Soleal Sling Syndrome (Proximal Tibial Nerve Compression)

Wikis > Neurology > Nerve Entrapment > Soleal Sling Syndrome (Proximal Tibial Nerve Compression)

Soleal Sling Syndrome is an entrapment,impingement or compression of the proximal tibial nerve at the soleal sling posterior and distal to the knee. The soleal sling is the band of fascia between the tibia and fibula that the two heads of the soleus muscle arises from deep to the gastrocnemius muscle. This location is also called the tendinous arch of the soleus. The soleal sling creates a “bottleneck” which the tibial nerve, popliteal artery and vein must pass to reach the deep posterior compartment. The site of entrapment or compression of the tibial nerve is typically around 9cm below the popliteal crease. It was first described by Mastaglia et al in 1981.

May co-exist with tarsal tunnel (double crush phenomenon) and explain a significant number of failed tarsal tunnel releases.

Not clear
Could be anatomical variations such as anomalous gastrocnemius muscle heads; a hypertrophied gastrocnemius or popliteus muscle
May be due to pressure from space occupying lesions eg Baker’s cyst
Some do have a history of trauma to the area.

Clinical Features:
Almost all have pain on palpation of the posterior calf where the soleal sling is, about 9 cm below the popliteal crease.
Numbness, dysesthesia on the plantar surface of foot.
Skin hypersensitivity.
Feeling of ‘tightness’ in the calf muscles.
Positive Tinel sign in calf elicited by percussion at the site of the entrapment.
Weakness of the flexor hallucis longus muscle.
May have pain on plantar aspect of foot.

MR neurography can show nerve T2 hyperintensity and regional muscle denervation changes (Chhabra et al, 2011). Diagnostic ultrasound can also be used to visualize the soleal sling (Radar et all 2016)

Differential diagnosis: tarsal tunnel syndrome; neuropathy; popliteal artery entrapment (up to 25% of these have parathesias in their feet); myofascial trigger points (tender area at site of compression could easily be misdiagnosed as a trigger point); posterior compartment syndrome (surgery for this will also decompress the soleal sling); lumbar radiculopathy

Treatment of Soleal Sling Syndrome:
Surgical decompression (Willaims et al, 2012)
Manual therapies to “release” the area of the compression could be tried.

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