My last article was the first of a series of articles that will address certain common ankle injuries as well as some common foot injuries. I focused on osteochondral defects and peroneal tendon injuries. This week I will focus on tarsal tunnel syndrome.
Before I focus in on tarsal tunnel syndrome specifically, I wanted to raise a general point that is available to plaintiffs/claimants attorneys on cross-examination with respect to foot injuries.
It is necessarily true that good blood circulation is crucial for the overall health of the body since blood is responsible for bringing oxygen and essential nutrients to the entire body. The body cannot function without proper blood flow.
Likewise, injuries cannot heal properly without proper blood flow. For some obvious reasons and some not-so-obvious reasons, foot and ankle injuries are particularly susceptible to a poor recovery because of poor blood flow. On the more obvious side, the foot and ankle get less blood flow than any other part of the body because of the distance from the heart.
It is important to note that this blood flow is affected not just because of the distance from the heart, it is also affected because the mechanism for bringing the blood to the foot and ankle is actually more impeded or congested near the foot and ankle than other parts of the body (i.e., it is almost like a bottleneck at or near the foot and ankle). Likewise, many individuals who have been injured may have a pre-existing condition that affects the blood flow to the foot and ankle such as diabetes or a heart problem. The plaintiffs attorney should be prepared to argue that a pre-existing condition that is no fault of the plaintiff is affecting his or her recovery.
It is also a defense ploy to blame smoking for poor blood flow and a slow recovery. There is some merit to this argument and the plaintiffs attorney should avoid arguing over this issue.
With respect to tarsal tunnel syndrome, specifically, it is a compression neuropathy and painful foot condition in which the tibial nerve is compressed as it travels through the tarsal tunnel. Tarsal tunnel syndrome is also known as tibial nerve dysfunction. The tarsal tunnel is located on the inside of the leg.
It essentially runs underneath the inner bump of the ankle known as the malleolus. Tarsal tunnel occurs when there is damage to the tibial nerve. It is important to note that the tibial nerve is one of the lower branches of the sciatic nerve of the leg. As a result there can be overlap between the symptoms of a tibial nerve injury and a sciatic nerve injury, which emanates from the lumbar spine.
The tibial nerve supplies movement and sensation to the back of the leg (calf) and the foot muscles. An injury to the tibial nerve can have severe consequences. The plaintiffs attorney should be aware that the typical symptoms associated with tarsal tunnel syndrome are similar to other nerve injuries. That is, the plaintiff may experience a burning sensation in the foot or lower leg, numbness or tingling in the foot or lower leg and maybe most importantly severe pain in the foot or the lower leg.
In addition, tarsal tunnel syndrome is known to cause weakness of the foot muscles as well as weakness in the toes and ankle.
While there is some medical literature to suggest that tarsal tunnel syndrome may be idiopathic (appear with no known cause), most defense medical examiners will concede that it is well accepted that tarsal tunnel syndrome can emanate from a single trauma.
For instance, a direct blow to the tibial nerve can cause tarsal tunnel or it can be caused from complications after a tendon, ligament or bone injury such as swelling, which compresses the tibial nerve. In the workers’ compensation setting it is important to note that just like carpal tunnel syndrome, which compresses the median nerve in the wrist, repetitive stresses at work on the tibial nerve can cause tarsal tunnel syndrome. So if your client is repetitively using a foot pedal at work or doing anything that may entrap the nerve over a period of time, he or she may be susceptible to developing tarsal tunnel syndrome.
Although there are many similarities between carpal tunnel syndrome and tarsal tunnel syndrome, most physicians would concede that tarsal tunnel syndrome is a much more serious condition and much more likely to have a debilitating effect.
From a clinical standpoint aside from assessing symptoms and complaints of pain, the examining physician is most likely to detect tarsal tunnel syndrome by performing a Tinel’s maneuver (percussion testing of the tibial nerve). The test is the same test used to detect carpal tunnel syndrome in the wrist. Likewise, in terms of diagnostic testing, the most often used test to identify tarsal tunnel syndrome is an EMG/NCV study. This test can objectively detect either increased or decreased sensitivity of the tibial nerve, either of which may be indicative of a tarsal tunnel injury.
Treatment of tarsal tunnel syndrome runs the gamut from conservative, noninvasive treatment to surgical repair together with pain medication and anti-inflammatories.
In order to effectively represent a client suffering from tarsal tunnel syndrome, as with all injuries, the plaintiffs/claimants attorney must familiarize himself or herself with the injury and understand the nomenclature the defense medical witness will utilize.
I plan to continue with additional foot and ankle injuries in the upcoming articles.
Brandon Swartz is a founding partner of Swartz Culleton. His practice focuses on all types of personal injury cases including wrongful death, medical malpractice, civil rights violations, motor vehicle, premises liability, products liability, trucking accidents and workers’ compensation.