# data[].attributes.body
https://forms.gle/VA8yYci98GgAUgEB9

# data[].attributes.body
https://forms.gle/LTo5tiFCjE1NDCaVA

# data[].attributes.body
- Recuerda empezar siempre lentamente y con una intensidad leve progresiva
- Evita movimientos bruscos o de impacto
- Si sientes dolor o incomodidad, detente de inmediato
- Mantén una buena postura

# data[].attributes.body
En caso de hernia discal, es mejor NO realizar los siguientes ejercicios:
- Aeróbicos de alto impacto
- Movimientos basados en flexión
- Levantamiento de peso con piernas
- Abdominales
- Movimientos de torsión
- Ejercicios de fuerza central de alto nivel
- Levantamiento de pesas por encima de la cabeza
- Inclinación hacia adelante repetitiva en la cintura.

# data[].attributes.body
RECUERDA QUE SI PRESENTAS ALGUNOS DE LOS SÍNTOMAS QUE MENCIONAMOS DEBES CONSULTAR A UN PROFESIONAL QUE TE ORIENTE ¡CADA CASO ES DISTINTO!

# data[].attributes.body
Mira este video: https://www.youtube.com/watch?v=vg8bkNnABA4

# data[].attributes.attachment_link.title
Kinesiotaping o vendaje neuromuscular. ¿Qué es y cómo funciona?

# data[].attributes.body
Guíate con las imágenes de estas páginas:
- https://www.ccohs.ca/oshanswers/ergonomics/office/stretching.html
- https://ehs.virginia.edu/Ergonomics-Stretch-Breaks.html

# data[].attributes.attachment_link.readable_text
Why is stretching important?
Back to top
No matter how well a workstation is designed, problems may arise if attention is not paid to the way the work is done. Working at a computer often involves very few changes in body position. This lack of movement can lead to muscle pain and strain.

What can be done to minimize this strain?
Back to top
It is recommended that a person break for 5-10 minutes for every hour spent at a workstation. If possible, it is ideal to stand up and walk for this time (e.g., work tasks that involve standing, walking, or at minimum, a change of body position). Some of these stretches can be done at the same time.

Vary the work tasks. Break up keyboarding tasks work by doing other job duties or tasks that involve moving around or changing body position. Try to stand up and move around.

Look away from the screen occasionally and focus your eyes on an object far away.

Take regular rest breaks to ease muscle aches, eye strain and stress.

Relax your muscles, stretch and change position.

Hold the stretch for a reasonable time (e.g., 10-20 seconds).

Breathe normally.

Do not bounce, pull/push excessively, or lock your joints. You should feel a stretch, but not pain.

If you feel pain or severe discomfort, stop stretching. Ask your medical professional for advice.

What are some stretches for the hands and forearms that can be done at the workstation?
Back to top
1. a) Start with your hand open.

b) Make a fist. Keep your thumb straight, not tucked under your fingers.

c) Slide your finger tips up your palm so the tips of your fingers are near the base of your fingers and you should feel a stretch. Do not force your fingers with your other hand if something is painful.

2. With your hand open and facing down, gently bend wrist from side to side, as far as possible. Hold for 3 to 5 seconds. Repeat 3 times.

3. Start by stretching your arm and hand out and slowly rotate the wrist down until you feel a stretch. Hold for 3 to 5 seconds. Next, rotate the palm up until you feel a stretch. Repeat 3 times.

4. Grasp your hand and hold your fingers with the other hand. Slowly bend your wrist down until you feel a stretch. Hold for 3 to 5 seconds. Relax. Repeat 3 times. Then slowly bend your wrist up until you feel the stretch. Hold and relax as above.

5. Sitting with your elbows on the table and palms together, slowly lower wrists to the table until you feel a stretch (your elbows will move outward a bit). Be sure to keep your palms together throughout the stretch. Hold 5 to 7 seconds. Relax. Repeat 3 times.

What are some stretches for the neck and shoulders?
Back to top
1. Shoulder Shrug: The purpose of the shoulder shrug is to relieve early symptoms of tightness or tension in the shoulder and neck area.

Raise the top of your shoulders towards your ears until you feel slight tension in your neck and shoulders. Hold this feeling of tension for 3 to 5 seconds. Then relax your shoulders downward into their normal position. Do this 2 or 3 times.

2. Head Glide: The head glide helps to stretch your chest, neck and shoulder muscles.

Sit or stand upright. Without lifting your chin, glide your head straight back. You are know you are doing this exercise right if it gives you the feeling of a double chin. Hold for 20 counts and repeat 5 to 10 times.

3. Neck Relaxer: This exercise helps to relax the neck.

Drop your head slowly to the left, trying to touch your left ear to your left shoulder. Repeat on the right side. Slowly drop your chin to your chest, turn your head all the way to the left, then turn all the way to the right.

4. Shoulder Roll: This exercise will help relax the shoulder muscles.

Slowly roll your shoulders backward five times in a circular motion. Next, roll your shoulders forwards.

5. Chest stretch:

Place your hands behind your head, and squeeze your shoulder blades together.

What are some stretches for the back, side and legs?
Back to top
1. Back / Side Stretch:

Interlace your fingers and lift your arms over your head, keeping the elbows straight. Press arms as far back as you can. To stretch your sides, slowly lean to the left and then to the right. In a similar way, you can also bring your arms in front of your body, or behind to stretch the shoulder blades and chest.

2. Middle / Upper Back Stretch:

Hold your right arm with your left hand just above the elbow. Gently push your elbow toward your left shoulder. Hold stretch for 5 seconds. Repeat with your left arm.

3. Back Curl (will also stretch your legs):

Grasp your shin. Lift the leg off the floor. Bend forward (curling your back), and reach your nose to your knee. Repeat with the other leg.

4. Ankle Flex and Stretch:

Hold one foot off the floor with your leg straight. Alternately flex your ankle (point your toes up) and extend (point your toes down). Repeat with the other leg.

5. Leg Lift:

Sit forward on the chair so that your back is not touching the chair's back. Place feet flat on the floor. With a straight leg, lift one foot a few inches off the floor. Hold momentarily, and return your foot to the floor. Repeat with the other leg.

6. Standing stretch:

When standing, keep knees slightly bent. Place your hands on your lower back and gently push your hands forward while leaning back slightly.

7. Hip stretch:

Sit with one leg across the other. Place your arm or elbow on the outside of the crossed leg. Gently apply pressure, while looking the opposite way. Repeat with the other leg.

Adapted from: Office Ergonomics Safety Guide, by CCOHS.

Fact sheet confirmed current: 2020-01-17

Fact sheet last revised: 2014-04-03

# data[].attributes.attachment_link.keywords[]
fiches techniques sur la sécurité des substances

# data[].attributes.attachment_link.keywords[]
environmental health and safety legislation

# data[].attributes.attachment_link.title
Office Ergonomics - Stretching - At the Workstation

# data[].attributes.attachment_link.description
Why is stretching important? No matter how well a workstation is designed, problems may arise if attention is not paid to the way the work is done.

# data[].attributes.body
- https://www.ncbi.nlm.nih.gov/books/NBK513273/
- https://tuhospital.es/traumatologia/tunel-carpiano/
- https://orthoinfo.aaos.org/en/diseases--conditions/carpal-tunnel-syndrome/
- https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Herniated-Disc

# data[].attributes.attachment_link.readable_text
Continuing Education Activity

Tarsal tunnel syndrome is sometimes referred to as tibial nerve dysfunction or posterior tibial nerve neuralgia. It is an entrapment neuropathy that is associated with the compression of the structures within the tarsal tunnel. It can be thought of as analogous to carpal tunnel syndrome of the wrist, but occurs at the ankle and is much less common than carpal tunnel syndrome. This activity addresses the presentation, evaluation, and management of tarsal tunnel syndrome and examines the role of an interprofessional team approach on the care of affected patients.

Objectives:

Identify the signs and symptoms of tarsal tunnel syndrome with the structures that are entrapped.

Describe the management strategies for tarsal tunnel syndrome.

Review the potential complications of tarsal tunnel syndrome.

Outline interprofessional team strategies for improving care coordination and communication to enhance outcomes for patients affected by tarsal tunnel syndrome.

Access free multiple choice questions on this topic.
Introduction

Tarsal tunnel syndrome sometimes referred to as tibial nerve dysfunction or posterior tibial nerve neuralgia, is an entrapment neuropathy that is associated with the compression of the structures within the tarsal tunnel. It is similar to carpal tunnel syndrome of the wrist although much less common.[1][2][3][4]

The tarsal tunnel is a narrow fibro-osseous space that runs behind and inferior to the medial malleolus. It is bounded by the medial malleolus anterosuperiorly, by the posterior talus and calcaneus laterally, and is held against the bone by the flexor retinaculum which extends from the medial malleolus to the medial calcaneus and prevents medial displacement of its contents.

The tarsal tunnel includes multiple important structures. It contains the tendons of the posterior tibialis, flexor digitorum longus (FDL), and flexor hallucis longus (FHL) muscles. The posterior tibial artery and vein, as well as posterior tibial nerve (L4-S3), also pass through it. The orientation of these structures within the tarsal tunnel is noteworthy. From medial to lateral, they are the tibialis posterior tendon, FDL tendon, posterior tibial artery and vein, posterior tibial nerve, and FHL tendon.

The posterior tibial nerve passes between the FDL and FHL muscles before it bifurcates in the tarsal tunnel, forming the medial and lateral plantar nerves. In 5% of people, the bifurcation occurs before the tarsal tunnel. The medial plantar nerve passes deep to the abductor hallucis and FHL muscles and provides sensation to the medial half of the foot and first 3.5 digits and motor function to the lumbricals, abductor hallucis, flexor digitorum brevis, and flexor hallucis brevis. The lateral plantar nerve passes directly through the abductor hallucis muscle belly and provides sensory innervation of the medial calcaneus and lateral heel and motor function to the flexor digitorum brevis, quadratus plantae, and abductor digiti minimi. The medial calcaneal nerve typically branches off of the posterior tibial nerve proximal to the tarsal tunnel and provides sensory innervation to the posteromedial heel. In 25% of patients, it branches off of the lateral plantar nerve or runs superficial to the flexor retinaculum.

Etiology

Tarsal tunnel syndrome is divided into intrinsic and extrinsic etiologies.[5][6]

Extrinsic causes include poorly fitting shoes, trauma, anatomic-biomechanical abnormalities (tarsal coalition, valgus or varus hindfoot), post-surgical scarring, systemic diseases, generalized lower extremity edema, systemic inflammatory arthropathies, diabetes, and post-surgical scarring.

Intrinsic causes include tendinopathy, tenosynovitis, perineural fibrosis, osteophytes, hypertrophic retinaculum, and space-occupying or mass effect lesions (enlarged or varicose veins, ganglion cyst, lipoma, neoplasm, and neuroma). Arterial insufficiency can lead to nerve ischemia.

The mechanism of impingement can be identified in approximately 80% of cases.

Epidemiology

The incidence of tarsal tunnel syndrome is unknown. It is a relatively rare and often underdiagnosed disease. It is higher in females than in males and can be seen at any age.

Pathophysiology

Tarsal tunnel syndrome results from the compression of the posterior tibial nerve or one of its two branches, the lateral or medial plantar nerve, within the tarsal tunnel. Up to 43% of patients have a history of trauma including events such as ankle sprains. Abnormal biomechanics can contribute to disease progression. Risk factors include systemic diseases such as diabetes mellitus, hypothyroidism, gout, mucopolysaccharidosis, and hyperlipidemia.

History and Physical

There is no specific test for the diagnosis of tarsal tunnel syndrome, and diagnosis is made with a detailed history and clinical examination.

The predominant complaint is pain directly over the tarsal tunnel that radiates to the arch and plantar foot. Patients with tarsal tunnel syndrome will frequently report a sharp shooting pain in the foot, numbness on the plantar surface, radiation of pain and paresthesias along the distribution of the posterior tibial nerve, pain with extremes of dorsiflexion and eversion, and a tingling or burning sensation. These symptoms may localize to the medial ankle or plantar surface of the foot or be vaguer, making diagnosis difficult. Their symptoms will vary depending on whether the entire posterior tibial nerve is compressed or if it is the lateral or medial plantar branches. The symptoms may worsen at night, with walking or standing, or after physical activity, and typically get better with rest. Dysesthesias may worsen at night, disturbing sleep. The patient may note weakness in the muscles of the foot.

On exam, the provider may observe pes planus, pronated foot, or talipes equinovarus. In chronic cases, atrophy, weakness of the intrinsic foot muscles, and contractures of the toes may be appreciated. They are typically tender on deep palpation of the tarsal tunnel. The gait should be analyzed for abnormalities including excessive pronation or supination, toe eversion, excessive foot inversion or eversion, and antalgic gait.

Light touch and two-point discrimination should be tested. The patient may have diminished plantar sensation in the distribution of either the medial or lateral plantar nerve. Muscle strength and foot range of motion should be assessed. Strength deficits are typically a late finding in tarsal tunnel syndrome.

The Tinel test involves lightly tapping over the tarsal tunnel repeatedly. Pain or tingling in the distribution of the nerve is a positive test. Sensitivity is low at 25% to 75%; specificity is 70% to 90%. The dorsiflexion-eversion test involves passively dorsiflexing and everting the ankle to end range of motion and holding for 10 seconds. Reproduction of symptoms is a positive sign due to compression of the posterior tibial nerve in this position. This test is positive in 82% of patients with tarsal tunnel syndrome.

Tarsal Tunnel Syndrome Severity Rating Scale

A score of 10 indicates a normal foot and 0 indicates the most symptomatic foot.

Evaluation

Plain radiographs of the ankle and, possibly, the foot are the initial imaging study of choice. These may help identify any structural abnormalities including osteophytes, hindfoot varus and valgus, tarsal coalition, or evidence of previous trauma. Magnetic Resonance Imaging (MRI) is not sensitive for the diagnosis of the tarsal tunnel but may help include or exclude other causes of the patient's symptoms. Ultrasound can be used to evaluate the soft tissue structures. The nerve and its bifurcations can be observed. Either ultrasound or MRI can evaluate other soft tissue abnormalities including tendonitis or tenosynovitis, lipomas or other growths, varicose veins, and ganglion cysts.[7]

Electromyography (EMG) and nerve conduction studies (NCS) are frequently abnormal in patients with tarsal tunnel syndrome. Sensory nerve conduction studies are more likely to be abnormal than motor nerve conduction studies; however, the sensitivity and specificity are suboptimal. False-negative tests are not uncommon and thus do not rule out the diagnosis.

Treatment / Management

Management of tarsal tunnel syndrome remains challenging due to diagnostic uncertainty and lack of clarity over which patients would benefit from conservative versus surgical management. Tarsal tunnel syndrome can be managed nonoperatively or operatively. This decision is generally guided by the etiology of the disease, degree of loss of function of the foot and ankle, as well as muscle atrophy.[8][9]

Conservative management and success vary based upon the etiology of tarsal tunnel syndrome. The goal is to decrease pain, inflammation, and tissue stress. Ice can be used. Oral analgesics including acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) can be helpful. Neuropathic pain medications include gabapentin, pregabalin, and tricyclic antidepressants can be tried. Topical medications can also be used, including lidocaine and NSAIDs.

Physical therapy soft tissue modalities that may help include ultrasound, iontophoresis, phonophoresis, and E-stim. Calf stretching and nerve mobility or nerve gliding can also help with symptoms. Strengthening the tibialis posterior can help. Activity modification also plays a role in managing symptoms. Kinesiology tape can be used for arch support and biomechanical stress reduction.

Orthotic shoes can be used to correct biomechanical abnormalities and offload the tarsal tunnel. A medial heel wedge or heel seat may reduce traction on the nerve by inverting the heel. Night splints can be tried, and patients who fail to respond to the above therapy can be placed in a walking boot temporarily. Footwear with appropriate arch support may help reduce symptoms. CAM (controlled, ankle, motion) walker or walking boots may be tried.

If a ganglion cyst is present, it can be aspirated under ultrasound guidance. Corticosteroid injections into the tarsal tunnel may help with edema.

Surgery is indicated if conservative management fails to resolve the patient's symptoms or if a definitive cause of entrapment is identified. Patients with symptoms caused by a space-occupying lesion generally respond well to surgical management. Abnormally slow nerve conduction across the posterior tibial nerve is predictive of failed conservative therapy.

Surgical management involves the release of the flexor retinaculum from its proximal attachment near the medial malleolus down to the sustentaculum tali. Surgical success rates vary from 44% to 96%. Patients with a positive Tinel sign preoperatively tend to respond better to surgical decompression than those who do not. Younger patients and those with a short history of symptoms, early diagnosis, clear etiology, and no previous ankle pathology tend to respond better to surgery.

Differential Diagnosis

The differential diagnoses of tarsal tunnel syndrome is broad, making diagnosis difficult. These include:

Compartment syndrome of the deep flexor compartment

Degenerative changes (calcaneal spurs, arthrosis of the joints of the foot)

Inflammatory conditions of the ligaments and fascia of the foot and ankle.

Intersection syndrome of the FHL and FDL at the knot of Henry

L5 and S1 nerve root compression

Neurogenic intermittent claudication

Prognosis

The prognosis of tarsal tunnel is variable. In patients with an identifiable etiology due to mass effect diagnosed early in the disease course, the response is generally favorable. Patients without an identifiable cause and who do not respond to conservative therapy generally do not do as well with surgical intervention. A positive Tinel sign is a strong predictor of surgical relief.

Complications

Untreated or refractory tarsal tunnel syndrome can result in neuropathies of the posterior tibial nerve and its branches. Patients may have persistent pain. Subsequent motor weakness and atrophy can develop. Postoperative complications include impaired wound healing, infection, and scar formation. Surgical decompression may not adequately resolve pain and other symptoms.

Postoperative and Rehabilitation Care

Postoperative rehab is aimed at protecting the joint and nerve integrity and controlling inflammation, pain, and swelling. As rehab continues, the therapist and patient work to prevent contraction and adhesions of scar tissue while maintaining soft tissue and joint mobility. Return to normal gait, walking, and running are long-term goals.

Consultations

The tarsal tunnel syndrome is a difficult, rare diagnosis. As such, cases are best managed by an orthopedic specialist. Depending on the etiology, surgical management may be indicated.

Deterrence and Patient Education

There are no clear guidelines for the prevention or deterrence of tarsal tunnel syndrome.

Patients should be aware that there are many causes of foot and ankle pain, some of which are uncommon including tarsal tunnel syndrome. If a patient has foot and ankle pain as well as other concerning symptoms such as burning, numbness, tingling, and muscle weakness, they should seek the care of a medical professional.

Pearls and Other Issues

The tarsal tunnel syndrome is an entrapment neuropathy of the medial ankle.

It is an uncommon but underdiagnosed cause of foot and ankle pain.

Patients tend to have pain originating from the tarsal tunnel radiating down to the plantar foot; however, symptoms can vary.

There is no best test to diagnose tarsal tunnel syndrome, and it is a combination of history, exam, imaging, and electromyography and nerve conduction studies.

Conservative therapy can be tried in most patients.

If a definitive cause is identified, surgical decompression can provide good results.

Enhancing Healthcare Team Outcomes

Management of tarsal tunnel syndrome remains challenging due to diagnostic uncertainty and lack of clarity over which patients would benefit from conservative versus surgical management. Hence, the condition is best managed by an interprofessional team that consists of a podiatrist, orthopedic surgeon, orthopedic nurse, and physical therapist.

Conservative treatment may help some patients but the key is physical therapy, change in shoes, and modification of activity. For those with a compressive lesion, surgery may be beneficial. Regardless of the treatment path chosen, the orthopedic nurse should monitor the results and report back to the clinician regarding progress or lack thereof, so therapy can change if needed.

The overall prognosis for patients with tarsal tunnel syndrome is guarded. Relapse and remissions are common and some patients never achieve complete relief from symptoms. [Level 5]

References

1.

Calvo-Lobo C, Painceira-Villar R, López-López D, García-Paz V, Becerro-de-Bengoa-Vallejo R, Losa-Iglesias ME, Palomo-López P. Tarsal Tunnel Mechanosensitivity Is Increased in Patients with Asthma: A Case-Control Study. J Clin Med. 2018 Dec 12;7(12) [ PMC free article: PMC6306873 ] [ PubMed: 30545067 ]

2.

3.

4.

5.

Hong CH, Lee YK, Won SH, Lee DW, Moon SI, Kim WJ. Tarsal tunnel syndrome caused by an uncommon ossicle of the talus: A case report. Medicine (Baltimore). 2018 Jun;97(25):e11008. [ PMC free article: PMC6024474 ] [ PubMed: 29923985 ]

6.

7.

8.

Mansfield CJ, Bleacher J, Tadak P, Briggs MS. Differential examination, diagnosis and management for tingling in toes: fellow's case problem. J Man Manip Ther. 2017 Dec;25(5):294-299. [ PMC free article: PMC5810784 ] [ PubMed: 29449772 ]

9.

# data[].attributes.attachment_link.description
Tarsal tunnel syndrome sometimes referred to as tibial nerve dysfunction or posterior tibial nerve neuralgia, is an entrapment neuropathy that is associated with the compression of the structures within the tarsal tunnel. It is similar to carpal tunnel syndrome of the wrist although much less common.[1][2][3][4]