Tarsal Tunnel Syndrome

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What is the Tarsal Tunnel?

The tarsal tunnel is an anatomical location that refers to the narrow space that lies on the medial aspect (inside) of the ankle. The tarsal tunnel is protected by a thick ligament known as the flexor retinaculum. The flexor retinaculum’s main job is to protect the neurovascular structures and tendons located within the tunnel. This includes the posterior tibial nerve, which is a branch of the sciatic nerve and an important structure in relation to tarsal tunnel syndrome.

What is Tarsal Tunnel Syndrome?

Tarsal Tunnel Syndrome, is the squeezing or compression of the posterior tibial nerve as it runs through the tarsal tunnel. This can result in the production of symptoms on the inside of the ankle and/or on the sole of the foot.

What are the symptoms of Tarsal Tunnel Syndrome?

People suffering with Tarsal Tunnel Syndrome usually experience one or more of the symptoms below. Symptoms can vary between individuals. Some can experience the symptoms to progress gradually. Others may find that the symptoms begin suddenly and are very intense.

  • Symptoms can include:
  • Ankle pain, that may be described as sharp or shooting.
  • A burning or tingling sensation in the sole of the foot or inside of the ankle.
  • Numbness on the inside of the ankle that can extend to the sole of the foot.
  • Symptoms are usually worse at night.
  • Symptoms may increase with prolonged standing or walking.
  • Symptoms can be relieved by rest or elevation.
  • Pain may refer to the back of the calf

What are the common causes of Tarsal Tunnel Syndrome?

The causes of Tarsal Tunnel Syndrome include anything that causes compression onto the posterior tibial nerve. These can include:
Flat feet. This condition is medically known as pes planus and refers to the reduction in the inside arch of the foot resulting in a outwards tilting of heel. This consequently, produces strain onto the inside aspect of the heel and therefore increased compression on the tibial nerve.

Ankle injury. Ankle sprain or fracture can cause inflammation and swelling around the ankle area. This build up of pressure in the ankle can cause compression of the nerve as it runs through the tarsal tunnel.

Other conditions such as diabetes or arthritis. These conditions can cause swelling and therefore compression onto the nerve.
Benign growths. Benign bony growths can form within the tarsal tunnel which can decrease the space in the tunnel and cause compression onto the posterior tibial nerve.

Varicose veins and ganglion cysts can form in and around the tarsal tunnel and cause increased pressure within the tarsal tunnel. This can result in increased pressure onto the nerve.

Swollen and inflamed tendons. There are three tendons that run through the tarsal tunnel: The posterior tibialis, flexor digitorum longus and flexor hallucis longus. These tendons run through the tarsal tunnel and attach to different locations within the foot to help with movement and stability of the foot. When these tendons become overused or injured they can inflame and subsequently cause compression into the posterior tibial nerve.

How is Tarsal Tunnel Syndrome diagnosed?

In order to diagnose Tarsal Tunnel syndrome your healthcare practitioner will carry out a
detailed medical history and clinical examination. During your initial consultation your practitioner will ask you a series of questions including if there has been any trauma to the ankle. This will then be followed by a indepth physical examination of your foot and ankle including range of motion testing and provocative orthopedic tests to understand where the symptoms are coming from. The most likely test your practitioner will perform is Tinel’s test. This orthopedic test involves the gentle tapping of the tibial nerve as it runs through the tarsal tunnel. If symptoms are experienced and exacerbated by the applied pressure from the tapping, this is a positive outcome and an indication of tarsal tunnel syndrome.

Further medical imaging and nerve conduction testing may be required to understand the severity of the condition and to understand the underlying cause of the symptoms. These tests can include but are not limited to:

MRI – this form of imaging is used to assess the soft tissues located in the ankle and foot. It can also detect any abnormal mass or bony growth that may be causing the compression.

Electromyography- this form of testing is used to detect any nerve dysfunction.

What are the treatment options for Tarsal Tunnel Syndrome?

The type and length of treatment required for Tarsal Tunnel Syndrome depends on the cause and severity of symptoms. Some of the treatment options available are listed below.

Conservative Management

Rest. Minimising the weight bearing activity on the ankle and foot can help reduce the load and therefore compression onto the ankle.

Ice. Using a cold compress or ice pack onto the inside of the ankle for 20 minutes several times a day can help with reducing any inflammation in and around the tarsal tunnel. Make sure to wrap the ice pack in a thin towel to protect the skin surface.

Medication. Non-steroidal anti-inflammatory medication (NSAIDs) such as ibuprofen may be recommended to help with reducing inflammation in the ankle. It is recommended to speak to your GP before taking any new medication. When NSAIDs are prescribed by your doctor they may also prescribe you with another medication that will help protect your stomach lining. This is because prolonged NSAID usage can upset the lining of your stomach.

Physical Therapy. Hands on physical therapy and exercise prescription can be used to help with reducing the symptoms of tarsal tunnel syndrome and improve the strength of the ankle and foot. This is particularly important when the symptoms are caused by flat feet.

Corticosteroid Injection. In some cases corticosteroid injection may be prescribed by your doctor to help with reducing the inflammation within the ankle.

Shoe orthotics. In cases where the cause of tarsal tunnel syndrome is due to flat feet. Your physical therapist may suggest custom orthotics to help correct and maintain the inside arch of the foot. This will help reduce the pressure on the inside of the ankle.

Surgical Intervention
In cases where symptoms have not improved with conservative management, surgical decompression surgery may be suggested. During this surgery a incision is made from the back of the ankle down to the arch of the foot. This releases the tension within the flexor retinaculum helping to relieve the pressure on the posterior tibial nerve.

In cases where surgical intervention is necessary your orthopedic surgeon will discuss the best type of surgery needed and will answer any questions you may have about the surgery.

Can Tarsal Tunnel Syndrome be prevented?

Not all causes of Tarsal Tunnel Syndrome can be prevented. However, It is essential to get an early diagnosis and treatment in order to prevent permanent damage to the nerve.

What are the best exercises for Tarsal Tunnel Syndrome*?

In cases where the cause of your tarsal tunnel syndrome is caused by flat feet then strengthening exercises of the ankle and foot can be used to help improve foot and ankle biomechanics and relieve the pressure on the inside of the ankle. It is recommended that before starting these exercises you get a thorough physical examination and clinical diagnosis to fully understand the cause of your symptoms.

Tibialis posterior strengthening. Place a resistance band around your ankles. Stand with your feet hip distance apart and a slight bend in the knees. Begin by slowly rotating your feet outward to create a small arch in the middle of your foot. Relax your foot back to the starting position. Repeat 10 times.

Single leg balance proprioception clock. Begin with standing on the affected leg. Reach forwards as far as you can touching the toe of the opposite leg to 12 o’clock. Bring the leg back to the middle. Reach the leg out at 1 o’clock then bring it back to the centre. Repeat all the way around the clock face. Bend your standing knee slightly to help with balance. Repeat 5 times.

Pencil lifts. Sit or stand with your knee straight but not locked. Place a pencil onto the floor near the toes. Begin by slowly attempting to pick up the pencil with the toes. Once the pencil has been picked up, hold for 10-15 seconds. Relax the toes to drop the pencil back on the ground. Repeat 10 times.

Calf stretching. Stand face onto a wall with your feet in a split stance position (one leg in front, one leg behind with the heels on the ground and knees straight). Begin by pushing the front hip forwards and bend the front knee. A stretch should be felt in the calf of the back leg. Hold for 20- 25 seconds and repeat 5 times. In order to feel the stretch in the lower portion on the calf, slightly bend the knee of the back leg.

*It is always recommended to get the go ahead from your GP, osteopath or physiotherapist before starting any of the above exercises.

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