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Ankle & Foot
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Medial Pain
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Tibialis Posterior
FHL
Deltoid Ligament
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Tarsal Tunnel
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Compression of the median nerve at the wrist as it passes beneath the flexor retinaculum in close association with the flexor tendons of the fingers is a well recognised entity. The tarsal equivalent of carpal tunnel syndrome describes compression of the posterior tibial nerve as it passes through the tarsal tunnel in association with the posterior tibial and flexor digitorum tendons. The posterior tibial nerve is the major branch of the sciatic nerve formed above the knee following division of the common peroneal nerve. At the level of the ankle joint it passes through the tarsal tunnel dividing into its terminal branches the medial and lateral plantar nerves. A number of other important branches include the lateral calcaneal nerve. There is some variation in the location of these nerve divisions which may occur either prior, during or after passage through the tarsal tunnel. A number of causes of tarsal tunnel have been described but the most common is the formation of ganglion or synovial cysts which arise in the region of the adjacent ankle joint. Synovial cysts most frequently arise from the posterior subtler joint whereas ganglion cysts may arise from any of the adjacent ligamentous structures. Cysts may also track from the talonavicular joint posteriorly. Any other mass lesion including lipoma or neurilemmoma may contribute to compression. Other causes include tenosynovitis of tibialis posterior and flexor digitorum although this is usually in combination with some other impingement. An accessory soles muscle and new bone formation around a talocalcaneal coalition are other potential causes. Clinically the patient complains of tenderness along the medial aspect of the foot which may be associated with sensory disturbances particularly on the plantar aspect of the foot.
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Two other nerves that are important on the medial aspect of the ankle are the medial and inferior calcanea nerves. The plantar fascia is innervated predominantly by the inferior calcaneal nerve, which arises from the lateral branch of the tibial nerve. The nerve supplies the motor innervation to the flexor digitorum brevis, the quadrates plantae and the abductor digit minimi. It passes along the medial border of the os calcis before passing between abductor hallucis and quadrates plantae muscle. It then passes in a soft tissue tunnel between abductor hallucis and flexor digitorum brevis before reaching the plantar fascia. The nerve may become entrapped particularly if there is muscle hypertrophy leading to symptoms which mimic plantar fasciopathy. The most common cause is compression as it traverses underneath the heel by a large plantar spur either in isolation or in association with plantar fasciitis. Compression may also occur occurs as the nerve passes between abductor hallucis and quadrates plantae. Muscle hypertrophy is generally the cause of compression in this location, rather than a synovial cyst ganglion or neuroma. In the absence of a specific compression cause, chronic traction is assumed to underlie symptoms. A positive Tinel's sign over the nerve aids diagnosis. Compression may lead to atrophy of Ab Dig Min (see image). The medial calcaneal nerve may be injured during surgical pin placement. Neuroma of this nerve may also underlie heel pad symptoms.
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