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Fortier LM, Leethy KN, Smith M, McCarron MM, Lee C, Sherman WF, Varrassi G, Kaye AD. An Update on Posterior Tarsal Tunnel Syndrome. Orthop Rev (Pavia) 2022; 14:35444. [PMID: 35769658 PMCID: PMC9235437 DOI: 10.52965/001c.35444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 01/12/2022] [Indexed: 09/14/2023] Open
Abstract
Posterior tarsal tunnel syndrome (PTTS) is an entrapment neuropathy due to compression of the tibial nerve or one of its terminal branches within the tarsal tunnel in the medial ankle. The tarsal tunnel is formed by the flexor retinaculum, while the floor is composed of the distal tibia, talus, and calcaneal bones. The tarsal tunnel contains a number of significant structures, including the tendons of 3 muscles as well as the posterior tibial artery, vein, and nerve. Focal compressive neuropathy of PTTS can originate from anything that physically restricts the volume of the tarsal tunnel. The variety of etiologies includes distinct movements of the foot, trauma, vascular disorders, soft tissue inflammation, diabetes mellitus, compression lesions, bony lesions, masses, lower extremity edema, and postoperative injury. Generally, compression of the posterior tibial nerve results in clinical findings consisting of numbness, burning, and painful paresthesia in the heel, medial ankle, and plantar surface of the foot. Diagnosis of PTTS can be made with the presence of a positive Tinel sign in combination with the physical symptoms of pain and numbness along the plantar and medial surfaces of the foot. Initially, patients are treated conservatively unless there are signs of muscle atrophy or motor nerve involvement. Conservative treatment includes activity modification, heat, cryotherapy, non-steroidal anti-inflammatory drugs, corticosteroid injections, opioids, GABA analog medications, tricyclic antidepressants, vitamin B-complex supplements, physical therapy, and custom orthotics. If PTTS is recalcitrant to conservative treatment, standard open surgical decompression of the flexor retinaculum is indicated. In recent years, a number of alternative minimally invasive treatment options have been investigated, but these studies have small sample sizes or were conducted on cadaveric models.
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Affiliation(s)
| | - Kenna N Leethy
- Louisiana State University Shreveport School of Medicine
| | - Miranda Smith
- Louisiana State University Shreveport School of Medicine
| | | | - Christopher Lee
- Department of Internal Medicine, Creighton University School of Medicine-Phoenix Regional Campus
| | | | | | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University New Orleans
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Terle PM, Iwanaga J, Olewnik Ł, Tubbs RS. Previously Unreported Case of Variant Posterior Tibial Vein Forming a Loop Adjacent to the Posterior Tibial Artery. Cureus 2022; 14:e22248. [PMID: 35340515 PMCID: PMC8930017 DOI: 10.7759/cureus.22248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 11/28/2022] Open
Abstract
The posterior tibial vein (PTV) is formed distally by the medial and lateral plantar veins and ends proximally at the joining with the peroneal vein. Variations of the PTV can result in unique clinical presentations. Such variations at the proximal location have been classified previously, but few have been identified distally. In an adult male cadaver, we identified a unilateral distal PTV variation that bifurcated posterior to the medial malleolus. This bifurcation rejoined inferiorly to the medial malleolus and formed a loop that was transected by the posterior tibial artery from deep to superficial. Although this PTV variation is rare, we believe it could be clinically significant for tarsal tunnel syndrome (TTS) and catheter-directed thrombolysis (CDT) of deep vein thrombosis (DVT). Such anatomical variations should be documented and added to clinical databases to improve patient outcomes and diagnostic techniques.
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Rodríguez-Merchán EC, Moracia-Ochagavía I. Tarsal tunnel syndrome: current rationale, indications and results. EFORT Open Rev 2021; 6:1140-1147. [PMID: 35839088 PMCID: PMC8693231 DOI: 10.1302/2058-5241.6.210031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Tarsal tunnel syndrome (TTS) is a neuropathy due to compression of the posterior tibial nerve and its branches. It is usually underdiagnosed and its aetiology is very diverse. In 20% of cases it is idiopathic. There is no test that diagnoses it with certainty. The diagnosis is usually made by correlating clinical history, imaging tests, nerve conduction studies (NCSs) and electromyography (EMG). A differential diagnosis should be made with plantar fasciitis, lumbosacral radiculopathy (especially S1 radiculopathy), rheumatologic diseases, metatarsal stress fractures and Morton’s neuroma. Conservative management usually gives good results. It includes activity modification, administration of pain relief drugs, physical and rehabilitation medicine, and corticosteroid injections into the tarsal tunnel (to reduce oedema). Abnormally slow nerve conduction through the posterior tibial nerve usually predicts failure of conservative treatment. Indications for surgical treatment are failure of conservative treatment and clear identification of the cause of the entrapment. In these circumstances, the results are usually satisfactory. Surgical success rates vary from 44% to 96%. Surgical treatment involves releasing the flexor retinaculum from its proximal attachment near the medial malleolus down to the sustentaculum tali. Ultrasound-guided tarsal tunnel release is possible. A positive Tinel’s sign before surgery is a strong predictor of surgical relief after decompression. Surgical treatment achieves the best results in young patients, those with a clear aetiology, a positive Tinel’s sign prior to surgery, a short history of symptoms, an early diagnosis and no previous ankle pathology. Cite this article: EFORT Open Rev 2021;6:1140-1147. DOI: 10.1302/2058-5241.6.210031
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Affiliation(s)
- E. Carlos Rodríguez-Merchán
- Department of Orthopaedic Surgery, La Paz University Hospital, Madrid, Spain
- Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research – IdiPAZ (La Paz University Hospital – Autonomous University of Madrid), Madrid, Spain
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Inthasan C, Vaseenon T, Mahakkanukrauh P. Anatomical study and branching point of neurovascular structures at the medial side of the ankle. Anat Cell Biol 2020; 53:422-434. [PMID: 32814704 PMCID: PMC7769108 DOI: 10.5115/acb.20.087] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 06/23/2020] [Accepted: 07/21/2020] [Indexed: 01/07/2023] Open
Abstract
Nerve entrapment and blood circulation impairment associated with the medial side of the ankle are not uncommon. The purpose of this study was to describe the anatomical basis of neurovascular structures of the medial ankle which comprised the number, origin, branching pattern, and branching point. Forty feet of fresh cadavers were examined by using 2 reference lines: the malleolar-calcaneal (MC) and navicular-calcaneal (NC) axes. We recorded number, origin, length of the 2 axes, the locations and widths of neurovascular structures on MC and NC axes, the branching point of neurovascular structures, and the branching pattern of neurovascular structures was recorded and was separated into 5 types. The posterior tibial nerve (PTN) bifurcated to plantar and calcaneal nerves and branched proximally to the tarsal tunnel (TT). The posterior tibial artery bifurcated to plantar and calcaneal arteries and branched inferiorly to PTN and within the TT. The calcaneal nerves and arteries had more variation of number and origin. The most common branching point of calcaneal nerves and arteries is within the TT, except the medial calcaneal nerve. It branched proximally to the TT. The anatomical knowledge from this study is important for the diagnosis and treatment of clinicians.
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Affiliation(s)
- Chanatporn Inthasan
- PhD Degree Program in Anatomy, Department of Anatomy, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Tanawat Vaseenon
- Department of Orthopedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Pasuk Mahakkanukrauh
- Department of Anatomy, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Forensic Osteology Research Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Excellence in Osteology Research and Training Center (ORTC), Chiang Mai University, Chiang Mai, Thailand
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Won SH, Kim J, Min TH, Chun DI, Yi Y, Han SH, Cho J. Tarsal tunnel syndrome secondary to osteochondroma of the calcaneus: a case report. BMC Musculoskelet Disord 2020; 21:491. [PMID: 32711480 PMCID: PMC7382807 DOI: 10.1186/s12891-020-03530-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 07/21/2020] [Indexed: 11/12/2022] Open
Abstract
Background Tarsal tunnel syndrome is an entrapment neuropathy that can be provoked by either intrinsic or extrinsic factors that compresses the posterior tibial nerve beneath the flexor retinaculum. Osteochondroma, the most common benign bone tumor, seldom occur in foot or ankle. This is a rare case of tarsal tunnel syndrome secondary to osteochondroma of the sustentaculum tali successfully treated with open surgical excision. Case presentation A 15-year-old male presented with the main complaint of burning pain and paresthesia on the medial plantar aspect of the forefoot to the middle foot region. Hard mass-like lesion was palpated on the posteroinferior aspect of the medial malleolus. On the radiological examination, 2.5 × 1 cm sized bony protuberance was found below the sustentaculum tali. Surgical decompression of the posterior tibial nerve was performed by complete excision of the bony mass connected to the sustentaculum tali. The excised mass was diagnosed to be osteochondroma on the histologic examination. After surgery, the pain was relieved immediately and hypoesthesia disappeared 3 months postoperatively. Physical examination and radiographic examination at 2-year follow up revealed that tarsal tunnel was completely decompressed without any evidence of complication or recurrence. Conclusions As for tarsal tunnel syndrome secondary to the identifiable space occupying structure with a distinct neurologic symptom, we suggest complete surgical excision of the causative structure in an effort to effectively relieve symptoms and prevent recurrence.
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Affiliation(s)
- Sung Hun Won
- Department of Orthopaedic Surgery, Bone & Joint center, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Jahyung Kim
- Department of Orthopaedic Surgery, Seoul Hospital, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Tae-Hong Min
- Department of Orthopaedic Surgery, Seoul Hospital, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Dong-Il Chun
- Department of Orthopaedic Surgery, Seoul Hospital, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Young Yi
- Department of Orthopaedic Surgery, Seoul Paik Hospital, Inje University, Seoul, Republic of Korea
| | - Sang Hak Han
- Department of Pathology, Chuncheon Sacred Heart Hospital, Hallym University, Chuncheon, Republic of Korea
| | - Jaeho Cho
- Department of Orthopaedic Surgery, Chuncheon Sacred Heart Hospital, Hallym University, 77, Sakju-ro, Chuncheon-si, Gangwon-do, 200-704, Republic of Korea.
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Urits I, Smoots D, Franscioni H, Patel A, Fackler N, Wiley S, Berger AA, Kassem H, Urman RD, Manchikanti L, Abd-Elsayed A, Kaye AD, Viswanath O. Injection Techniques for Common Chronic Pain Conditions of the Foot: A Comprehensive Review. Pain Ther 2020; 9:145-160. [PMID: 32107725 PMCID: PMC7203280 DOI: 10.1007/s40122-020-00157-5] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Indexed: 11/05/2022] Open
Abstract
Purpose of Review This is a comprehensive literature review of the available evidence and techniques of foot injections for chronic pain conditions. It briefly describes common foot chronic pain syndromes and then reviews available injection techniques for each of these syndromes, weighing the available evidence and comparing the available approaches. Recent Findings Foot and ankle pain affects 20% of the population over 50 and significantly impairs mobility and ability to participate in activities of daily living (ADLs), as well as increases fall risk. It is commonly treated with costly surgery, at times with questionable efficacy. Injection therapy is challenging when the etiology is anatomical or compressive. Morton’s neuroma is a budging of the interdigital nerve. Steroid, alcohol, and capsaicin injections provide some benefit, but it is short lived. Hyaluronic acid (HA) injection provided long-term relief and could prove to be a viable treatment option. Achilles tendinopathy (AT) is most likely secondary to repeat tendon stress—platelet-rich-plasma (PRP) and prolotherapy have been trialed for this condition, but more evidence is required to show efficacy. Similar injections were trials for plantar fasciitis and achieved only short-term relief; however, some evidence suggests that PRP injections reduce the frequency of required therapy. Tarsal tunnel syndrome, a compressive neuropathy carries a risk of permanent neural injury if left untreated. Injection therapy can provide a bridge to surgery; however, surgical decompression remains the definitive therapy. When the etiology is inflammatory, steroid injection is more likely to provide benefit. This has been shown in several studies for gout, as well as osteoarthritis of the foot and ankle and treatment-refractory rheumatoid arthritis. HA showed similar benefit, possibly due to anti-inflammatory effects. Stem cell injections may provide the additional benefit of structure restoration. Summary Chronic foot pain is common in the general population and has significant associated morbidity and disability. Traditionally treated with surgery, these are costly and only somewhat effective. Injections provide an effective alternative financially and some evidence exists that they are effective in pain alleviation. However, current evidence is limited and the benefit described from injection therapy has been short-lived in most cases. Further studies in larger populations are required to evaluate the long-term effects of these treatments.
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Affiliation(s)
- Ivan Urits
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Daniel Smoots
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | | | - Anjana Patel
- Georgetown University School of Medicine, Washington, DC, USA
| | - Nathan Fackler
- Georgetown University School of Medicine, Washington, DC, USA
| | - Seth Wiley
- Arizona State University, Tempe, AZ, USA
| | - Amnon A Berger
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Hisham Kassem
- Department of Anesthesiology, Mount Sinai Medical Center, Miami Beach, FL, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Alaa Abd-Elsayed
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Omar Viswanath
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA.,Valley Anesthesiology and Pain Consultants - Envision Physician Services, Phoenix, AZ, USA.,Department of Anesthesiology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
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Iborra A, Villanueva M, Sanz-Ruiz P. Results of ultrasound-guided release of tarsal tunnel syndrome: a review of 81 cases with a minimum follow-up of 18 months. J Orthop Surg Res 2020; 15:30. [PMID: 31992296 PMCID: PMC6988231 DOI: 10.1186/s13018-020-1559-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/14/2020] [Indexed: 12/03/2022] Open
Abstract
Background This study aims to analyse the clinical results of ultrasound-guided surgery for the decompression of the tibial nerve, including its distal medial and lateral branches, to treat tarsal tunnel syndrome. These structures are the complete flexor retinaculum and the deep fascia of the abductor hallucis muscle, including individualised release of the medial and lateral plantar nerve tunnels. Method This is a retrospective review of 81 patients (36 men and 45 women) with an average age of 41 years old (32–62) and an average clinical course of 31 months (8–96) compatible with idiopathic tarsal tunnel syndrome, who underwent ultrasound-guided decompression of the proximal and distal tarsal tunnel between February 2015 and November 2017 (both months included), with a minimum follow-up of 18 months. Results Based on the Takakura et al. scale for the 81 patients, 76.54% obtained excellent results, 13.58% good results, and 9.87% poor results. The patients with the longest course of symptoms displayed the worst results. Conclusion Although 9% of patients did not improve, ultrasound-guided tarsal tunnel release might be a viable alternative to conventional open approaches.
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Affiliation(s)
- A Iborra
- Department of Podiatry, Faculty of Health Sciences, University of La Salle, Institute Avanfi, 28020, Madrid, Spain. .,Avanfi Institute and Unit for Ultrasound-guided Surgery, Hospital Beata María Ana, Calle Orense 32, 1, 28020, Madrid, Spain.
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Abstract
OBJECTIVE The purpose of this article is to review imaging after commonly encountered surgical interventions of the ligaments, tendons, and soft tissues around the ankle. Intraoperative images, when available, are provided to improve conceptual understanding of these complex procedures. CONCLUSION Surgical interventions in the ankle are becoming more prevalent with increasing athletic demands and emerging focus on techniques for prevention of joint injury. Knowledge of the surgical techniques, imaging appearances, and complications in the postoperative ankle is necessary for the accurate diagnosis of postoperative complications and for optimal patient care.
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Nam SH, Kim JY, Ahn J, Park Y. Plexiform Neurofibroma of the Posterior Tibial Nerve Misdiagnosed as Proximal Tarsal Tunnel Syndrome: A Case Report. Surg J (N Y) 2018; 4:e18-e22. [PMID: 29497706 PMCID: PMC5830161 DOI: 10.1055/s-0038-1632405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 01/12/2018] [Indexed: 10/27/2022] Open
Abstract
Plexiform neurofibromas of the foot are rare, benign tumors of the peripheral nerves. Diagnosis can be challenging if they present with symptoms mimicking other peripheral nerve pathologies. Tarsal tunnel syndrome is an entrapment syndrome of the entire tibial nerve behind the medial malleolus and under the flexor retinaculum. The clinical presentation typically includes posteromedial pain, positive Tinel's sign, and neurogenic signs, including both the sensation of numbness and the actual hypoesthesia and clawing of the toes. Here, we report the case of a 59-year-old female patient with plexiform neurofibroma with symptoms similar to those of tarsal tunnel syndrome. The plexiform neurofibroma was surgically excised and the nerve function was partially preserved.
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Affiliation(s)
- Sang Hyun Nam
- Department of Plastic and Reconstructive Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, South Korea
| | - Jung Yeon Kim
- Department of Pathology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, South Korea
| | - Jaeki Ahn
- Department of Physical Medicine and Rehabilitation, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, South Korea
| | - Yongbum Park
- Department of Physical Medicine and Rehabilitation, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, South Korea
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Doneddu PE, Coraci D, Loreti C, Piccinini G, Padua L. Tarsal tunnel syndrome: still more opinions than evidence. Status of the art. Neurol Sci 2017; 38:1735-1739. [DOI: 10.1007/s10072-017-3039-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 06/17/2017] [Indexed: 11/28/2022]
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Abstract
Posterior tarsal tunnel syndrome is the result of compression of the posterior tibial nerve. Anterior tarsal tunnel syndrome (entrapment of the deep peroneal nerve) typically presents with pain radiating to the first dorsal web space. Distal tarsal tunnel syndrome results from entrapment of the first branch of the lateral plantar nerve and is often misdiagnosed initially as plantar fasciitis. Medial plantar nerve compression is seen most often in running athletes, typically with pain radiating to the medial arch. Morton neuroma is often seen in athletes who place their metatarsal arches repetitively in excessive hyperextension.
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Affiliation(s)
- Eric Ferkel
- Southern California Orthopaedic Institute, 6815 Noble Avenue, Van Nuys, CA 91405, USA.
| | - William Hodges Davis
- OrthoCarolina Foot and Ankle Institute, 2001 Vail Avenue, #200B, Charlotte, NC 28207, USA
| | - John Kent Ellington
- OrthoCarolina Foot and Ankle Institute, 2001 Vail Avenue, #200B, Charlotte, NC 28207, USA
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Kim DI, Kim YS, Han SH. Topography of human ankle joint: focused on posterior tibial artery and tibial nerve. Anat Cell Biol 2015; 48:130-7. [PMID: 26140224 PMCID: PMC4488641 DOI: 10.5115/acb.2015.48.2.130] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 03/31/2015] [Accepted: 05/26/2015] [Indexed: 11/27/2022] Open
Abstract
Most of foot pain occurs by the entrapment of the tibial nerve and its branches. Some studies have reported the location of the tibial nerve; however, textbooks and researches have not described the posterior tibial artery and the relationship between the tibal nerve and the posterior tibial artery in detail. The purpose of this study was to analyze the location of neurovascular structures and bifurcations of the nerve and artery in the ankle region based on the anatomical landmarks. Ninety feet of embalmed human cadavers were examined. All measurements were evaluated based on a reference line. Neurovascular structures were classified based on the relationship between the tibial nerve and the posterior tibial artery. The bifurcation of arteries and nerves were expressed by X- and Y-coordinates. Based on the reference line, 9 measurements were examined. The most common type I (55.6%), was the posterior tibial artery located medial to the tibial nerve. Neurovascular structures were located less than 50% of the distance between M and C from M at the reference line. The bifurcation of the posterior tibial artery was 41% in X-coordinate, -38% in Y-coordinate, and that of the tibial nerve was 48%, and -10%, respectively. Thirteen measurements and classification showed statistically significant differences between both sexes (P<0.05). It is determined the average position of neurovascular structures in the human ankle region and recorded the differences between the sexes and amongst the populations. These results would be helpful for the diagnosis and treatment of foot pain.
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Affiliation(s)
- Deog-Im Kim
- Department of Nursing, College of Nursing, Keimyung University, Daegu, Korea
| | - Yi-Suk Kim
- Department of Anatomy, Ewha Womans University School of Medicine, Seoul, Korea
| | - Seung-Ho Han
- Department of Anatomy, Chung-Ang University College of Medicine, Seoul, Korea
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