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Validity of the Tinel Sign and Prevalence of Tibial Nerve Entrapment at the Tarsal Tunnel in Both Diabetic and Nondiabetic Subjects

A Cross-Sectional Study

Rinkel, Willem D., M.D.; Castro Cabezas, Manuel, M.D., Ph.D.; van Neck, Johan W., Ph.D.; Birnie, Erwin, Ph.D.; Hovius, Steven E. R., M.D., Ph.D.; Coert, J. Henk, M.D., Ph.D.

Plastic and Reconstructive Surgery: November 2018 - Volume 142 - Issue 5 - p 1258–1266
doi: 10.1097/PRS.0000000000004839
Hand/Peripheral Nerve: Original Articles

Background: Nerve entrapments like carpal tunnel syndrome are more prevalent in patients with diabetes, especially in those with diabetic polyneuropathy. Our study aims were to investigate the validity of the Tinel sign in diagnosing tibial neuropathy and determine the prevalence of tibial nerve entrapment in both a diabetic and nondiabetic population.

Methods: Two hundred forty nonneuropathic subjects with diabetes and 176 diabetic subjects with neuropathy participating in the prospective Rotterdam Diabetic Foot Study and 196 reference subjects without diabetes and without neuropathy complaints were evaluated. All subjects underwent sensory testing of the feet, and complaints were assessed using the Michigan Neuropathy Screening Instrument. The Tinel sign was defined as discriminative and valid for diagnosing tibial nerve entrapment when the nerve-related Michigan Neuropathy Screening Instrument subscore of neuropathic symptoms differed at least 5 percent between the Tinel-positive and Tinel-negative subjects. When the sign was valid, prevalence estimates of tibial nerve entrapment at the tarsal tunnel were calculated.

Results: Significantly more neuropathic symptoms (p < 0.002) and higher sensory thresholds (p < 0.0005) were observed in (compressed) tibial nerve–innervated areas, indicating that a positive Tinel sign at the tarsal tunnel is a valid measure of tibial nerve abnormality. The prevalence of tibial nerve entrapment in diabetic patients was 44.9 percent (95 percent CI, 40.1 to 49.7 percent) versus 26.5 percent (95 percent CI, 20.3 to 32.7 percent) in healthy controls (p < 0.0001).

Conclusions: Tibial nerve entrapment is more prevalent in diabetic subjects than in controls. The significantly more frequently reported neuropathic complaints and concomitant sensory disturbances provide evidence for the role of superimposed entrapment neuropathy in diabetes-related neuropathy.


Rotterdam and Utrecht, The Netherlands

From the Department of Plastic-, Reconstructive- and Hand Surgery, Erasmus University Medical Center; the Department of Plastic-, Reconstructive- and Hand Surgery, the Department of Internal Medicine/Centre for Diabetes, and the Department of Statistics and Education, Franciscus Gasthuis & Vlietland; the Xpert Clinic, Hand and Wrist Surgery; and the Departments of Obstetrics and Gynecology and Plastic-, Reconstructive- and Hand Surgery, Utrecht Medical University Center, Utrecht University.

Received for publication November 19, 2017; accepted June 1, 2018.

Disclosure: None of the authors has a financial interest in any of the products or devices mentioned in this article.

Willem D. Rinkel, M.D., Department of Plastic-, Reconstructive- and Hand Surgery, UMCU–University Medical Center Utrecht, Room G.04-122, Box 85500, 3508 GA Utrecht, The Netherlands,

©2018American Society of Plastic Surgeons