Tarsal Tunnel Syndrome

What are Tarsals?

The short bones that form a bridge between medial malleolus (ankle) and metatarsals (forefoot) are called tarsals. Tarsal tunnel is the passage situated underneath the bony bit on the inner side of the medial malleolus. This passage facilitates the posterior tibial nerve to pass through it.

Tarsal Tunnel Syndrome (TTS) or Posterior Tibial Neuralgia

What is Tarsal Tunnel Syndrome (TTS) or Posterior Tibial Neuralgia?

In simple terms, compression of the posterior tibial nerve is known a tarsal tunnel syndrome or posterior tibial neuralgia. In other words, this is an entrapment neuropathy in which posterior tibial nerve is compressed due to overt pressure exerted on the nerves. At the time of walking or running, if the foot gets overpronated, then immense pressure is exerted on the nerves resulting in inflammation of the nerves. In most of the cases, both the feet can be affected by tarsal tunnel syndrome or posterior tibial neuralgia. This is because of overpronation in which both feet are involved.

In rare cases, we can find anterior tarsal tunnel syndrome. The term rare is used because very rarely the deep peroneal nerves, that are present at the front part of the ankle, are compressed resulting in anterior tarsal tunnel syndrome. Usually the symptoms are felt on top of the foot radiating down into first and second toes.

Symptoms of Tarsal Tunnel Syndrome (TTS) or Posterior Tibial Neuralgia

  • Pain with prolonged walking can be a symptom of tarsal tunnel syndrome or posterior tibial neuralgia.
  • Pain with jogging or running.
  • Symptoms of tarsal tunnel syndrome or posterior tibial neuralgia can also include burning pain that radiates into the toes, heel or foot.
  • Severe night time pain.
  • Worst pain with activities and less at rest.
  • When the nerve situated behind the medial malleolus is tapped, it produces pain.

In most of the cases, tarsal tunnel syndrome or posterior tibial neuralgia is mistaken by plantar fasciitis. This is because the pain is generated in both the cases from medial part of the heel. The symptoms that would defer between these usually are numbness and tingling sensation.

Causes of Tarsal Tunnel Syndrome (TTS) or Posterior Tibial Neuralgia

The Following Are Some Common Causes Of Tarsal Tunnel Syndrome or Posterior Tibial Neuralgia:

  • Tarsal tunnel syndrome or posterior tibial neuralgia occurs due to trauma or spontaneous injury.
  • Diabetes mellitus.
  • Rheumatoid arthritis.
  • Over usage.
  • Severe arthritis of the ankle joint can also cause tarsal tunnel syndrome or posterior tibial neuralgia.
  • Fusion of tarsal bones which is usually called talonavicular coalition.
  • Sports injuries.

Treatment Modalities of Tarsal Tunnel Syndrome (TTS) or Posterior Tibial Neuralgia

How Can An Athlete Take Care Of Tarsal Tunnel Syndrome or Posterior Tibial Neuralgia?

  • Athletes suffering from tarsal tunnel syndrome or posterior tibial neuralgia must restrain from further sports activities the moment he experiences pain.
  • If there is any swelling, then cold water fomentation should be done.
  • Take the help of physio if available on the site.
  • Consult Podiatrist immediately if pain and swelling persist.
  • Podiatrist may give a script for medicines or suggest orthotics if required. As a final option, the doctor may go for steroid injection.
  • Athletes suffering from tarsal tunnel syndrome or posterior tibial neuralgia should take rest for the period suggested by the doctor.

What Measures A Podiatrist Or A Sports Medicine Specialist Would Suggest to Treat Tarsal Tunnel Syndrome or Posterior Tibial Neuralgia?

Initially, the treating doctor would suggest conservative measures such RICE (rest, ice, compression, elevation) treatment for tarsal tunnel syndrome or posterior tibial neuralgia.

The athlete suffering from tarsal tunnel syndrome or posterior tibial neuralgia will be advised to refrain from any sports activities which can aggravate the symptoms.

Along with conservative treatment for tarsal tunnel syndrome or posterior tibial neuralgia, doctor may also suggest MRI/Nerve conduction studies or x-ray to further evaluate the structural conditions, any cyst formation, arthritic conditions, site of compression or entrapment, etc.

Based on the above-mentioned studies, it will be decided whether conservative treatment will suffice or surgical treatment is necessary to treat tarsal tunnel syndrome or posterior tibial neuralgia.

Surgical Treatment for Tarsal Tunnel Syndrome (TTS) or Posterior Tibial Neuralgia

If initial conservative measures do not resolve the pain symptoms associated with tarsal tunnel syndrome or posterior tibial neuralgia, as a final resort, surgery will be recommended by the doctor. Surgical treatment for tarsal tunnel syndrome or posterior tibial neuralgia includes decompression of the nerve in order to release the compressed soft tissue structures. This will open up the space in the compressed structure of the nerve. We can find mixed results of this type of surgery in which risk of complications is a bit high. Recovery time for tarsal tunnel syndrome or posterior tibial neuralgia after the surgery will defer from person to person, which vary from weeks to months.

How to Assess Tarsal Tunnel Syndrome?

  • Initially foot and ankle are observed.
  • What are the causes for pain and swelling? Such as overpronation, sports injury, excess stress, etc.
  • Tinel's test will be done as discussed earlier.
  • In case of tarsal tunnel syndrome or posterior tibial neuralgia, when the area around inner ankle bone i.e., medial malleolus is palpated, it will be tender.

Treatment and Rehabilitation Process for Tarsal Tunnel Syndrome or Posterior Tibial Neuralgia

  • Usually in any case, conservative treatment will be initiated. This would mainly include RICE treatment.
  • If swelling and pain associated with tarsal tunnel syndrome or posterior tibial neuralgia does not subside with RICE treatment, then the patient will be recommended to setup rehab program with physical therapist.
  • Depending upon the severity of tarsal tunnel syndrome or posterior tibial neuralgia, physical rehab program will be formulated.
  • Physical therapist would first work on reducing pain and inflammation caused due to tarsal tunnel syndrome or posterior tibial neuralgia.
  • Then, as tolerance increases, strengthening exercises will be given.
  • Most of the cases of tarsal tunnel syndrome or posterior tibial neuralgia do not require surgery, but specific and appropriate rehab program should be setup under the supervision of physical therapist or an instructor.
  • Returning to full unrestricted activities will be based on the recovery, tolerance, and strength of the foot.

How to Reduce Pain and Inflammation Associated with Tarsal Tunnel Syndrome or Posterior Tibial Neuralgia?

  • Initial treatment for tarsal tunnel syndrome or posterior tibial neuralgia would include RICE (rest, ice, compression, elevation).
  • Do not put any sort of pressure on the affected foot.
  • Give complete rest until the pain and swelling associated with tarsal tunnel syndrome or posterior tibial neuralgia subsides.
  • As the symptoms subside, modify activities by exchanging them will alternative activities such as instead of running switch to bicycling or swimming.
  • Use of medication as prescribed by the doctor.

How to Correct Biomechanical Dysfunction?

In case of athletes, they tend to exert excessive pressure while walking or running during which the foot tends to roll inward direction or overpronate. This may lead to tarsal tunnel syndrome or posterior tibial neuralgia. If proper treatment is not done assuming that taking rest will take care of everything, then tarsal tunnel syndrome or posterior tibial neuralgia may become worse leading to surgery. So getting the condition assessed by a doctor is very important. Doctor may suggest the following:

  • Foot orthotics.
  • Braces.
  • Crutches to keep the weight off of the foot.
  • Specially manufactured sports shoes.

Why Stretching And Strengthening Is Important For Early Recovery From Tarsal Tunnel Syndrome or Posterior Tibial Neuralgia?

One would always love to return to normal daily and customary activities after a break from injury causing tarsal tunnel syndrome or posterior tibial neuralgia. So, in order to resume normal activities, strength is very important. Very often, people will discontinue stretching and strengthening exercise once the pain and inflammation due to tarsal tunnel syndrome or posterior tibial neuralgia subsides assuming that all is well. This is not correct. One should be aware of the fact that strengthening exercises should be continued to avoid further damage to the structure. Usually, muscles of the leg (especially of the back) require strength to support bony structures. So, stretching exercises should be continued even after fully recovery from tarsal tunnel syndrome or posterior tibial neuralgia for at least a month or two. All supporting ligaments, tendons, and muscles should be considered at the time of performing exercises.

Keep Surgery as a Last Resort for Treating Tarsal Tunnel Syndrome or Posterior Tibial Neuralgia

In most of the cases, surgical treatment for tarsal tunnel syndrome or posterior tibial neuralgia can be avoided by taking appropriate initial conservative treatment. In cases where the injury or pain associated with tarsal tunnel syndrome or posterior tibial neuralgia is ignored for prolonged period of time, any further injury will lead to surgery. In some cases, where there is no response for conservative treatment after a specified period of time, surgery would be warranted. Surgery would be compulsory in cases where Tinel's sign and electrodiagnoistic studies are positive. After the surgery to treat tarsal tunnel syndrome or posterior tibial neuralgia, it would take a minimum of 4 to weeks for the symptoms to improve and 4-6 months to regain complete strength. In any case, physical rehabilitation would be very helpful in speeding up the recovery process.

Exercises for Tarsal Tunnel Syndrome (TTS) or Posterior Tibial Neuralgia

Some Common Stretching Exercises for Tarsal Tunnel Syndrome or Posterior Tibial Neuralgia:

It is very important to consult a doctor or physical therapist before performing any type of exercises mentioned below.

  • To get tightness in the muscles, stretch the calf muscle as frequent as possible.
  • When slight pressure is exerted on to the foot, then 90 degrees angle should be elicited without any difficulty or having to exert excessive force.
  • In case of soleus muscle, the same type of test is done, but knee is bent in this case.
  • Shortening of the large gastroc muscles can be done by bending knee.
  • Stretching of the gastroc muscle is done by placing the heel of the leg on the flat surface or floor and stretching in forward direction, hold this posture for 10-12 seconds and then release; repeat this 4-5 times. Perform this set of exercise at least three to four times a day. Then increase the holding duration to 30 seconds and increase thereupon as tolerated.
  • Stretch the soleus muscle by bending the leg at the knee, hold it and release it. Repeat it 3-4 times a day.
  • Stand on the edge of the step, making sure the heel is dropping downwards. Do this exercise gently and carefully. Stand in this posture for 10-15 sec and release, repeat 4-5 times. Repeat this set at least three to four times a day.
  • Stretching of the plantar fascia. Pull the big toe back towards your body, hold it for 20-30 sec, repeat it 4-5 times. Repeat this set for a minimum of 3-4 times in a day.
  • Rolling of plantar fascia. Rolling of the foot over a round object such as ball, bar, rolling pin or cylinder. In this exercise, pressure should be applied downwards and repeat the rolling process. Do not repeat if there is severe pain.
  • In case of tarsal tunnel syndrome caused due to overpronation, stretching of the overpronated muscle will be very effective. In this exercise, posterior tibial muscle will be strengthened.

Additional Exercises for Tarsal Tunnel Syndrome (TTS) or Posterior Tibial Neuralgia

  • Contraction of the posterior tibialis muscle without moving foot or ankle. Sitting on the flat surface and placing the ankle on the outer edge of the table leg or chair. Then ask someone to apply pressure or resistance with the hand. Then, you should press the foot inward trying to stop the resistance applied by the hand. Try to hold this for ten seconds, then rest, and repeat five to ten times, and three sets in a day. Increase repetitions depending on the tolerance.
  • A band is tied for resistance around the foot and the outer end of the ankle is attached to the rack. Turn the foot inwards opposing the band's resistance. Steadily revert back to the original state, hold/rest, and then restart the set again. Repeat it 10-15 times and a minimum of three sets in a day. Increase the repetitions depending on the tolerance.
  • To perform peroneal muscle exercise, help of physical therapist or any family members is required. Other person should push the foot in pronated position and patient should resist this motion, then slowly release it. Slowly increase the force and intensity of pronation as tolerated. This exercise needs supervision of a physical therapist initially.
  • Bearfoot walking, especially on toes. Just walk on tip of the toes. Repeat it as often as possible and increase the duration as tolerated.
  • Heel walk. This exercise will help in strengthening the calf muscles as well as foot muscles. Walk on heels for 30 seconds with around 10 sets. Increase the duration and repetitions as tolerated.

It is very important to perform any of the above-mentioned exercise under supervision of the doctor or physical therapist.

Written, Edited or Reviewed By:

, MD, FFARCSI

Last Modified On: September 17, 2016

Pain Assist Inc.

Pramod Kerkar
  Note: Information provided is not a substitute for physician, hospital or any form of medical care. Examination and Investigation is necessary for correct diagnosis.

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