Continuing Education Activity
Tarsal tunnel syndrome is sometimes referred to as tibial nerve dysfunction or posterior tibial nerve neuralgia. It is an entrapment neuropathy that is associated with the compression of the structures within the tarsal tunnel. It can be thought of as analogous to carpal tunnel syndrome of the wrist, but occurs at the ankle and is much less common than carpal tunnel syndrome. This activity addresses the presentation, evaluation, and management of tarsal tunnel syndrome and examines the role of an interprofessional team approach on the care of affected patients.
Identify the signs and symptoms of tarsal tunnel syndrome with the structures that are entrapped.
Describe the management strategies for tarsal tunnel syndrome.
Review the potential complications of tarsal tunnel syndrome.
Outline interprofessional team strategies for improving care coordination and communication to enhance outcomes for patients affected by tarsal tunnel syndrome.
Tarsal tunnel syndrome sometimes referred to as tibial nerve dysfunction or posterior tibial nerve neuralgia, isan entrapment neuropathy that is associated with the compression of the structures within the tarsal tunnel. It is similar to carpal tunnel syndrome of the wrist although much less common.
The tarsal tunnel is a narrow fibro-osseous space that runs behind and inferior to the medial malleolus. It is bounded by the medial malleolus anterosuperiorly, by the posterior talus and calcaneus laterally, and is held against the bone by the flexor retinaculum which extends from the medial malleolus to the medial calcaneus and prevents medial displacement of its contents.
The tarsal tunnel includes multiple important structures. It contains the tendons of the posterior tibialis, flexor digitorum longus (FDL), and flexor hallucis longus (FHL) muscles. The posterior tibial artery and vein, as well as posterior tibial nerve (L4-S3), also pass through it. The orientation of these structures within the tarsal tunnel is noteworthy. From medial to lateral, they are the tibialis posterior tendon, FDL tendon, posterior tibial artery and vein, posterior tibial nerve, and FHL tendon.
The posterior tibial nerve passes between the FDL andFHL muscles before it bifurcates in the tarsal tunnel, forming the medial and lateral plantar nerves. In 5% of people, the bifurcation occurs before the tarsal tunnel. The medial plantar nerve passes deep to the abductor hallucis and FHL muscles and provides sensation to the medial half of the foot and first 3.5 digits and motor function to the lumbricals, abductor hallucis, flexor digitorum brevis, and flexor hallucis brevis. The lateral plantar nerve passes directly through the abductor hallucis muscle belly and provides sensory innervation of the medial calcaneus and lateral heel and motor function to the flexor digitorum brevis, quadratus plantae, and abductor digiti minimi. The medial calcaneal nerve typically branches off of the posterior tibial nerve proximal to the tarsal tunnel and provides sensory innervation to the posteromedial heel. In 25% of patients, it branches off of the lateral plantar nerve or runs superficial to the flexor retinaculum.
Tarsal tunnel syndrome is divided into intrinsic and extrinsic etiologies.
Extrinsic causes include poorly fitting shoes, trauma, anatomic-biomechanical abnormalities (tarsal coalition, valgus or varus hindfoot), post-surgical scarring, systemic diseases, generalized lower extremity edema, systemic inflammatory arthropathies, diabetes, and post-surgical scarring.
Intrinsic causes include tendinopathy, tenosynovitis, perineural fibrosis, osteophytes, hypertrophic retinaculum, and space-occupying or mass effect lesions (enlarged or varicose veins, ganglion cyst, lipoma, neoplasm, and neuroma). Arterial insufficiency can lead to nerve ischemia.
The mechanism of impingement can be identified in approximately 80% of cases.
The incidence of tarsal tunnel syndrome is unknown. It is a relatively rare and often underdiagnosed disease. It is higher in females than in males and can be seen at any age.
Tarsal tunnel syndrome results from the compression of the posterior tibial nerve or one of its two branches, the lateral or medial plantar nerve, within the tarsal tunnel. Up to 43% of patients have a history of trauma including events such as ankle sprains. Abnormal biomechanics can contribute to disease progression. Risk factors include systemic diseases such as diabetes mellitus, hypothyroidism, gout, mucopolysaccharidosis, and hyperlipidemia.
History and Physical
There is no specific test for the diagnosis of tarsal tunnel syndrome, and diagnosis is made with a detailed history and clinical examination.
The predominant complaint is pain directly over the tarsal tunnel that radiates to the arch and plantar foot. Patients with tarsal tunnel syndrome will frequently report a sharp shooting pain in the foot, numbness on the plantar surface, radiation of pain and paresthesias along the distribution of the posterior tibial nerve, pain with extremes of dorsiflexion and eversion, and a tingling or burning sensation. These symptoms may localize to the medial ankle or plantar surface of the foot or be vaguer, making diagnosis difficult. Their symptoms will vary depending on whether the entire posterior tibial nerve is compressed or if it is the lateral or medial plantar branches. The symptoms may worsen at night, with walking or standing, or after physical activity, and typically get better with rest. Dysesthesias may worsen at night, disturbing sleep. The patient may noteweakness in the muscles of the foot.
On exam, the provider may observe pes planus, pronated foot, or talipes equinovarus. In chronic cases, atrophy, weakness of the intrinsic foot muscles, and contractures of the toes may be appreciated. They are typically tender on deep palpation of the tarsal tunnel. The gait should be analyzed for abnormalities including excessive pronation or supination, toe eversion, excessive foot inversion or eversion, and antalgic gait.
Light touch and two-point discrimination should be tested. The patient may have diminished plantar sensation in the distribution of either the medial or lateral plantar nerve. Muscle strength and foot range of motion should be assessed. Strength deficits are typically a late finding in tarsal tunnel syndrome.
The Tinel test involves lightly tapping over the tarsal tunnel repeatedly. Pain or tingling in the distribution of the nerve is a positive test. Sensitivity is low at 25% to 75%; specificity is 70% to 90%. The dorsiflexion-eversion test involves passively dorsiflexing and everting the ankle to end range of motion and holding for 10 seconds. Reproduction of symptoms is a positive sign due to compression of the posterior tibial nerve in this position. This test is positive in 82% of patients with tarsal tunnel syndrome.
Tarsal Tunnel Syndrome Severity Rating Scale
A score of 10 indicates a normal foot and 0 indicates the most symptomatic foot.
Scoring for each symptom:
2 points for the absence of features
1 point for some features
0 points for definite features
The five symptoms:
Spontaneous pain or pain with movement,
Muscle atrophy or weakness
Plain radiographs of the ankle and, possibly, the foot are the initial imaging study of choice. These may help identify any structural abnormalities including osteophytes, hindfoot varus and valgus, tarsal coalition, or evidence of previous trauma. Magnetic Resonance Imaging (MRI) is not sensitive for the diagnosis of the tarsal tunnel but may help include or exclude other causes of the patient's symptoms. Ultrasound can be used to evaluate the soft tissue structures. The nerve and its bifurcations can be observed. Either ultrasound or MRI can evaluate other soft tissue abnormalities including tendonitis or tenosynovitis, lipomas or other growths, varicose veins, and ganglion cysts.
Electromyography (EMG) and nerve conduction studies (NCS) are frequently abnormal in patients with tarsal tunnel syndrome. Sensory nerve conduction studies are more likely to be abnormal than motor nerve conduction studies; however, the sensitivity and specificity are suboptimal. False-negative tests are not uncommon and thus do not rule out the diagnosis.
Treatment / Management
Management of tarsal tunnel syndrome remains challenging due to diagnostic uncertainty and lack of clarity over which patients would benefit from conservative versus surgical management. Tarsal tunnel syndrome can be managed nonoperatively or operatively. This decision is generally guided by the etiology of the disease, degree of loss of function of the foot and ankle, as well as muscle atrophy.
Conservative management and success vary based upon the etiology of tarsal tunnel syndrome. The goal is to decrease pain, inflammation, and tissue stress. Ice can be used. Oral analgesics including acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs) can be helpful. Neuropathic pain medications include gabapentin, pregabalin, and tricyclic antidepressants can be tried. Topical medications can also be used, including lidocaine and NSAIDs.
Physical therapy soft tissue modalities that may help include ultrasound, iontophoresis, phonophoresis, and E-stim. Calf stretching and nerve mobility or nerve gliding can also help with symptoms. Strengthening the tibialis posterior can help. Activity modification also plays a role in managing symptoms. Kinesiology tape can be used for arch support and biomechanical stress reduction.
Orthotic shoes can be used to correct biomechanical abnormalities and offload the tarsal tunnel. A medial heel wedge or heel seat may reduce traction on the nerve by inverting the heel. Night splints can be tried, and patients who fail to respond to the above therapy can be placed in a walking boot temporarily. Footwear with appropriate arch support may help reduce symptoms. CAM (controlled, ankle, motion) walker or walking boots may be tried.
If a ganglion cyst is present, it can be aspirated under ultrasound guidance. Corticosteroid injections into the tarsal tunnel may help with edema.
Surgery is indicated if conservative management fails to resolve the patient’s symptoms or if a definitive cause of entrapment is identified. Patients with symptoms caused by a space-occupying lesion generally respond well to surgical management. Abnormally slow nerve conduction across the posterior tibial nerve is predictive of failed conservative therapy.
Surgical management involves the release of the flexor retinaculum from its proximal attachment near the medial malleolus down to the sustentaculum tali. Surgical success rates vary from 44% to 96%. Patients with a positive Tinel sign preoperatively tend to respond better to surgical decompression than those who do not. Younger patients and those with a short history of symptoms, early diagnosis, clear etiology, and no previous ankle pathology tend to respond better to surgery.
The differential diagnoses of tarsal tunnel syndrome is broad, making diagnosis difficult. These include:
Compartment syndrome of the deep flexor compartment
Degenerative changes (calcaneal spurs, arthrosis of the joints of the foot)
Inflammatory conditions of the ligaments and fascia of the foot and ankle.
Intersection syndrome of the FHL and FDL at the knot of Henry
L5 and S1 nerve root compression
Neurogenic intermittent claudication
The prognosis of tarsal tunnel is variable. In patients with an identifiable etiology due to mass effect diagnosed early in the disease course, the response is generally favorable. Patients without an identifiable cause and who do not respond to conservative therapy generally do not do as well with surgical intervention. A positive Tinel sign is a strong predictor of surgical relief.
Untreated or refractory tarsal tunnel syndrome can result in neuropathies of the posterior tibial nerve and its branches. Patients may have persistent pain. Subsequent motor weakness and atrophy can develop. Postoperative complications include impaired wound healing, infection, and scar formation. Surgical decompression may not adequately resolve pain and other symptoms.
Postoperative and Rehabilitation Care
Postoperative rehab is aimed at protecting the joint and nerve integrity and controlling inflammation, pain, and swelling. As rehab continues, the therapist and patient work to prevent contraction and adhesions of scar tissue while maintaining soft tissue and joint mobility. Return to normal gait, walking, and running are long-term goals.
The tarsal tunnel syndrome is a difficult, rare diagnosis. As such, cases are best managed by an orthopedic specialist. Depending on the etiology, surgical management may be indicated.
Deterrence and Patient Education
There are no clear guidelines for the prevention or deterrence of tarsal tunnel syndrome.
Patients should be aware that there are many causes of foot and ankle pain, some of which are uncommon including tarsal tunnel syndrome. If a patient has foot and ankle pain as well as other concerning symptoms such as burning, numbness, tingling, and muscle weakness, they should seek the care of a medical professional.
Pearls and Other Issues
The tarsal tunnel syndrome is an entrapment neuropathy of the medial ankle.
It is an uncommon but underdiagnosed cause of foot and ankle pain.
The etiology is broad.
Patients tend to have pain originating from the tarsal tunnel radiating down to the plantar foot; however, symptoms can vary.
There is no best test to diagnose tarsal tunnel syndrome, and it is a combination of history, exam, imaging, and electromyography and nerve conduction studies.
Conservative therapy can be tried in most patients.
If a definitive cause is identified, surgical decompression can provide good results.
Enhancing Healthcare Team Outcomes
Management of tarsal tunnel syndrome remains challenging due to diagnostic uncertainty and lack of clarity over which patients would benefit from conservative versus surgical management. Hence, the condition is best managed by an interprofessional team that consists of a podiatrist, orthopedic surgeon, orthopedic nurse, and physical therapist.
Conservative treatment may help some patients but the key is physical therapy, change in shoes, and modification of activity. For those with a compressive lesion, surgery may be beneficial. Regardless of the treatment path chosen, the orthopedic nurse should monitor the results and report back to the clinician regarding progress or lack thereof, so therapy can change if needed.
The overall prognosis for patients with tarsal tunnel syndrome is guarded. Relapse and remissions are common and some patients never achieve complete relief from symptoms. [Level 5]
Tarsal Tunnel Syndrome. Image courtesy S Bhimji MD
Tarsal Tunnel Anatomy. Image courtesy O.Chaigasame
Anterior Tarsal Tunnel Syndrome- Note the dorsal soft tissue swelling and dorsal osteophyte from the metatarsal-cuneiform joint causing distal paresthesias due to medical dorsal cutaneous nerve entrapment. Contributed by Mark A. Dreyer, DPM, FACFAS
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Disclosure: John Kiel declares no relevant financial relationships with ineligible companies.
Disclosure: Kimberly Kaiser declares no relevant financial relationships with ineligible companies.
Nonsurgical treatment for TTS includes anti-inflammatory medications or steroid injections into the tarsal tunnel to relieve pressure and swelling. Braces, splints or other orthotic devices may help reduce pressure on the foot and limit movement that could cause compression on the nerve.
Tarsal tunnel syndrome can be managed or cured with a wide variety of treatment options, but regardless of what the underlying condition is, it's essential to get early treatment to prevent permanent nerve damage.What causes tarsal tunnel to flare up? ›
Certain injuries or trauma such as an ankle sprain, fracture or valgus foot deformity may cause inflammation and swelling that can lead to tarsal tunnel syndrome. In addition, certain disorders such as diabetes and arthritis can also cause inflammation and swelling that can lead to tarsal tunnel syndrome.Does it hurt to walk with tarsal tunnel syndrome? ›
Pain, the most common symptom of tarsal tunnel syndrome, usually has a burning or tingling quality that may occur when a person stands, walks, or wears a particular type of shoe. Pain located around the ankle (usually on the inner side) and extending to the toes usually worsens during walking and is relieved by rest.What happens if tarsal tunnel is left untreated? ›
Untreated or refractory tarsal tunnel syndrome can result in neuropathies of the posterior tibial nerve and its branches. Patients may have persistent pain. Subsequent motor weakness and atrophy can develop.Is tarsal tunnel serious? ›
Are there long-term effects from tarsal tunnel syndrome? Without treatment, TTS can lead to nerve damage. If you develop nerve damage, it can be permanent and irreversible. You may have difficulty walking, exercising or performing your daily activities.Do compression socks help tarsal tunnel syndrome? ›
Supporting devices help in decompressing the nerve and give better posture for the foot, thus relieving pain. Some of them are compression socks, specially designed shoes, and soles that can potentially reduce the pressure on the tibial nerve and are recommended in the treatment of tarsal tunnel syndrome.What is the best exercise for tarsal tunnel syndrome? ›
Step 1: Sit on a chair and lift your injured leg off the ground. Step 2: Slowly rotate your ankle clockwise five times. Step 3: Rotate your ankle counterclockwise five times. If both feet have tarsal tunnel syndrome, repeat with the other leg.
Most people will recover from the trauma of tarsal tunnel surgery itself within 4-6 weeks of an uncomplicated operation. However, depending on the general health of the patient, factors such as diabetes, morbid obesity, smoking, and poor conditioning may increase healing time for a surgical wound.How do you test for tarsal tunnel syndrome? ›
Tarsal Tunnel Compression Test (Durkan's)
Tarsal Tunnel Compression Test: Examiner presses firmly over the flexor retinaculum for up to 30 seconds or until symptoms develop. Test is considered positive if paresthesia, numbness, or pain develop in tibial nerve or distal branches in the foot.
MR imaging with its excellent soft tissue contrast can demonstrate clearly the anatomy of the tarsal tunnel and its contents. MRI is able to demonstrate a space-occupying lesion and its relationship to the posterior tibial nerve and its branches.Does a brace help tarsal tunnel syndrome? ›
People with tarsal tunnel syndrome who have severe symptoms and nerve damage or flat feet may benefit from wearing a brace such as the McDavid Ultralight Ankle Brace 195, which offers incredible ankle protection. A brace will reduce the amount of pressure on the foot and help the ankle heel faster.Is tarsal tunnel worse at night? ›
Symptoms may be worse at night. The pain tends to be aggravated by prolonged standing or walking, normally worsens as the day progresses and can usually be relieved by rest, elevation or massage. Pain may radiate along the sole of the foot, sometimes up into the calf.Is tarsal tunnel neuropathy? ›
Tarsal tunnel syndrome is an unusual form of peripheral neuropathy. It occurs when there is damage to the tibial nerve. The area in the foot where the nerve enters the back of the ankle is called the tarsal tunnel. This tunnel is normally narrow.What is the difference between plantar fasciitis and tarsal tunnel syndrome? ›
TTS pain is more often described as burning or tingling and is felt with palpation just below the ankle bone. Commonly a tingling sensation extends to the heel, toes, or arch. Plantar fasciitis pain is located more along the bottom of the foot, primarily near the heel.Is tarsal tunnel surgery worth it? ›
Tarsal tunnel syndrome is an often overlooked injury that, if left untreated, could limit movement. For severe cases, tarsal tunnel release surgery is the best way to treat this condition.Do you need surgery for tarsal tunnel? ›
If conservative treatment fails, surgical intervention may be warranted to free the tibial nerve from any fascial covering. Surgery for tarsal tunnel syndrome is most successful in cases where there is a well-defined mass causing the compression and less predictable in other circumstances.When is tarsal tunnel surgery necessary? ›
Surgical intervention is usually advised if the symptoms are due to an isolated abnormal soft tissue mass in the tarsal tunnel. If non-operative measures fail to improve symptoms in other conditions causing tarsal tunnel syndrome, then surgery can treat the problem causing the nerve compression.Does a podiatrist treat tarsal tunnel syndrome? ›
The proper diagnosis and treatment of tarsal tunnel syndrome will involve you seeing a doctor that specializes in the care of the lower extremities. This type of doctor is called a podiatrist. Tarsal tunnel syndrome can be treated non-surgically or surgically depending on the severity of the condition.Is heat or ice better for tarsal tunnel syndrome? ›
In severe cases an orthotic may make it hurt worse because it puts too much pressure on the pinched nerve. You can elevate your foot and apply ice at the same time if you have any swelling. Putting a heating pad on the inside of your ankle may also help increase circulation to the pinched nerve and relieve pain.
Chiropractic Can Help
It can also shift your bones, muscles, and other soft tissues, leading to compression in areas that shouldn't have it, such as the tarsal tunnel. Since chiropractic care impacts the nervous system, it's a great approach to treating tarsal tunnel naturally.
Tarsal tunnel syndrome is a rare condition and often underdiagnosed. A variety of symptoms are possible, such as: tingling or burning pain (paraesthesia), hyperaesthesia and sensory impairment (dysesthesia). These are felt on the plantar face of the ankle and foot.How painful is tarsal tunnel surgery? ›
I is normal to experience mild to moderate pain, numbness, or tingling for the first 2 weeks following surgery. Please come to the emergency department if you are suffering from severe pain. You will get back to most of your activities by 3 months. Swelling often remains for 6-12 months.How long does it take for tarsal tunnel syndrome to heal? ›
Tarsal tunnel syndrome can take anywhere from 2 weeks to 6 months. Once you begin therapy you will start to feel better. The time frame for recovery depends on the extent and cause of the nerve compression. Rehabilitation is important to restore ankle strength and balance and to prevent a recurrence.What is the best exercise for tarsal tunnel? ›
Step 1: Sit on a chair and lift your injured leg off the ground. Step 2: Slowly rotate your ankle clockwise five times. Step 3: Rotate your ankle counterclockwise five times. If both feet have tarsal tunnel syndrome, repeat with the other leg.
As with any peripheral nerve surgery, tarsal tunnel surgery is demanding and can sometimes be excessively difficult. Additionally, one may not have a full appreciation of the outcome until some point in the postoperative period — if at all — when the nerve has had adequate time for recovery and/or regeneration.Can a podiatrist treat tarsal tunnel syndrome? ›
The proper diagnosis and treatment of tarsal tunnel syndrome will involve you seeing a doctor that specializes in the care of the lower extremities. This type of doctor is called a podiatrist. Tarsal tunnel syndrome can be treated non-surgically or surgically depending on the severity of the condition.Are you put to sleep for tarsal tunnel surgery? ›
Preparation: Patients receive general anesthesia. The surgeon makes a small incision on the inner ankle to expose the flexor retinaculum, a band of fibrous tissue that forms the tarsal tunnel's outer wall.Do they put you to sleep for tarsal tunnel surgery? ›
Tarsal tunnel release surgery is typically performed under general anesthesia, where you will not be awake.How long do you wear a boot after tarsal tunnel surgery? ›
You will have a dressing and a sandal/shoe following surgery. A sandal/shoe will be worn for 2 weeks. At 2 weeks, you will wean off the boot and begin walking in a regular shoe.
Orthopedic surgeons of The Institute for Foot and Ankle Reconstruction at Mercy work with patients to provide the best treatment options available to relieve foot numbness and tingling due to tarsal tunnel syndrome.