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The Journal of Bone and Joint Surgery (American) 83:1835-1839 (2001)
© 2001 The Journal of Bone and Joint Surgery, Inc.

Scientific Article

The Dorsiflexion-Eversion Test for Diagnosis of Tarsal Tunnel Syndrome

Mitsuo Kinoshita, MD, Ryuzo Okuda, MD, Junichi Morikawa, MD, Tsuyoshi Jotoku, MD and Muneaki Abe, MD

Investigation performed at the Department of Orthopedic Surgery, Osaka Medical College, Takatsuki City, Osaka, Japan

Mitsuo Kinoshita, MD
Ryuzo Okuda, MD
Junichi Morikawa, MD
Tsuyoshi Jotoku, MD
Muneaki Abe, MD
Department of Orthopedic Surgery, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki City, Osaka 569-8686, Japan. E-mail address for M. Kinoshita: mitsuok{at}poh.osaka-med.ac.jp

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: The clinical diagnosis of tarsal tunnel syndrome lacks objectivity and consistency. We have devised a new diagnostic physical examination test in which the tibial nerve is compressed as it runs beneath the flexor retinaculum behind the medial malleolus. In this test, the ankle is passively maximally everted and dorsiflexed while all of the metatarsophalangeal joints are maximally dorsiflexed and held in this position for five to ten seconds.

Methods: We performed this test on fifty normal volunteers (100 feet) and on thirty-seven patients (forty-four feet) treated operatively for tarsal tunnel syndrome between 1987 and 1997. We performed the maneuver both preoperatively and postoperatively and recorded any consequent changes in the signs and symptoms; during the operation we observed the altered anatomical relationships in the tarsal tunnel that were produced by the maneuver. The average duration of follow-up was three years and eleven months.

Results: Before the operation, the signs and symptoms of tarsal tunnel syndrome were intensified or induced by the maneuver in fifteen of the twenty feet of the patients who reported numbness, in fifteen of the seventeen feet of those who reported pain alone, and in six of the seven feet of those who had combined numbness and pain. Local tenderness was intensified in forty-two of forty-three feet, and it was induced in one foot in which it had been previously absent. A Tinel sign became more pronounced in forty-one feet, and the sign was induced in three feet in which it had been absent previously. During the operation, the tibial nerve was stretched and compressed beneath the laciniate ligament when the ankle was dorsiflexed, the heel was everted, and the toes were dorsiflexed. Preoperative signs and symptoms disappeared on an average of 2.9 months after the operation, and they could not be induced by repeating the test except in three patients, all of whom had tarsal tunnel syndrome subsequent to a fracture of the calcaneus. In the normal volunteers, no symptoms or signs could be induced by the test.

Conclusion: This new physical examination test is effective in facilitating the diagnosis of tarsal tunnel syndrome.


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