Tarsal Tunnel Syndrome

What is tarsal tunnel syndrome (TTS)?

It is likely that you have heard of carpal tunnel syndrome (CTS), a common wrist condition involving characteristic pain, numbness, and/or weakness in the hand and fingers. This is due to the compression or irritation of the median nerve as it passes through the wrist into the hand. Tarsal tunnel syndrome (TTS), also known as tibial nerve dysfunction or posterior tibial nerve neuralgia, is a similar but less common condition affecting the tibial nerve of the leg presenting with similar symptoms in the bottom of the foot.

The Tarsal Tunnel

Analogous to the carpal tunnel of the wrist, the tarsal tunnel is a narrow passageway on the inner side of the heel. Several bones of the foot and ankle such as the medial malleolus, talus, and calcaneus make up the borders of the tarsal tunnel. The roof of the tarsal tunnel is the flexor retinaculum, a band of thick connective tissue, protecting structures such as tendons, arteries, veins, and the tibial nerve as they make their way into the foot.

Causes of TTS

The etiology of TTS is broad as it may develop from anything that may increase compression or strain on the tibial nerve, including:

• Increased swelling from an ankle sprain, foot/ankle surgery

• Systemic diseases (e.g., arthritis, diabetes) causing swelling and nerve compression

• Intrinsic factors (e.g., inflammation of the tendon and related structures, varicose veins, ganglion cyst, bone spurs) that take up space in the tarsal tunnel

Signs and Symptoms of TTS

• Burning, tingling, pins and needles on the bottom of the foot or medial arch

• Weakness and/or impaired control of intrinsic muscles of the foot

• Pain and paresthesia at end-range dorsiflexion or eversion

• Aggravated with walking, standing, or after physical activity; improves with rest

• Symptoms worse at night and disturbing sleep

• Impaired balance of the affected foot

Who is at risk for developing TTS?

Several factors may increase the risk of developing TTS:

• Age and sex: TTS is more commonly seen in adults females compared to males

• Pregnancy: More common in the third trimester of pregnancy due to increased ankle swelling, postural abnormalities, and pregnancy-associated weight gain.

• History of trauma: Chronic ankle sprains, past foot/ankle surgery

• Anatomic/biomechanical factors: Flat feet, fallen arches, poorly fitted footwear

• Occupation/Activity: More common in athletes and individuals that are weight-bearing for prolonged periods of time

Assessment of TTS

A diagnosis of TTS will involve collecting a detailed patient history and examination by a clinician. A clinical examination may involve provocative tests that aim to reproduce signs and symptoms. One example:

Triple Compression Stress Test: The clinician passively moves the affected foot into end-range plantarflexion and inversion to end-range, followed by compression of the tibial nerve behind the medial malleolus for 30 seconds. A positive test is indicated by pain, tingling, and/or numbness along the bottom of the foot.

The signs of symptoms of TTS overlap with a variety of conditions that may affect the foot and ankle. These conditions may include plantar fasciitis, L5/S1 nerve root compression, Achilles tendonitis, and Morton metatarsalgia. As a result, it is imperative to receive a comprehensive assessment from a qualified clinician to make sure you are set up on the right track to recovery.

Diagnostic Imaging and Testing for TTS

In addition to patient history and clinical examination, additional testing may be considered to determine a specific etiology for TTS:

• X-ray: May be helpful to identify possible structural abnormalities such as osteophyte formation or hindfoot structure

• MRI: Not used to diagnose TTS but can help rule in or out other factors that may be causing the symptoms

• Ultrasound: Can be used to identify various intrinsic soft-tissue structures that may be present such as tendonitis/tenosynovitis, ganglion cysts, and varicose veins

• Electromyography (EMG) or nerve conduction: Assesses motor and sensory function of the tibial nerve

Treatment for TTS

Conservative treatment is generally indicated for the management of TTS with non-specific etiology. The goals of treatment will range from reducing swelling and inflammation and improving strength and mobility, with an overall goal to reduce stress of the affected tissues. Physiotherapy, chiropractic, and massage therapy for TTS may include:

• Education: Learning about TTS and how to modify existing activities will be key to developing an effective self-management plan

• Biomechanical analysis: A global movement assessment may provide some insight into potential biomechanical factors that may contribute to the development of TTS

• Exercise prescription: Can help improve muscle strength, motor control, and mobility

• Neural mobilization exercises: Can improve sensory symptoms in individuals with TTS when included in a physical rehabilitation program (Kavlak & Uyger, 2011)

• Massage therapy: Myofascial release and instrument assisted soft tissue mobilization

• (IASTM) can address increased muscle tone and help improve mobility and pain reduction

• Orthotics assessment: Can support improved biomechanics and offload the tarsal tunnel

• Alternative modalities: Medical acupuncture and therapeutic ultrasound can help supplement the management of TTS through pain modulation and reducing swelling

Medical management for TTS may involve corticosteroid injections to reduce swelling in the tarsal tunnel region. Surgical treatment for TTS may be indicated if conservative management is unsuccessful or if a definitive cause for TTS is identified.

Conclusion

TTS is an analogous condition to CTS that affects the tibial nerve as it travels from the back of the leg into the foot, resulting in characteristic pain, tingling, and/or numbness on the bottom of the foot. The causes of TTS are broad and treatment approaches will depend on the cause of entrapment. In general, conservative treatment is initially recommended for individuals with non-specific TTS. Get a head start on your road to recovery with a Rehab Hero physiotherapy, chiropractic, and massage therapy practitioner today.

Written by: Alex Wu

Alex is a North York based physiotherapy resident that can be found in the Hullmark Centre. Growing up having enjoyed playing sports, he aims to get others to the level of function needed to enjoy their activity. Outside of the clinic you can find him playing basketball, ultimate frisbee or going for runs.

References

Kavlak, Y., & Uygur, F. (2011). Effects of nerve mobilization exercise as an adjunct to the conservative treatment for patients with tarsal tunnel syndrome. Journal of manipulative and physiological therapeutics, 34(7), 441-448.

Kiel, J., & Kaiser, K. (2018). Tarsal tunnel syndrome.

McSweeney, S. C., & Cichero, M. (2015). Tarsal tunnel syndrome—a narrative literature review.

The Foot, 25(4), 244-250.

https://www.hopkinsmedicine.org/health/conditions-and-diseases/tarsal-tunnel-syndrome

https://www.physio-pedia.com/Tarsal_Tunnel_Syndrome

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