Tarsal Tunnel Syndrome

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The tarsal bones of the foot are important for stability and movement. Your tarsal bones are located in the rearfoot (also called hindfoot) and midfoot areas of your foot. These bones are also known collectively as the tarsus.

There are a total of seven bones within the tarsal bones group, such as:

  • Calcaneus – Also known as the heel bone.
  • Talus – Also known as the ankle bone.
  • Navicular – Which is located at the top of the foot between the ankle bone and the cuneiform bones.
  • Cuboid – Provides stability for the foot and helps with the movement of the toes.
  • Intermediate cuneiform – The intermediate cuneiform is important in the flexibility of the foot.
  • Medial cuneiform – Anchors several of the ligaments in the foot.
  • Lateral cuneiform – Helps form the arch of the foot.

 

Generally, the calcaneus is the largest of the tarsal bones and is the largest bone in the entire foot.

The tibial nerve is a mixed nerve with both motor and sensory function, and part of the peripheral nervous system. Mixed motor and sensory nerves enable electrical impulses to travel between muscle cells and the spinal cord. Impulses from the tibial nerve then travel to the brain to help provide sensory information and manage the voluntary and involuntary movement of your lower limbs. Branches of the tibial nerve connect to muscles in the back of the leg. This enables you to move your leg, foot, and toes.

Tarsal tunnel syndrome is a medical condition associated with numbness, pain, and a tingling or burning sensation in the ankles and feet. It results from compression of the posterior tibial nerve, which provides feeling and muscle mobility to the forward parts of the foot. The tarsal tunnel is the posterior tibial nerve’s pathway through the ankle into the foot, named for the tiny and irregularly shaped tarsal bones that comprise the hindfoot. It also contains arteries, veins, and tendons, protected by a tough sheath of a ligament.

The exact incidence of tarsal tunnel syndrome in the population is unknown, though women and men appear similarly affected by it. If tarsal tunnel syndrome is ever left untreated, it can lead to nerve damage and permanent disability. Therefore, it is recommended to seek immediate medical attention with an orthopedic specialist to rule out tarsal tunnel syndrome.

Causes & Symptoms

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Tarsal tunnel syndrome can be caused by any condition that causes compression of the tibial nerve or its branches as it passes through the tarsal tunnel. A wide variety of conditions can cause tarsal tunnel syndrome including space-occupying lesions or masses, which may increase pressure in the tunnel. Such lesions include tumors consisting of the following below:

  • Lipoma – A lipoma is a round or oval-shaped lump of tissue that grows just beneath the skin. It is made of fat, moves easily when you touch it, and does not typically cause pain. Lipomas can appear anywhere in the body, but they are most common on the back, trunk, arms, feet, shoulders, and neck.
  • Ganglioma – These are neoplasms composed of neoplastic neuronal cells, a gangliocytoma, or a combination of neoplastic neurons and neoplastic glial cells, which is known as ganglioglioma. These tumors are more common in children and young adults with a predilection for the temporal lobes.
  • Schwannoma – A schwannoma is a tumor that develops from the schwann cells in the peripheral nervous system. Schwannomas can usually be found in the sheath that covers the nerves. In addition, cancerous schwannomas most frequently affect the sciatic nerve of the leg, the brachial plexus nerve in the arm, and the group of nerves in the lower back.

Additional conditions that can cause tarsal tunnel syndrome include a benign bony growth in the tarsal tunnel (exostosis), enlarged veins (varicose), and inflammation of the synovial membrane (proliferative synovitis). Certain injuries or trauma such as an ankle sprain, fracture, or valgus foot deformity may cause inflammation and swelling that can lead to tarsal tunnel syndrome. Furthermore, certain disorders such as diabetes and arthritis can also cause inflammation and swelling that can lead to this condition.

Several symptoms of tarsal tunnel syndrome may vary from one person to another. In some cases, symptoms can develop suddenly, and in others, gradually. Some affected patients may experience a sharp, shooting pain along the tibial nerve.

This nerve branches off from the sciatic nerve and runs down the lower leg to the ankle and then the foot. Pain can be severe enough to cause a person to limp. Some people affected by tarsal tunnel syndrome may also describe a radiating pain that can’t be localized to one spot. Other symptoms linked to this condition include:

  • Numbness that is located in the affected area.
  • Burning or tingling sensation (paresthesia) which is often described as similar to “pins and needles”.
  • Pain that may radiate up from the ankle to the calf.
  • Long-lasting pain due to standing or walking over time.
  • Trouble sleeping at night because of the pain (insomnia).

Who gets Tarsal Tunnel Syndrome?

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Certain risk factors associated with tarsal tunnel syndrome include:

  • Having flatfeet – The excess stress put on the ankles by having untreated flatfeet can contribute to tarsal tunnel syndrome.
  • Systemic diseases – including arthritis, diabetes, and peripheral artery disease may contribute to swelling and stiffness that increase pressure on the posterior tibial nerve.
  • Injury to the foot – Injuries, like stubbing your toe or spraining your ankle, can cause swelling and damage to the tarsal tunnel area leading to tarsal tunnel syndrome.
  • Occupational labor – Occupations that require long periods of walking or standing, which puts pressure on the structures within the ankles.
  • Obesity – Overweight or obesity are common factors that can lead to tarsal tunnel syndrome due to the stress put on the ankle joint.

How does it affect you? How serious is it?

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If the posterior tibial nerve remains compressed and inflamed over a long period of time, nerve damage can become permanent. You might also experience some loss of motor function in your feet, which can increase your risk of stumbling or falling. Chronic pain from untreated tarsal tunnel syndrome can also result in a poor quality of life.

Recommended Treatment & Rehabilitation

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Diagnosing tarsal tunnel syndrome is a step-to-step process. Your physician will begin by giving you a physical exam, asking questions about your symptoms, and recording your medical history. He / she will then test for tarsal tunnel syndrome by using one or a combination of the following methods:

 

Tinel’s sign test

The Tinel sign test is commonly used with imaging tests to locate compressed or squeezed nerves and nerve regrowth. It is often used to diagnose carpal tunnel syndrome, although, it can also be used to rule out other similar conditions, such as cubital tunnel syndrome, Guyon’s canal syndrome, and sciatica.

Electromyography (EMG)

Electromyography is a medical test of electrical activity in the muscles and nerves. EMGs can be used to determine the effectiveness of the posterior tibial nerve in delivering the brain’s electrical impulses to the muscles and nerves of the foot.

X-rays or magnetic resonance imaging (MRI) scans

MRIs or X-rays can provide insight into the presence of bone spurs or other intrusive masses in the ankle or foot, which can be indicators of tarsal tunnel syndrome.

Surgery

Surgery is a great alternative when non-invasive treatments fail to provide relief. The goal of surgery is to expand the tarsal tunnel, thereby relieving pressure on the posterior tibial nerve, by cutting the flexor retinaculum ligament. The latter is one of the tarsal tunnel’s structural elements, however, it also serves to reinforce any pressure being applied to the posterior tibial nerve when the tunnel is otherwise constricted. Tarsal tunnel surgery is usually performed on an outpatient basis, with a complete recovery time of up to 3 to 6 weeks.

All surgeries require incisions. Therefore, this means there is a chance of infection but with a low percentage of it happening. When infections do arise, they’re considered serious. That is why it is very important to follow the care instructions given to you by your doctor, including keeping your wound clean and dry and taking any prescribed antibiotics.

 

Physiotherapy

Physiotherapy can play a vital role in helping patients experiencing tarsal tunnel syndrome to improve and maintain their regular daily function and activities. Your physiotherapist will work with you to develop a helpful treatment program to address your goals. Because the signs and symptoms of tarsal tunnel syndrome may vary, the ultimate approach to care will also vary. Therefore, your therapist may provide the following recommendations below:

  • Muscle-strengthening exercises – Strengthening activities for any muscles affected by tarsal tunnel syndrome, such as the tibialis posterior muscle in the back of your lower leg, can help alleviate further pain linked to this condition.
  • Nerve gliding activities – Gentle exercises that move and glide the nerves may help reduce symptoms and improve function.
  • Balance and coordination activities – Work to improve your balance and coordination, which are often affected by tarsal tunnel syndrome.
  • Supporting equipment – It is recommended to apply ankle taping, a custom orthotic, or bracing to position the foot to decrease stress on the posterior tibial nerve.

Although there are no proven strategies for preventing tarsal tunnel syndrome, there are certain ways to minimize stress to the foot and ankle, such as choosing appropriate footwear, wearing custom shoe inserts, minimizing the amount of time spent standing on hard surfaces, and improving and maintaining strength in the muscles of your legs, ankles, and feet. In addition, early detection of tarsal tunnel syndrome signs will help you and your medical providers start the best management of the condition, which may increase your long-term well-being.

Below are a few exercises you can perform to help boost your recovery from tarsal tunnel syndrome:

 

Heel-toe raises

Using the back of a chair or counter for support, lift the heels off the floor to stand on the toes. Hold for 5 seconds before slowly lowering back down to the floor. Repeat this exercise 15 times with two sets and a 30-second rest between each set. Once the injured foot becomes stronger, try standing on the injured foot only.

Calf stretch

Stand and face a wall with the hands placed on the wall at eye level. Next, take a lunge position by placing the injured foot slightly behind with the heel flat on the ground and the other leg slightly forwards with a bent knee. Turn the back foot inwards slightly. Then, gently lean towards the wall until there is a stretch in the back calf. Hold this position for 15-30 seconds, then repeat this method 3-4 times a day.

Balance exercise

Stand beside a chair, using it for support if needed, with the injured foot furthest from the chair. Stand on the injured foot and slightly bend the knee. Bend forward from the waist and reach forward with the hand furthest from the chair. Repeat this exercise 15 times with 2 sets.

Alternative & Homeopathic Treatment

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The initial courses of homeopathic treatment for tarsal tunnel syndrome include the PRICE principle, which stands for Protect, Rest, Ice, Compression, and Elevation, as described below:

  • Protect – In more severe cases, it is necessary to protect the damaged area. This may be done through the use of a walking boot or in some cases, a cast may be necessary to restrict movement completely which allows the nerve, joint, and surrounding tissues a chance to heal.
  • Rest – In this case, rest would indicate tapering down from your regular exercise activity and discontinuing running.
  • Ice – Apply ice to the affected area. The rule for icing is to apply ice no more than 20 minutes per hour.
  • Compression – This helps prevent and decrease swelling. Swelling can cause increased pain and slow the healing response, so limit it as much as possible. A compression stocking can help to limit the amount of swelling and promote blood flow back out of the lower leg.
  • Elevation – Depending on your pain level and the amount of swelling present, this step may be more or less beneficial.

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