The

BY CAPTAIN

Tarsal-Tunnel
CHARLES KECK,

Syndrome
Medical Hospital, Corps, Fort United Hood, SWiss Texa.s Army

From

the

United

States

Army

The syndrome attention

existence seen in the by Goldner

of

tarsal-tunnel

syndrome,

similar

to

the

carpal-tunnel

wrist and A review

unrelated to acute trauma, of the literature from 1932

was first called to my through 1960 revealed

that compression which has been The

tunnel

of the posterior tibial previously recognized case report illustrates

nerve in its fibro-osseous tuminel is an entity but not adequately stressed 1,2,4,5,6,7W the essential features of the tarsal-

following
syndrome.

REPORT

OF

CASE

Present
Fort
noted

Illness
States training
standing

A twenty-year-old white male recruit was admitted to the United Hood, Texas, on August 26, 1959. While in the fourth week of basic numbness over the plantar aspect of the toes and foot on prolonged
initially relieved progressed to his

Army Hospital, the patient first

and he
pain

walking.

Rest
numbness

symptoms,

but

complete

and needles
Despite

and burning
bilateral symptoms

his

anesthesia. on the plantar he continued

with continued He described aspect of both

to carry

training
transient

over
episodes

a two-week
when
was

period,
had
present.

the
pins

feet, but at no time

his recruit training.

on with

Past

History
in his
service.

The patient had always been in good health. He had played worked as a waiter for one year prior to his induction into the
of frost

high
There

school
was no

band
past

and

had

history

bite,

exposure

to

poison, of the feet.

familial

disease,

weakness

of the

upper

extremity,

diabetes,

leprosy,

or abnormalities

Physical
temperature

Examination weight
98.4
90

The patients
was

at admission
Fahrenheit:
diastolic.

was General

degrees

170 pounds; his height his pulse, seventy-two;

physical examination

was five feet, eleven respiration, twenty;

revealed a well

inches
and

his
blood well

pressure,

132 and

systolic,

developed,

nourished
structure posterior
except for

white

male.
alignment.

tibia!
digiti
nerve

pulses
quinti.

Inspection of the lower extremities revealed good muscles with normal foot Skin color, hair distribution, capillary circulation, and dorsalis pedis and were normal. A complete muscle test revealed normal tone and strength
interossei, lumbricales, complete anesthesia flexor over digitorum the sensory brevis, abductor of hallucis, the posterior and

non-functioning

abductor

There

was

distribution

tibia!
vascular
produced

(Figs.
cordlike

1-A,

1-B,
structure

and
localized

1-C).
just

Palpation
posterior to

of the medial
the medial

aspect

of the ankle
in the over region this

revealed
of the
was

a firm,
neuroarea within

longitudinal,

malleolus
proximally

bundle mild

with mild paresthesiae

in the

tenderness. soles of the

Percussion
feet.

indurated

General

neurological

examination

normal

limits.

Laboratory cent

Studies

Hematocrit was forty-five; white blood count was 9,150, with 70 per cent neutrophils, 27 per lymphocytes, 1 per cent eosinophils, and 2 per cent basophils. Sedimentation rate was zero. Total protein was 6.9 with albumin 4.4 and globulin 2.5 grams per 100 milliliters. Uric acid was 5.1 milligrams per 100 milliliters. Rheumatoid latex fixation test was negative. Serological test for syphilis was non-reactive. Fasting blood glucose was 107 milligrams per 100 milliliters. A urinalysis was within normal limits. Roentgenograms of the feet and chest were within normal limits.

Course

in the Hospital
to the

and
hospital,

Follow-up
the patient
was placed THE

On admission
180

on absolute
JOURNAL

bedrest. OF BONE

lie

received

whirlSURGERY

AND

JOINT

TilE

TARSA

L-TUNNEL

SYNDROME

181

lJ(;.

I -Il

Fm;. 1-A

Figs. 1-A, 1-B, and 1-C: The distribuof complete anesthesia is indicated in black. Note in Fig. 1-C the extent of the tion

operative
Posterior

incision
tihial

for decompression
nerve in the tarsal

of the
tunnel.

..

ill
FI(;. I-C pool week. un(ler til)ial Osseous constricted massage On The nerve tarsal the general was area to the lower hospital with findings extremities day, were enlarged
grossly

with

no

change tibia!

iii his on

PllYsic:il each thigh

condition l)umldle for at was

over

a period

of one

eighth anesthesia

the
the

posterior

neurovascular

explored

bilaterally

a l)nellmatic same

tourniquet bilaterally.

hemostasis.

operative tunnel.
veills

A fusiform
of constriction nerve appeared
Just

enlargement
the entrance edematous

of tile
amid yellowish.

posterior
fibreTile

found
measured

proximal
Tile
which

and

distal
segments
resembled

to a point
of the one centimeter
a varicoecle.

of the

approximately tarsal tunnel, with distal of fibrous patiemit the to tile each from roof by noted hours weme whirlpool duty eighteen
by

in lemigth.
posterior

There
to

were
the

four the

tortuous
malleolus

posterior
the
Veins. osseous

tii)ial
roof point of muscles.
tunnels

medial mierve.
roof.

fil)rous This

of
were

the coincided

acting compressed

similar

to portion

a waist of the
of

cincher, l)osterior
tile entire

constricted
tii)ial
fibrous

cluster
Both fibreof

of

decompressed

longitudinal

division

Electrical
the no after i)rOdUced

stimulation intrinsic distal high ings. feet and

the

nerve, Stimulation

point nerve two of both l)osterior, Partial : normal

of of the

constriction, to tunnels tile tortuous, below-the-knee return

produced point left plaster over motor and of tibia! enlarged was

a weak constriction veins

contraction was and removed was pressure aspect

present

proximal tarsal

motor
low

response.
ligation. was

A segment
The the accomplished twenty-four

open the
power

and

the skin

closed.
dressof both
within

Immobilization Postoperatively and toes

splints

of sensation tenth

plantar
were

within hours. The consisting

sensation on the

forty-eight

sutures

removed massage on

postoperative exercises and operation. completed

day,

when the basic

walking feet and

was

permitted.
was instituted

Following

a two-week
in

convalescent
October

leave,
and months COMMENT

a progressive
strengthening 22,1959, after

regimen

of physical
for his

therapy
legs. He

The patient was discharged to full continues to remain asymptomatic

training.

The than foot

VOL.

tarsal-tunnel

symidrome

is an
to

entity

which

is probably

more

common as acute cases that

the literature would lead one strain or plantar fascitis. This

44-A.

believe; case report

it is frequently diagnosed is one of a series of four

NO.

1. JANUARY

1962

182 have been approximately these the entity frequently the patients of activity. type recognized 2,500 are
this in

CHARLES

KECK

during recruits presumably

a period receive in good In

of two years basic training health

at Fort Hood, each month. for the

Texas, where The fact that low incidence of

inductees

accounts

age group. seen, this syndrome are better able

a civilian practice, where poor foot structure is is probably more common but less dramatic, since to control their symptoms by voluntary restriction finding in this or nerve-trunk present.

Rest pain, which has been described as a frequent significant of neuropathy, was not observed. The Valleix phenomenon, tenderness proximal and distal to the area of compression, was
SUMMARY

A case
in a twenty-year-old

report

illustrating white male

the

essential army recruit and

features that

of the

tarsal-tunnel It is assumed frequently

syndrome that than this the

is described. it occurs more

syndrome literature

is commonly would lead

misdiagnosed one to believe.

REFERENCES
1.
CLARK,

K. : Peripheral

Nerve

Injuries

Associated

with

Fractures.

Postgrad. the Knee,

Med., with

27: 476-479, a Follow-up

1960. 2. FAHLUND, G. T. R. : Suture of the Posterior Study of the Clinical Results. J. Neurosurg., 3. GOLDNER, J. L. : Personal communication.

Tibial Nerve Below 3: 223-233, 1946.

4. 5. 6.
7.

KOPELL,

Extremity.
POLLOCK,

ROAF,

H. P., and THOMPSON, W. A. L. : Peripheral Entrapment Neuropathies of the Lower New England J. Med., 262: 56-60, 1960. L. J., and DAVIS, LOYAL: Peripheral Nerve Injuries. Am. J. Surg., 18: 361-401, 1932. R. : Suture of the External and Internal Popliteal Nerves. British J. Surg., 33: 382-385, \V. C. : Posterior Tibia! Nerve Injuries. Southern Surgeon, 14: 124-129, 1948.

1946.
WARD,

THE

JOURNAL

OF BONE

AND

JOINT

SURGERY