Abstract
Background
Tarsal tunnel syndrome, also known as posterior tibial neuralgia, is a compressive neuropathy of the posterior tibial nerve or one of its divisions (calcaneal, lateral plantar or medial plantar nerve) within the tarsal tunnel. This scoping review aims to systematically map and summarise current literature regarding the management of tarsal tunnel syndrome.
Methods
PubMed, Embase, Emcare, Medline and Cinahl were searched using the terms ‘tarsal tunnel’, ‘syndrome’, ‘entrapment’, ‘compression’, ‘posterior tibial’, ‘neuropathy’ and ‘neuralgia. Two stage title abstract screening was performed. Observational studies reporting the outcome of treatment of tarsal tunnel syndrome were included.
Results
A total of 32 studies were included in the review. Excellent or good results are seen in 75.3 % of cases, with the remainder (24.7 %) achieving fair or poor outcomes. Factors which may influence outcome include patient age, symptom duration, aetiology, co-morbidities, pre-treatment symptom severity and nerve fibrosis.
Conclusions
Although favourable outcomes are seen in the majority of cases, poor results are not uncommon. A range of prognostic factors are identified; however, firm conclusions cannot be drawn from the findings of individual low-quality studies. Further research in identifying prognostic factors may aid in clinical decision making and management of patient expectations.
Level of evidence
Level IV Scoping review.
Keywords: Tarsal tunnel syndrome, Review, Neuralgia, Posterior tibial nerve: foot
1. Introduction
The tarsal tunnel is a fibro-osseous tunnel found beneath the flexor retinaculum. The region is bordered by the medial wall of the talus, and distal tibia, calcaneus, with the roof and inferior margins being formed by the flexor retinaculum.1,2 A number of structures are found in the tarsal tunnel including the flexor hallucis longus tendon, posterior tibial nerve, artery and vein, flexor digitorum longus tendon and tibialis posterior tendon.1,2
Tarsal tunnel syndrome, also known as posterior tibial neuralgia, is a compressive neuropathy of the posterior tibial nerve or one of its divisions (calcaneal, lateral plantar or medial plantar nerve) within the tarsal tunnel.1,2 The condition typically presents with pain in the region of the tarsal tunnel with radiation to the longitudinal arch as well as paraesthesia. These symptoms may be exacerbated following long periods of standing or walking, with relief after rest or leg elevation.1, 2, 3
The incidence of tarsal tunel syndrome is currently not known however there is evidence that it is more prevalent in women compared to men.
Causes of tarsal tunnel syndrome may be divided into extrinsic and intrinsic aetiologies.1, 2, 3, 4 Extrinsic disease may be caused through systemic inflammatory arthropathy, diabetes mellitus, post-surgical scar formation, trauma, obesity, use of tight footwear and biomechanical abnormalities such as hind foot varus or valgus. On the other hand, intrinsic aetiologies include osteophytes, ischaemia of the posterior tibial nerve due to arterial insufficiency, hypertrophic retinaculum tendinopathy and space occupying lesions such as tumours, ganglia and enlarged veins.2,3
The diagnosis of tarsal tunnel syndrome relies heavily on clinical examination and history with key signs being pain over the tarsal tunnel, sensory symptoms like burning and numbness and a positive Tinel's sign. Differential diagnoses include plantar fasciitis, peripheral neuropathy and lumbar radiculopathy. Imaging and electrophysiological tests can help to support the diagnosis.1
Conservative or non-operative treatments such as physiotherapy, analgesia followed by corticosteroids and failing this surgical decompression can be used to treat persistent cases.1
Various treatment techniques may be used in the management of tarsal tunnel syndrome. Previous authors have described the use of conservative measures such as activity modification, administration of anti-inflammatory medication, use of orthotic shoes, immobilisation and physiotherapy.5, 6, 7, 8 For patients who fail to show improvement after conservative treatment, surgical decompression may also be considered.6,8,9
This scoping review aims to summarise the current range of management techniques reported, identifying areas in which further research is required. Through this, we aim to enhance readers’ understanding of the management options available and guide clinical decision making in terms of developing an appropriate management protocol on an individual patient specific basis.
2. Materials and methods
The recommended methodology for a scoping review was first developed by Arksey and O'Malley with more recent updates published by Levac et al. and Peters et al. of the Joanna Briggs institute.10, 11, 12 These three guidelines share five common methodological principles, all of which are described below and have been used to guide this review.
2.1. Identification of the research question
Initially a scoping review investigating both the diagnosis and management of tarsal tunnel syndrome was proposed. However, after an initial literature search a large amount of literature concerning both these aspects of the condition was retrieved. It was therefore felt that focusing on both diagnosis and treatment in the same review would not be feasible and may reduce the breadth and quality of analysis and discussion. The following final review questions were therefore developed:
-
i.
What strategies are currently reported for the management of tarsal tunnel syndrome and what is their efficacy?
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ii.
Do treatment strategies and outcomes vary according to the specific underlying cause of tarsal tunnel syndrome or the length of symptoms before treatment?
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iii.
In which areas is further research required?
2.2. Identification of relevant studies
A thorough computer-based search was performed in PubMed, OVID Embase, OVID Emcare, OVID Medline and CINAHL. The search strategy was initially developed in PubMed and utilised relevant free text and medical subject heading (MeSH) terms including ‘tarsal tunnel’, ‘syndrome’, ‘entrapment’, ‘compression’, ‘posterior tibial’, ‘neuropathy’ and ‘neuralgia’. The Boolean operators ‘and’, ‘or’, were used to combine these terms where relevant to produce final search strings. The full search strategy is detailed in the supplementary information (Appendix Table A1). Searches were conducted in June 2024, with no language or date restriction imposed. Review articles retrieved through database searching were subject to manual reference list checking to ensure retrieval of all potentially relevant studies.
2.3. Study selection
Mendeley reference management software was used to identify and remove duplicate articles, whilst Rayyan systematic review web app was used to facilitate record keeping during both the title/abstract and full text screening stages.13
Initial title abstract screening followed by full text screening was performed independently by two reviewers (ZA & AB) (initials hidden for double blind peer review) according to the following a priori criteria:
Population: Any patients with tarsal tunnel syndrome.
Intervention: No specific Intervention was required. Studies reporting any type of treatment for tarsal tunnel syndrome were included.
Comparison: No specific comparison group was required.
Outcome: No specific outcome measure was required for inclusion. Studies reporting any outcome measures following treatment of tarsal tunnel syndrome were included. Particular outcomes of interest were validated scoring systems used in the field of foot and ankle surgery such as the American orthopaedic foot and ankle score (AOFAS), Manchester Oxford foot questionaries (MOXFQ) or visual analogue scale (VAS). Studies failing to separate outcomes between patients with tarsal tunnel syndrome and those with other conditions in the same cohort, were excluded. Studies failing to report treatment outcomes were also excluded.
Study Design: Observational studies (case series, case control and observational studies) as well as randomised control trials were included. Case reports, review articles, commentaries, abstracts and letters to the editor were excluded. Studies describing less than ten patients with tarsal tunnel syndrome were also excluded.
Date: No date restrictions were imposed during either the search or screening stage.
Language: Whilst no language restrictions were imposed during database searching, studies written in languages other English were excluded during screening.
2.4. Data charting
Following discussion between the review team, an initial draft extraction form was created using Microsoft excel. The headings used in the pilot form are shown in the appendix (appendix Table A2).
Two reviewers (AI & AB) (initials hidden for double blind peer review) independently extracted data from the first ten included studies, before meeting to discuss the requirement for any amendments. Following this meeting it was felt appropriate to add two further columns to the pilot extraction sheet: ‘influence of length of symptoms and other factors on treatment outcome’ and ‘use of conservative measures before surgical treatment’. The final extraction sheet was then used to extract data from all included studies. This iterative development of a data charting sheet is recommended by Levac et al. and Peters et al..11,12
2.5. Collating, summarising and reporting the results
A qualitative thematic approach to the reporting and summarising of results was employed throughout. This method uses identification of key themes found in the literature and summarising results, according to these different themes, using tables and narrative review. Such an approach is commonly used when performing scoping reviews as it provides reviewers the ability to map and summarise the literature according to these important themes, as is congruent with the purpose of a scoping review.14 A PRISMA flow diagram displaying the numbers of articles retrieved during database searching and removed at each screening stage is provided (Fig. 1). Study characteristics such as author, year of publication, study type, number of patients and mean follow up period is also provided below (Table 1).
Fig. 1.
PRISMA flow diagram detailing the number of studies retrieved and removed at each screening stage.
Table 1.
Descriptive characteristics of all studies including: first author, year of publication, study type, number of patient, mean age, male:female ratio and follow up period. M:F: male: female ratio, NA: Not available.
| Author | Type of Study | Number of Patients | Mean Age in Years (range) | M:F | Follow up in Months (range) |
|---|---|---|---|---|---|
| Alpar et al.6 | Case Series | 26 | 53 (18–63) | 14:12 | 12 |
| Baba et al.15 | Case Series | 34 | 41 (14–73) | 9:25 | 45.6 (12–84) |
| Bailie & Kelikian5 | Case Series | 44 | 38 (12–65) | 24:20 | 35 (15–102) |
| Barker et al.16 | Case Series | 44 | 45 | 12:32 | 26.4 (12–66) |
| De Stoop et al.17 | Case Series | 23 | 41 (21–60) | 16:11 | 30 (12–72) |
| Edwards et al.7 | Case Series | 17 | 17–71 | 9:8 | NA |
| Fujihara et al.18 | Case Series | 12 | 77.9 (70–87) | 3:9 | 7 (3–13) |
| Gondring et al.8 | Case Series | 46 | 47.2 | NA | Approximately 1.5 |
| Gultac et al.19 | Cohort | 29 | 42.5 (24–67) | 10:19 | 38 (13–88) |
| Iborra et al.20 | Case Series | 81 | 41 (32–62) | 36:45 | Minimum 18 |
| Iborra et al.21 | Case Series | 23 | 54 | 9:14 | NA |
| Jerosch et al.9 | Case Series | 75 | 50.6 (17–77) | 21:54 | 39 (6–100) |
| Kinoshita et al.22 | Case Series | 18 | 23.6 (12–64) | 7:11 | 58.6 (24–118) |
| Krishnan23 | Case Series | 24 | 54.6 (28–82) | 18:6 | 30 (6–72) |
| Lam24 | Case Series | 10 | 45.5 (23–73) | 6:4 | 12.5 (3–30) |
| Linschied et al.25 | Case Series | 34 | 50 (29–71) | 16:18 | 24 (3–48) |
| Mahan et al.26 | Case Series | 40 | 40.5 (21–72) | 5:35 | 17.2 |
| Mondelli et al.27 | Case Series | 23 | 47.4 (17–74) | 9:14 | 10–30 |
| Mullick & Dellon28 | Case Series | 77 | 42 | NA | 43.2 |
| Nagaoka & Satou29 | Case Series | 30 | 40.5 (12–70) | 16:14 | 27.5 (8–114) |
| Nirenberg30 |
Cohort |
44 |
52 (22–78) |
18:26 |
0.5–1 |
| Pfeiffer & Cracchiolo31 | Case Series | 32 | 13–72 | 6:24 | 31 (24–118) |
| Reichert et al.4 | Case Series | 31 | 46 (25–63) | 10:21 | 12 |
| Sammarco & Chang32 | Case Series | 62 | 49 (17–80) | 18:44 | 58 (12–185) |
| Stern & Joyce33 | Case Series | 13 | 34.9 (20–60) | 6:7 | 34 (9–69) |
| Sung & Park (2009)34 | Case Series | 13 | 51.3 (34–65) | 8:5 | 14.5 (2–39) |
| Takakura et al. (1991)35 | Case Series | 45 | 38.2 (10–71) | 21:24 | 57 (12–156) |
| Turan et al.36 | Case Series | 18 | 15–59 | 4:14 | 18 (1–31) |
| Urguden et al.37 | Case Series | 12 | 39.5 (25–57) | 3:9 | 83 (12–143) |
| Ward & Porter38 | Case Series | 17 | 55 | NA | 23 |
| Yassin et al.39 | Case Series | 13 | NA | NA | Minimum 24 |
| Yu et al.40 | Cohort | 107 | 95 older than 40 | 44:63 | 26 (5–74) |
2.6. Methodological quality/risk of bias assessment
All three commonly used scoping review methodological frameworks published by Arksey and O'Malley, Levac et al. and Peters et al. write that, unlike systematic reviews, quality assessment of study methodology is not generally performed or congruent with the remit of a scoping review.10, 11, 12 Therefore, no methodological quality assessment of studies included in this review was performed, beyond identification of study type (case series, cohort study, randomised control trial etc.).
3. Results
The literature searching strategy outlined above, resulted in the retrieval of 2829 unique articles, of which 32 (1.13 %) were included following title/abstract and full-text screening (Fig. 1). The pooled number of patients across all studies is 1115 (Table 1) with a weighted mean age of 45.2 years (range: 12–87 years).
3.1. Treatment methods
Of the 32 included studies, all report use of surgical decompression of the posterior tibial nerve and its branches in the management of tarsal tunnel syndrome.
A total of 17 studies report failure of a conservative treatment regime involving non-steroidal anti-inflammatory medication, orthoses or steroid injections, prior to surgical intervention. A further four studies specifically describe results of such non-operative treatment8,25, 27, 29
Endoscopic techniques are described in a further two studies.23,39 Ultrasound guidance is described by three studies,18, 20, 21 whilst Gondring et al.8 reports use of fluoroscopic contrast imaging to aid effective decompression.
Two studies make specific reference to use of the Singh technique.4,40 This method involves an incision in the centre of the medial malleolus, extending into the abductor hallucis muscle. The flexor retinaculum is then dissected, and the tibial nerve and its branches are separated from the retinaculum. The abductor hallucis fascia is released and the medial and lateral tarsal tunnels are lysed. If fibrosis is found on inspection, the posterior tibial nerve is split along the long axis to alleviate impingement.40
One study specifically reports results of revision decompression for previously failed tarsal tunnel surgery.16
3.2. Outcome measures
A large degree of heterogeneity was seen with regards to the outcome measures used by authors of included studies (Table 2). The most common index of outcome evaluation was a three-, four- or five-point subjective scale assessing post-operative symptoms, including grades such as excellent, good, fair and poor. The Takakura scale and AOFAS score was used by six and five studies respectively.35 The Takakura scale uses five domains including pain (spontaneous or on movement), burning pain, Tinel sign, sensory disturbance and muscle atrophy/weakness to assess outcome. The maximum score is 10, which is considered an excellent result and equivalent to a normal result, a score of 8 or 9 indicates a good results, 6 or 7 a fair result and five or below a poor outcome. Less commonly used indices include the functional foot score FFS), Wong-Baker FACES scale and authors’ own subjective categorisation of treatment success/failure. Iborra et al. (2020) describes treatment outcomes in terms of compartmental pressure within the tarsal tunnel.21
Table 2.
Outcome measures used in included studies. The total number of outcome measures does not equal the total number of studies as some studies used more than one measure.
| Outcome score | Number of studies |
|---|---|
| Authors' own three/four/five level grading scale | 14 |
| Takakura scale | 6 |
| American Orthopaedic Foot and Ankle society Score (AOFAS) | 5 |
| Visual analogue (VAS) pain score | 3 |
| Wong-Baker FACES scale | 1 |
| Symptom Severity Score (SSS) | 1 |
| Authors' own 10 Point numeric rating scale | 2 |
| Maryland Foot Score (MFS) | 1 |
| Functional Foot score (FFS) | 2 |
| Compartmental pressure | 1 |
| Authors own subjective analysis of success | 1 |
3.3. Outcomes
Although a number of studies mention patients failing conservative treatment measures prior to receiving surgical treatment, there is often no mention of the efficacy of such non-operative management. Gondring et al.8 reports that conservative treatment with non-steroidal anti-inflammatory drugs (NSAIDs) and a nocturnal immobilisation brace was sufficient in 14/46 (30.4 %) of patients, whilst the remaining 34 required surgical treatment due to a lack of symptom improvement. Patients treated with conservative therapy alone showed a significant improvement in the Wong-Baker FACES pain scale in the distribution of the medial calcaneal, medial plantar and lateral plantar nerve distributions, whilst those receiving surgical decompression only showed significant improvement in the medial calcaneal and medial plantar regions only. Nagaoka & Satou et al. describes a series of patients with tarsal tunnel syndrome due to ganglia.29 Of the 30 patients included the ganglion in one patient (3.3 %) spontaneously resolved before surgical intervention was offered. The case series of Mondelli et al. describes excellent/good results were seen in 4/5 (80 %) of those receiving surgery and 10/15 (66.7 %) of those receiving conservative treatment.27 Linscheid et al. describes surgical treatment in 24 and non-operative treatment in 10 patients. Good results were seen in 50 % (12/24) of those receiving surgery and 4/10 (40 %) of those given conservative treatment.25 Bailie & Kelikian reports that out of 126 patients treated for tarsal tunnel syndrome in the study period, 47 (37 %) required surgical treatment after failing conservative therapy such as splinting, orthotics, NSAID medication and/or corticosteroid injection.5
Treatment results of studies using a 3–5 level grading system, or the Takakura scale are displayed (Table 3.)The study of Takakura et al. reports an increase in mean Takakura score from 3.8 pre-operatively, to 8.1 following surgical intervention.35 However, this study is not included in the table as scores were not classified into the categories outlined. When pooling treatment outcome across suitable studies, an excellent, very good or good result was seen in the majority (518/688, 75.3 %) of cases, whilst fair or poor outcomes were seen in 170/688 (24.7 %) cases (Table 3). The proportion of excellent outcomes according to the Takakura scale/authors own 3–5-point scale ranged from 16.7 % to 87.5 %, whilst the proportion of poor outcomes varied between 2.6-% 40 %. Unfortunately, we were unable to perform a formal meta-analysis comparing excellent/good outcome rates between studies due to the inherent heterogeneity in the low-level study designs used. Furthermore, there a number of confounding factors which may affect treatment outcome such as patient age/gender, symptom duration and aetiology. It is not possible to control these factors between studies using the current case series study designs, which again renders between study comparisons challenging. It is also important to note that the criteria authors use to define excellent, good, fair or poor outcomes may vary between studies.
Table 3.
Results of studies which utilised either a 3–5 level graded outcome scale or the Takakura score to assess treatment outcomes. Studies using the Takakura scale are highlighted in bold font. Baba et al. grades outcomes on a scale of 1–4, with 1 being the best and 4 the worst. In the above table, these grades were converted such that 1 represented an excellent outcome, 2 good, 3 fair and 4 poor. Lam et al. divided outcomes into three categories: complete relief, partial relief and symptoms sufficiently relieved to enable patient to walk. In the above table, these grades were converted into excellent, good and fair respectively as these symptoms most closely aligned to the definition of excellent, good and fair outcomes used in other studies.
| Author | Excellent | Very Good | Good/improved | Fair/Moderate/satisfactory | Poor/unsatisfactory | Total |
|---|---|---|---|---|---|---|
| Baba | 26 (70.3 %) | – | 6 (16.2 %) | 3 (8.1 %) | 2 (5.4 %) | 37 feet (34Patients) |
| Barker | 25 (54.3 %) | – | 11 (23.9 %) | 6 (13.0 %) | 4 (8.7 %) | 46 feet (44 patients) |
| De Stoop | 5 (18.5 %) | 11 (40.7 %) | 8 (29.6 %) | 3 (11.1 %) | 27 feet (23 patients) | |
| Edwards | 14 (87.5 %) | 1 (6.3 %) | 1 (6.3 %) | 16 | ||
| Iborra | 62 (76.5 %) | 11 (13.6 %) | 8 (9.9 %) | 81 | ||
| Kinoshita | 15 (83.3 %) | 3 (16.7 %) | 18 | |||
| Krishnan | 8 (33.3 %) | 10 (41.7 %) | 4 (16.7 %) | 2 (8.3 %) | 24 | |
| Lam | 8 (80 %) | 1 (10 %) | 1 (10 %) | 10 | ||
| Linschield | 16 (47.1 %) | 8 (23.5 %) | 10 (29.4 %) | 34 | ||
| Mahan | 11 (24.4 %) | 16 (35.6 %) | 5 (11.1 %) | 13 (28.9 %) | 45 | |
| Mondelli | 5 (25.0 %) | 9 (45 %) | 6 (30.0 %) | 20 | ||
| Mullick | 63 (81.8 %) | 8 (10.4 %) | 4 (5.2 %) | 2 (2.6 %) | 77 | |
| Nagaoka | 21 (72.4 %) | – | 8 (27.6 %) | 29 | ||
| Pfeiffer | 5 (16.7 %) | 8 (26.7 %) | 5 (16.7 %) | 12 (40 %) | 30 | |
| Stern | 8 (53.3 %) | 3 (20.0 %) | 3 (20.0 %) | 1 (6.6 %) | 15 feet (13 patients) | |
| Sung | 6 (46.2 %) | – | 1 (7.7 %) | 3 (23.1 %) | 3 (23.1 %) | 13 |
| Turan | 11 (61.1 %) | 4 (22.2 %) | 3 (16.7 %) | 18 | ||
| Urguden | 3 (23.1 %) | 6 (46.2 %) | 2 (15.4 %) | 2 (15.4 %) | 13 feet (12 patients) | |
| Yu | 38 (28.1 %) | 47 (34.8 %) | 19 (14.1 %) | 31 (22.7 %) | 135 feet (107 patients) | |
| Total | 334 (48.5 %) | 13 (1.9 %) | 171 (24.9 %) | 67 (9.7 %) | 103 (15.0 %) | 688 |
The study of Yu et al. is the only study to directly compare the efficacy of two treatment strategies, with 36 feet treated using the Singh procedure and 99 treated with non-Singh procedures.40 A significantly higher proportion of cases in the Singh group showed excellent/good treatment results.
One study each described significant improvements in American Orthopaedic Foot and Ankle Society (AOFAS), symptom severity score (SSS), FFS and Maryland Foot score (MFS) post-operatively (Table 4). Two studies reported significant post-operative improvements in Visual analogue scale (VAS) scores. One study reported significant post-operative improvements in the FFS Score.
Table 4.
Displaying pre and post-operative SSS, FFS, AOFAS and VAS scores of studies reporting this information.
| Author | Index | Pre-operative score | Post-operative score | Significant improvement? |
|---|---|---|---|---|
| Bailie | SSS | 46 | 27 | Yes |
| FFS | 10 | 50 | Yes | |
| Sammarco | MFS | 61 | 80 | Yes |
| AOFAS | Not recorded | 80 | NA | |
| Jerosch | AOFAS | Not recorded | 44 | NA |
| VAS | Not reported | Not reported | Yes, in 53/75 (70.1 %) | |
| Yassin | AOFAS | 55 | 83 (12 months) 88 (24 months) |
Not reported |
| Sung | AOFAS | 77.8 | 92.7 | Yes |
| VAS | 6.4 | 2.2 | Yes | |
| Reichert | AOFAS | 32.8 | 57.6 | Not reported |
| VAS | 5.2 | 1.2 | Not reported | |
| Gultac (Standard Incision) | FFS | 61.9 | 88.4 | Yes |
| Gultac (Mini-open Incision) | FFS | 63.4 | 89.8 | Yes |
Gondring et al. reports significant post-operative improvement in pain intensity according to Wong-Baker FACES scale.8 This scale requires patients to choose their level of pain according to a series of faces starting with a smiling face at 0 representing no pain to a crying face at 10 indicating the worst possible pain. Fujiahra et al. evaluates treatment outcome using ten-point numerical scales assessing sole pain/numbness, foreign body-sensation and burning/cold sensation.18 Significant reductions were seen in all three scoring dimensions post-operatively.
A similar ten-point scale assessing sensory and motor deficit was also used by Barker et al.16 The post-operative mean score of 2.7 was significantly lower than the pre-operative means of 6.0, indicating an improvement in sensory/motor symptoms. Iborra et al. describes a significant decrease in mean tarsal tunnel pressure from 59 mmHg pre-operatively, to 0.3 mmHg following surgical intervention.21 Alpar et al. concludes that surgical treatment was successful in 21/26 (81 %) and unsuccessful in 5/26, with success being defined subjectively by the patient themselves (19 %).6
3.4. Complications
The occurrence of post-operative complications is clearly reported in 12 studies, involving a total of 409 cases (Table 5). The most commonly described complications were wound healing problems, including wound dehiscence, skin necrosis and scart issue formation. The overall pooled recurrence rate was 11.2 %.
Table 5.
Displaying complications reported by studies including: wound healing complications, infections, haematoma and others.
| Author | Wound healing | Infection | Haematoma | Other | Total Complication Rate |
|---|---|---|---|---|---|
| Bailie | 13 hypertrophic scars | 2 suture abscesses +3 superficial wound infection | 1 | 2 | 21/46 (44.47 %) |
| Gondring | 1 wound dehiscence | 1 | 2/46 (4.3 %) | ||
| Iborra | Haematoma most common, number not specified | NA | |||
| Mondelli | 2 relapses | 2/23 (8.7 %) | |||
| Jerosch | 3 superficial wound infection | 3/75 (4.0 %) | |||
| Barker | 1 skin necrosis | 1/44 (2.3 %) | |||
| Krishnan | 1 wound dehiscence | 2 relapses | 3/24 (12.5 %) | ||
| Alpar | 4 significant scar tissue | 4/26 (15.4 %) | |||
| Linschield | 1 above knee amputation for pain control | 1/34 (2.9 %) | |||
| Edwards | 1 relapse | 1/17 (5.9 %) | |||
| Pfeiffer | 1 delayed wound healing | 3 | 4/32 (12.5 %) | ||
| Urguden | 1 relapse | 1/13 (7.7 %) | |||
| Gultac | 3 (2 Standard incision and 1 Mini-open incision) | 3/29 (10.3 %) | |||
| Total | 21 | 14 | 2 | 7 | 46/409 (11.2 %) |
3.5. Factors affecting treatment outcome
A total of 16 individual studies, outlined below, did identify patient/treatment related factors which may influence results achieved (Table 6). Unfortunately, it was not possible to pool and compare outcomes according to factors such as aetiology and duration of pre-treatment symptoms due to a variety of factors including heterogeneity in the categories used to classify aetiology between studies, heterogeneity with respect to outcome assessment methods used between studies, low level case series study design and inability to control for confounding factors which may also influence treatment outcome.
Table 6.
Displaying the patient and treatment related factors, reported by individual studies, which may influence treatment outcomes.
| Author | Factor |
|---|---|
| Bailie | Post-operative SSS and FFS significantly lower for patients with a traumatic aetiology, compared to those with non-traumatic aetiology. Of the non-traumatic cases, 86 % of patients were very satisfied with the treatment, whilst only 34 % of the traumatic cases were satisfied. |
| Sammarco | Patients who suffered with symptoms for 12 months or less before surgical treatment showed a mean increase in FMS of 30 points (range 7–60), whilst those with a treatment delay of up to 2 years showed a mean increase of only 14.8 points (2–29). No significant difference in pre/post-operative scores between patients with traumatic and non-traumatic aetiology |
| Gondring | Comparison between patients who received conservative treatment only and those who required surgery due to a lack of improvement. The surgical group had significantly more foot co-morbidities such as Morton's neuroma, plantar fasciitis and gastrocnemius contracture. The surgical group also showed a significantly greater pre-treatment pain intensity according to the Wong-Baker FACES scale and a significantly greater motor latency. |
| Baba | The treatment outcome was significantly worse in cases with symptoms for at least 12 months, fibrosis around the affected nerve, history of ankle sprain and increased pre-operative symptom severity. Favourable results were seen in patients with tarsal tunnel syndrome caused by a ganglion. |
| Iborr | Treatment outcomes were worse in those with bilateral tarsal tunnel syndrome. Only 8/16 patients with bilateral disease achieved excellent or good results, compared to 100 % (65/65) in the unilateral group. |
| Jerosch | A positive correlation was reported between the pre-operative duration of symptoms and time to recovery |
| Nagaoka | The surgical outcome did not correlate with the size of the causative ganglion or he pre-operative electrophysiological findings. |
| Barker | The presence of a co-existing lumbosacral disc prolapse was a prognostic indicator of poor results. Patients with other co-existing neuropathies did not show and significant difference in pre-operative scores but did show significantly lower post-operative scores compared to patients without other co-existing neuropathies. |
| Krishnan | Of the 13 patients with concomitant disease (such as polyneuropathy, peripheral vascular disease and diabetes), only one (7.7 %) achieved an excellent outcome, whilst of the 11 patients without concomitant pathology, 7/11 (63.6 %) showed an excellent outcome. |
| Mahan | No significant differences in Takakura scores found between different aetiologies of tarsal tunnel syndrome. |
| Yu | A significantly higher excellent/good result rate was observed in the space occupying lesion group (86.8 %), compared to the idiopathic group (42.9 %) and the ‘other’ group (50 %). The excellent/good rate was also higher in those receiving epineurium neurolysis compared to those not and in those with findings suggestive of tibial nerve injury on pre-operative electromyography (EMG). |
| Turan | Of the 18 patients included, the post-operative symptoms were said to be unchanged in three. All three of these patients had a traumatic aetiology and two were patients with the longest duration of symptoms in the cohort. |
| Reichert | Significantly greater improvement in Vas and AOFAs found in those patients with an external compression aetiology (trauma and additional navicular bone) compared to idiopathic cases and cases with an internal aetiology (ganglion, neuroma, lipoma). The internal aetiology group showed significantly greater post-operative improvements in VAS and AOFAS compared to the idiopathic group. |
| Alpar | This study describes the treatment of traumatic tarsal tunnel syndrome. Patients with a successful treatment outcome showed a lower mean age of 36 years, compared to 50 years in the unsuccessful group. |
| Pfeiffer | No correlation was found between a positive pre-operative electrodiagnostic test and treatment outcome. OF the 6 patients who had received previous surgical treatment for tarsal tunnel syndrome, none were completely satisfied post-operatively, one had a fair result, two a good result and three remained dissatisfied. Of the 5 completely satisfied patients, (3, 60 %) had a space occupying lesion. Patient age was found to be significant with regards to treatment outcome, with better results seen on younger patients. |
| Gultac | Significant improvement in both standard and mini-open incision in FFS score. However the mini-open incision has reduced anaesthesia time and better cosmetic appearance |
4. Discussion
This scoping review aimed to systematically identify and summarise current evidence regarding the management of tarsal tunnel. Our results highlight a lack of high-quality evidence surrounding this condition, with only 1 level 3 cohort article included, with the remaining 29 articles all being level 4 case series studies. Authors describe similar open/endoscopic surgical decompression strategies, with four studies also specifically describing results of conservative treatment methods such as NSAIDs, orthoses and steroid injection.8,25, 27, 29 There is a large degree of variation in outcome reporting, with the majority of studies assessing treatment results using either a 3–5 level grading subjective grading scale based on patient reported symptoms or the scoring scale described by Takakura et al.35 Of the studies specifically reporting outcomes using these scales, excellent or good results were seen in 75.3 % of cases. Similarly, of the five studies using the AOFAS score, three (60 %) report mean post-operative scores within the range arbitrarily considered to represent a ‘good’ outcome (80 points or more).32, 34, 39 However, less favourable outcomes are not rare with poor outcomes also reported in approximately 15 % of cases and fair results seen in a further 9.7 %.
Identifying patient related factors and differences in treatment strategy which may influence the development of poor outcomes is important with regards to guiding clinical decision making and informing patient expectations. Unfortunately performing a meta-analysis to compare outcomes according to factors such as treatment strategy used (for example, open versus endoscopic decompression), aetiology, patient age/co-morbidities and duration of symptom was not possible. This was due to the low quality of case series studies included, inconsistency and heterogeneity in reporting of outcomes and lack of separation of outcomes according to the factors described. However, some potential factors may be identified using the current evidence. For example, Bailie & Kelikian and Reichert et al. report superior outcomes in those with a traumatic aetiology, whilst Yu et al. and Reichert et al. report that the presence of space occupying lesions such as ganglia may also lead to facilitate favourable outcomes.4,5,40 Factors that may lead to poor outcomes include, bilateral tarsal tunnel syndrome, idiopathic disease, nerve fibrosis, increased pre-operative symptom severity, increased duration of pre-operative symptoms, increased age and presence of co-morbidities such as co-existing neuropathy, peripheral vascular disease, Morton's neuroma and plantar fasciitis (Table 6). Although individual studies allude to the above factors and their potential influence on treatment outcomes, the current low-quality evidence does not allow definitive conclusions about prognostic factors to be drawn. For example, it is possible that those with a traumatic aetiology show superior outcomes only due to a decreased treatment delay in these patients. It is not possible to separate and control for factors such as these using low level case series and cohort study designs. It is therefore crucial that further high-level comparative research such as randomised controlled trails are performed to elucidate the impact of the above treatment and patient related factors on outcomes. The identification of such prognostic factors may allow clinicians to stratify expected treatment outcomes and manage patient expectations according to these expected results.
The studies of Gondring et al. and Bailie & Kelikian suggest that non-operative management may be sufficient and effective for 30.4 % and 37 % of patients respectively.5,8 Furthermore, the results of Gondring et al. and Linschied et al. described above, suggest that such non-operative measures may produce similar outcomes to surgical decompression.8,25 However, again, further research is required in determining the efficacy of conservative treatments as the majority of studies do not describe the number of patients who showed good symptomatic improvement following conservative treatment alone. Gondring et al. performed a comparison of pre-treatment characteristics between patients for whom conservative treatment was deemed sufficient and those requiring further surgical intervention following failure of conservative measures.8 The surgical group showed a greater pre-treatment pain intensity according to the Wong-Baker FACES scale, greater nerve motor latency and increased number of foot co-morbidities. It could therefore be suggested that these factors may influence the likelihood of response to conservative treatment alone. However, valid and robust conclusions cannot be drawn from the results of a single level 4 case series and therefore further high-quality research investigating the factors which predispose patients to a lack of respoken to conservative treatment should be performed. Such work would again aid clinical decision making by allowing clinicians to stratify patients with regards to their likely response to non-operative treatment. This may also again be beneficial for managing patient expectations in terms of the extent of treatment they may require.
It must be acknowledged that this review is not without its limitations. For example, a large proportion of the studies included in this review are greater than ten years old. However, we believe the inclusion of these older studies is important. As mentioned, this scoping review aims to map and summarise the literature regarding the treatment of tarsal tunnel syndrome. To achieve this, it is crucial that all relevant studies are included, regardless of their date of publication.
5. Conclusions
In Conclusion, there is currently a paucity of high-quality literature investigating the treatment of tarsal tunnel syndrome. Existing treatment methods appear to produce good results in the majority of cases; however, poor outcomes are not rare. Included studies suggest a number of prognostic factors which may influence treatment success, however definitive conclusions cannot be drawn from the results of individual case series studies. Further research in identifying prognostic factors for both surgical and conservative treatment may aid in clinical decision making and the stratification of patients according to the extent of treatment required and associated outcomes.
Author statement
Ibrahim Haq: data curation, formal analysis, metholdogy, writing original draft, writing review and editing.
Anjuli Banerjee: conceptualization, data curation, formal analysis, metholdogy, project administration, writing original draft, writing review and editing.
Adil Iqbal: conceptualization, data curation, formal analysis, project administration, supervision, writing original draft, writing review and editing.
Zaki Arshad: conceptualization, data curation, formal analysis, project administration, supervision, writing original draft, writing review and editing.
Maneesh Bhatia: conceptualization, project administration, supervision, writing review and editing.
Ethics approval
Ethical approval was not required as this study only contains data extracted from previous studies which are freely available online.
Funding
No funding was received for this work.
Informed consent
Not required for a scoping review.
Declaration of competing interest
Declarations of Interest: The senior author, Mr Maneesh Bhatia is a member of the scientific committee of the European Foot and Ankle Society and the educational committee of the British Foot and Ankle Society.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.jcot.2024.102489.
Appendix A. Supplementary data
The following are the Supplementary data to this article:
References
- 1.Ahmad M., Tsang K., Mackenney P.J., Adedapo A.O. Tarsal tunnel syndrome: a literature review. Foot ankle Surg Off J Eur Soc Foot Ankle Surg. 2012;18(3):149–152. doi: 10.1016/j.fas.2011.10.007. [DOI] [PubMed] [Google Scholar]
- 2.McSweeney S.C., Cichero M., M S.C. Tarsal tunnel syndrome-A narrative literature review. Foot. 2015;25(4):244–250. doi: 10.1016/j.foot.2015.08.008. [DOI] [PubMed] [Google Scholar]
- 3.Doneddu P.E., Coraci D., Loreti C., Piccinini G., Padua L. Tarsal tunnel syndrome: still more opinions than evidence. Status of the art. Neurol Sci Off J Ital Neurol Soc Ital Soc Clin Neurophysiol. 2017;38(10):1735–1739. doi: 10.1007/s10072-017-3039-x. [DOI] [PubMed] [Google Scholar]
- 4.Reichert P.P., Zimmer K., Wnukiewicz W., et al. Results of surgical treatment of tarsal tunnel syndrome. Foot Ankle Surg. 2015;21(1):26–29. doi: 10.1016/j.fas.2014.08.013. [DOI] [PubMed] [Google Scholar]
- 5.Bailie D.S., Kelikian A.S. Tarsal tunnel syndrome: diagnosis, surgical technique, and functional outcome. Foot Ankle Int. 1998;19(2):65–72. doi: 10.1177/107110079801900203. [DOI] [PubMed] [Google Scholar]
- 6.Alpar E.K., Howell N., Masood I. Traumatic tarsal tunnel syndrome: the outcome of surgical decompression. Foot Ankle Surg. 2002;8(1):41–44. doi: 10.1046/j.1460-9584.2002.00304.x. [DOI] [Google Scholar]
- 7.Edwards W.G., Lincoln C.R., Bassett FH 3rd, Goldner J.L. The tarsal tunnel syndrome. Diagnosis and treatment. JAMA. 1969;207(4):716–720. [PubMed] [Google Scholar]
- 8.Gondring W.H., Trepman E., Shields B., et al. Tarsal tunnel syndrome: assessment of treatment outcome with an anatomic pain intensity scale. Foot Ankle Surg. 2009;15(3):133–138. doi: 10.1016/j.fas.2008.10.003. [DOI] [PubMed] [Google Scholar]
- 9.Jeroshc J., Schunck J., Khoja A. Results of surgical treatment of tarsal tunnel syndrome. Foot Ankle Surg. 2006;12(4):205–208. doi: 10.1016/j.fas.2006.05.001. [DOI] [Google Scholar]
- 10.Arksey H., O'Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol Theory Pract. 2005 doi: 10.1080/1364557032000119616. Published online. [DOI] [Google Scholar]
- 11.Levac D., Colquhoun H., O'Brien K.K. Scoping studies: advancing the methodology. Implement Sci. 2010 doi: 10.1186/1748-5908-5-69. Published online. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Peters M.D.J., Godfrey C.M., Mcinerney P., Baldini Soares C., Khalil H., Parker D. Joanna Briggs Institute Reviewer’s Manual; 2017. Chapter 11: Scoping Reviews. [Google Scholar]
- 13.Ouzzani M., Hammady H., Fedorowicz Z., Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev. 2016 doi: 10.1186/s13643-016-0384-4. Published online. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Kastner M., Tricco A.C., Soobiah C., et al. What is the most appropriate knowledge synthesis method to conduct a review? Protocol for a scoping review. BMC Med Res Methodol. 2012 doi: 10.1186/1471-2288-12-114. Published online. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Baba H., Wada M., Annen S., Azuchi M., Imura S., Tomita K. The tarsal tunnel syndrome: evaluation of surgical results using multivariate analysis. Int Orthop. 1997;21(2):67–71. doi: 10.1007/s002640050122. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Barker A.R., Rosson G.D., Dellon A.L. Outcome of neurolysis for failed tarsal tunnel surgery. J Reconstr Microsurg. 2008;24(2):111–118. doi: 10.1055/s-2008-1076086. [DOI] [PubMed] [Google Scholar]
- 17.De Stoop N., Suykens S., Goossens M., Coppens M., Badile N., Dewitte A. Tarsal tunnel syndrome: clinical and pathological results. Acta Orthop Belg. 1989;55(3):461–466. [PubMed] [Google Scholar]
- 18.Fujihara F., Isu T., Kim K., et al. Artery transposition using indocyanine green for tarsal tunnel decompression. World Neurosurg. 2020;141:142–148. doi: 10.1016/j.wneu.2020.06.042. [DOI] [PubMed] [Google Scholar]
- 19.Gültac E., Kılınç B., Kılınç C.Y., Yücens M., Aydogan N.H., Öznur A. Comparison of tunnel ligament release instrument assisted minimally open surgery and conventional open surgery in the treatment of tarsal tunnel syndrome. J Orthop Surg (Hong Kong) 2020;28(3):1–7. doi: 10.1177/2309499020971868. [DOI] [PubMed] [Google Scholar]
- 20.Iborra A., Villanueva M., Sanzz-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(1):30. doi: 10.1186/s13018-020-1559-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Iborra Marcos A., Villanueva Martinez M., Sanz-Ruiz P., et al. Ultrasound-Guided proximal and distal tarsal decompression: an analysis of pressures in the tarsal, medial plantar, and lateral plantar tunnels. Foot Ankle Spec. 2020 doi: 10.1177/1938640020905423. Published online February. [DOI] [PubMed] [Google Scholar]
- 22.Kinoshita M., Okuda R., Yasuda T., et al. Tarsal tunnel syndrome in athletes. Am J Sports Med. 2006;34(8):1307–1312. doi: 10.1177/0363546506286344. [DOI] [PubMed] [Google Scholar]
- 23.Krishnan K.G. Endoscopic decompression of the tarsal tunnel. Tech Foot Ankle Surg. 2010;9(2):52–57. doi: 10.1097/BTF.0b013e3181dfeb20. [DOI] [Google Scholar]
- 24.Lam S.J. Tarsal tunnel syndrome. J Bone Joint Surg Br. 1967;49(1):87–92. doi: 10.1302/0301-620x.49b1.87. [DOI] [PubMed] [Google Scholar]
- 25.Linscheid R.L., Burton R.C., Fredericks E.J. Tarsal-tunnel syndrome. South Med J. 1970;63(11):1313–1323. doi: 10.1097/00007611-197011000-00026. [DOI] [PubMed] [Google Scholar]
- 26.Mahan K.T., Rock J.J., Hillstrom H.J., et al. Tarsal tunnel syndrome. A retrospective study. J Am Podiatr Med Assoc. 1996;86(2):81–91. doi: 10.7547/87507315-86-2-81. [DOI] [PubMed] [Google Scholar]
- 27.Mondelli M., Giannini F., Reale F. Clinical and electrophysiological findings and follow-up in tarsal tunnel syndrome. Electroencephalogr Clin Neurophysiol. 1998;109(5):418–425. doi: 10.1016/s0924-980x(98)00039-3. [DOI] [PubMed] [Google Scholar]
- 28.Mullick T., Dellon A.L., M T., Mullick T., Dellon A.L. Results of decompression of four medial ankle tunnels in the treatment of tarsal tunnels syndrome. J Reconstr Microsurg. 2008;24(2):119–126. doi: 10.1055/s-2008-1076089. [DOI] [PubMed] [Google Scholar]
- 29.Nagaoka M., Satou K. Tarsal tunnel syndrome caused by ganglia. J Bone Joint Surg Br. 1999;81(4):607–610. doi: 10.1302/0301-620x.81b4.9546. [DOI] [PubMed] [Google Scholar]
- 30.Nirenberg M.S. Injection of the abductor hallucis muscle in the diagnosis and treatment of distal tarsal tunnel syndrome. J Am Podiatr Med Assoc. 2023;113(2):1–8. doi: 10.7547/20-238. [DOI] [PubMed] [Google Scholar]
- 31.Pfeiffer W.H., Cracchiolo A 3rd. Clinical results after tarsal tunnel decompression. J Bone Joint Surg Am. 1994;76(8):1222–1230. doi: 10.2106/00004623-199408000-00012. http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med3&NEWS=N&AN=8056802 [DOI] [PubMed] [Google Scholar]
- 32.Sammarco G.J., Chang L. Outcome of surgical treatment of tarsal tunnel syndrome. Foot Ankle Int. 2003;24(2):125–131. doi: 10.1177/107110070302400205. [DOI] [PubMed] [Google Scholar]
- 33.Stern D.S., Joyce M.T. Tarsal tunnel syndrome: a review of 15 surgical procedures. J Foot Surg. 1989;28(4):290–294. [PubMed] [Google Scholar]
- 34.Sung K., Park S.J. Short-term operative outcome of tarsal tunnel syndrome due to benign space-occupying lesions. Foot Ankle Int. 2009;30(8):741–745. doi: 10.3113/FAI.2009.0741. [DOI] [PubMed] [Google Scholar]
- 35.Takakura Y., Kitada C., Sugimoto K., Tanaka Y., Tamai S. Tarsal tunnel syndrome. Causes and results of operative treatment. J Bone Joint Surg Br. 1991;73(1):125–128. doi: 10.1302/0301-620X.73B1.1991745. [DOI] [PubMed] [Google Scholar]
- 36.Turan I., Rivero-Melián C., Guntner P., Rolf C. Tarsal tunnel syndrome. Outcome of surgery in longstanding cases. Clin Orthop Relat Res. 1997;(343):151–156. [PubMed] [Google Scholar]
- 37.Urguden M., Bilbasar H., Ozdemir H., et al. Tarsal tunnel syndrome - the effect of the associated features on outcome of surgery. Int Orthop. 2002;26(4):253–256. doi: 10.1007/s00264-002-0351-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Ward P.J., Porter M.L. Tarsal tunnel syndrome: a study of the clinical and neurophysiological results of decompression. J R Coll Surg Edinb. 1998;43(1):35–36. [PubMed] [Google Scholar]
- 39.Yassin M., Garti A., Weissbrot M., Heller E., Robinson D. Treatment of anterior tarsal tunnel syndrome through an endoscopic or open technique. Foot. 2015;25(3):148–151. doi: 10.1016/j.foot.2015.05.007. [DOI] [PubMed] [Google Scholar]
- 40.Yu X., Jiang Z., Pang L., Liu P. Surgical efficacy analysis of tarsal tunnel syndrome: a retrospective study of 107 patients. Cell Tissue Bank. 2020;22:115–122. doi: 10.1007/s10561-020-09871-y. Published online October. [DOI] [PubMed] [Google Scholar]
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