Nerve compression in the foot

A.A GDE AGUNG ANOM ARIE WIRADANA

INTRODUCTION

Mortons metatarsalgia which is diagnosed clinically is the most common and

important. Tarsal tunnel syndrome, has a euphonious title, for a rare
condition.

It requires careful clinical assessment and ancillary tests for accurate

diagnosis, whether it afects the posterior tibial or deep peroneal nerve.

MORTONS METATARSALGIA

History

The pain of a Mortons neuroma was first described by Lewis Durlacher,

Surgeon Chiropodist to QueenVictoria,
inCorns and Bunionspublished in1845

It constitutes a most troublesome and severe complaint and one very difficult
of removal.

The patient complains of a severe pain between two of the toes, along the
inside of one or the other, generally the second and third

Extends up the leg and is increasedwhen the toes are pressed togethermore

particularly after walking.

In 1876 Morton,2 Surgeon to the Philadelphia Orthopaedic Hospital, described

A Peculiar and Painful Articulation of the Fourth Metatarsophalangeal
Articulation

He observed that the afection which had been seen more frequently in
females , which he attributed not only to the delicacy and pliability of the
female foot as compared with the male foot.

Then fitfth metatarsal is thus pressed against the head and neck of the fourth
metatarsal

His treatment was excision of the metatarsal shaft with a quarter of an inch

from the associatedproximal phalanx

Hoadley, ofChicago,in 1893 described six patients. He operated on only one of

them and cut down on the sole of the foot and

without any difficulty found the digital branches of the lateral plantar
nerve

He found a small neuroma on the nerve,

His other patients improved by shoe modification, which consisted of

reinforcement of the sole ofwide shoes.

Jones in1897 considered excision of the metatarsal head, excision of the

joint, or amputation of the metatarsal head and toe.

He also mentioned part excision of digital plantar nerve but did not
elaborate on this

Hoadleys observations do not seem to have aroused great interest amongst

his contemporaries until nearly 40 years later in 1935 when Sir Harold Stiles
was operated on for longstanding metatarsalgia

In 1940 Betts of Adelaide6 reported 10 patients on whom he had resected the

fourth plantar digital nerve with a plantar incision. McElvenny reported 12
neuromas in 11 patients and advocated a dorsalweb-splitting incision

In1951 Mulder of Amsterdam described a clinical test for Mortons neuroma in

which a click is elicited from the afected foot by exerting pressure around the
forefootwith the left hand and at the same time using the right thumb to put
pressure on the sole at the site of the suspected neuroma

Clinical Picture

The digital nerve most commonly affected supplies the cleft between the
third and four toes (i.e. middle and ring).

Sometimes the cleft between the second and third toes is involved, and very
rarelyboth.

The patient is usually a young ormiddle-agedwomanwith awide age range

from 17 to 70 years. Men are much less frequently affected than women.

Symptoms

Acute neulargic pain

In the common case of involvement of the 3/4 cleft

pain may be referred to the tip of the fourth toe.

The foot is comfortable on rising from bed in the morning, but pain develops
after walking or standing in closed well-sitting footwear

Some patients complain of pain at night causing broken sleep. During the day
the patients may gain temporary relief by a few minutes of rest.

The pain is unpleasant and disturbing. It may be intermittent with long

periods of quiescence.

Signs

the importance of a clear and detailed history

The cardinal sign is pain on pressure upwards and backwards in the web over the point of
division of the nerve.

The best way to elicit this pain is alternately to compress and release the forefoot with one
hand, while maintaining pressure in the web with one finger of the other hand.

The objective sign, the click, is found more frequently than the subjective sign, the pain. It is
known as Mulders click and must not be confused with the common painless

Recently, attempts have been made by using ultrasound and MRI to

demonstrate the lesion prior to operation. Both techniques seemequally successful.Nevertheless,

the diagnosis should be possiblewithout ancillary tests.

How to eclici
Mulders click

Pathology

An enlarged communicating branch between the medial and lateral plantar

nerves may be an important factor in the frequent involvement of the nerve
to the third interspace as it probably acts as a tether

In cases with a short history, the artery and nerve, both slightly swollen, are
found to be adherent to the transverse ligament are found to be adherent to
the transverse ligament

The pathogenesis of the neuroma is the same as entrapment syndromes else

where. The digital neuroma found in Mortons metatarsalgia is quite unlike
the typical neuromatous outgrowthswhich develop in injured nerves.

Figure 2 The variations of

the anastomosis between
the medial and lateral
plantar nerves. There is a
strong link and more
tethering of the nerve to
the 3/4 space in some
cases.Common pattern
on the right. (From Foot
and Ankle 1984.
Permission has
been requested.)

However, the histological features of a Mortons neuroma are not specific and
can be foundin the nerves of normal elderlypatients as a result of age and
use.

The microscopic anatomy shows separation of individual nerve fibres by a

proliferating collagenmatrix.

The presence of Renaut bodies suggests a compressive pathology. Renaut

bodies are loosely textured, whorled, cell-sparse structures in the subperineural space of peripheral nerves but this diagnostic feature is only seen
on electronmicroscopy

Blood vessels showperiarterial fibrosis and endarteritis obliterans

It is important to note that if one sends a specimen for histology the fact that
the pathologist reports it as compatible with Mortons Neuroma does notmean
that you have cured the patient butmerely that you have excised a digital
nerve

Treatment

Minor symptoms may be controlled by open types offootwear and limitation

of weight-bearing activities

Injection of the intermetatarsal bursa with hydrocortisone may occasionally

relieve symptoms

Otherwise the only treatment in my view is excision of the neuroma

Unless this includes about 2 cm of nerve proximal to the ligament, the

inevitable terminal neuroma may adhere to the transverse ligament and
cause symptoms

British surgeons generally follow the example set by Betts of Adelaide and use
a longitudinal plantar incision across the tread in the line of the interspace.

This gives direct access to all the structures concerned. The anatomy is
clearly visible

A slightly longer incision when retracted allows inspection of the adjacent

interspace as well

Most North American surgeons prefer a dorsal incision in the web giving
limited access to one interspace only, as they want to avoid a scar on the
weight-bearing area.

Gauthier in 1978 15 advocated simple division of the intermetatarsal ligament

as the treatment of choice and claimed 83% success . An additional 15% were
improved but had some persistence of pain.

Okafor et al.16 with a similar technique reported a 98% satisfaction rate

OperativeTechnique

Plantar approach A longitudinal incision is made in the line of the appropriate

interspace (3/4 or 2/3)

Once the skin has been incised a self-retaining retractor helps separate
themargins of the wound

the neuroma and the Y-shaped distal bifurcation into digital nerves

As the neuroma is removed some of the adjacent wall of the intermetatarsal

bursa usually comes away with it (Fig. 4)

Aftermeticulous skin closure a pressure dressing is applied with plaster wool

and a crepe bandage, and the tourniquet is released.

After 24 h the patient may walk in a wooden-soled sandal. To ensure sound

wound healing the sutures should not be removed for14 days.

Dorsal approach

A longitudinal incision about 3 cmlong is made on the dorsal aspect of the

afected interspace.

The deep transverse intermetatarsal ligament is divided to expose the

underlying neuroma which can be made obviousbypressure in the sole

A self-retaining retractor is useful to separate the metatarsal heads.

The neuroma is resectedwith1cm of normal nerve proximal to it, and

distally at theY-shaped bifurcation.

Decompression The approach is dorsal as above. After division of the

intermetatarsal ligament the nerve with the neuroma is dissected free and
left lying away from contactwith the plantar fascia

Results

The results of surgery by excision of the neuroma through a dorsal approach

were reported by Mann and Reynolds in 1983to be 84% successful.

TARSAL TUNNEL SYNDROME

First described in 196219, 20 this is a diagnosis to be made with care. In

comparison with the carpal tunnel syndromeit is very rare

must include electrodiagnostic tests and MRI scanning

The flexor retinaculum is about half the thickness of the transverse carpal
ligament at the wrist. The shape of the tarsal tunnel with its thin retinacular
covering makes it unlikely that compression of the posterior tibial nervewill
occur unless there is a space-occupying lesion within the tunnel such as a
ganglion, lipoma or anomalous muscle belly

Takakura et al.who reported that in most cases in need of an operation

therewas a space-occupying lesion.

In cases with a clear-cut lesion an excellent result can be expected from

surgery

Figure 4 Stages in the plantar dissection of a neuroma.

(A)
preliminary dissection, and (B) withthe neuroma
exposed.

Figure 5 A neuroma excised

with bursal tissue and a
long
proximal segmentto avoid a
terminalneuroma.

Symptoms

There is difuse burning pain and paraesthesiae over the region of the
distribution of the medial plantar nerve.

The pain may be aggravated by walking and relieved by rest. It may beworse
at night.

Examination

A curved incision is used which starts above the flexor retinaculum and ends
just distal to it. The procedure is aimed at decompression of the posterior
tibial nerve and its medial and lateral plantar nerve branches.

The nerve should be exposed proximally above the level of the flexor
retinaculum and traced distally into the foot

Postoperatively the foot and ankle should be splinted in plaster for 2 weeks to
allow sound healing of the operation wound.

Complications

Augustijn and Vanneste described three cases of tarsal tunnel syndrome in

which the underlying cause was a more proximal lesion

in two cases an arterial lesion and in one a tibial fracture and thus the
possibility of a more proximal lesion must be excluded.

Birch et al state that their experience of failures of tarsal tunnel surgery have
been discouraging.

This shows the importance of careful and accurate preoperative investigations

to ensure that the diagnosis is correct.

ANTERIOR TARSALTUNNEL
SYNDROME

The symptoms are pain on the dorsum of the foot with occasional radiation
into the wirst web space. Pain usually occurs with athletic activities and
subsides when the shoe is removed and with rest.

The causes of the onset of the syndrome included a contusion of the dorsum
of the foot, tight shoe laces, talonavicular osteophytes, a ganglion and pes
cavus.

Treatment consisted of division of the inferior extensor retinaculum and the

removal of any space occupying lesion such as a ganglion.

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