NERVE OF THE LOWER LIMB

GROUP MEMBERS
 Sharifah Firdawina Bt Syid Ayob
 Syarifah Liyana Amira Bt Syed Abdullah

 Siti Mastura Bt Mirom

 Siti Nurliana Bt Zulkefli

 Siti Sarah Bt Abd Rahman

 Syadza Norain Bt Ahmad Zainuddin

 Syahedatul Shakinah Bt Jailany

 Syahirah Bt Ghazali

 Taqiah Bt Borhan

 Wan Ahmad Fathiizuddin Bin Wan Jamaluddin

OBJECTIVES
 Identify and recognize the nerve of the lower limb

 Study the course and the branch of each nerve

 Recognize the nerve injuries and what is the effect to the

lower limb
FEMORAL NERVE

By :
Siti Mastura Binti Mirom
09-1-225
FEMORAL NERVE
 The largest branch of lumbar plexus
 One of the femoral triangle component

 But not one of the femoral sheath components

Origin
Dorsal division of ventral rami of 2nd, 3rd, and 4th lumbar
nerve.
LUMBAR PLEXUS
FEMORAL NERVE
FEMORAL TRIANGLE
COURSE

Descend through the psoas major

Pass behind the inguinal ligament

Enters thigh, and split into anterior and posterior division

ANTERIOR DIVISION

Muscular branch

Sartorius muscle
POSTERIOR DIVISION

Muscular branches

Pectineus Quadriceps
muscle muscle
CUTANEOUS SUPPLY BY FEMORAL NERVE
NERVE INJURY
Causes:
 Direct trauma

 Prolonged pressure on nerve

 Breaking bone of pelvis

 Lithotomy position

Symptoms:
 Sensation changes in the thigh, knee, or leg

 Weakness of knee or leg

 Difficulty in going up and downstair

OBTURATOR NERVE

By :
Syahirah Ghazali
09-1-230
INTRODUCTION
• 1. The largest nerve in the anterior lumbar plexus.
• 2. The lumbar plexus is a nerve network or grouping of
nerves of the low back area.
• 3. Serves as a pathway for electrochemical signals
connecting the brain to the back, abdomen, groin and
knees.
• 4. Also considered as a part of the peripheral nervous
system.
ORIGIN: L. 2, 3, 4

COURSE: 1) It emerges at the medial border of

psoas major
2) Then, it descends on the side wall of the
pelvis till it reaches the obturator canal.
3) In the obturator canal, it divides
into anterior and posterior division.
ANTERIOR DIVISION
Passes on the ‘anterior surface of adductor brevis’
(deep to pectineus & adductor longus)

Distribution:
Motor supply: Adductor longus
Adductor brevis
Adductor magnus
Cutaneous supply: Skin of medial side of thigh
Articular branch: To the hip joint
POSTERIOR DIVISION
Passes through obturator externus. Then, it descends
vertically downwards on the ‘posterior surface of
adductor brevis’ (anterior to adductor magnus)

Distribution:
Motor supply: Obturator externus, adductor magnus
Articular branch: To the knee joint
 INJURY
• Rare because the nerve lies deep into the pelvis.
• Can occur during pelvic or abdominal surgery.
• Numbness and pain radiating to inner thigh.
• Loss of sensation of medial part of the thigh
• Paralysis of adductor longus, brevis and magnus.
• Adduction thigh weakness can occur cause posture instability.
• Electrical tests can help to confirm the diagnosis.
CONT.
Treatment:
 Physical therapy

 General exercise program

 Massage therapy

 Ultrasound

 Electrical stimulation

Severe:
Injection of steroid
(obturator nerve block)
SUPERIOR GLUTEAL NERVE

By :
Syadza Norain Bt Ahmad Zainuddin
09-01-228
 The superior gluteal nerve is a nerve of gluteal region.
 It originates in the pelvis and supplies the gluteus medius
, the gluteus minimus, and the tensor fasciae lata
muscles.
 Superior gluteal nerve is responsible mainly for the
abduction of the muscles that are supplied by it.
 Origin  L4,L5,S1 (branch of sacral plexus)
Courses and
Distributions
Gluteus
medius
 Passes through the greater sciatic
notch above the upper border of
piriformis muscle, accompanied by
the superior gluteal vessels.

Passes between gluteus medius

and gluteus minimus where it
divides into

Inferior branch
Superior branch

Muscular branch :
gluteus minimus & tensor fasciae
Muscular branch: lata
gluteus medius Articular branch :
Hip joint
 Gluteus medius

Superior gluteal Gluteus minimus

nerve
 Nerve
Injury

In case of bilateral
paralysis, it leads to
“waddling” gait.

Leads to dropping of
Paralysis of the
the pelvis on the
unsupported side
gluteus medius and
“trendelenburg sign” gluteus minimus.

Weak abduction
in the affected
hip joint.
TRENDELENBURG SIGN
 When a person is asked to stand on one leg, the pelvis on
the unsupported side descends or drops.
 This indicate that the gluteus medius and gluteus
minimius on the supported side is weak or non-
functional.
 This clinical observation is a positive Trendelenburg
sign.
Causes :
- Disruption of the nerve supply to the abductors of the
thigh (gluteus medius, gluteus minimus, and 
tensor fasciae latae) by an injury or disease (i.e.
poliomyelitis), or when conditions such as congenital
dislocation of the hip joint exist.
- Trendelenburg sign -
Trendelenburg sign
INFERIOR GLUTEAL
NERVE

By :
Syahedatul Shakinah binti Jailany
09-1-229
ORIGIN

 Dorsal divisions of the 5th lumbar

 1st and 2nd sacral nerves

COURSE
 Leaves the pelvis through the greater sciatic foramen
 Below the piriformis

 Superficial to the sciatic nerve

BRANCHES
 Enter the deep surface of the
 gluteus maximus
 principal extensor of the thigh
 also gives off small branches to supply the deep gluteal
muscles
FUNCTION
 Hip extension
 Supplies gluteus maximus

Perform exercise with both affected and unaffected leg.

When standing on stabilizing leg, keep knee slightly bent.
Avoid twisting movements on stabilizing leg. Ensure body
remains upright - no rocking forward and backwards.
Isolate movement to hip, squeeze buttocks when extending
leg backwards. 
INJURY
 Difficulty in
 jumping
 climbing stairs
 rising from a seated position

 Subject to injury by compression

and ischemia in sedentary individuals
BLUNT INJURY ADHESION
 Blunt trauma to the buttocks can cause not only injury to
sciatic, but also to the superior and gluteal nerve as well.
 Piriformis muscle might compress the inferior gluteal nerve :-
 With fibrous band in muscle
 With pressure against sarcopinous ligament

 This can occur from minor pressure such as sitting on your

wallet to great pressure like direct blow to buttock area (fall
injury trauma).
 This triggered point often perpetuate muscle tightness, leading
directly to nerve compression.
SCIATIC NERVE

By :
Siti Nurliana Binti Zulkefli
09-1-226
SCIATIC NERVE
Origin : L4,L5-S1, S2, S3
Course
 From pelvis to gluteal region by passing
through the greater sciatic foramen
below piriformis muscle.
 Descends in middle line of the thigh.
Termination
At middle of the thigh, divide into two
terminal branches,which are:
 Medial popliteal (tibial) nerve :
anterior division of L4,L5-S1, S2, S3
 Lateral popliteal (common peroneal)
nerve : dorsal division of L4,L5-S1,
S2
 RELATION:

Superficial relations Deep relations

a) In gluteal region Descends from above downwards:
 Gluteus maximus Ischium
 Posterior cutaneous nerve of the thigh Tendon of obturator internus and two
b) In back of the thigh gemilli muscles
 Semimembranousus Quadratus femoris
 Semitendinosus Adductor magnus
 Long head of biceps femoris
Branches:
A) Muscular branches :
1. Medial popliteal (tibial) nerve:
 Semimembranousus.

 Semitendinosus.

 Long head of biceps femoris.

 Ischial part of adductor magnus.

2. Lateral popliteal (common

peroneal) nerve:
 Short head of biceps femoris.

B) Articular branches :
 Hip joint.

C) Terminal branches :
 Medial popliteal (tibial) nerve :
anterior division of L4,L5-S1, S2,
S3.
 Lateral popliteal (common
peroneal) nerve : dorsal division of
L4,L5-S1, S2.
Surface anatomy:
 A point at the junction
between the upper and
middle thirds of a line
between the posterior
superior iliac spine and the
ischial tuberosity.
 A point midway between the
greater trochanter and the
ischial tuberosity.
 A point at the middle of the
popliteal fossa.
Applied anatomy: Gluteal intermuscular injection
 Site : In the upper lateral quadrant of gluteal region or superior to a
line extending from the PSIS to the superior border of greater
trochanter.
 Cause :To avoid injury to the sciatic nerve.
Nerve Injuries:
 Sciatic nerve dysfunction is a condition in
which the sciatic nerve conducts impulses
abnormally.
Causes :
1. Pelvic or hip joint fracture.
2. Surgery femur fracture .
3. Gunshot or knife wounds to the leg injection
into the buttock .
4. Compression of the nerve from prolonged
sitting or lying.
5. Piriformis syndrome (a pain disorder
involving the narrow piriformis muscle in the
buttocks).
6. Slipped disk.
7. Degenerative disk disease.
8. Spinal stenosis.
9. Tumor.
Sign and symptoms:
1. decreased ability to flex the
knee.
2. decreased ability to move the
foot and toes in certain
directions.
3. numbness, burning, or tingling
in the leg.
4. pain in the lower back that may
travel to the back of the thigh
and calf.
 Motor loss : paralyses of hamstring
muscles, ischial part of adductor
magnus and all muscles of the leg and
foot – “flail foot”.
 Cutaneous loss : loss sensation below
knee except area along medial
malleolus and medial side of foot
which is supplied by saphenous
nerve.
 Deformity : “foot drop” due to effect
of gravity.
Prevention
Proper lifting techniques are important to
avoid a ruptured disk. These techniques
can be enhanced by the use of an
abdominal support belt. Other preventive
measures include the following: regular
physical activity rest breaks to interrupt
long periods of vibration, such as when
driving a car smoking cessation for
individuals who smoke weight
management for people who are obese.
Treatment
1. following steps to calm your symptoms
and reduce inflammation.
 Apply heat or ice to the painful area.
Try ice for the first 48 - 72 hours, then
use heat after that.
 Take over-the-counter pain relievers
such as ibuprofen (Advil, Motrin IB)
or acetaminophen (Tylenol).
 While sleeping, try lying in a curled-
up, fetal position with a pillow
between your legs. If you usually sleep
on your back, place a pillow or rolled
towel under your knees to relieve
pressure as  activity limitations.
2. If at-home measures do not help, your doctor
may recommend injections to reduce
inflammation around the nerve. Other medicines
may be prescribed to help reduce the stabbing
pains associated with sciatica.
3. Physical therapy exercises may also be
recommended. Additional treatments depend on
the condition that is causing the sciatica.
4. Non surgical spinal
decompression.
5. Massage therapy.
6. Weight loss reduces pressure
on spinal nerve.
7. Acupuncture.
Side effect of treatment
 Side effects of medicines include
allergic reactions and stomach upset.
 Surgery is associated with a risk of
infection, bleeding, and allergic reaction
to anesthesia.
MUSCULOCUTANEOUS NERVE

By :
Syarifah Liyana Amira Bt
Syed Abdullah
09-1-224
ROOT VALUE :
L5, S1
 ORIGIN COURSE

One of the two terminal  Passes downwards in

substance of peroneus
branches of common
longus muscle
peroneal nerve
 It descends between
peroneus longus and
Arise within substance peroneus brevis
of peroneus longus  Emerges between two
lateral to neck of fibula muscles and descends under
cover of deep fascia of leg
 In lower part of the front of
the leg, it pierces the deep
fascia and become
subcutaneous
 TERMINATION

 Itterminates by
dividing into
lateral and
medial terminal
branches which
descend
superficial to
both extensor
retinaculae to  located superficially between the
reach the dorsum lateral malleolus and extensor
of the foot hallucis longus tendon.
BRANCHES
Muscular branches Cutaneous distribution
 Peroneus longus and  Supply skin of the lower 2/3
peroneus brevis of the antero-lateral aspect of
the leg
Medial terminal branch Lateral terminal branch

 Skin of medial part of  Skin of lateral part of

dorsum of foot dorsum of foot
 Divide into 2 dorsal digital  Divide into 2 dorsal digital
branches nerves  for the 3rd & 4th
dorsal interdigital clefts
 medial side of the big toe
 second dorsal interdigital
cleft (between 2nd & 3rd toes)
INJURY
 The most common ligaments damaged are the calcaneofibular
and talofibular ligament
 Loss of blood supply for anterior compartment of the leg

 Impaired plantarflexion of foot

 Impaired eversion of foot

 Ankle drop (in trauma/surgery)

 Superfical peroneal nerve block (loss of sensory over

superolateral foot)
 A peroneal tunnel syndrome (entrapment of the superficial
peroneal nerve in which a fascial tunnel longer than 3 cm was
found at the anterior intermuscular septum)
NOTES
Terminal branches of the musculocutaneous nerve supply
the dorsum of the foot EXCEPT :

 medial border of the dorsum of the foot (supplied by

saphenous nerve)
 lateral border of the dorsum of the foot & lateral side of
the little toe (supplied by sural nerve)
 cleft between 1st & 2nd toes (supplied by anterior tibial
nerve)
ANTERIOR TIBIAL NERVE

By :
Siti Sarah Bt Abd Rahman
09-1-227
ORIGIN
 Oneof the two terminal branches of common
peroneal nerve.

 Arisewithin peroneous longus ,lateral to the neck of

fibula.
 COURSES

around the neck of fibula deep to the fibers of extensor digitorum

2. Pierces the anterior intermuscular septum to reach the anterior compartment.

3. Descends over the interosseous membrane accompanied by anterior tibial artery.

 4. Has TRIPLE RELATION to the anterior tibial artery:
a.In upper third of the leg ,lies lateral to the anterior tibial artery .
.In middle third of the leg ,lies anterior to the anterior tibial artery
n lower third of the leg ,lies lateral again Anterior
to thetibial
anterior
artery tibial arte

Anterior tibial nerve

escend and lies between extensor digitorum longus and tibialis a

6. Between extensor hallucis longus and tibialis anterior .

7. In lower part of the leg ,both anterior tibial nerve and artery are crossed by tendon
of extensor hallucis longus from lateral to medial.
es superficial and passes deep to the superior extensor retinaculum
I. Laterally :to tendon of extensor digitorum longus.
II.Medially :to tendon of extensor hallucis longus.
TERMINATION

 At distal border of inferior extensor retinaculum by dividing

into medial and lateral terminal branches.
 BRANCHES
1. Muscular branches :
i. Supply the four extensor muscles. (Extensor digitorum
longus,extensor hallucis longus, extensor digitorum
brevis).

2. Articular branches:
i. Supply the ankle, intertarsal and tarsometatarsal joints.

3. Terminal branches:
i. Lateral terminal branch: supply extensor digitorum
brevis, joints of the foot .
ii. Medial terminal branch: divides into 2 digital branches
that supply the adjacent sides between 1st and 2nd toes.
INJURIES OF ANTERIOR TIBIAL NERVE

 Loss of blood supply for anterior compartment of the leg.

 Cannot do dorsiflexion and plantarflexion.

 Cannot do eversion .

 Inability to do extension of toes

 Deep Fibular Nerve Entrapment
Definition: excessive may result in muscle
use of muscles injury and edema in
supplied by the deep the anterior
fibular nerve compartment.

may cause compression

of the deep fibular nerve
and pain in the anterior
compartment

many occur where the Pain occurs in the

nerve passes deep to the dorsum of the foot and
inferior extensor usually radiates to the
retinaculum and the web space between the
extensor hallucis brevis first and second toes.
POSTERIOR TIBIAL NERVE

By :
Wan Ahmad Fathiizuddin Bin
Wan Jamaluddin
09-1-232
POSTERIOR TIBIAL
NERVE
 ROOT VALUE
 L4, L5, S1, S2 & S3
 ORIGIN
 Itis the continuation of the medial popliteal nerve (tibial nerve) at
the lower border of popliteus muscle
COURSE

I It passes under the tendinous arch

●

together with posterior tibial artery

II Then it descends deep to soleus and

●

the first septum of the deep fascia

III
As it descends, it lies on tibialis posterior, flexor
●

digitorum longus, lower part of the posterior surface

of the tibia and ankle joint
 In the lower part of the leg, it becomes superficial being
covered only by skin, superficial fascia, and deep fascia.
 TERMINATION
 Itends deep to flexor retinaculum by dividing into medial and lateral
plantar nerve
RELATION
 The posterior tibial nerve has ‘triple relation’ with the posterior
tibial artery

I At first, the posterior tibial nerve

●

is medial to the popliteal artery.

II In the upper part of the leg, it

●

crosses superficial to the artery

III Finally, it continues downwards on the

●

lateral side of the posterior tibial artery.

BRANCHES

MUSCULAR BRANCHES
Deep part of soleus
Flexor digitorum longus
Flexor hallucis longus
Tibialis posterior

CUTANEOUS BRANCHES
Medial calcanean nerve
ARTICULAR BRANCHES
Ankle joint
MEDIAL CALCANEAN
NERVE
 BRANCHES (CONTINUES)

VASCULAR BRANCHES

●
They are symphatetic twigs to the posterior tibial artery and
its branches

TERMINAL BRANCHES

●
Medial plantar nerve
●
Lateral plantar nerve
NERVE INJURY

CAUSE

Fractures or other injury to the Pressure from a tumor or

back of the knee or lower leg abscess
 EFFECT

 Almost complete loss of the medial longitudinal arch

 Weak inversion of the foot
 Weak plantar flexion
 Loss of flexion of all joint in the big toe
 Loss of flexion of all joint in the lateral 4 toes
 Loss of sensory at the plantar surface of the foot except at the medial
part which is supplied by saphenous nerve
MEDIAL PLANTAR NERVE

By :
Taqiah Bt Borhan
09-1-231
ORIGIN

 The medial plantar nerve (internal plantar nerve), the

larger of the two terminal divisions of

the  posterior tibial nerve

 accompanies the medial plantar artery.
COURSES

 Passes deep to Abductor hallucis.

 Then it passes forwards between flexor digitorum brevis
and abductor hallucis.
 At the base of the 1st metatarsal bone, it terminates by
dividing into digital branches.
 Along its course it is related medially to the medial
plantar nerve.
 CUTAN
BRANCHES
PROPER
DIGITAL NERVE
EOUS
TO THE MEDIAL
SIDE OF THE
GREAT TOE

MUSC
ULAR

COMMON
DIGITAL
NERVE

ARTIC
ULAR
CUTANEOUS BRANCHES

 pierce the plantar aponeurosis between the Abductor

hallucis and the Flexor digitorum brevis and are

distributed to the skin of the sole of the foot

MUSCULAR BRANCHES

1. Abductor hallucis brevis

2. Fexor digitorum brevis

3. Flexor hallucis brevis

4. The first lumbricals

ARTICULAR BRANCHES

 supply the articulations of the tarsus and metatarsus

PROPER DIGITAL NERVE OF THE GREAT
TOE

 supplies the Flexor hallucis brevis and the skin on the

medial side of the great toe
THREE COMMON DIGITAL NERVE

1st common digital nerve

2nd common digital nerve

3rd common digital nerve

 1st : adjacent sides of the great and second toes
 2nd : adjacent sides of the second and third toes, and
those of the third, the adjacent sides of the third and
fourth toes.
 3rd : receives a communicating branch from the lateral
plantar nerve the first gives a twig to the first lumbricals
MEDIAL PLANTAR NERVE
INJURIES
TARSAL TUNNEL

 The tarsal tunnel is a fibro-osseous tunnel formed by the

flexor retinaculum, the medial wall of the calcaneus, the
posterior aspect of the talus, distal tibia, and medial
malleolus
 The posterior tibial artery, tibial nerve, and tendons of
the tibialis posterior, flexor digitorum longus, and flexor
hallucis longus travel in a bundle along this pathway,
through the tarsal tunnel.
 “Tom Does Very Nice Hat”
 A. The tibial nerve tunnel
( tibial n.)

 B. The medial plantar tunnel

( medial plantar n.)

 C. The lateral plantar tunnel

( lateral plantar n.)

 D. The calcaneal tunnel

( medial calcaneal n.)
TARSAL TUNNEL SYNDROM

 Tarsal tunnel syndrome is a compression neuropathy of

the tibial nerve that is situated in the tarsal canal
 Benign tumors or cysts, bone spurs, inflammation of the
tendon sheath, nerve ganglions, or swelling from a broken or
sprained ankle.
 Varicose veins can also cause compression of the nerve.
 Lower back problems
 TTS is more common in athletes, active people, or
individuals who stand a lot. Flat feet may cause an
increase in pressure in the tunnel region and this can
cause nerve compression.
SYMPTOMS

 Causes a vague pain in the sole of the foot.

 Most patients describe this pain as a burning or tingling
sensation.
 Typically made worse by activity, especially standing
and walking for long periods. Symptoms are generally
reduced by rest.
 Patients may feel pain if they touch theirr foot along the
course of the nerve.
 If the condition becomes worse, your foot may feel
numb and pain.
TREATMENT

1. Orthotics and footwear modifications

2. Local steroid or anti-inflammatory treatment

3. Where conservative measures fail, surgical exploration

may be appropriate.

(Tarsal tunnel release)

 
 Requires an incision behind the ankle extending down to
the arch of foot.
I. The ligament over the tibial nerve
II. The nerve is followed in the foot, and the tunnels for
the medial and lateral plantar nerves
III. The calcaneal branch which also is released.
 Cysts or other space-occupying problems may be
corrected at this time.
 If there is scarring within the nerve or branches, this is
relieved by internal neurolysis.
(Neurolysis is when the outer layer of nerve wrapping is opened
and the scar tissue is removed from within nerve.)
 Complications from this surgery include bleeding,
infection and delayed wound healing.
LATERAL PLANTAR NERVE

By :
Sharifah Firdawina Bt Syid Ayob
09-1-223
ORIGIN
From posterior tibial nerve pass
under cover of flexor
retinaculum then divides into
medial and lateral plantar
nerve.
COURSE
 It passes laterally between quadratus plantae and flexor
digitorum brevis. Near base of 5th metatarsal bone,
divides into

Superficial branches Deep branch

BRANCHES
 Before it’s division , it supplies

Flexor accessories Cutaneous to skin

and of lateral part
Abductor digiti minimi of sole
 Superficial branch

Lateral Plantar Digital Branch

supplies : divides into 2 branches to

supply :
Medial Plantar Digital Branch
 Skin of lateral side Adjoining side of 4 and 5
 th th

 Dorsum of little toe toe

 Flexor digiti minimi

brevis
 3rd plantar interosseus

 4th dorsal interosseus

DEEP BRANCH
 Run medially behind plantar arch between 3rd and 4th layer of
muscle

 Supplies :
- transverse head of adductor hallucis
- 2nd, 3rd, 4th lumbricals
- 1st, 2nd plantar intersosseus
- 1st, 2nd, 3rd dorsal interosseus
NERVE INJURY
1. Lateral plantar nerve injury following steroid injection for
plantar fasciitis

 Plantar fasciitis is inflammation of plantar fascia

 Steroid injection is used to treat severe cases of plantar fasciitis

and can cause complication at lateral plantar nerve
2. Lateral plantar nerve entrapment

- lateral plantar nerve becomes entrapped in the heel due to

inflammation or repeated injury

- treated by wearing arch supports and taking non steroid anti

inflammatory drugs (NSAID)
NERVE DEFORMITY
 TARSAL TUNNEL
SYNDROME
- compression on posterior tibial
nerve that produce symptoms
(tingling , burning, numbness and
pain ) anywhere along the path of
the nerve running from the inside
of the ankle into the foot.
 Causes
 enlarged or abnormal structures that occupies space within
tunnel
 ankle sprain

Treatment
rest, apply ice pack, oral medications
REFERENCES
 http://en.wikipedia.org/wiki/Femoral_nerve
 http://www.wisegeek.com/what-is-the-obturat

 Human anatomy lower limb by Dr. Ayman Ahmed Khanfour.

 http://en.wikipedia.org/wiki/Obturator_nerve

 http://en.wikipedia.org/wiki/Superior_gluteal_nerve

 http://en.wikipedia.org/wiki/File:Gray832.png

 Clinical Oriented Anatomy 6th Edition by Moore Dalley Agur

 http://en.wikipedia.org/wiki/Sciatic_nerve

 www.docroberts.com/Exercises.aspx

 http://en.wikipedia.org/wiki/Medial_plantar_nerve

 http://en.wikipedia.org/wiki/Tarsal_tunnel_syndrome

 module 5 musculo-skeletal system

 www.sportsinjuryclinic.net

 www.painclinic.org

 http://en.wikipedia.org/wiki/Medial_plantar_nerve

 http://en.wikipedia.org/wiki/Tarsal_tunnel_syndrome