Foot and Ankle Surgery 18 (2012) 149152

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Foot and Ankle Surgery

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Review

Tarsal tunnel syndrome: A literature review

M. Ahmad (MBBS, MRCS, FRCS (Tr & Orth))a,*, K. Tsang (MBBS, MRCS)b, P.J. Mackenney (FRCS (Tr & Orth))b, A.O. Adedapo (FRCS (Tr & Orth))b
a b

c/o Mr Adedapos Secretary, James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW, UK James Cook University Hospital, Middlesbrough, UK

A R T I C L E I N F O

A B S T R A C T

Article history: Received 18 September 2011 Accepted 21 October 2011 Keywords: Tarsal tunnel syndrome Literature review

Background: Tarsal tunnel syndrome (TTS) is an entrapment neuropathy of the posterior tibial nerve or its branches within its bro-osseous tunnel beneath the exor retinaculum on the medial side of the ankle. It is a rare but important condition which is regularly under diagnosed leading to a range of symptoms affecting the plantar aspect of the foot. Management of this entrapment neuropathy remains a challenge and we have therefore reviewed the published literature in an attempt to clarify aspects of initial presentation, investigation and denitive treatment including surgical decompression. We also assessed the continuing controversial role of electrodiagnostic techniques in its diagnosis. Conclusion: Recommendations from literature:  Excellent results with decompression in selected patients.  To prevent nerve brosis, decompression should be performed early.  Remain aware of false negative NCS (under-diagnosing of those with symptoms but normal NCS).  Role of NCS remains controversial with inability to predict which cases respond to decompression.  Poor outcome may be due to nerve brosis. 2011 Published by Elsevier Ltd on behalf of European Foot and Ankle Society.

Contents 1. 2. 3. 4. 5. 6. Introduction . . . . . . . . . . . . . . . . . . Anatomy. . . . . . . . . . . . . . . . . . . . . Aetiology . . . . . . . . . . . . . . . . . . . . Diagnosis . . . . . . . . . . . . . . . . . . . . Investigations . . . . . . . . . . . . . . . . . Management . . . . . . . . . . . . . . . . . 6.1. Non-operative . . . . . . . . . . . Surgical . . . . . . . . . . . . . . . . 6.2. Discussion . . . . . . . . . . . . . . . . . . . Surgical results . . . . . . . . . . 7.1. 7.2. Role of electrophysiological Conclusion . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... studies . ....... ....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 150 150 150 150 150 150 150 151 151 151 152 152

7.

8.

1. Introduction Tarsal tunnel syndrome (TTS) is an entrapment neuropathy of the posterior tibial nerve or its branches (medial plantar, lateral plantar and calcaneal nerves) within its bro-osseous tunnel

* Corresponding author. Tel.: +44 01642 850 850; mobile: +44 07966 349 556. E-mail address: mubashshar@doctors.org.uk (M. Ahmad).

beneath the exor retinaculum on the medial side of the ankle. It is a rare but important condition which is regularly under diagnosed leading to a range of symptoms affecting the plantar aspect of the foot. Accurate diagnosis can be difcult as symptoms are similar to those associated with other lower limb conditions. In addition, controversy remains with false negative electrophysiological studies contributing to the under diagnosis. Surgical intervention may benet cases where a denite point of entrapment is found.

1268-7731/$ see front matter 2011 Published by Elsevier Ltd on behalf of European Foot and Ankle Society. doi:10.1016/j.fas.2011.10.007

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Management of this entrapment neuropathy remains a challenge and we have therefore reviewed the published literature in an attempt to clarify aspects of initial presentation, investigation and denitive treatment including surgical decompression. We also assessed the continuing controversial role of electrodiagnostic techniques in its diagnosis. 2. Anatomy The tarsal tunnel is a bro-osseous tunnel beneath the exor retinaculum, behind and inferior to the medial malleolus. The oor is formed by the medial wall of the talus, calcaneum and the medial wall of the distal tibia. The exor retinaculum forms the superior and inferior margins as well as the roof. The structures that course within the tarsal tunnel are, from medial to lateral, tibialis posterior tendon, exor digitorum longus tendon, posterior tibial artery and vein, posterior tibial nerve and exor hallucis longus tendon. As the tibial nerve passes through the tarsal tunnel it bifurcates into medial and lateral plantar nerves. This bifurcation occurs proximal to the tunnel in 5% of cases [1]. These two branches exit the tarsal tunnel, pass through about 1 cm of fatty tissue, and then enter their own tunnels. The medial plantar nerve passes deep to abductor hallucis and exor hallucis longus muscles, and then divides into three digital nerves. The lateral plantar nerve passes directly through the abductor hallucis muscle belly as it traverses to the lateral side of the foot before its terminal divisions. Both the medial and lateral plantar nerves supply autonomic, sensory and motor bres to the plantar foot [2]. The medial calcaneal nerve is usually a branch of the posterior tibial nerve: it pierces the exor retinaculum to provide sensory innervation to the posterior and medial aspects of the heel. However there is variation in its anatomy where it may branch before and run supercial to the exor retinaculum [3] or arise from the lateral plantar nerve (25% of cases) [1]. 3. Aetiology Causes of TTS can be classied into either intrinsic, extrinsic, or combinations of the two. In a recent literature review it was estimated that in 80% of cases, the specic cause can be identied [1]. Intrinsic factors include: osteophytes, hypertrophic retinaculum, tendonopathy, space-occupying lesions such as enlarged veins, ganglia, lipoma, tumour and neuroma. Haemorrhage secondary to trauma may lead to adhesions and peri-neural brosis. Arterial insufciency may lead to ischaemia of the nerve accounting for sensory symptoms. The bro-osseous tunnel has several deep brous septa which blend with the adjacent periosteum. The neurovascular bundles are often attached to these septa, rendering itself more liable to minor degrees of traction on movement of the foot. Extrinsic causes include: direct trauma, constrictive foot wear, hind foot varus or valgus, generalised lower limb oedema (pregnancy, venous congestion), systemic inammatory arthropathy, diabetes and post surgical scarring. An entrapment of the rst branch of the lateral plantar nerve (Baxters nerve) is exacerbated by foot supination. 4. Diagnosis This is a clinical diagnosis based on a detailed history and clinical examination. Adjunctive imaging and electrophysiological studies provide additional information to plan management. The predominant symptom is pain directly over the tarsal tunnel behind the medial malleolus with radiation to the

longitudinal arch and plantar aspect of the foot including the heel. A sensation of tightness and to varying degree sensory symptoms of burning, tingling and numbness are usually present. Symptoms are exacerbated by activities such as prolonged standing or walking. Night symptoms are not uncommon, especially after a day of extended weight bearing activity. Rest and leg elevation will often relieve symptoms. Examination reveals tenderness on deep palpation with a positive Tinels sign. Provocation manoeuvres such as the dorsiexion-eversion test are useful [5]. In chronic cases, secondary toe contractures and weakness of the intrinsic foot muscles develop. Localised swelling may represent a space-occupying lesion. Sensory changes are conned to the distribution of any of the terminal branches of the posterior tibial nerve (medial and lateral plantar nerves or the calcaneal branches). The dorsum of the foot should not be affected except over the distal phalanges of the toes. 5. Investigations Plain X-rays of the ankle are useful in demonstrating structural abnormalities such as hind foot varus/valgus, tarsal coalitions, osteophytes or evidence of previous trauma. Magnetic resonance imaging adds further detail and is highly accurate (83%) when investigating space-occupying lesions [2]. Diagnostic ultrasound is increasingly used to detect ganglia, varicose veins, lipomas, tenosynovitis and talocalcaneal coalition [6]. High frequency machines can demonstrate high divisions of the tibial nerve; this can result in overlling of the tarsal canal by the medial and lateral plantar nerve branches. A complete electrophysiological study involves nerve conduction studies (NCS) and electromyography (EMG). They can be used independently but when used together both complement each other to provide information about peripheral nerves and muscles. They are useful in helping to separate patients with TTS from those with compression of the rst sacral nerve root. However there are several issues that make electrophysiological conrmation of TTS difcult. False negative tests are not uncommon and therefore do not rule out the diagnosis. 6. Management To increase the rate of positive outcomes, management should be directed at the specic cause. 6.1. Non-operative Conservative treatment options include anti-inammatory medication and activity modication combined with progressive mobilisation exercises [7]. Symptoms may also be controlled by decreasing the pressure over the nerve by using orthotic shoes [8], immobilisation with a night splint or removable boot walker [7]. Aspiration of ganglia may provide temporary benet and corticosteroid injections may be sufcient to reverse any intraneural oedema. Physiotherapy can include a variety of techniques including taping, bracing, stretching, icing, massage and ultrasound however evidence in the literature of its effectiveness is lacking. 6.2. Surgical Surgical intervention is considered after a failed course of nonoperative treatment and where a denite point of entrapment is found. Surgical technique utilises an open approach with a curved medial incision centred between the medial malleolus and the

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Achilles tendon. The incision is extended over the abductor hallucis muscle belly with a slight anterior curve just proximal to its calcaneal insertion. Deep dissection is performed to the level of the exor retinaculum with blunt techniques to avoid iatrogenic injury of nerve branches. When the exor retinaculum is identied, this tight fascial layer is lifted and a small stab incision is made into its central portion. A blunt device can then be introduced under the retinaculum to protect the nerve. The retinaculum is released along its entire course from the level of the dorsal abductor muscle belly to the proximal border. When the release is complete the posterior tibial nerve and its branches can be identied. Special care is taken to free the posterior tibial nerve from any small brous bands or deep prolongations from the retinaculum which may encircle it. It is important to carry out the decompression distally past the point where the posterior tibial nerve passes under the abductor hallucis. The supercial fascia that overlies the abductor muscle belly is identied and released. The muscle belly is then carefully retracted plantarly and the deep fascia of the abductor muscle is identied. This is the region of the greatest compression in most cases and the region that is most often not addressed during tarsal tunnel release. Two distinct tunnels are identied that divide the medial and lateral plantar nerves in the region of the deep abductor retinaculum. The tunnel is identied and released along its course with care taken to protect the nerve and venous plexus. Both tunnels are fully released with resection of the central brous septa to make one large passage for both nerves. It is important to remove the central septum to prevent brosis and to enlarge the entrance of the nerves into the foot. If however, the nerve divides into its two terminal plantar branches before it enters the sole of the foot, each plantar nerve should be decompressed separately [9]. There is a distinct tunnel for each calcaneal nerve branch as it passes below the abductor retinaculum into the plantar heel region. They are individually identied and decompressed. The posterior tibial nerve and the medial and lateral plantar nerves are then checked for internal brosis. The ideal is to be able to see the distinct fascicles of nerve without brosis. If brosis is noted a linear incision is made into the perineurium to free the fascicle branches thus releasing the circumferential brosis. The most common region of brosis is the distal posterior tibial nerve at its division. Extensive dissection should be avoided. Varicosities should be ligated and space-occupying lesions dissected free and excised. Post operatively patients are mobilised and enrolled into a physiotherapy rehabilitation programme. They are warned it can take up to a year for symptoms to resolve while the nerve bres begin to regenerate and the axonal ow recovers. 7. Discussion 7.1. Surgical results Reported success rates after tarsal tunnel decompression have varied in the literature from 44% to 96%. Handrix [10] discussed chronic intractable heel pain and presented successful outcome in 96% of patients with decompression of posterior tibial, medial and lateral plantar nerves, and the rst branch of the lateral plantar nerve. Several papers have quoted low success rates: Pfeiffer and Cracchiolo [11] described a successful outcome in only 44% of cases and Kaplan [12] reported 21 decompressions with only nine describing relief of symptoms. We feel the wide variation in success rate is partly due to patient selection, timing of surgical intervention but also the technique of decompression. One of the most predictable indicators of a favourable outcome following decompression is the presence of a positive Tinels sign. If

there is sensory decit in the absence of a positive Tinels sign, surgical intervention has a limited chance of recovering nerve function [13]. Cracchiolo and Pfeiffer [11] presented a 38% dissatisfaction rate and concluded the best indication to perform surgery is the presence of a space occupying lesion as in their study this produced the most predictable outcome. Nagaoka and Satou [14] conrmed this assertion when they presented successful outcomes following excision of ganglia in all 29 patients they treated with TTS. Timing of surgical intervention is important as chronic nerve compression leads to intraneural brosis which can be responsible for the later development of muscle wasting and weakness. Sammarco and Chang [15] reported on 75 patients and showed an improvement in foot score and better outcomes in those who had symptoms for shorter than one year. Tamai [16] suggested recovery of the nerve was poor when decompression was delayed (greater than 10 months from onset of symptoms) whereas early diagnosis and intervention had an excellent prognosis. Surgical techniques have improved with a more comprehensive release of foot nerves in addition to the posterior tibial nerve. Franson et al. achieved improved results after modifying their technique to include a more extensive and distal release of the posterior tibial nerve and its branches. A simple release of the exor retinaculum is often not sufcient to achieve an adequate tarsal tunnel release, although it does depend on the specic aetiology. Gould [17] evaluated a subset of patients with chronic proximal plantar fasciitis and distal tarsal tunnel syndrome. The authors present a surgical technique which employs a complete plantar fascia release combined with a proximal and distal tarsal tunnel release. They found that patients managed surgically had higher rates of total patient satisfaction (82%), with corresponding high rates of resolution of pain and elimination of activity limitations. Endoscopic decompression relies in the clinical suspicion that the only pathology is a tight exor retinaculum and has the advantage of limited soft tissue trauma and therefore faster recovery. Day and Naples described ve cases, all with excellent results [18]. 7.2. Role of electrophysiological studies In TTS motor bres of medial and lateral plantar nerves reveal prolonged latencies or reduced muscle action potentials in abductor hallucis and abductor digiti minimi respectively. Normal motor responses do not necessarily exclude TTS as pathology may be restricted to only sensory bres, especially early in the course of the condition [19]. In 17 patients Oh [19] found the motor response to be less sensitive with prolonged motor latencies in only 52% of cases, but abnormal sensory action potentials (SAP) responses in 90%. Sensory nerve conduction was abnormal in all the nerves in which the distal motor latency was prolonged. EMG of intrinsic foot muscles should be interpreted with caution as false positive results may lead to over diagnosis. Saeed [20] studied 70 asymptomatic subjects and found false positive reading in 10% of the abductor hallucis and in 11% of abductor digiti minimi muscles. Similarly, Alaranta [21] demonstrated false positive readings in 43% in 53 normal subjects. Harper [22] found 21% false positive readings, however only 10% in those under 60 years but 30% in those over 60 years. This may be due to age related nerve degeneration, difculty in activating foot muscles and pain inhibition secondary to painful needle examination. Kaplan [12] found no difference in motor nerve conduction studies between the control group and subjects with TTS. It has been suggested that SAP are a more sensitive test. This is supported in a review [23] of asymptomatic subjects where medial and lateral plantar responses were assessed: medial plantar sensory 98%, medial plantar mixed 99%, lateral plantar sensory 92% and lateral plantar mixed 91%. Ahmad [24] studied 25

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subjects with suspected TTS with sensory nerve conduction of the medial and lateral plantar nerves and reported abnormal conduction in 24 cases. Galardi [25] found that absence of the SAP was the most frequent abnormality; representing 92% in the lateral plantar nerve and 77% in the medial plantar nerve. Only 21% of TTS limbs had prolonged distal motor latencies to the abductor hallucis and all these patients also had sensory nerve abnormalities. Mixed NCS abnormalities were always associated with abnormal sensory NCSs. In contrast to electrophysiological studies of the upper limb which are easily recordable and reproducible, it may be difcult to similarly record motor and especially sensory responses from the nerves of the foot because of factors such as foot deformity, skin callosities, oedema as well as their possible absence in normal subjects. Sheratt [26] found that on stimulating the medial plantar nerve, action potentials were absent in 3 out of the 16 normal individuals. Ponsford [27] examined 59 asymptomatic subjects and found medial plantar sensory action potentials were recorded in all subjects, but lateral plantar sensory action potentials were absent in 20 subjects. However an absent response in itself is not necessarily pathological if it is absent on the contralateral asymptomatic side. In Gatens [28] study only 17% of normal subjects produced responses when the medial plantar nerve was stimulated and in none of the subjects when the lateral plantar nerve was stimulated. 8. Conclusion The diagnosis of TTS is made by history and examination not by nerve conduction studies. Appropriate use of electrodiagnostic and radiographic tests is necessary to conrm the diagnosis. A review of the published literature highlights a lack of high quality evidence based research and suggests the role of nerve conduction studies remains controversial. A review article [23] evaluated the usefulness of electrodiagnostic testing in patients with TTS. The studies reviewed were retrospective and revealed variability in the timing of assessments relative to symptom onset. However, they suggest that NCS appear to be more sensitive than EMGs and therefore may help to support a clinical diagnosis. Electrodiagnostic studies are useful in differentiating between lumbar-sacral radiculopathy and TTS but do not however assess aetiology which if not considered can lead to erroneous conclusions. A normal test does not exclude a compression of the posterior tibial nerve. Although some studies [29] have suggested an inability to predict success, our literature review does support the notion that in cases with a denite lesion, an excellent result can be expected from decompression when carried out soon after the onset of the condition. We suspect poor outcomes described in some studies may be due to intraneural brosis when decompression was performed late. In such cases, neurolysis may facilitate a second level of nerve decompression. Our recommendations for surgical intervention include:  History suggestive of TTS with a positive Tinels sign on examination.  Denite point of entrapment found including space-occupying lesions.  Decompression should be performed early if non-operative measures do not provide benet in the short term.

 No denitive recommendations can be provided on the usefulness of electrodiagnostic studies. Conict of interest No conict of interest present for any of the above authors and no funding was received for this study. References
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