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Diagnosing Tarsal Tunnel Syndrome: A Systematic Review of the Literature and a Call for Standardization
Nadine Boers, MD MSc1; Melanie Haverkamp, BSc2; Willem D. Rinkel, MD, PhD1; J Henk Coert, MD, PhD1
1Utrecht University Medical Center, Utrecht, Netherlands; 2University Medical Center Utrecht, Utrecht, Netherlands

Introduction: There is controversy on which diagnostic modalities contribute to the diagnosis of tarsal tunnel syndrome (TTS). Consequently, in both clinical practice and studies, differences exist. This leads to a variation in patients selected for treatment, making it difficult to compare outcomes between studies. Therefore, the aim of this review is to summarize the diagnostic criteria used in studies evaluating prevalence, diagnosis or treatment of TTS.
Methods: A literature review was conducted to identify all studies reporting diagnosis of TTS in multiple databases. Studies were included if they met the following inclusion criteria: (1) the main subject of the article is diagnosis or treatment of TTS; (2) description of the diagnosis of TTS in the study population; (3) an original data set of cases was used; (4) the study population consisted of a minimum of five adult patients diagnosed with TTS. Exclusion criteria were (1) cadaver or animal studies and (2) languages other than English or Dutch. Study characteristics collected included publication year, author, study aim, diagnostic modalities and clinical symptoms used for TTS diagnosis, number of patients diagnosed with TTS, etiology of TTS and exclusion criteria used in the study.
Results: In total, 3855 patients were represented in 84 included studies. Figure 1 shows the etiology of TTS in the included papers. Table 1 shows the (combination of) diagnostic modalities mandatory for TTS diagnosis. Figure 2 shows all diagnostic modalities, clinical symptoms and provocative tests used for TTS diagnosis. Provocative tests were used in 93% of studies in which a positive test was mandatory for TTS diagnosis in most studies. The most prevalent provocative test was the Tinel sign. Imaging studies were regularly performed but only MRI was mandatory for diagnosis in one study to confirm idiopathic TTS.
Conclusions: In this study we present a broad perspective of TTS diagnosis including clinical symptoms, provocation tests, electrodiagnostic studies, imaging techniques, local anesthesia test, ankle-brachial index and doppler. The diagnostic criteria reported in the included studies vary significantly, but the Tinel sign is the most used diagnostic modality. For accurate characterization and comparison of treatments, a clear consensus on diagnosing TTS must be formulated.



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