DEVI WUYSANG

Anatomy

•N.Ischiadicus
•N. Peroneus
communis
•N. Peroneus
superficialis
•N. Peroneus profunda
•N. Tibialis posterior
•N. Plantaris medialis
•N. Plantaris lateralis

M.Abductor hallucis
• Malleolus medialis
• M. Tibialis posterior
• M. Flexor digitorum
longus
• M. Flexor hallucis longus
• A. Tibialis posterior
• N. Tibialis posterior
ü N.plantaris lateralis
ü N.plantaris medialis
• Retinaculum flexorum
Tarsal tunnel berisi:
• n.Tibialis posterior
• a.Tibialis posterior
• TP tendon
• FDL tendon
• FHL tendon
ž Synonim: posterior tibial neuralgia,
ž TTS is a compression syndrome of the tibial nerve within the
tarsal tunnel.
ž Tarsal tunnel is found along the inner leg behind the medial
malleolus.
ž The posterior tibial artery, tibial nerve, and tendons of the
tibialis posterior, flexor digitorum longus, and flexor hallucis
longus travel in a bundle along this pathway, through the tarsal
tunnel.
ž In the tunnel, the nerve splits into three different paths. One
nerve (calcaneal) continues to the heel, the other two (medial
and lateral plantar nerves) continue on to the bottom of the
foot.
ž The tarsal tunnel is made up of bone on the inside and the flexor
retinaculum on the outside.
ž This condition was first described by Keck
and Lam in 1962.
ž The terminal aspect of the posterior tibial
nerve (L4-S1 nerve distribution) supplies the
motor function to the muscles of the foot
and the sensory innervation to the bottom of
the foot.
ž Varying degrees of entrapment of this nerve
may effect either motor function, sensory
function or both.
ž Contributingfactors that may cause tarsal
tunnel syndrome include :
¡ Kelainan anatomi terowongan tarsal
¡ trauma terowongan tarsal
¡ varicose veins,
¡ bone spurs and soft tissue tumors such as
ganglionic cysts.
¡ biomechanical instability of the foot caused by
pronation (flattening of the arch/pes planus) and
supination (high arch)
¡ Hormonal, metabolik, RA, OA
ž Pain and tingling in and around ankles and sometimes the toes
ž Swelling of the feet
ž Painful burning, tingling, or numb sensations in the lower legs. Pain
worsens and spreads after standing for long periods; pain is worse with
activity and is relieved by rest.
ž Electric shock sensations
ž Pain radiating up into the leg, and down into the arch, heel, and toes
ž Hot and cold sensations in the feet
ž A feeling as though the feet do not have enough padding
ž Pain while operating automobiles
ž Pain along the Posterior Tibial nerve path
ž Burning sensation on the bottom of foot that radiates upward
ž "Pins and needles"-type feeling and increased sensation on the feet
ž Tinel test: perkusi saraf di pergelangan kaki
ž Turks test: pemasangan torniket di atas malleolus dengan
tekanan antara sistol dan diastole selama 1 menit agar
terjadi stasis vena
ž Tes Kinoshita: dorsofleksi-eversi pergelangan kaki dan
dorsofleksi kaki selama 10detik
ž Tes Lam: inversi dengan tenaga dan rotasi medial kaki
selama 30detik
ž Tes Linscheid: penekanan digital kontinu pada saraf di
bawah dan belakang malleolus >= 1menit
ž Tes dengan tungkai ekstensi diangkat kemudian dorsofleksi
kaki
ž Atrofi otot intrinsic kaki
ž Deformitas valgus atau pes planus
ž EMG (electrodiagnostic test)
ž Plain X-Ray foot and ankle

ž MRI
ž USG neuromuscular and/or Doppler

à as indicated
ž Anamnesis: patient’s report of their pain and numbness on
foot and toes. Pain increase with prolonged
standing/walking and decrease at resting.
ž Physical examination: positive Tinel's sign.
ž Nerve conduction studies (not common, but may be used
as clinical diagnosis is possible.
ž Varicose veins within the tunnel are a common cause.

DIAGNOSIS:
Nyeri neuropati jebakan N. Tibialis (Tarsal Tunnel Syndrome)
ž Neuropati N. ischadicus
ž Tendinitis Achilles

ž Disfungsi tendon tibialis posterior

ž Fasitis plantaris (plantar fasciitis)
ž Arthritis
Non pharmacological treatment:
ž Rest, manipulation, strengthening of tibialis anterior,
tibialis posterior, peroneus and short toe flexors,
ž casting with a walker boot
ž wrapping, compression hose, and orthotics.

Pharmacological treatment:
ž NSAIDS and oral steroids
ž Corticosteroid and anesthetic injections,

Surgery:
If non-invasive treatment measures fail, surgery may
be recommended to decompress the area.
ž Many patients report good results.
ž Tarsal tunnel can greatly impact patients'
quality of life.
ž Depending on the severity, the ability to
walk distances people normally take for
granted (such as grocery shopping) may
become compromised.
ž Proper pain management and counseling is
often required.