Tarsal Tunnel Syndrome

What is Tarsal Tunnel Syndrome

Tarsal tunnel syndrome is a condition that happens when a nerve (tibial nerve) is irritated or squeezed (compressed) as it passes through an area on the inside of your ankle (tarsal tunnel).

The tarsal tunnel is a narrow passage through the connective tissue and bones in your feet (tarsals). The tibial nerve passes behind the large bony bump at your inner ankle (medial malleolus) and sends branches to your foot and toes.

This nerve helps supply feeling to your heel, to the bottom of your foot, and to some of your toe muscles.

Tarsal tunnel syndrome occurs when there is entrapment neuropathy of the posterior tibial nerve within the tarsal tunnel, which results in pain and paresthesia on the plantar side of the foot.

Any process that contributes to impingement or compression of the posterior tibial nerve as it passes through the tarsal tunnel can result in tarsal tunnel syndrome.

Common causes include tenosynovitis of the medial compartment tendons, ganglion cysts, nerve sheath tumors, and accessory muscles.

Tarsal tunnel syndrome usually causes ankle and foot pain that gets worse with activity.

What are the causes?

Tarsal tunnel syndrome can be caused by any condition that narrows the space in the tarsal tunnel.

Athletes may get tarsal tunnel syndrome from a fractured ankle or from an outward (eversion) ankle sprain that results in scarring or swelling. Other common causes include:

• Over-pronation. This is when your feet roll in and flatten too much when you stand, walk, or run.
• Extra pressure on the tarsal tunnel area from tight or stiff shoes or boots.
• Decreased room in the tarsal tunnel due to small, fluid-filled sacs (cysts) or growths on the bones near the tunnel (exostosis).

The tarsal tunnel syndrome occurs when the posterior tibial nerve is compressed at the flexor retinaculum, located posterior and inferior to the medial malleolus. Patients often have a burning dysesthesia of the toes and sole of the foot that extends proximally to the medial malleolus and is often improved by walking.

A positive Tinel’s sign (obtained by percussing posterior to the medial malleolus) and a positive tourniquet test (applying pressure over the flexor retinaculum) will often reproduce the symptoms.

Holding the ankle for 10 seconds in dorsiflexion and eversion will also exacerbate symptoms.

This occurs more often in women and is associated with trauma, fracture, valgus deformity, hypermobility, inflammatory arthritis (up to 25% of patients with RA), diabetes, and occupational factors.

Treatment consists of antiinflammatory medications, local steroid injection, and orthotics. Surgical release is indicated when conservative measures fail.

What increases the risk?

This condition is more likely to develop in people who:

• Play sports where they wear high, stiff boots, such as downhill skiing.
• Play sports with repetitive motion, such as running.
• Play sports on uneven surfaces that can lead to a sprained ankle, such as soccer or football.
• Have had an inner ankle injury.
• Have flat feet.
• Have a condition such as diabetes, hypothyroidism, or rheumatoid arthritis.

What are the symptoms of Tarsal Tunnel Syndrome?

Symptoms of Tarsal Tunnel Syndrome include:

• Burning pain behind the ankle, in the heel, or in the foot that gets worse if you are standing, walking, or running.
• Numbness or a tingling sensation (pins and needles) in your heel, foot, or toes.

At first, your symptoms may get worse with activity and be relieved with rest. Over time, your symptoms may become constant or come on sooner with less activity.

How is Tarsal Tunnel Syndrome diagnosed?

Tarsal Tunnel Syndrome is diagnosed based on your symptoms, medical history, and physical exam. During the exam, your health care provider may tap on the area below your ankle to check for tingling in your foot or toes. Your health care provider may also inject numbing medicine into the tarsal tunnel to see if it relieves your pain. You may also have other tests, including:

• X-rays to check bone structure.
• MRI or ultrasound to examine nerve and tendon structures and find where your nerve is getting compressed.
• An electrical study of nerve function (electromyography, or EMG).

How is Tarsal Tunnel Syndrome treated?

Treatment of Tarsal Tunnel Syndrome may include:

• Wearing a removable splint or boot for ankle support.
• Using a shoe insert (orthotic) to help support your arch.
• Using ice to reduce swelling.
• Taking pain medicine.
• Having medicine injected into your ankle joint to reduce pain and swelling.
• Starting range-of-motion exercises and strengthening exercises.
• Gradually returning to full activity. The timing will depend on the severity of your condition and your response to treatment.

You may need surgery if there is a soft tissue growth or a bone growth, or if other treatments have not helped. After surgery, you may need to wear a removable splint or boot for support. You also may need physical therapy.

Follow these instructions at home:

If you have a splint or boot:

• Wear the splint or boot as told by your health care provider. Remove it only as told by your health care provider.
• Loosen the splint or boot if your toes tingle, become numb, or turn cold and blue.
• If your splint or boot is not waterproof:
  • Do not let it get wet.
  • Cover it with a watertight covering when you take a bath or shower.
• Keep the splint or boot clean.

Managing pain, stiffness, and swelling

• If directed, put ice on the injured area.
  • Put ice in a plastic bag.
  • Place a towel between your skin and the bag.
  • Leave the ice on for 20 minutes, 2–3 times a day.
• Move your toes often to avoid stiffness and to lessen swelling.
• Raise (elevate) your foot above the level of your heart while you are sitting or lying down.

Driving

• Ask your health care provider when it is safe to drive if you have a splint or boot on a foot that you use for driving.
• Do not drive or operate heavy machinery while taking prescription pain medicine.

Activity

• Return to your normal activities as told by your health care provider. Ask your health care provider what activities are safe for you.
• Do exercises as told by your health care provider.

General instructions

• Do not use any tobacco products, such as cigarettes, chewing tobacco, and e-cigarettes. Tobacco can delay healing. If you need help quitting, ask your health care provider.
• Take over-the-counter and prescription medicines only as told by your health care provider.
• Keep all follow-up visits as told by your health care provider. This is important.

How is Tarsal Tunnel Syndrome prevented?

• Give your body time to rest between periods of activity.
• Make sure to wear supportive and comfortable shoes during athletic activity.
• Do not over-tighten ski boots or the laces on high-top shoes.
• Be safe and responsible while being active to avoid falls.

Contact a health care provider if:

• Your ankle pain is not getting better.
• You are unable to support (bear) body weight on your foot without pain.

Tarsal Tunnel Syndrome Rehabilitation

Ask your health care provider which exercises are safe for you. Do exercises exactly as told by your health care provider and adjust them as directed. It is normal to feel mild stretching, pulling, tightness, or discomfort as you do these exercises, but you should stop right away if you feel sudden pain or your pain gets worse. Do not begin these exercises until told by your health care provider.

Stretching and range of motion exercises

These exercises warm up your muscles and joints and improve the movement and flexibility of your foot. These exercises also help to relieve pain, numbness, and tingling.

Exercise A: Gastrocnemius, standing

1. Stand with your hands against a wall.
2. Extend your left / right leg behind you, and bend your front knee slightly.
3. Keep your left / right heel on the floor and keep your back knee straight as you shift your weight toward the wall. Do this without arching your back. You should feel a gentle stretch in your back calf.
4. Hold this position for __________ seconds.
5. Return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

Exercise B: Tibial nerve glide

1. Sit on a stable chair with both feet on the floor.
2. Clasp your hands together behind your back. Gently round your back and tuck your chin toward your chest.
3. Position your left / right foot so your toes are tipped up toward your shin and aimed out to the side.
4. Slowly straighten your knee as far as you can without increasing your symptoms.
5. Hold this position for __________ seconds.
6. Slowly bend your left / right knee to return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

Strengthening exercises

These exercises build strength and endurance in your foot. Endurance is the ability to use your muscles for a long time, even after they get tired.

Exercise C: Plantar flexors

1. Sit on the floor with your left / right leg straight out in front of you.
2. Loop a rubber exercise band around the ball of your left / right foot. The ball of your foot is on the walking surface, right under your toes. Hold the ends of the band in your hands.
3. Slowly point your left / right toes downward, pushing them away from you.
4. Hold this position for __________ seconds.
5. Slowly return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

Exercise D: Ankle inversion

1. Sit on the floor with your legs straight out in front of you.
2. Loop a rubber exercise band around the ball of your left / right foot. The ball of your foot is on the walking surface, right under your toes. Hold the ends of the band in your hands or secure the band to a stable object.
3. Slowly push your foot inward, toward your other leg.
4. Hold this position for __________ seconds.
5. Slowly return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

Exercise E: Arch lifts (foot intrinsics)

1. Sit in a chair with your feet flat on the floor.
2. Keeping your big toe and your heel on the floor, lift only your arch, which is on the inner edge of your left / right foot. Do not move your knee or scrunch your toes. This is a small movement.
3. Hold this position for __________ seconds.
4. Slowly return to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.