Indian Journal of Physical Medicine and Rehabilitation
Volume 31 | Issue 4 | Year 2020

Pictorial CME

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A 17-year-old female patient, a Bharatanatyam dancer, without any known systemic comorbidities presented with excruciating pain in both feet for the last 5 months for which she was unable to walk and literally became bedridden for the same duration, her pain was sudden in onset, progressive in nature and initiates soon after she used to start walking. Previously she was diagnosed with a case of complex regional pain syndrome (CRPS) and a lumbar sympathetic plexus block was given from outside but no significant improvement was noticed, pain recurs after a fortnight.

On examination, her VAS for pain was 10/10. The patient had bilateral pes planus (Fig. 1). Paresthesia over both sole and dorsum of toes with tenderness over the tarsal tunnel. So a clinical diagnosis of tarsal tunnel syndrome was considered.

NCS of both distal lower limbs was done which was normal. Even CT scan was also normal except few changes over the tarsal tunnel (Fig. 2). Interestingly, USG of her both ankle (Figs 3 and 4) showed thickening of both post-tibial nerves under the tarsal tunnel. Then, she was planned for a diagnostic block of post-tibial nerve with 2 mL lignocaine (2%) and 1 mL bupivacaine (0.5 %) at the same setting under USG guidance, which showed significant improvement of pain immediately after the procedure. So, she was provisionally diagnosed as a case of bilateral tarsal tunnel syndrome. Subsequently, USG-guided post-tibial nerve block with 40 mL DMPA with 2 mL lignocaine (2%) and 1 mL bupivacaine (0.5) relieved her pain. Shoe modification and lifestyle modification was advised thereafter.

Fig. 1: Bilateral pes planus

Fig. 2: Normal CT scan

Fig. 3: USG of ankle

Fig. 4: Thickened post-tibial nerve under the tarsal tunnel

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