Tarsal Tunnel Syndrome

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Definition/Description

Tarsal tunnel syndrome results when the posterior tibial nerve is compressed within the tarsal tunnel (similar with the carpal tunnel syndrome in the wrist).

Clinically Relevant Anatomy

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.

Epidemiology /Etiology

Etiology of Tarsal tunnel syndrome
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                                                         post-traumatic edema
Pes planus                                                                  post-traumatic adhesions

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

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. 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.) Valgus of the foot and the ankle.(fig2.) (5).

Clinical Presentation

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. The symptoms occur mainly in the evenings and at night, especially after prolonged standing and walking. In the morning there are only few complaints

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.

Diagnostic Procedures

Diagnosis of tarsal tunnel syndrome includes subjective information, diagnostic testing including MRI, CT scans or x-rays and electrodiagnostic studies.

The physiotherapist uses a “tinel’s sign” 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 a entrapment of the nerve by surrounding tissues.

Alongside this test, the physiotherapist can use a “straight leg raise” test to be sure it’s a nerve problem. (6)

They can also do a dorsiflexion-eversion test (fig4.), if the test is positve it may be the cause of the intrapment of the nerve in the tarsal tunnel. In this test the distal posterior tibal nerve is stretcht and compresed. If the patient has pes planus it increase a abduction of the forefoot and a valgus deviation of the hindfoot. Thereby increasing tension on the tibial nerve. This is a commen cause of tarsal tunnel syndrome.

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

To examine tarsal tunnel syndrome, Tinel’s sign is often used to make the diagnosis. Tinel’s sign is when two fingers are used to tap the medial ankle just behind the malleolus medialis. When the patient feels an electric shock sensation the test is positive and indicates the location of the entrapment. The posterior tibial nerve splints into three branches at the level of the medial ankle, a Tinel’s sign may be positive for all three branches or just one isolated branch. Two common areas of entrapment are found as the posterior tibial nerve passes beneath the lacinate ligament and/or the upper margin of the abductor hallucis muscle.

Outcome Measures

Outcome measures for Tarsal Tunnel Syndrome could include the FAAM or the Rating Scale for the Severity of Tarsal Tunnel Syndrome (as above).

Management / Interventions

Nonoperative interventions include non-steroidal anti-inflammatory agents, local steroid 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.

Treatment of physiotherapeutic: 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 edema and scarring of the foot and ankle. The 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)

Medical Management

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

Stretching exercises for improving the flexibility in the calf muscles and encouraging the tibial nerve to glide within the tarsal tunnel may also benefit the patient when suffering from tarsal tunnel syndrome.

Key Research

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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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.

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.
2. Diagnosing heel pain in adults. Aldridge, Tracy. 2004, Southern Illinois University School of Medicine, pp. 332-338.
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.
4. Baldassarre, A. E. The foot as microcosm and macrocosm. reflessologia. [Online] [Cited: November 3, 2010.] http://www.reflessologia.it/libro_eng_chapter1b.htm.
5. Hilversum, Nederlandse Vereniging van Podotherapeuten in. Ziektebeelden tarsaal tunnel syndroom. podotherapie. [Online] [Cited: November 3, 2010.] http://www.podotherapie.nl/pages/LSShowElementsPage_v2.asp?ListID=134&elemid=2769&articleid=131348:131352&token=110267653@LcaNiiNaOadMcgPa.
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] [Cited: november 16, 2010.] http://www.ncbi.nlm.nih.gov/pubmed/16838375.
7. Reid, David C. Sport injury assensment and rehabilitation. United States of America : Churchill livingstone, 1992, pp. 260-262.
8. Tarsal tunnel syndrome caused by ganglia. M. Nagaoka, K. Satou. 1998, The journal of bone & joint surgery (Br), pp. 607-610.