Tarsal Tunnel Syndrome
Original Editor - Staci Burns, Jonathan Blondeel
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Definition/Description[edit | edit source]
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Clinically Relevant Anatomy[edit | edit source]
The tarsal tunnel is a fibro-osseous tunnel formed by a number of bone structures and some muscles namely the talus, calcaneus, M. flexor digitorum longus and the M. flexor hallucis longus. This structures forming 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 deep to 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. It lies also posterior of the tibial artery and anterior to the M. flexor hallucis longus. Posteroinferior to the medial malleolus, it split into three nerves: the medial plantar nerve, the calcaneal nerve and the lateral plantar nerve. The make a curve around the medial malleolus into the foot. (1)
Epidemiology /Etiology[edit | edit source]
Tarsal Tunnel Syndrome occurs when there is an entrapment neuropathy of the tibial nerve. This entrapment could be caused by trauma that would cause inflammation or bleeding, hypertrophy of the flexor hallicus longus, space occupying lesions, or foot deformity. Space occupying lesions include tumors, talocalcaneal coalition, ganglion cyst, or an accessory muscle and/or bone. Flatfoot deformity in particular is also another causitive factor.
Clinical Presentation[edit | edit source]
Clinical features are burning pain at the medial malleolus radiating into the toes and sole and heel,along with paraethesia in the distrubution 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.
Differential Diagnosis
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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.
Diagnostic Procedures[edit | edit source]
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Diagnosis of tarsal tunnel syndrome includes subjective information, diagnostic testing including MRI, CT scans or x-rays and electrodiagnostic studies, a (+) tinel sign.
There is also a rating scale for tarsal tunnel syndrome to determine the severity of the syndrome.
The Rating Scale for the Severity of Tarsal Tunnel 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 |
(A normal foot scores 10 points)
Examination[edit | edit source]
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Outcome Measures[edit | edit source]
Outcome measures for Tarsal Tunnel Syndrome could include the FAAM or the Rating Scale for the Severity of Tarsal Tunnel Syndrome (as above).
Medical Management[edit | edit source]
Nonoperative interventions include non-steriodal anti-inflammatory agents, local steriod injections, physical therapy, and foot orthosis. 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.
Physical Therapy Management[edit | edit source]
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Key Research[edit | edit source]
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Resources
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Clinical Bottom Line[edit | edit source]
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Recent Related Research (from Pubmed)[edit | edit source]
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References[edit | edit source]
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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.
