A pes cavus (high arch) foot type can be present on the exam, which can contribute to dorsal compressive forces and abnormal fitting of shoe-gear.Ī full lower extremity musculoskeletal and neurologic exam should be performed, including muscle strength, vibratory, light touch, temperature, and two-point discrimination exams. Extreme active or passive plantar flexion of the ankle may reproduce the patients' symptoms due to a stretching/compression of the nerve. Palpation of the ankle may reveal edema or a space-occupying lesion (varicose vein or ganglion), while palpation of the foot may reveal palpable dorsal osteophytes (bone spurs). On physical exam, repetitive percussion of the DPN may reproduce radiating paresthesias in the distal (Tinnel sign) or proximal (Valleix sign) directions. The patient may recall a history of acute trauma (ankle sprain or hyper-plantar flexion injury) or repetitive microtrauma (runner or military trainee). The most common location of symptoms is the dorsal forefoot, more specifically the distal dorsal first webspace. Symptoms are typically intermittent and exacerbated by physical activity and alleviated by rest and elevated. Patients will typically complain of sharp shooting pain, numbness, or tingling along the distribution of the DPN or its terminal branches. Symptoms of tarsal tunnel syndrome may include the following:Ī detailed patient history and clinical examination are the most important factors for an accurate diagnosis of ATTS. The common peroneal nerve receives contributions from the L4 through S2 nerve roots. Contents of the anterior tarsal tunnel include the dorsalis pedis artery/vein, deep peroneal nerve, tibialis anterior tendon, extensor hallucis longus tendon, extensor digitorum longus tendon, and peroneus tertius. The anterior tarsal tunnel is a fibro-osseous tunnel along the anterior ankle in which the borders include the inferior extensor retinaculum (superficially/roof), medial malleolus (medially), lateral malleolus (laterally), and the talonavicular joint capsule (deep/floor). In the anterior leg, the DPN provides motor innervation to the tibialis anterior (TA), extensor digitorum longus (EDL), peroneus tertius, and extensor hallucis longus (EHL) muscles. The EDB and EHB muscles are innervated by the lateral terminal branch of the DPN while the medial branch runs beside the dorsalis pedis artery in the dorsal foot and is purely sensory providing innervation to the first webspace. It then divides into the medial and lateral terminal branches. The DPN bifurcates from the CPN in the anterior compartment of the lower leg and travels along the interosseous membrane. Just proximal to the ankle joint, the DPN courses between the extensor hallucis longus tendon and the extensor digitorum longus tendon. The deep peroneal nerve is one of two terminal branches off the common peroneal nerve (CPN). Two other anatomic locations of entrapment have been described and include deep to the extensor hallucis longus tendon overlying the talonavicular joint and deep to the extensor hallucis brevis muscle overlying the first and second tarsometatarsal joints. ATTS, also known as deep peroneal nerve (DPN) entrapment, is a compression neuropathy of the DPN most commonly caused by the tight fascia band in the anterior ankle called the inferior extensor retinaculum. Koppel and Thompson first described anterior tarsal tunnel syndrome (ATTS) in 1960.
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