Extensile decompression of the proximal and distal tarsal tunnel combined with partial plantar fascia release in the treatment of chronic plantar heel pain

An anatomical approach to the tarsal tunnel syndrome: what can ankle's medial side anatomy reveal to us?

BACKGROUND

The heel is a complex anatomical region and is very often the source of pain complaints. The medial heel contains a number of structures, capable of compressing the main nerves of the region and knowing its anatomical topography is mandatory. The purpose of this work is to evaluate if tibial nerve (TN) and its main branches relate to the main anatomical landmarks of the ankle's medial side and if so, do they have a regular path after emerging from TN.

METHODS

The distal part of the legs, ankles and feet of 12 Thiel embalmed cadavers were dissected. The pattern of the branches of the TN was registered and the measurements were performed according to the Dellon-McKinnon malleolar-calcaneal line (DML) and the Heimkes Triangle (HT).

RESULTS

The TN divided proximal to DML in 87.5%, on top of the DML in 12,5% and distal in none of the feet. The Baxter's nerve (BN) originated proximally in 50%, on top of the DML in 12,5% and distally in 37.5% of the cases. There was a strong and significant correlation between the length of DML and the distance from the center of the medial malleolus (MM) to the lateral plantar nerve (LPN), medial plantar (MPN) nerve, BN and Medial Calcaneal Nerve (MCN) (ρ: 0.910, 0.866, 0.970 and 0.762 respectively, p <  0.001).

CONCLUSIONS

In our sample the TN divides distal to DML in none of the cases. We also report a strong association between ankle size and the distribution of the MPN, LPN, BN and MCN. We hypothesize that location of these branches on the medial side of the ankle could be more predictable if we take into consideration the distance between the MM and the medial process of the calcaneal tuberosity.

Effectiveness and safety of warm needling therapy combined with electroacupuncture for patients with plantar heel pain syndrome: A protocol for systematic review and meta-analysis

BACKGROUND

Several studies have reported positive therapeutic effects of electroacupuncture, warm needling, or a combination of the 2 for heel pain; however, the quality of the evidence is limited by methodological limitations. Given that there are no high-quality meta-analyses or reviews incorporating the available evidence, the aim of this study was to systematically review the level I evidence in the literature to determine whether a combination of electroacupuncture and warm needling therapy is more beneficial than acupuncture alone in patients with plantar heel pain syndrome.

METHODS

From the inception to May 2022, the Wanfang, CNKI, EMBASE, PubMed, Web of Science, and Cochrane Library electronic databases will be searched using the key phrases "acupuncture", "warm needling", "electroacupuncture", "heel pain", "plantar pain", and "prospective" for all relevant studies. The outcomes include pain, physical disability, plantar fascia thickness, and foot functional status. Quality assessment of all studies included in this review will be independently assessed by 2 reviewers using the Cochrane Collaborations tool. We consider significant heterogeneity between trials if I2 > 50%, and severe heterogeneity if I2 > 75%. When significant heterogeneity is indicated, we will find the source of heterogeneity by subgroup or sensitivity analysis.

RESULTS

The results of our review will be reported strictly following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines and the recommendations of the Cochrane Collaboration.

CONCLUSIONS

We initially hypothesized that combination therapy would lead to better treatment outcomes.Registration number: 10.17605/OSF.IO/VWBYJ.

Evaluation and Treatment of Chronic Plantar Fasciitis

Plantar fasciitis is the most common cause of chronic heel pain in adults, affecting both young active patients and older sedentary individuals. It results from repetitive stress to the plantar fascia at its origin on the medial tubercle of the calcaneus and is often associated with gastrocnemius tightness. The diagnosis can be made clinically with a focused history and physical examination; imaging is reserved for atypical presentations and those that do not respond to initial treatment. The most common presenting symptom is aching plantar heel pain, which is worst with first step in the morning or after periods of rest. Diagnosis is confirmed with point tenderness at the origin of the plantar fascia on the medial tubercle of the calcaneus. Initial treatment consists of activity modification, anti-inflammatory medication, gastrocnemius and plantar fascia stretching, and an in-shoe orthosis that lifts and cushions the heel. These nonoperative treatments lead to complete resolution of pain in 90% of patients but can take 3-6 months. Patients who remain symptomatic despite a 6-month trial of nonoperative therapy may be considered for minimally invasive treatment or surgery. Platelet-rich plasma injections and therapeutic ultrasound are among a number of minimally invasive treatments that stimulate the body's healing response. Corticosteroid injections temporarily relieve pain, but may increase the risk of plantar fascia rupture and fat pad atrophy. Botulinum toxin injections relax the calf muscles, which decreases the stress in the plantar fascia. Operative treatments include gastrocnemius recession and medial head of gastrocnemius release, which decrease the stress on the plantar fascia and partial planter fasciotomy, which stimulates a healing response.

LEVEL OF EVIDENCE

Level V, expert opinion.

Ultrasound-guided decompression surgery of the distal tarsal tunnel: a novel technique for the distal tarsal tunnel syndrome-part III

BACKGROUND

The aim of this study was to provide a safe ultrasound-guided minimally invasive surgical approach for a distal tarsal tunnel release concerning nerve entrapments.

METHODS AND RESULTS

The study was carried out on ten fresh-frozen feet. All of them have been examined by high-resolution ultrasound at the distal tarsal tunnel. The surgical approach has been marked throughout the course of the medial intermuscular septum (MIS, the lateral fascia of the abductor hallucis muscle). After the previous steps, nerve decompression was carried out through a MIS release through a 2.5 mm (± 0.5 mm) surgical portal. As a result, an effective release of the MIS has been obtained in all fresh-frozen feet.

CONCLUSION

The results of our anatomic study indicate that this novel ultrasound-guided minimally invasive surgical approach for the release of the MIS might be an effective, safe and quick decompression technique treating selected patients with a distal tarsal tunnel syndrome.

Ultrasound-guided decompression surgery of the tarsal tunnel: a novel technique for the proximal tarsal tunnel syndrome-Part II

Background

The aim of this study is to provide a safe ultrasound-guided minimally invasive surgical approach for a proximal tarsal tunnel release concerning nerve entrapments.

Methods and results

The study was carried out on ten fresh-frozen feet. All of them were examined by high resolution ultrasound at the medial ankle region. The surgical approach was marked throughout the course of the flexor retinaculum (laciniate ligament). Once the previous steps were done, the flexor retinaculum release technique was carried out with a 2-mm entry only. As a result, an effective and safe release of the flexor retinaculum was obtained in all fresh-frozen feet.

Conclusion

The results of our anatomic study indicate that our novel ultrasound-guided minimally invasive surgical approach for the release of the flexor retinaculum might be an effective, safe and quick decompression technique treating selected patients with a proximal tarsal tunnel syndrome.

Recurrent tarsal tunnel syndrome

Recurrence of tarsal tunnel syndrome after surgery may be due to inadequate release, lack of understanding or appreciation of the actual anatomy involved, variations in the anatomy of the nerve(s), failure to execute the release properly, bleeding with subsequent scarring, damage to the nerve and branches, persistent hypersensitivity of the nerves, and preexisting intrinsic damage to the nerve. Approaches include more thorough release, use of barrier materials to decrease adherence of the nerve to surrounding tissues to avoid traction neuritis, excisions of neuromas using conduits, and consideration of nerve stimulators and systemic medications to deal with persistent neural pain.

Neurolysis for failed tarsal tunnel surgery

The purpose of the present study was to investigate the causes of failure after tarsal tunnel release and the operative findings in the secondary interventions and the outcomes. The data from 8 patients who had undergone revision surgery for failed tarsal tunnel release at least 12 months earlier were evaluated retrospectively. Only the patients with idiopathic tarsal tunnel syndrome were included, and all had unilateral symptoms. Neurophysiologic tests confirmed the clinical diagnosis of failed tarsal tunnel release in all patients. Magnetic resonance imaging revealed varicose veins within the tarsal tunnel in 1 patient (12.5%) and tenosynovitis in another (12.5%). Open tarsal tunnel release was performed in all patients, and the tibialis posterior nerve, medial and lateral plantar nerves (including the first branch of the lateral plantar nerve), and medial calcaneal nerve were released in their respective tunnels, and the septum between the tunnels was resected. The outcomes were assessed according to subjective patient satisfaction as excellent, good, fair, or poor. During revision surgery, insufficient release of the tarsal tunnel, especially distally, was observed in all the patients, and fibrosis of the tibialis posterior nerve was present in 1 (12.5%). The outcomes according to subjective patient satisfaction were excellent in 5 (62.5%), good in 2 (25%), and fair in 1 (12.5%). The fair outcome was obtained in the patient with fibrosis of the nerve. Insufficient release of the tarsal tunnel was the main cause of failed tarsal tunnel release. Releasing the 4 distinct tunnels and permitting immediate mobilization provided satisfactory results in patients with failed tarsal tunnel release.