Tarsal Tunnel Syndrome


Article Author:
John Kiel


Article Editor:
Kimberly Kaiser


Editors In Chief:
Donald Kushner
Annabelle Dookie


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
2/4/2019 4:01:25 PM

Introduction

Tarsal tunnel syndrome, sometimes referred to as tibial nerve dysfunction or posterior tibial nerve neuralgia, is an entrapment neuropathy that is associated with the compression of the structures within the tarsal tunnel. It is similar to carpal tunnel syndrome of the wrist although much less common.[1][2][3][4]

The tarsal tunnel is a narrow fibro-osseous space that runs behind and inferior to the medial malleolus. It is bounded by the medial malleolus anterosuperiorly, by the posterior talus and calcaneus laterally, and is held against the bone by the flexor retinaculum which extends from the medial malleolus to the medial calcaneus and prevents medial displacement of its contents.  

The tarsal tunnel includes multiple important structures. It contains the tendons of the posterior tibialis, flexor digitorum longus (FDL), and flexor hallucis longus (FHL) muscles. The posterior tibial artery and vein, as well as posterior tibial nerve (L4-S3), also pass through it. The orientation of these structures within the tarsal tunnel is noteworthy. From medial to lateral, they are the tibialis posterior tendon, FDL tendon, posterior tibial artery and vein, posterior tibial nerve, and FHL tendon.

The posterior tibial nerve passes between the FDL and FHL muscles before it bifurcates in the tarsal tunnel, forming the medial and lateral plantar nerves. In 5% of people, the bifurcation occurs before the tarsal tunnel. The medial plantar nerve passes deep to the abductor hallucis and FHL muscles and provides sensation to the medial half of the foot and first 3.5 digits and motor function to the lumbricals, abductor hallucis, flexor digitorum brevis, and flexor hallucis brevis. The lateral plantar nerve passes directly through the abductor hallucis muscle belly and provides sensory innervation of the medial calcaneus and lateral heel and motor function to the flexor digitorum brevis, quadratus plantae, and abductor digiti minimi. The medial calcaneal nerve typically branches off of the posterior tibial nerve proximal to the tarsal tunnel and provides sensory innervation to the posteromedial heel. In 25% of patients, it branches off of the lateral plantar nerve or runs superficial to the flexor retinaculum.

Etiology

Tarsal tunnel syndrome is divided into intrinsic and extrinsic etiologies.[5][6]

  • Extrinsic causes include poorly fitting shoes, trauma, anatomic-biomechanical abnormalities (tarsal coalition, valgus or varus hindfoot), post-surgical scarring, systemic diseases, generalized lower extremity edema, systemic inflammatory arthropathies, diabetes, and post-surgical scarring.
  • Intrinsic causes include tendinopathy, tenosynovitis, perineural fibrosis, osteophytes, hypertrophic retinaculum, and space-occupying or mass effect lesions (enlarged or varicose veins, ganglion cyst, lipoma, neoplasm, and neuroma). Arterial insufficiency can lead to nerve ischemia. 

The mechanism of impingement can be identified in approximately 80% of cases.

Epidemiology

The incidence of tarsal tunnel syndrome is unknown. It is a relatively rare and often underdiagnosed disease. It is higher in females than in males and can be seen at any age.

Pathophysiology

Tarsal tunnel syndrome results from the compression of the posterior tibial nerve or one of its two branches, the lateral or medial plantar nerve, within the tarsal tunnel. Up to 43% of patients have a history of trauma including events such as ankle sprains. Abnormal biomechanics can contribute to the disease progression. Risk factors include systemic diseases such as diabetes mellitus, hypothyroidism, gout, mucopolysaccharidosis, and hyperlipidemia.

History and Physical

There is no specific test for the diagnosis of tarsal tunnel syndrome, and diagnosis is made with a detailed history and clinical examination.

The predominant complaint is pain directly over the tarsal tunnel that radiates to the arch and plantar foot. Patients with tarsal tunnel syndrome will frequently report a sharp shooting pain in the foot, numbness on the plantar surface, radiation of pain and paresthesias along the distribution of the posterior tibial nerve, pain with extremes of dorsiflexion and eversion, and a tingling or burning sensation. These symptoms may localize to the medial ankle or plantar surface of the foot or be vaguer, making diagnosis difficult. Their symptoms will vary depending on whether the entire posterior tibial nerve is compressed or if it is the lateral or medial plantar branches. The symptoms may worsen at night, with walking or standing, or after physical activity, and typically get better with rest. Dysesthesias may worsen at night, disturbing sleep. The patient may note weakness in the muscles of the foot.

On exam, the provider may observe pes planus, pronated foot, or talipes equinovarus. In chronic cases, atrophy, weakness of the intrinsic foot muscles, and contractures of the toes may be appreciated. They are typically tender on deep palpation of the tarsal tunnel. The gait should be analyzed for abnormalities including excessive pronation or supination, toe eversion, excessive foot inversion or eversion, and antalgic gait.

Light touch and two-point discrimination should be tested. The patient may have diminished plantar sensation in the distribution of either the medial or lateral plantar nerve. Muscle strength and foot range of motion should be assessed. Strength deficits are typically a late finding in tarsal tunnel syndrome.

The Tinel test involves lightly tapping over the tarsal tunnel repeatedly. Pain or tingling in the distribution of the nerve is a positive test. Sensitivity is low at 25% to 75%; specificity is 70% to 90%. The dorsiflexion-eversion test involves passively dorsiflexing and everting the ankle to end range of motion and holding for 10 seconds. Reproduction of symptoms is a positive sign due to compression of the posterior tibial nerve in this position. This test is positive in 82% of patients with tarsal tunnel syndrome.

Tarsal Tunnel Syndrome Severity Rating Scale

A score of 10 indicates a normal foot and 0 indicates the most symptomatic foot.

  • Scoring for each symptom:
    • 2 points for the absence of features
    • 1 point for some features
    • 0 points for definite features
  • The five symptoms:
    • Spontaneous pain or pain with movement,
    • Burning pain
    • Tinel sign
    • Sensory disturbance
    • Muscle atrophy or weakness

Evaluation

Plain radiographs of the ankle and, possibly, the foot are the initial imaging study of choice. These may help identify any structural abnormalities including osteophytes, hindfoot varus and valgus, tarsal coalition, or evidence of previous trauma. MRI is not sensitive for the diagnosis of tarsal tunnel but may help include or exclude other causes of the patient's symptoms. Ultrasound can be used to evaluate the soft tissue structures. The nerve and its bifurcations can be observed. Either ultrasound or MRI can evaluate other soft tissue abnormalities including tendonitis or tenosynovitis, lipomas or other growths, varicose veins and ganglion cysts.[7]

Electromyography (EMG) and nerve conduction studies (NCS) are frequently abnormal in patients with tarsal tunnel syndrome. Sensory nerve conduction studies are more likely to be abnormal than motor nerve conduction studies; however, the sensitivity and specificity are suboptimal. False negative tests are not uncommon and thus do not rule out the diagnosis.

Treatment / Management

Management of tarsal tunnel syndrome remains challenging due to diagnostic uncertainty and lack of clarity over which patients would benefit from conservative versus surgical management. Tarsal tunnel syndrome can be managed nonoperatively or operatively. This decision is generally guided by the etiology of the disease, degree of loss of function of the foot and ankle, as well as muscle atrophy.[8][9]

Conservative management and success varies based upon the etiology of tarsal tunnel syndrome. The goal is to decrease pain, inflammation, and tissue stress. Ice can be used. Oral analgesics including acetaminophen and NSAIDs can be helpful. Neuropathic pain medications include gabapentin, pregabalin, and tricyclic antidepressants can be tried. Topical medications can also be used, including lidocaine and NSAIDs.

Physical therapy soft tissue modalities that may help include ultrasound, iontophoresis, phonophoresis, and E-stim. Calf stretching and nerve mobility or nerve gliding can also help with symptoms. Strengthening the tibialis posterior can help. Activity modification also plays a role in managing symptoms. Kinesiology tape can be used for arch support and biomechanical stress reduction.

Orthotic shoes can be used to correct biomechanical abnormalities and offload the tarsal tunnel. A medial heel wedge or heel seat may reduce traction on the nerve by inverting the heel. Night splinting can be tried, and patients who fail to respond to the above therapy can be placed in a walking boot temporarily. Footwear with appropriate arch support may help reduce symptoms. CAM (controlled, ankle, motion) walker or walking boots may be tried.

If a ganglion cyst is present, it can be aspirated under ultrasound guidance. Corticosteroid injections into the tarsal tunnel may help with edema.

Surgery is indicated if conservative management fails to resolve the patient’s symptoms or if a definitive cause of entrapment is identified. Patients with symptoms caused by a space-occupying lesion generally respond well to surgical management. Abnormally slow nerve conduction across the posterior tibial nerve is predictive of failed conservative therapy.

Surgical management involves the release of the flexor retinaculum from its proximal attachment near the medial malleolus down to the sustentaculum tali. Surgical success rates vary from 44% to 96%. Patient’s with a positive Tinel sign preoperatively tend to respond better to surgical decompression than those who do not. Younger patients and those with a short history of symptoms, early diagnosis, clear etiology, and no previous ankle pathology tend to respond better to surgery.

Differential Diagnosis

The differential diagnosis of tarsal tunnel syndrome is broad, making diagnosis difficult. This includes plantar fasciitis, intersection syndrome of the FHL and FDL at the knot of Henry, Achilles tendonitis, retrocalcaneal bursitis, polyneuropathy, L5 and S1 nerve root compression, Morton metatarsalgia, compartment syndrome of the deep flexor compartment, neurogenic intermittent claudication, degenerative changes (calcaneal spurs, arthrosis of the joints of the foot), and inflammatory conditions of the ligaments and fascia of the foot and ankle.

Prognosis

The prognosis of tarsal tunnel is variable. In patients with an identifiable etiology due to mass effect diagnosed early in the disease course, the response is generally favorable. Patients without an identifiable cause and who do not respond to conservative therapy generally do not do as well with surgical intervention. A positive Tinel sign is a strong predictor of surgical relief.

Complications

Untreated or refractory tarsal tunnel syndrome can result in neuropathies of the posterior tibial nerve and its branches. Patient’s may have persistent pain. Subsequent motor weakness and atrophy can develop. Postoperative complications include impaired wound healing, infection, and scar formation. Surgical decompression may not adequately resolve pain and other symptoms.

Postoperative and Rehabilitation Care

Postoperative rehab is aimed at protecting the joint and nerve integrity and controlling inflammation, pain, and swelling. As rehab continues, the therapist and patient work to prevent contraction and adhesions of scar tissue while maintaining soft tissue and joint mobility. Return to normal gait, walking, and running are long-term goals.

Consultations

Tarsal tunnel is a difficult, rare diagnosis. As such, cases are best managed by an orthopedic specialist. Depending on the etiology, surgical management may be indicated.

Deterrence and Patient Education

There are no clear guidelines for the prevention or deterrence of tarsal tunnel syndrome.

Patients should be aware that there are many causes of foot and ankle pain, some of which are uncommon including tarsal tunnel syndrome. If a patient has foot and ankle pain as well as other concerning symptoms such as burning, numbness, tingling, and muscle weakness, they should seek the care of a medical professional.

Pearls and Other Issues

  • Tarsal tunnel is an entrapment neuropathy of the medial ankle.
  • It is an uncommon but underdiagnosed cause of foot and ankle pain.
  • The etiology is broad.
  • Patients tend to have pain originating from the tarsal tunnel radiating down to the plantar foot; however, symptoms can vary.
  • There is no best test to diagnose tarsal tunnel syndrome, and it is a combination of history, exam, imaging, and electromyography and nerve conduction studies.
  • Conservative therapy can be tried in most patients.
  • If a definitive cause is identified, surgical decompression can provide good results.

Enhancing Healthcare Team Outcomes

Management of tarsal tunnel syndrome remains challenging due to diagnostic uncertainty and lack of clarity over which patients would benefit from conservative versus surgical management. Hence, the condition is best managed by a multidisciplinary team that consists of a podiatrist, orthopedic surgeon, and physical therapist.

Conservative treatment may help some patients but the key is physical therapy, change in shoes and modification of activity. For those with a compressive lesion, surgery may be beneficial.

The overall prognosis for patients with tarsal tunnel syndrome is guarded. Relapse and remissions are common and some patients never achieve complete relief from symptoms. (Level V)

 

 


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Tarsal Tunnel Syndrome - Questions

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In a patient with tarsal tunnel syndrome, what nerve is affected?



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In a patient with tarsal tunnel syndrome, the medial border is made by which of the following structures?



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Which is the most appropriate diagnostic test for tarsal tunnel syndrome?



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In a patient with tarsal tunnel syndrome, the lateral border is made by which of the following structures?



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Which of the following structures is NOT found in the tarsal tunnel?



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What is the MOST common cause of tarsal tunnel syndrome in adults?



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Which does not contribute to the development of tarsal tunnel syndrome?



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A 33 year old female presents with pain in her left foot, especially the heel area. She claims the pain is worsened with standing and walking and eases with rest. She had had many x-rays of the foot but nothing has been found. She notes that the pain often goes up the leg and she is not able to sleep at night. She denies any trauma, uses no medications, and does not exercise. The provider feels that she has a posterior tibial neuropathy and decided to perform a nerve block for diagnostic purposes. Where should the injection to block the posterior tibial nerve be made?



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A 34-year-old man has a past history of ankle trauma. He presents with painful paresthesias of the forefoot, heel, and calf. Tenderness is demonstrable along the posterior tibial nerve's distribution in the ankle. The most likely diagnosis is:



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A 34-year-old male presents with medial ankle pain radiating to the plantar surface of his foot. He reports no specific trauma, and it’s been going on for months. He describes the pain as burning. On exam, his symptoms worsen with tapping of the area behind is medial malleolus without any obvious weakness, atrophy or motor deficits. What should be done next?



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A 24-year-old female with rheumatoid arthritis and systemic lupus erythematosus presents for evaluation of medial ankle pain. She reports no trauma history and her symptoms are burning and made worse with ambulation or activity. On exam, there are no signs of infection, and it is suspected that this patient may have tarsal tunnel syndrome. What diagnostic modality will best help evaluate this patient?



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A 51-year-old male with a history of a bimalleolar fracture when he was 19 requiring surgical intervention presents for worsening foot and ankle pain. Patient localizes to the medial malleolus. He describes a pins and needles sensation. On exam, there is atrophy of some of the foot muscles most notably on the plantar surface. He also has diabetes mellitus. On his screening radiographs, there is some heterotrophic ossification and osteophytes around the medial joint space. What management is indicated?



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A 36-year-old male with poorly controlled diabetes mellitus presents with paresthesias and pain of the lateral plantar aspect of his right foot. Occasionally he has pain behind the inside of his ankle too. He reports no history of trauma. In addition to wanting help managing his symptoms, he is inquisitive and wants to know what the cause of his symptoms are. What should he be told?



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A student is rotating on an orthopedic service seeing patients in the clinic. A patient has ankle pain suspicious for tarsal tunnel syndrome. What are the anatomic contents of the tarsal tunnel and which compartment of the leg they from where they originate?



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Tarsal Tunnel Syndrome - References

References

Calvo-Lobo C,Painceira-Villar R,López-López D,García-Paz V,Becerro-de-Bengoa-Vallejo R,Losa-Iglesias ME,Palomo-López P, Tarsal Tunnel Mechanosensitivity Is Increased in Patients with Asthma: A Case-Control Study. Journal of clinical medicine. 2018 Dec 12;     [PubMed]
Stødle AH,Molund M,Nilsen F,Hellund JC,Hvaal K, Tibial Nerve Palsy After Lateralizing Calcaneal Osteotomy. Foot     [PubMed]
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Rinkel WD,Castro Cabezas M,van Neck JW,Birnie E,Hovius SER,Coert JH, Validity of the Tinel Sign and Prevalence of Tibial Nerve Entrapment at the Tarsal Tunnel in Both Diabetic and Nondiabetic Subjects: A Cross-Sectional Study. Plastic and reconstructive surgery. 2018 Nov;     [PubMed]
Hong CH,Lee YK,Won SH,Lee DW,Moon SI,Kim WJ, Tarsal tunnel syndrome caused by an uncommon ossicle of the talus: A case report. Medicine. 2018 Jun;     [PubMed]
Komagamine J, Bilateral Tarsal Tunnel Syndrome. The American journal of medicine. 2018 Jul;     [PubMed]
Schuh A,Handschu R,Eibl T,Janka M,Hönle W, [Tarsal tunnel syndrome]. MMW Fortschritte der Medizin. 2018 Apr;     [PubMed]
Mansfield CJ,Bleacher J,Tadak P,Briggs MS, Differential examination, diagnosis and management for tingling in toes: fellow's case problem. The Journal of manual     [PubMed]
Tu P, Heel Pain: Diagnosis and Management. American family physician. 2018 Jan 15;     [PubMed]

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