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CONDITION/DISORDER SYNONYMS

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  • Tarsal tunnel syndrome (TTS)

  • Posterior tibial neuralgia

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ICD-9-CM CODE

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  • 355.5 Tarsal tunnel syndrome

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ICD-10-CM CODE

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  • G57.50 Tarsal tunnel syndrome, unspecified lower limb

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PREFERRED PRACTICE PATTERNS

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  • 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Localized Inflammation

  • 5F: Impaired Peripheral Nerve Integrity and Muscle Performance Associated with Peripheral Nerve Injury

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PATIENT PRESENTATION

A 27-year-old male recreational runner/jogger presents with right ankle and foot pain and numbness of 2 weeks duration. The patient reports spraining his ankle 6 months ago when he turned his ankle inward while jogging on an uneven surface. He sustained a sprain to his medial ankle that resolved uneventfully in 2 to 3 weeks. Upon returning to running/jogging, the patient noted stiffness and generalized right lower-extremity weakness but denied ankle or leg pain. Patient reports that he returned to his typical jogging mileage of more than 35 miles/week with 2 weeks of return to jogging. At this time, he reports medial ankle and foot paresthesia/numbness beneath his medial malleolus that travels into the medial arch and plantar aspect of his foot and heel. Numbness/paresthesia is increased shortly after initiating jogging and is notable with standing and walking, especially if the patient wears sandals or flip-flops. Upon palpation, the patient reports pain and tenderness inferior to his medial malleolus. The patient has a positive Tinel sign with testing inferior to medial malleolus. Weakness noted for flexion of the big toe.

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KEY FEATURES

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Description
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  • Tarsal tunnel syndrome is an entrapment syndrome of the tibial nerve behind (posterior to) the medial malleolus and under the flexor retinaculum or laciniate ligament.1

  • Structures that pass through the tarsal tunnel

    • Flexor hallucis longus muscle

    • Flexor digitorum longus muscle

    • Tibialis posterior muscle

    • Posterior tibial nerve

    • Posterior tibial artery

  • The tibial nerve supplies movement and sensation to the calf and foot muscles.

  • The deep and superficial aponeuroses of the leg form the laciniate ligament, which is closely attached to the sheath of the three adjacent flexor tendons, the posterior tibial, the flexor digitorum, and flexor hallucis.1

  • Tarsal tunnel is a peripheral neuropathy that occurs when there is damage to the tibial nerve, one of the lower branches of the sciatic nerve of the leg.

  • Nerve entrapment sites, branches of tibial nerve:

    • Lateral plantar nerve (LPN): Supplies most of the foot muscles and the skin of the lateral one-third of the plantar aspect of the fourth and fifth toes.2

      • The first branch of the LPN innervates the flexor digitorum brevis, quadratus plantae, and abductor digiti minimi.

    • Medial calcaneal nerve: Sensory innervations to heel fat pad and superficial tissues over the inferior aspect of the calcaneus.

    • Medial plantar nerve: Innervations of abductor hallucis, flexor hallucis brevis, flexor digitorum brevis, first lumbrical, and skin of the medial ...

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