the deep peroneal nerve.

SIGNS AND SYMPTOMS

This entrapment neuropathy presents primarily as pain, numbness, and paresthesias of the dorsum of the foot that radiates into the first dorsal web space. These symptoms may also radiate proximal to the entrapment into the anterior ankle. There is no motor involvement unless the distal lateral division of the deep peroneal nerve is involved. Nighttime foot pain analogous to the nocturnal pain of carpal tunnel syndrome is often present. The patient may report that holding the foot in the everted position decreases the pain and paresthesias of anterior tarsal tunnel syndrome.

Physical findings include tenderness over the deep peroneal nerve at the dorsum of the foot. A positive Tinel’s sign just medial to the dorsalis pedis pulse over the deep peroneal nerve as it passes beneath the fascia is usually present. Active plantar flexion will often reproduce the symptoms of anterior tarsal tunnel syndromes. Weakness of the extensor digitorium brevis may be present if the lateral branch of the deep peroneal nerve is affected.

TREATMENT

Mild cases of tarsal syndrome will usually respond to conservative therapy, and surgery should be reserved for more severe cases. Initial treatment of tarsal tunnel syndrome should consist of treatment with simple analgesics, nonsteroidal anti-inflammatory drugs, or cyclooxygenase-2 inhibitors and splinting of the ankle. At a minimum, the splint should be worn at night, but 24 hours a day is ideal. Avoidance of repetitive activities thought to be responsible for the evolution of tarsal tunnel syndrome, such as prolonged squatting or wearing shoes that are too tight, will also help ameliorate the patient’s symptoms. If the patient fails to respond to these conservative measures, a next reasonable step is injection of the tarsal tunnel with local anesthetic and steroid.

Tarsal tunnel injection is performed by placing the patient in the supine position with the leg extended. It should be remembered that the most common cause of pain radiating into the lower extremity is herniated lumbar disc or nerve impingement secondary to degenerative arthritis of the spine, not disorders involving the common or deep peroneal nerve per se. Other pain syndromes that may be confused with deep peroneal nerve entrapment include lesions either above the origin of the common peroneal nerve, such as lesions of the sciatic nerve, or lesions at the point at which the common peroneal nerve winds around the head of the fibula.

The described injection technique is useful in the treatment of anterior tarsal tunnel syndrome. Anterior tarsal tunnel syndrome is characterized by persistent aching of the dorsum of the foot that is sometimes associated with weakness of the toe extensors. This pain is frequently worse at night and may awaken the patient from sleep. It is relieved by moving the affected ankle and toes. Anterior tarsal tunnel syndrome can occur after squatting and leaning forward for long periods of time, such as when planting flowers. Diabetics and others with vulnerable nerve syndrome may be more susceptible to the development of this syndrome. Most patients with anterior tarsal tunnel syndrome can be treated with deep peroneal nerve blocks with local anesthetic and steroid combined with avoidance techniques.

Low intensity laser therapy as well as a coordinated wellness program is also effective in treating this disorder.

Low Intensity Laser Therapy (LILT)

The low intensity Laser (LILT) sends photons (light) into the injured tissues and can penetrate two to three inches to treat affected areas. It uses a natural enhancement of the cellular machinery that can and has been dynamically measured in published studies to promote healing without burning affected tissue. Once the photons find the injured tissues, they stimulate and energize the cells to repair and strengthen at a remarkable rate. The treatment does not hurt, takes about 30 minutes and is very cost advantageous.

Wellness Program

A wellness program whichindividualizes treatment for age, performance and function has been shown in pilot studies to improve the overall health and well being of the individuals evaluated. A well conceived dietary and supplementary regimen based on scientific age–related decline in certain necessary compounds can improve quality of life, correct the ravages of hormone imbalance, balance critical neurotransmitter function without resorting to powerful drugs for depression that often have unfavorable side-effect profiles and restore vitality and youth in daily exercise routines. Furthermore, when wellness products are utilized with success, individuals often seek less costly interventions including unnecessary surgeries and narcotic options to treat pain. For more information go to www.drpwellness.com.