Tibial Nerve Injury - Etiology, Symptoms, and Treatment

What Is Tibial Nerve Injury?

Tibial neuropathy refers to any dysfunction of the tibial nerve. The most typically comprehended establishment is tarsal tunnel syndrome, which is tibial neuropathy as it traverses through the tarsal tunnel at the ankle level. The tibial nerve in the lower leg, proximal to the tarsal tunnel, delivers motor innervation to the gastrocnemius, soleus, popliteus, flexor hallucis longus, flexor hallucis digitorum, tibialis posterior, and plantaris muscles. The medial plantar nerve replenishes the abductor hallucis, flexor digitorum brevis, flexor hallucis brevis, and the first lumbrical muscles. The lateral plantar nerve provides the remainder of the muscles of the plantar surface of the foot, which comprises the abductor digiti minimi, quadratus plantae, abductor hallucis, flexor digiti minimi brevis, plantar interossei, dorsal interossei, and three lateral lumbrical muscles of the foot.

What Is the Etiology of Tibial Nerve Injury?

Tibial neuropathy occurs due to any disorder that marks a lesion of the tibial nerve in the inferior extremity. Trauma to the ankle is a significant threat characteristic for the expansion of tibial neuropathy. Ankle sprains and ankle fractures lead to scar tissue, bony fragments, and bone spurs which can put tension on the tibial nerve. Likewise, trauma to the knee induces injury to the tibial nerve, such as a posterior knee dislocation. Tarsal tunnel syndrome is a contraction of the tibial nerve as it tours under the transverse tarsal ligament. Other reasons comprise lipomas (slow-growing fatty lesions), tumors (uncontrolled and progressive growth of abnormal tissue), Baker's cysts (a fluid-filled cyst present behind the knee), and different space-occupying masses. Some surgical strategies, such as calcaneal osteotomy conducted for foot deformities, have been demonstrated to have increased the intricacy rates of tarsal tunnel syndrome. In addition, there have been documented possibilities of tibial neuropathy secondary to anatomical variants in the muscles.

The region in the foot where the nerve joins the ankle's rear is called the tarsal tunnel. This tunnel is generally thin. When the tibial nerve is condensed, it impacts the signs of tarsal tunnel syndrome. Force on the tibial nerve occurs due to any of the following reasons:

• Swelling from an injury, like a sprained ankle.

• An irregular expansion, such as a bone spur, clots in the joint (ganglion cyst), and surges (varicose) veins.

• Flat feet.

• A high-arched foot.

• Systemic diseases, like diabetes (a metabolic condition that causes increased blood glucose levels), low thyroid function (hypothyroidism), and arthritis (swelling and pain in one or more joints).

What Is the Epidemiology of Tibial Nerve Injury?

The incidence of tibial neuropathy is unspecified. Secluded tibial neuropathy is a moderately unusual diagnosis but can be noticed post-trauma, inflammatory infections, and diabetes mellitus. In addition, tibial nerve lesions in the tarsal tunnel are noticed at a raised incidence in patients with rheumatoid arthritis (an inflammatory disease that affects the joints of the hands and feet).

What Are the Symptoms of Tibial Nerve Injury?

• The extensively typical symptoms of tibial neuropathy are pain and a modification in sensation in the plantar characteristic of the foot and toes. Usually, distress is also discovered around the medial malleolus, where the tibial nerve flies. Symptoms get worsened by passive ankle inversion.

• A fundamental component of tibial neuropathy at the tarsal tunnel is the sparing of feeling over the heel. The calcaneal branch of the tibial nerve branches off proximal to the tarsal tunnel and will not be influenced by tarsal tunnel lesions.

• The Tinel’s sign is experimented with by dabbing over the suspected nerve entrapment area. A positive sign is demonstrated by the reproduction of pain and tingling in the diffusion of the nerve. A favorable Tinel's sign is noticed at the ankle if the origin of the discomfort is in the tarsal tunnel.

• The patient's gait should be assessed, comprising heel walking, toe walking, and tandem gait. Overpronation is noticed with ambulation, which can seat the tibial nerve under raised tension.

• If a proximal lesion of the tibial nerve is doubted, experimenting with the gastrocnemius and soleus muscles is fundamental to evaluating for deficiency.

• If tarsal tunnel syndrome is presumed, strength testing is unpredictable due to the complication in sampling the intrinsic foot muscles on inspection. Sensory testing should be accomplished, consisting of an evaluation of both pinprick and light touch.

• The patellar and Achilles reflexes (knee reflexes that are important for walking) should be approximated from side to side, although this is a nonspecific conclusion that is noticed in radiculopathy and polyneuropathy.

• In addition, these reflexes are not complicated depending on the area of the lesion. Tarsal tunnel syndrome commonly does not involve the Achilles reflex.

What Is the Diagnosis of Tibial Nerve Injury?

• Plain Radiography- It is a helpful commencing juncture for presumed tarsal tunnel syndrome to specify conceivable fractures and osteophytes and consider all-around foot configuration. Computerized tomography (CT) and magnetic resonance imaging (MRI) of the lower extremity enable a glance for exact motorized reasons for tibial nerve injury like regional inflammation, mass lesions, and bony spurs. Magnetic resonance imaging also helps in determining masses.

• Ultrasound- It delivers a quick, vibrant investigation to administer the diagnosis, especially in presumed tarsal tunnel syndrome cases. It is also beneficial in ruling out different conceivable bases of the manifestations, especially plantar fasciitis. If the plantar fascia is more prominent than 4.6 centimeters in consistency and hypoechoic, this is symbolic of plantar fasciitis. The tibial nerve is envisioned at the grade of the medial malleolus and is hyperechoic.

• Color Doppler- It is also utilized to determine the tibial artery and vein. The posterior tibial and flexor digitorum longus tendons are specified by their anisotropy.

• Electrodiagnostic- Thistesting with nerve conduction studies (NCS) and electromyography (EMG) are the fundamental tests in diagnosing tibial neuropathy.

• Mixed and Sensory Investigations- Mixed and sensory investigations of the medial and lateral plantar nerves should be accomplished. Nerve conduction studies disclose reduced sensory nerve action potentials (SNAPs) in the medial and lateral plantar nerves. It is typical for investigations of these nerves to be problematic to accept. The possibilities of these nerves are usually diminutive in amplitude and need averaging.

What Is the Treatment of Tibial Nerve Injury?

• The treatment of tibial neuropathy relies on the stringency of signs and nerve injury. Physical therapy is a fundamental therapy for all tibial neuropathy patients.

• A physical therapy strategy consists of maintaining the tibial nerve innervated muscles.

• Nerve gliding exercises, kinesiology taping, electrical stimulation, and therapeutic ultrasound are some helpful aids for tibial neuropathy.

• Gait analysis enables determining contributing characteristics like overpronation of the foot, which puts more pressure on the tibial nerve. A medial heel insert is positioned in the shoe for patients with hyperpronation.

• Oral non-steroidal anti-inflammatory drugs also help with distress and inflammation.

• Gabapentin, Pregabalin, Duloxetine, and Amitriptyline are often used for neuropathic pain.

• An ultrasound-guided corticosteroid injection into the tarsal tunnel and another contraction region is also helpful for reducing symptoms.

• Surgical intervention is demonstrated for more complex or refractory issues, mainly when muscle atrophy and intense weakness exist, which signifies axonal nerve injury.

• The precise surgical technique varies established on the site of tibial nerve entanglement. Typically, it implicates the escape of the flexor retinaculum and fascia into the foot to send out the medial and lateral plantar nerves.

Conclusion:

Numbness and tingling of the foot are typical manifestations that can be anticipated for different reasons. Tibial neuropathy is an infrequent reason. However, it is significant to be determined and dealt with properly and get around long-term complications. Although tarsal tunnel syndrome is a considerably well-known etiology, tibial neuropathy can arise at any part of the tibial nerve. This article illustrates the evaluation and therapy of tibial neuropathy and accentuates the part of the interprofessional squad in supervising patients with this ailment.