Tarsal tunnel syndrome, the lower extremity analogue of the far more common carpal tunnel syndrome in the wrist, is a condition that causes pain in the foot due to compression of the tibial nerve with the tarsal tunnel. The tarsal tunnel is located in the ankle behind the medial malleolus, superficial to the bones (calcaneus and talus) and covered by the flexor retinaculum. The posterior tibial nerve courses through the tarsal tunnel, and can be compressed there. When this nerve is compressed, presenting symptoms include localized tenderness or pain, numbness and paresthesia in the areas supplied by the posterior tibial nerve. Tarsal tunnel syndrome can caused by space occupying lesions (such as a ganglion cyst); it may also be caused by deformities of the foot and ankle that decrease the volume of the tarsal tunnel (or stretch the nerve itself). Except in the case of a defined space-occupying lesion, treatment is almost always non-operative.
Structure and function
The tarsal tunnel is the space located posterior and inferior to the medial malleolus; lateral to the calcaneus and talus, and medial to the flexor retinaculum.
The contents of the tarsal tunnel, from anterior to posterior, include the tibialis posterior tendon, the flexor digitorum longus tendon, the posterior tibial artery, tibial nerve, and flexor hallucis longus (Figure 1). The tibial nerve divides within the tarsal tunnel into the calcaneal nerve coursing towards the heel and the medial and lateral plantar nerves which supply the bottom of the foot.
The flexor retinaculum ensures that the contents of the tunnel remain in it, but of course subjects these contents to compression if the space is reduced.
Tarsal tunnel is thought to differ from carpal tunnel syndrome in that in the ankle, direct extrinsic compression is less often the cause. Rather, repetitive traction, causing scarring of the segment of the nerve within the tarsal tunnel, can the source of symptoms. Of course, extrinsic compression from a bone spur or a ganglion, or synovial proliferation from a tendon disorder (as might be seen in the wrist as well) can be a cause as well.
As pressure increases with the tarsal tunnel, blood flow decreases and the nerve becomes ischemic. Malfunction of the nerve, in turn, yield the presenting symptoms of tingling and numbness.
Patients with tarsal tunnel syndrome typically complain of numbness in the foot radiating to the big toe and the first 3 toes, pain, burning, electrical sensations, and tingling over the base of the foot and the heel. A broader area of symptoms suggest either nerve entrapment proximal to the tarsal tunnel, or a generalized neuropathy.
Because even slight amounts of increased fluid in the tarsal tunnel (edema) can cause a critical decrease in blood flow (perfusion), patients may report that prolonged standing and walking, causing a gravity-related accumulation of fluid, makes their symptoms worse.
Compression of the tibial artery may cause ischemia to the intrinsic muscles of the foot with painful cramping accordingly.
On physical examination, patients will often have a flat foot.
Palpation over the tarsal tunnel will produce localized pain (tenderness) as well as a radiation into the sole of the foot. This latter sensation is called a “Tinel’s sign”, though of course it is not a true sign but a provoked and seemingly specific symptom. (Such symptoms, that are highly specific though still not objective signs, may be designated “wigns”–a whined sign, so to speak. www.ncbi.nlm.nih.gov/pubmed/19557488)
Sensory examination of the foot may reveal some decreased sensation on the sole of the foot, although in most patients this is not the case.
Muscle atrophy and claw-toe deformities suggest chronic compression.
The physical exam should concentrate not only on establishing or excluding tarsal tunnel syndrome, but also conditions on the differential diagnosis (see below). Thus, a complete neurovascular exam is mandatory.
Nerve conduction studies will often show a decreases in conduction velocity in the tibial nerve precisely as it courses under the flexor retinaculum.
Weightbearing x-rays of the foot should be assessed to exclude fractures and bone spurs, as well as malalignment (for example, hindfoot varus or valgus) that can alter the geometry of the tarsal tunnel.
CT scans, ultrasound or MRI might be needed to rule out space-occupying lesions within the tarsal tunnel. These include ganglions, lipomas, or (rarely) accessory muscles within the tarsal tunnel. Detection of a mass is critical, as unless and until it is removed, the patient is unlikely to improve. (By contrast, without a mass, surgery is rarely indicated.)
The true incidence of tarsal tunnel syndrome is difficult to determine given that the condition may be mistakenly labeled under some other heading. The National Institutes of Health’s website on rare diseases says “The incidence and prevalence of tarsal tunnel syndrome is unknown.” (https://rarediseases.info.nih.gov/diseases/7733/tarsal-tunnel-syndrome) Of course, the very fact that tarsal tunnel syndrome is considered by the NIH to be “rare” means that affects fewer than 200,000 people in the United States.
The differential diagnosis of tarsal tunnel syndrome can be consider to have two components. The first is the true differential diagnosis–that is, the list of condition that may instead be responsible for a presentation similar to that of tarsal tunnel syndrome. Beyond that, once the diagnosis is established, there is a second differential diagnosis list to consider, namely, the other conditions that may be responsible for causing the tarsal tunnel syndrome itself.
In the first category, the main considerations are lumbar radiculopathy and peripheral neuropathy (most often caused by diabetes). A complex regional pain syndrome (formerly known as Reflex Sympathetic Dystrophy) could be responsible as well, though the finding would almost certainly not be limited to the tibial nerve.
Conditions that may be the cause of tarsal tunnel syndrome include trauma (fracture fragments causing compression or ligament injury causing instability and traction on the nerve); space occupying lesions such as ganglion cyst, benign tumors, swollen tendons or varicose veins; ankle deformities such as pes planus (flat foot).
There are no true “red flags” with tarsal tunnel syndrome, though the presentation of tarsal tunnel syndrome-like complaints may be the first sign of otherwise undetected diabetes, peripheral artery disease or disc herniation/spinal stenosis.
Treatment options and outcomes
If patient has confirmed tarsal tunnel syndrome caused by a space-occupying lesion, that offending structure should be removed. Beyond that, the vast majority of patients with tarsal tunnel syndrome can (and should) be treated non-operatively. Only with prolonged failure of non-operative treatment in a patient with positive nerve conduction studies and severe symptoms should surgical release be considered.
The primary approach to treating this condition is to attempt to decrease the repetitive traction injury across the nerve and the other structures in this area of the foot. In this regard, treatment is quite similar to that for acquired adult flatfoot deformity and plantar fasciitis.
Comfort shoes designed to disperse the force more evenly across the foot can be very helpful. Weight loss should be recommended to patients who need it, though the futility of most weight loss programs should temper the enthusiasm (and scolding tone) of the recommender.
A prefabricated orthotic with a supportive arch will help to disperse the force more evenly across the foot may also be helpful.
Physical therapy to establish exercise program characterized by appropriate fitness and stretching exercises, as well as some localized massage to help desensitize the area and perhaps breakdown scar may be of some benefit. Stretching exercises designed to stretch the calf muscle and thereby indirectly decrease the load through this area of the foot may also be helpful.
Limiting the patients walking can reduce symptoms but may impede weight loss (and be impractical for other reasons. It may be more effective to suggest limited standing, an activity which can produce symptoms with fewer health benefits than those involving motion.
Corticosteroid injections may help to decrease the swelling around the nerve in the short and intermediate term. However, it is unclear what effect they have in the long term. In addition it is possible to injure the nerve during the injection process.
Primary resection of space occupying lesions causing isolated tarsal tunnel syndrome can relieve symptoms reliably (as long as the nerve is neither scarred nor damaged prior to surgery). Beyond that, operative treatment includes tarsal tunnel release and other procedures to correct deformity causing compression may be used.
Tarsal tunnel release comprises release of the flexor retinaculum and neurolysis of the tibial nerve and its branches. The latter includes removal of scar tissue, if any, as well as fascial releases.
There is limited evidence that surgery is effective. One study in the Journal of Bone and Joint Surgery [https://www.ncbi.nlm.nih.gov/pubmed/8056802] reported 44% good or excellent results a 38% incidence of patients “clearly dissatisfied with the result and had no long-term relief of the pain.” Complications were seen in 13% of patients as well, including three wound infections.
Risk factors and prevention
Tarsal tunnel syndrome is known to affect individuals that stand a lot. Strenuous activities involving repetitive eversion, inversion, and plantarflexion at high velocities can produce the symptoms of tarsal tunnel syndrome.
Obesity is a double risk factor in that weight alone can cause mechanical overload, but it is also associated with diabetes (which causes a neuropathy that may make the nerve less tolerant of even mild compression).
Rheumatoid arthritis, hypothyroidism and gout are thought to be associated with tarsal tunnel syndrome.
A helpful mnemonic for structures coursing through the tarsal tunnel (from anterior to posterior): “Tom, Dick, and very nervous Harry.” (Tibialis posterior tendon, flexor Digitorum longus tendon, posterior tibial Artery, posterior tibial Vein, tibial Nerve, flexor Hallucis longus tendon)
Tarsal tunnel, posterior tibial nerve, pes planus, plantar fasciitis, tarsal tunnel release
Perform a comprehensive history and physical that can identify tarsal tunnel syndrome as well as rival conditions on the differential diagnosis list. Recognize the deformities of the foot and ankle that may place undue traction on the posterior tibial nerve.
- need a nice, simplified view of the anatomy of the TT
Figure 2: Location of pain in patient presenting with tarsal tunnel syndrome.(from footeducation.com http://www.footeducation.com/wp-content/uploads/2010/08/tarsal-tunnel-syndrome-Figure-1-300x235.png)
Figure 3: MRI showing fluid-filled ganglion (arrow) that is compressing the posterior tibial nerve. (from footeducation.com http://www.footeducation.com/wp-content/uploads/2010/08/Figure-3-Tarsal-Tunnel-Syndrome-Ganglion-Panchbhavi-04-19-2014.png)