What is Tarsal Tunnel Syndrome?
Tarsal tunnel syndrome is a foot condition caused by tibial nerve compression or compression of tibial nerve branches as the nerve passes under the flexor retinaculum in the ankle region. Tarsal tunnel syndrome typically presents with pain and numbness that radiates from the medial aspect of the ankle generally distally (Kuhn & Thomas, 2007).
What is the cause of tarsal tunnel syndrome?
There are many factors that can contribute to tarsal tunnel syndrome. The following may contribute to the development of tarsal tunnel syndrome:
· The posterior tibial nerve can be compressed by soft tissue masses, such as lipomas, tendon sheath ganglia, neoplasms, varicose veins, nerve sheath, and nerve tumors (Frey & Kerr, 1993).
· Bony prominences such as exostoses may contribute to tarsal tunnel syndrome (Frey & Kerr, 1993).
· Rearfoot valgus and abducted forefoot may contribute to the load on the tibial nerve and therefore increasing neuropathic symptoms (Daniels, Lau & Hearn, 1998).
· “The cause of tarsal tunnel syndrome can be identified in 60–80% of cases, the most common causes being trauma (17%), varicosities (13%), heel varus (11%), fibrosis (9%), and heel valgus (8%)” (Lau & Daniels, 1999).
What are the symptoms of tarsal tunnel syndrome?
Symptoms for tarsal tunnel syndrome include sharp pain, numbness, muscular atrophy resulting in motor issues, and gait abnormality such as limp and overpronation. Rearfoot valgus may initiate the symptoms of tarsal tunnel syndrome due to increased tension on the tendon (Daniels, Lau & Hearn, 1998).
Who is more likely to be affected by tarsal tunnel syndrome?
There have not been many studies on the exact incidence of tarsal tunnel syndrome (Lau & Daniels, 1999). There is a higher incidence of tarsal tunnel syndrome in women than men (Hudes K.,2010). There have been studies that link tarsal tunnel syndrome to Rheumatoid arthritis. (Baylan et al., 1981). There may also be a link between patients with lumbosacral radiculopathy and tarsal tunnel syndrome (Zheng et al., 2015). Pes planus and hyper pronation have been associated with tarsal tunnel syndrome, but prevalence is unclear (Hudes K., 2010). More research needs to be conducted into the epidemiology of tarsal tunnel syndrome.
What are other conditions that may commonly be confused with tarsal tunnel syndrome?
Plantar fasciopathy may present as similar to tarsal tunnel syndrome due to heel pain
Stress fractures such as calcaneal stress fractures may present with a sharp pain that is similar in location to tarsal tunnel syndrome
Peripheral neuropathies such as those caused by diabetes may present as tarsal tunnel syndrome due to localized numbness in the tarsal region and can be excluded by performing a neurological assessment such as testing proprioception, sensation, and vibration perception as well as assessing risk factors (Boulton et al., 1998).
How can I get a diagnosis of tarsal tunnel syndrome?
Book an appointment with our experienced podiatrists at Bondi Podiatry who can diagnose tarsal tunnel syndrome.
Tarsal tunnel syndrome can be diagnosed by identifying symptoms, risk factors in patient history and through clinical tests. One clinical test is called Tinel’s sign. When pressure is applied to the tibial nerve it will cause a tingling sensation and this would be a positive indicator of tarsal tunnel syndrome. Electromyography can detect nerve disfunction and an MRI can be used to identify if there is a structure impinging the nerve (Bailie & Kelikian, 1998).
How can I treat tarsal tunnel syndrome?
· Steroid injections into the tarsal canal can relieve pain caused by tarsal tunnel syndrome (Jackson & Haglund, 1991).
· Use of local anesthetic which can reduce pain in patients with tarsal tunnel syndrome. However additional nerve injury can occur if needles are placed incorrectly in the tarsal canal (Jackson & Haglund, 1991).
· Physical therapy can reduce soft-tissue edema to reduce pressure in the tarsal tunnel in addition to muscle strengthening exercises, such as exercises that target the posterior tibialis muscle (DiDomenico & Masternick, 2006).
· Foot orthoses and taping can reduce tension on the tibial nerve by reducing the load on the medial aspect of the door with a medial longitudinal posting to relieve symptoms of tarsal tunnel syndrome (DiDomenico & Masternick, 2006).
· Night splints can be used for valgus foot types and are commonly used in clinical practice in the treatment of tarsal tunnel syndrome, however, this treatment method has not shown to be a long-term solution (Hudes K., 2010).
· Surgery can be considered when conservative management fails to treat tarsal tunnel syndrome. Soft tissue and bony masses may require surgical removal to alleviate the symptoms of tarsal tunnel syndromes (Sammarco & Chang, 2003). Surgical decompression may have positive symptom-relieving results such as a decrease in pain and numbness for tarsal tunnel syndrome. However, symptoms may not subside completely due to a multifactorial cause and there is a risk of irreversible nerve damage. A study by Mann (1986) demonstrated that 75% of patients who have undergone decompression have relief from pain, and 25% have little or no relief. Repeated surgery for tarsal tunnel syndrome has not shown benefit. Surgical treatment has been found to reduce pain in the medial calcaneal and plantar nerve area, but not in the lateral plantar nerve region (Mann & Du Vries, 1986).
· Non-operative treatment has been documented to reduce pain after treatment for tarsal tunnel syndrome on a study of 46 patients using the Wong-Baker FACES Pain scale. Patients experienced significantly reduced pain in medial plantar and calcaneal and lateral plantar nerve regions (Gondring, Trepman & Shields, 2009) (NHMRC: Level III-3).
· Neurolysis of the nerve can be considered as a treatment modality for tarsal tunnel syndrome if adhesions or scarring is the cause of nerve impingement or in the case of failed surgery (Barker, Rosson & Dellon, 2008) (NHMRC: Level III-2). More research needs to be conducted as there is limited high-level evidence to guide the clinical management of tarsal tunnel syndrome (DiDomenico & Masternick, 2006).
What is the long-term outlook (prognosis) for tarsal tunnel syndrome?
If treated, the symptoms of tarsal tunnel syndrome can be resolved within months. However, more research needs to be conducted in the diagnosis, management, and prognosis of tarsal tunnel syndrome. A conservative management approach is recommended; however, surgery is most successful within the first twelve months of the onset of tarsal tunnel syndrome (Sammarco & Chang, 2003). If surgery fails or there are issues such as adhesions, neurolysis is a treatment option for tarsal tunnel syndrome (Barker, Rosson & Dellon, 2008).
We treat feet from all over Sydney, particularly the Eastern Suburbs. As podiatrists in Bondi Junction, we are happy to treat anyone that comes to our Sydney clinic. Our local area includes Bondi Junction, Bondi, Bondi Beach, North Bondi, Rose Bay, Tamarama, Coogee, Randwick, Bellevue Hill, Dover Heights, Vaucluse, and Edgecliff.
References:
Bailie, D., & Kelikian, A. (1998). Tarsal Tunnel Syndrome: Diagnosis, Surgical Technique, and Functional Outcome. Foot & Ankle International, 19(2), 65-72. doi: 10.1177/107110079801900203
Barker, A., Rosson, G., & Dellon, A. (2008). Outcome of Neurolysis for Failed Tarsal Tunnel Surgery. Journal Of Reconstructive Microsurgery, 24(2), 111-118. doi: 10.1055/s-2008-1076086
Baylan, S., Paik, S., Barnert, A., Ko, K., Yu, J., & Persellin, R. (1981). PREVALENCE OF THE TARSAL TUNNEL SYNDROME IN RHEUMATOID ARTHRITIS. Rheumatology, 20(3), 148-150. doi: 10.1093/rheumatology/20.3.148
Boulton, A., Gries, F., & Jervell, J. (1998). Guidelines for the diagnosis and outpatient management of diabetic peripheral neuropathy. Diabetic Medicine, 15(6), 508-514. doi: 10.1002/(sici)1096-9136(199806)15:6<508::aid-dia613>3.0.co;2-l
Brukner, P., & Khan, K. (2012). Brukner and Khan’s Clinical Sports Medicine (4th ed.).
Daniels, T., Lau, J., & Hearn, T. (1998). The Effects of Foot Position and Load on Tibial Nerve Tension. Foot & Ankle International, 19(2), 73-78. doi: 10.1177/107110079801900204
DiDomenico, L., & Masternick, E. (2006). Anterior Tarsal Tunnel Syndrome. Clinics In Podiatric Medicine And Surgery, 23(3), 611-620. doi: 10.1016/j.cpm.2006.04.007f
Frey, C., & Kerr, R. (1993). Magnetic Resonance Imaging and the Evaluation of Tarsal Tunnel Syndrome. Foot & Ankle, 14(3), 159-164. doi: 10.1177/107110079301400309
Gondring, W., Trepman, E., & Shields, B. (2009). Tarsal tunnel syndrome: Assessment of treatment outcome with an anatomic pain intensity scale. Foot And Ankle Surgery, 15(3), 133-138. doi: 10.1016/j.fas.2008.10.003
Haro, H. (2014). Translational research of herniated discs: current status of diagnosis and treatment. Journal Of Orthopaedic Science, 19(4), 515-520. doi: 10.1007/s00776-014-0571-x
Hudes K. (2010). Conservative management of a case of tarsal tunnel syndrome. The Journal of the Canadian Chiropractic Association, 54(2), 100–106.
Jackson, D., & Haglund, B. (1991). Tarsal tunnel syndrome in athletes. The American Journal Of Sports Medicine, 19(1), 61-65. doi: 10.1177/036354659101900110
Kuhn, H., & Thomas, M. (2007). Biomechanical Evaluation of Two Clinical Tests for Plantar Heel Pain: The Dorsiflexion-Eversion Test for Tarsal Tunnel Syndrome and the Windlass Test for Plantar Fasciitis. Fuß & Sprunggelenk, 5(3), 227. doi: 10.1016/s1619-9987(08)60426-2
Lau, J., & Daniels, T. (1999). Tarsal Tunnel Syndrome: A Review of the Literature. Foot & Ankle International, 20(3), 201-209. doi: 10.1177/107110079902000312
Sammarco, G., & Chang, L. (2003). Outcome of Surgical Treatment of Tarsal Tunnel Syndrome. Foot & Ankle International, 24(2), 125-131. doi: 10.1177/107110070302400205
Thomas, J., Christensen, J., Kravitz, S., Mendicino, R., Schuberth, J., & Vanore, J. et al. (2010). The Diagnosis and Treatment of Heel Pain: A Clinical Practice Guideline–Revision 2010. The Journal Of Foot And Ankle Surgery, 49(3), S1-S19. doi: 10.1053/j.jfas.2010.01.001
Zheng, C., Zhu, Y., Jiang, J., Ma, X., Lu, F., Jin, X., & Weber, R. (2015). The prevalence of tarsal tunnel syndrome in patients with lumbosacral radiculopathy. European Spine Journal, 25(3), 895-905. doi: 10.1007/s00586-015-4246-x