1/ Another THREAD on nerve entrapment...
This time the victim is the TIBIAL NERVE (TN).
“Tibia” is Latin for “shinbone” AND “flute”... but what about a “flute” made of “shinbone”??
Yep, that happened. Here’s a copy of a Tibial Flute originally made 10,000 yrs ago in Germany...
2/ Time for a little anatomy review.
The TN splits off the sciatic nerve and is sometimes called the “Posterior Tibial Nerve” in the lower leg.
3/ The TN is commonly vulnerable to entrapment at 2 sites:
1) Tibial Tunnel (TT)
2) Proximal Soleus (SSS... explained later)
Let’s dive into 1)...
4/ The TT travels along the posterior-medial ankle,
has the flexor retinaculum as its ceiling and
its bony floor consists of the posteromedial talus, the medial navicular, & the medial calcaneus.
5/ It contains (from anterior to posterior):
“TOM” - the tibialis posterior (TP) tendon,
“DICK” - the flexor digitorum longus (FDL) tendon,
“&” - the TN neurovascular bundle,
“HARRY” - the flexor hallucis longus (FHL) tendon.
6/ The TN gives off the medial calcaneal nerve (MCN) just prior to entering the tunnel,
and splits within/soon after exiting the tunnel to form the lateral plantar nerve (LPN), medial plantar nerve (MPN), & Inferior Calcaneal Nerve (ICN).
👉* Remember ICN & MPN *👈
7/ Methods of entrapment:
• ankle DF & Eversion
• history of foot/ankle fracture/dislocation
• pronated foot
• edematous conditions
These conditions could create a tension entrapment at the distal end of the tunnel.
8/ What you *could* find in the clinic w/ TT Entrapment:
• local and radiating symptoms with palpation of the tunnel
• weak flexion of toes
• weak big toe aBDuction (secondary effect)
• sensory changes along sole of foot (burning pain, tingling, numbness)
9/ So, why point out the MPN & ICN earlier?
Think back to people with sharp pain in the yellow circle marked below.
Yeah...
That’s right... “PLANTAR FASCIITIS” could be neurogenic!!!
10/ In some cases of “plantar fasciitis” folks end up “failing” conservative treatments because nobody took the time to check for neurogenic causes of their pains!
11/ Let’s move on to a less common TN entrapment site...
Entrapment at Proximal Soleus (called the Soleus Sling Syndrome) occurs where it passes through a tunnel between the superficial and deep posterior compartments of the leg at the origin of the soleus muscle.
12/ SSS presents with:
• pain in the popliteal fossa and proximal calf (aggravated by active and passive dorsiflexion of the foot)
• inability to bear weight
• weakness of toe flexion
• sensory deficits on the sole of the foot
All of which are aggravated by walking.
13/ Clinical note:
People reporting of persistent posterior leg “tightness” should be checked for neurogenic involvement.
For these folks, stretching doesn’t help, but they can’t stop stretching their hamstrings/calves!
Think: repetitive hamstring tears, calf strains, etc.
14/ Common conservative treatment strategies?
• orthotics
• address pathomechanics involved with foot pronation & excessive hind foot eversion
• check shoes
• check running form & walking mechanics
• check hip mobility
15/ IF full trials of conservative strategies fail, then neurolysis may be indicated.
Better evaluation begets better treatment strategies.
Like a mentor of mine once said:
“If you aren’t looking for it, then you won’t see it.”
Extra: apparently bone flutes can still be purchased in Europe...
trinoxsamoni-lutherie.com/products/bone-…
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