Tarsal Tunnel Syndrome

Original Editor - Staci Burns, Jonathan Blondeel

Top Contributors - Admin, Blondeel Jonathan, Dieter Schuddinck, Rani Sileghem, Staci Burns, Kim Jackson, Rachael Lowe, Jesse Lemmens, Vidya Acharya, 127.0.0.1, Tarina van der Stockt, Kai A. Sigel, WikiSysop, Jenny Wong and Naomi O'Reilly  

Search Strategy

First of all we searched information via the central library of the university. Afterwards we searched on the internet using scientific databases like PubMed, web of knowledge and Medline. First we tried searching with keywords such as ‘tarsal tunnel syndrome’ but this information was too general so we narrowed it down by adding terms like ‘physical therapy’ and ‘diagnostics’. We used some in- and exclusion criteria and we only used articles in French or English. For additional information we used Google scholar. We also tried typing names of journals based on the foot and ankle.

Definition/Description

Tarsal tunnel syndrome, also known as posterior tibial neuralgia, is a compression neuropathy and a painful foot condition in which the tibial nerve is impinged and compressed as it travels through the tarsal tunnel. This is a compression syndrome of the tibial nerve within the tarsal tunnel. This tunnel is located along the inner leg behind the medial malleolus. (1)
Tarsal tunnel syndrome is a rare entrapment neuropathy of the posterior tibial nerve and its branches within the fibro-osseous tarsal tunnel. (11) These branches include the medial calcaneal, medial plantar and lateral plantar nerves individually or collectively. (15) This pathology is characterized by pain in the ankle foot and toes. This entrapment can be caused by the inflammation of the tissues around the tibial nerve; another possible cause can be damage of the flexor hallucis longus (FHL) tendon. (13)(15)

Clinically Relevant Anatomy

The tarsal tunnel is a fibro-osseous tunnel formed by a number of bone structures (the talus and calcaneus) and some muscles (M. flexor digitorum longus (FDL) and the M. flexor hallucis longus). These structures form the floor of the tarsal tunnel. The roof contains the retinaculum flexorum that goes behind and below the medial malleolus. The distal end of the tunnel is narrow and blends with the superficial and deep fascia of the M. abductor hallucis. The posterior tibial nerve runs along the M. soleus in the posterior compartment. The nerve exits the compartment and passes deep to the retinaculum flexorum between the calcaneus and the medial malleolus. The tunnel also contains the posterior tibial artery which runs anterior to the M. flexor hallucis longus. This neurovascular package runs between the FDL and FHL tendons. (11) Posteroinferior to the medial malleolus, it split into three nerves: the medial plantar nerve, the calcaneal nerve and the lateral plantar nerve. They make a curve around the medial malleolus towards the foot.(1)

From medial to lateral the structures coursing through the tunnel are: the tendon of the tibialis posterior, the tendon of the flexor digitorum longus, posterior tibial artery and vein, posterior tibial nerve and the tendon of the flexor hallucis longus. (13)

Epidemiology /Etiology

Etiology of Tarsal tunnel syndrome

Anatomic factors	Tumor	Trauma	Inflammatory factors	Miscellaneous factors
Septa Areolar tissue Retinaculum synovial Vascular anomalies Valgus alignment Pes planus Foot deformities	Neuroma Lipoma Cyst and ganglion Tendon tumors Neurolemmoma Osteochondroma	Fractures Contusions Postsurgical adhesions Sprains Laceration Post-traumatic edema Exostoses Post-traumatic adhesions Talocalcaneal coalition Sport lesions	Rheumatoid arthritis Ankylosing spondylitis Tenosynovitis	Footwear Overuse syndrome Training surfaces Aging fluid retention Pregnancy Weight gain

Anatomic factors              Tumor                                 Trauma
septa                               neuroma                              factures
areolar tissue                    lipoma                                 contusions
retinaculum synovial          cyst and ganglion                 postsurgical adhesions
Vascular anomalies           tendon tumors                      sprains
Muscular variations            neurolemmoma                    laceration
Valgus alignment                osteochondroma                  post-traumatic edema
Pes planus                                                                   exostoses

Foot deformities                                                           post-traumatic adhesions

                                                                                   talocalcaneal coalition

                                                                                   sport lesions
Inflammatory factors           Miscellaneous factors
Rheumatoid arthritis            footwear
Ankylosing spondylitis         overuse syndrome
tenosynovitis                       training surfaces 
thrombophlebitis               aging fluid retention 
chronic uremia                     pregnancy 
                                          weight gain

The cause of tarsal tunnel syndrome can be intrinsic or extrinsic to the tunnel: (11)
• Intrinsic factors include: osteophytes, hypertrophic retinaculum, tendinopathy, and space occupying lesions such as enlarged veins, ganglia, lipoma, tumor and neuroma.
• Extrinsic factors include: direct trauma, constrictive footwear, hind foot varus or valgus, generalised lower limb oedema (as a result of pregnancy and venous congestion), systemic inflammatory arthropathy, diabetes and surgical scarring. (13)

This syndrome occurs when there is an entrapment neuropathy of the tibial nerve. This entrapment could be an extrinsic cause as consequence of surgery or trauma that would cause inflammation or bleeding, hypertrophy of the flexor hallicus longus, or an intrinsic cause caused by space occupying lesions or foot deformity. Space occupying lesions include tumors, talocalcaneal coalition, ganglion cyst, venous plexus or varicosities, lipomas, osteophytes (11) or an accessory muscle and/or bone. Flatfoot deformity in particular is also another causative factor. Usually it’s the deformity of the foot and ankle that causes the tarsal tunnel syndrome. The most common causes are an over pronation (fig1.) (4), valgus of the foot and the ankle. (fig2.) (4) (5) and ganglion cyst (9). Also if the patient has pes planus it increases abduction of the forefoot and a valgus deviation of the hind foot. Thereby it increases tension on the tibial nerve. This is also one of the most common causes of tarsal tunnel syndrome. (2) (8)

In some cases, chronic renal failure can be a cause of peripheral neuropathies and entrapment neuropathies. Dialysis-related amyloidosis can also be considered as the etiology. (12)

Clinical Presentation

Clinical features are burning pain at the medial malleolus radiating into the toes, the sole and the heel of the foot, along with paresthesia in the distribution of the posterior tibial nerve that is aggravated by weight bearing. Sensory impairment may develop, though motor deficits are often uncommon. The symptoms may vary according to the nerves affected: the calcaneal nerves are purely sensory and supply the heel; the medial plantar nerve innervates the medial aspect of the sole and the medial 3 or 4 toes and their associated muscles; and the lateral plantar nerve supplies the remainder of the skin on the plantar aspect of the sole and toes, and the small muscles that control the lateral toes. The symptoms occur mainly in the evenings and at night, especially after prolonged standing and walking. In the morning there are only few complaints. (5)

The tibial nerve innervates the entire sole that is why symptoms can be spread through the foot. Varied clinical presentation may occur because of the different sites of entrapment. The most common symptoms are: pain, paresthesia, numbness. Typical complaints are: poorly localized, burning pain and paresthesia along the plantar surface of foot and toes. Pain becomes worse after or during weight-bearing activities and improves with rest. (16) Pain is the most prominent symptom, which is localized directly over the medial malleolus with radiation to the longitudinal arch and plantar aspect of the foot including the heel. (13) Pain begins in the plantar part of the forefoot and extends to the toes. It is usually aggravated in the night due to the modification of foot posture that causes the posterior tibial nerve to be restrained or venous congestion. There is rarely motor weakness or atrophy of intrinsic foot muscles. (12) Common manifestations of tarsal tunnel syndrome is a positive Tinel’s sign and pain felt on provocation using passively maximally dorsiflexion and eversion of the ankle while all the metatarsophalangeal joints are performing dorsiflexion. They are held in this position for 5-10 seconds. Most common and objective symptom is a diminished sensation. (16)

Differential Diagnosis

When evaluating for Tarsal Tunnel Syndrome, in general you want to differential diagnosis between tarsal tunnel syndrome and lumbar radiculopathies and/or peripheral nerve injuries.

There are other differential diagnoses. They include polyneuropathy, radiculopathy, deep flexor compartment syndrome, Morton’s Metatarsalgia and plantar fasciitis. Plantar fasciitis is the most common and the most probably misdiagnosis. (18)

There are some studies about electrophysiological tests as a way to differentiate tarsal tunnel syndrome from compression of the first sacral nerve root. However false negative tests aren’t uncommon. (13)

Diagnostic Procedures

Diagnosis of tarsal tunnel syndrome includes subjective information, diagnostic testing including MRI, CT scans or x-rays and electro diagnostic studies. The physiotherapist can also do some tests to see what’s wrong with the foot (see physical therapy management).

The diagnosis of tarsal tunnel syndrome is a clinical diagnosis based on detailed medical history and clinical examination. Medical imagining and electrophysiological studies provide additional information. (13) The tests that the physician can perform are mostly provocative tests. When performing these tests the symptoms linked to tarsal tunnel syndrome can be registered. (14)

As seen in recent studies, diagnosis of tarsal tunnel syndrome can also be established by the following three indicators:
1. Pain in the heel, forefoot and mid-foot
2. Positive Tinel’s sign at the tarsal tunnel
3. Abnormal nerve conduction study of the medial plantar and lateral plantar nerve or any two combinations of the nerves. (15)

Examination

The physiotherapist can use a “Tinel’s Test” test to examine if there’s a problem with the nerve in the ankle. When this test is positive, it may be due to the entrapment of the nerve by surrounding tissues. (1) (9)

The “Tinel’s Test” is a specific test for the carpal tunnel syndrome. This syndrome is due to the compression of the median nerve in the carpal tunnel in the wrist. The “Tinel’s Test” can also be used to examine whether the tibial nerve is compressed in the ankle. (17)

This test is performed by taping over the nerve to promote a sensation of tingling or “pins and needles” along the nerve distribution in the ankle or in the wrist. It is positive when the patient feels tingling in the distal area due to the entrapment of the nerve. However, when the test is negative, the patient feels no pain. (17)

To examine whether there is a problem with the nerve, a physician can use palpation over the flexor retinaculum or Tinel's test. (18) Tinel's test is performed by taping the area below the medial malleolus. The test is positive when it results in tingling along the nerve distribution. (16)Alongside this test, the physiotherapist can use the “straight leg raise” test to provoke symptoms similar to a nerve problem. (6) Another test that can be use is a dorsiflexion-eversion test (fig4.), if the test is positive it may be due to the entrapment of the nerve in the tarsal tunnel. In this test the distal posterior tibial nerve is stretched and compressed. Diagnosis of tarsal tunnel syndrome is largely clinical. This test can only give a suspicion of tarsal tunnel syndrome.

The dorsiflexion-eversion test and the inversion test may both increase symptoms. When performing dorsiflexion and eversion of the foot, tension is applied on the nerve. The volume of the tarsal tunnel is decreased when inversion of the foot is been performed. This shows that either of these tests can reproduce pain or increase the symptoms. (18)

In 2012 there has been a research for a more specific test; this was also a provocative test, called the triple compression stress test. This test can be used to have a more objective diagnose of tarsal tunnel syndrome. The test had 85.9% sensitivity and 100% specificity. The test is performed by bringing the foot passively in full plantar flexion (A), in inversion (B) and applying an even and constant digital pressure over the posterior tibial nerve for 30s (C). This test is positive when symptoms are reported. (14)

Outcome Measures

Outcome measures for Tarsal Tunnel Syndrome could include the foot and ankle mobility measure (FAAM) (10) or the Rating Scale for the Severity of Tarsal Tunnel Syndrome (table 2) (9). There is also a rating scale for tarsal tunnel syndrome to determine the severity of the syndrome..

Symptom:                                                  Absent                Some                   Definite

Pain, spontaneous or on movement                  2                         1                           0
Burning pain                                                   2                         1                           0
Tinel sign                                                       2                         1                           0
Sensory disturbance                                       2                         1                           0
Muscle atrophy or weakness                           2                         1                           0

 

Table 2: rating scale for severity of tarsal tunnel syndrome(9)
(A normal foot scores 10 points)

According to a recent study, an anatomic pain intensity scale may be useful in treatment evaluation, documentation and follow-up assessment of treatment outcome in tarsal tunnel syndrome. (15)

Management / Interventions
Non-operative interventions include non-steroidal anti-inflammatory agents, local steroid injections, physical therapy, and foot orthotics. However, if the patient does not respond to non-operative treatment, then posterior tibial nerve decompression is performed. Outcomes after surgical removal of space occupying lesions, such are ganglion cysts, are usually good, although a 17% recurrence during long-term follow-up despite complete surgical resection has been reported.

Medical Management

Non-operative interventions or conservative managements include non-steroidal anti-inflammatory agents, local steroid injections, physical therapy, and foot orthotics. However, if the patient does not respond to non-operative treatment, then posterior tibial nerve decompression is performed.
Outcomes after surgical removal of space occupying lesions, such are ganglion cysts, are usually good, although a 17% recurrence during long-term follow-up despite complete surgical resection has been reported.

Non-operative treatment of tarsal tunnel syndrome can be non-steroidal anti-inflammatory medication and local anti-inflammation salve such as zostrix, rodlen labs. Vernon hills combined with night time plantar neutral-immobilization brace. (15) (1B)

Another non-operative treatment is the use of immobilisation with a night splint or a removable boot walker. Aspiration of the ganglia can provide a temporary benefit and corticosteroid injections. (13)(2A)

Surgical management can consist of posterior tibial nerve decompression and cryosurgery.
After surgery, post-surgical physical therapy will be needed. This is only performed when the non-operative management doesn’t work. (18)

Physical Therapy Management

Physiotherapeutic treatment: the therapist must give the patient advice on intensity of training, impact of terrain, building up mileage and spacing of training sessions.(7) The most modalities of the physiotherapeutic should be aimed at reducing oedema and scarring of the foot and ankle. They include application of ice after activity, laser, ultrasound and shortwave diathermy. These modalities may be successful with recently acquired symptoms but rarely help an established neuropathy. (7)
Because the highly associated valgus of the heel and pronated forefoot, a trail of medial arch support or medial heel wedge may be considered. Tight lacing of the shoes may exacerbate the problem. When edema is present, support hose may be useful. (7)

Physical therapy can include a variety of techniques such as taping, bracing, stretching, icing, massage and ultrasound. However, evidence in the literature of its effectiveness is lacking. (13)(2A)

Conservative treatment of tarsal tunnel syndrome in a recent study include rest, non-steroidal anti-inflammatory drugs, corticosteroid injections, extracorporeal shockwave therapy, laser, local anesthetic injections, heel pads and heel cups, night splints, medial longitudinal arch supports, strapping, foot-orthotics, soft-soled shoes, stretching of the Achilles tendon and plantar fascia, ultrasound and casting. Treatments are directed towards reducing pain, inflammation and tissue stress, also restoring muscle strength, flexibility, lower extremity mobility and restoring soft tissue mobility. (16)(1B)

There are different stages in treating this syndrome:

• Acute stage: Initially reduce inflammation, tissue stress and pain using physical agents,    orthotics devices and taping. Therapeutic exercise and manual therapy can also be use.
• Sub-acute stage: Improve strength and flexibility of posterior tibialis muscle.
• Settled stage: Improve functional mobility, strength in weight bearing and flexibility bilaterally in  the posterior tibialis muscle. (18)

Key Research

add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)

A rare case of an accessory flexor hallucis longus causing tarsal tunnel syndrome. (11)
Tarsal tunnel syndrome in a patient on long-term peritoneal dialysis: case report. (12)

Resources

Foot and Ankle Surgery

Clinical Bottom Line

A variety of intrinsic and extrinsic factors can cause the entrapment and compression of the posterior tibial nerve which leads to Tarsal Tunnel Syndrome.
Currently, conservative and surgical interventions are used to treat Tarsal Tunnel Syndrome. These interventions pose minimal complications and positive outcomes.
Nevertheless, the prognosis is still dependent on identifying the mechanism of the peripheral nerve compression and the influence of comorbidities. (18)

Recent Related Research (from Pubmed)

Tarsal tunnel syndrome and flexor hallucis longus tendon hypertrophy.
1. Mark Harries, Clyde Williams, William D. Stanish and Lyle J. Micheli. Oxford textbook of sports medicine. Great Britain : Butler & Tanner ltd., frame, 2000, pp. 699-700.(B)
2. Diagnosing heel pain in adults. Aldridge, Tracy. 2004, Southern Illinois University School of Medicine, pp. 332-338.(B)
3. Treatment of hyperesthetic neuropathic pain in diabetics decompression of the tarsal tunnel. T. Jeffery Wieman, M.D., F.A.C.S., and Vijaykumar G. Patel, M.D., F.R.C.S. 1995, ANNALS OF SURGERY, pp. 660-665.(B)
4. Baldassarre, A. E. The foot as microcosm and macrocosm. reflessologia. [Online] [Citaat van: 3 November 2010.] http://www.reflessologia.it/libro_eng_chapter1b.htm.(C)
5. Hilversum, Nederlandse Vereniging van Podotherapeuten in. Ziektebeelden tarsaal tunnel syndroom. podotherapie. [Online] [Citaat van: 3 November 2010.] http://www.podotherapie.nl/pages/LSShowElementsPage_v2.asp?ListID=134&elemid=2769&articleid=131348:131352&token=110267653@LcaNiiNaOadMcgPa.(B)
6. Division of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, QLD 4072 St. Lucia, Australia. Strain and excursion of the sciatic, tibial, and plantar nerves during a modified straight leg raising test. pubmed. [Online] [Citaat van: 16 november 2010.] http://www.ncbi.nlm.nih.gov/pubmed/16838375.(A)
7. Evidence of Validity for the Foot and Ankle Ability Measure (FAAM). Martin, RobRoy L., et al., et al. Pittsburgh : American Orthopaedic Foot & Ankle Society, Inc., 2005.(A)
8. Reid, David C. Sport injury assensment and rehabilitation. United States of America : Churchill livingstone, 1992, pp. 260-262.(B)
9. Tarsal tunnel syndrome caused by ganglia. M. Nagaoka, K. Satou. 1998, The journal of bone & joint surgery (Br), pp. 607-610.(B)
10. Tarsal tunnel syndrome causes and results. YOSHINORI TAKAKURA, CHIKARA KITADA, KAZUYA SUGIMOTO,YASUHITO TANAKA, SUSUMU TAMAI. Japan : British Editorial Society of Bone and Joint Surgery, 1991.(A)

11. Lin D, Williams C and Zaw H. A rare case of an accessory flexor hallucis longus causing tarsal tunnel syndrome. Foot Ankle Surg 20: e37-e39, 2014 http://www.footanklesurgery-journal.com/article/S1268-7731(14)00030-7/abstract (3B)
12. Ozdemir O, Calisaneller T, Sonmez E and Altinors N. Tarsal tunnel syndrome in a patient on long-term peritoneal dialysis: case report. Turk Neurosurg 17: 283-285, 2007. http://www.turkishneurosurgery.org.tr/pdf/pdf_JTN_540.pdf (3B)
13. Ahmed, M. , Tsang, K. , Mackenney, P.J. and Adedapo, A.O. Tarsal tunnel syndrome: A literature review. Elsevier , 3, 2012, 149-152. http://www.footanklesurgery-journal.com/article/S1268-7731(11)00122-6/abstract (2A)
14 Abouelela, A.A., Zohiery, A.K. The triple compression test for diagnosis of tarsal tunel syndrome. Elsevier The Foot, 3, 2012, 146-149. http://www.thefootjournal.com/article/S0958-2592(12)00020-X/abstract (2B)
15. William H. Gondring M.D., Elly Trepman M.D, Byron Shields B.S. Tarsal tunnel syndrome: Assessment of treatment outcome with an anatomic pain intensity scale, Foot and Ankle Surgery 15, 2009 133-138 http://www.footanklesurgery-journal.com/article/S1268-7731(08)00117-3/abstract (1B)
16. Yasemin Kavlak, PT, PhD and Fatma Uygur, Effects of Nerve Mobilization Exercise as an Adjunct to the Conservative Treatment For Patients With Tarsal Tunnel Syndrome, Journal of Manipulative and Physiological Therapeutics, September 2011 volume 34 number 7 http://linkinghub.elsevier.com/retrieve/pii/S0161-4754(11)00125-4 (1B)
17. http://www.physio-pedia.com/Tinel%E2%80%99s_Test

References

Kinoshita M, Okuda R, Yasuda T and Abe M. Tarsal Tunnel Syndrome in Athletes. Am J Sport Med. 2006;34:1307-1312.
Takakura Y, Kitada C, Sugimoto K, Tanaka Y, Tamai S. Tarsal Tunnel Syndrome: Causes and Results of operative treatment. J Bone Joint Surg [Br]. 1991;73-B:125-8.
Erikson SJ, Quinn SF, Kneeland JB et al. MRI Imaging of the Tarsal Tunnel and Related Spaces: Normal and Abnormal Findings with Anatomical Correlation. AJR. 1990;155:323-328.
Low HL and Stephenson G. These boots weren't made for walking: Tarsal Tunnel Syndrome. CMAJ. 2007;176 (10):1415-1416. (9)

Brandon Plyler, Maiela Martinez, Caleb Melde, Matt Gieringer. Tarsal Tunnel Syndrome: A Clinical Management Guideline. Texas State University, Department of Physical Therapy. August 2012.
http://ptcoop.org/wp-content/uploads/2012/08/TTS-CMG.pdf (18)
http://www.wiscboneandjoint.com/services/foot-ankle-conditions/tarsal-tunnel-syndrome (19)