Tarsal Tunnel Syndrome
- 1 Other Names
- 2 Background
- 3 Pathophysiology
- 4 Risk Factors
- 5 Differential Diagnosis
- 6 Clinical Features
- 7 Evaluation
- 8 Classification
- 9 Management
- 10 Rehab and Return to Play
- 11 Complications and Prognosis
- 12 See Also
- 13 References
- Entrapment neuropathy of the posterior tibial nerve
- Tarsal Tunnel Syndrome (TTS)
- Posterior tibial neuralgia
- This page describes entrapment of the Posterior Tibial Nerve (PTN) as it courses through the Tarsal Tunnel
- First clinical description in 1918 by Von Malaise (need citation)
- Named by Keck and Lam in 1962 in two separate reports
- Relatively rare condition; epidemiology is not well described in the literature
- Entrapment neuropathy of the PTN as it courses through the flexor retinaculum on the medial side of the ankle
- Rare disorder which causes motor and sensory deficits on the plantar aspect of the foot
- Diagnosis and management remain challenging to clinicians
- Direct trauma
- Constrictive foot wear
- Hind foot varus or valgus
- Generalized lower limb edema (pregnancy, venous congestion)
- Systemic inflammatory arthropathies
- Diabetes Mellitus
- Post surgical scarring
- Can be due to more than one intrinsic or extrinsic cause
- Posterior Tibial Nerve
- Tarsal Tunnel
- Fibro-osseous tunnel beneath the flexor retinaculum, behind and inferior to the medial malleolus
- Floor: medial wall of the talus, calcaneus and the medial wall of the distal tibia
- Contents from medial to lateral:
- Female > Male
- Fractures & Dislocations
- Muscle and Tendon Injuries
- Ligament Injuries
- Nerve Injuries
- Predominant symptom is pain directly over tarsal tunnel, behind medial mal radiating into the heel and plantar foot
- Paraesthesia, dysesthesia and hyperaesthesia along the medial ankle radiating into the sole, heel or digits 
- Burning, numbness, or tingling in the foot
- Worsens with standing and walking
- Night symptoms may be reported
- Improve with rest, elevation
- Note the dorsum of the foot should be asymptomatic
- Symptoms are rarely bilateral
Physical Exam: Physical Exam Ankle
- Tenderness on deep palpation of the tarsal tunnel
- Valleix Phenomenon may be present
- Recommended to test two point discrimination on plantar surface
- Tinel Test: Performed at medial malleolus may reproduce smptoms
- Dorsiflexion Eversion Test: Dorsiflex the ankle and toes with eversion can reproduce symptoms
- Triple Compression Stress Test: Ankle plantarflexed, inverted with direct pressure over tibial nerve
- Plantarflexion Inversion Test: place in maximal plantarflexion and inversion for 10 to 15 seconds
- Tarsal Tunnel Compression Test:
- Standard Radiographs Ankle
- Often normal but looking for structural abnormalities
- Potential findings
- Hind foot varus/valgus
- tarsal coalitions
- Evidence of previous trauma
- May provide evidence of direct nerve compression
- Hypoechoic and never enlargement proximally to entrapment 
- Numkarunarunrote found it may provide evidence of nerve compression by demonstrating nerve enlargement, changes in echogenicity
- Therimadasamy et al. found patients averaged a cross-sectional area of 0.17 cm2 on the pathological side vs. 0.10 cm2 on the unaffected side
- Lee et al found mean cross-sectional area of 24 mm2 in patients with diabetic tibial nerve pathology vs. 12 mm2 in people without a neuropathy
- Can be used to evaluate for
- Varicose veins
- Talocalcaneal coalition
- Can be considered if osseous abnormalities found in plain xray
- Adjunct study that should be taken in context with history and exam
- Can not be used in isolation to make the diagnosis
- Evaluate motor and sensory function
- Sensitivity of EMG is 90% 
- Useful to distinguish patients with TTS and more proximal lesions
- Not applicable
- Vast majority of cases are nonoperative initially
- However treatment should be directed at the specific cause
- Overall, the literature is weak regarding management of TTS
- Activity modification
- Physical Therapy
- Consider taping, bracing
- Stretching and strengthening of the calf, tibialis anterior and posterior, peroneal and short toe-flexor muscles
- Orthotic shoes may decrease pressure over the nerve
- Also consider night splint, removal boot walker
- Custom orthoses to support the medial and lateral longitudinal arches of the affected foot
- Aspiration of ganglia may provide temporary benefit
- Corticosteroid Injection if intra- or perineural edema
- Failure of conservative management
- Definitive indications of entrapment
- Tarsal tunnel release 
Rehab and Return to Play
- Needs to be updated
Return to Play/ Work
- Needs to be updated
Complications and Prognosis
- Surgical release
- Predictors of good surgical outcome
- Short history of foot pain
- Presence of a ganglion
- No history of trauma or sprain
- Light working duties
- Delay in decompression more than 10 months
- Predictors of poor relief from surgery
- Incorrect initial diagnosis
- Incomplete surgical release of the tarsal tunnel
- Adhesive neuritis following initial decompression measures
- Intraneural damage/disruption associated with direct neural trauma or systemic disease
- Presence of a space-occupying lesion or double crush syndrome
- May be an effective alternative to standard surgical interventions
- Chronic pain
- Sensory dysfunction
- Complex Regional Pain Syndrome
- Recurrence of symptoms
- Incomplete surgical release
- Postoperative scar formation at the surgical site
- Luis Beltran, J. B. (2010). Entrapment Neuropathies III: Lower Limb. Seminars in Musculoskeletal Radiology, 501-511
- Keck C. The tarsal-tunnel syndrome. J Bone Joint Surg Am. 1962;44:180-2.
- Lam, S. J. S. "A tarsal-tunnel syndrome." The Lancet 280.7270 (1962): 1354-1355.
- Lee, M. F., et al. "Tarsal tunnel syndrome caused by talocalcaneal coalition." Clinical imaging 26.2 (2002): 140-143.
- McSweeney, Simon C., and Matthew Cichero. "Tarsal tunnel syndrome—a narrative literature review." The Foot 25.4 (2015): 244-250.
- Havel PE, Ebraheim NA, Clark SE. Tibial branching in the tarsal tunnel. Foot Ankle 1988;9:117–9.
- Reade BM, Longo DC, Keller MC. Tarsal tunnel syndrome. Clin Podiatr Med Surg 2001;18(3):395–408.
- Lau, John TC, and Tim R. Daniels. "Tarsal tunnel syndrome: a review of the literature." Foot & ankle international 20.3 (1999): 201-209.
- M Kinoshita, R. O. (2001). The Dorsiflexion-Eversion Test for Diagnosis of Tarsal Tunnel Syndrome. The Journal of Bone and Joint Surgery, 1835-1839
- John Lau, T. D. (1999). Tarsal Tunnel Syndrome: A Review of the Literature. Foot & Ankle International, 201-209
- Frey, Carol, and Roger Kerr. "Magnetic resonance imaging and the evaluation of tarsal tunnel syndrome." Foot & ankle 14.3 (1993): 159-164.
- Jon Jacobson, T. W. (2016). Sonography of Common Peripheral Nerve Disorders With Clinical Correlation. The American Institute of Ultrasound in Medicine , 683-693.
- Numkarunarunrote, Numphung, et al. "Retinacula of the foot and ankle: MRI with anatomic correlation in cadavers." American Journal of Roentgenology 188.4 (2007): W348-W354.
- Therimadasamy, A., et al. "Combination of ultrasound and nerve conduction studies in the diagnosis of tarsal tunnel syndrome." Neurology India 59.2 (2011): 296.
- Lee, Doohi, and Damien M. Dauphinée. "Morphological and functional changes in the diabetic peripheral nerve: using diagnostic ultrasound and neurosensory testing to select candidates for nerve decompression." Journal of the American Podiatric Medical Association 95.5 (2005): 433-437.
- Nagaoka M, Matsuzaki H. Ultrasonography in tarsal tunnel syndrome. J Ultrasound Med 2005;24:1035–40.
- Troy Watson, R. A. (2002). Distal Tarsal Tunnel Release With Partial Plantar Fasciotomy for Chronic Heel Pain: An Outcome Analysis. Foot & Ankle International.
- Gessini L, Jandolo B, Pietrangeli A. The anterior tarsal syndrome. J Bone Joint Surg 1984;66A:786–7.
- Eric Ferkel, W. D. (2015). Entrapment Neuropathies of the Foot and Ankle. Clinics in Sports Medicine, 791-801
- Radin, Eric L. "Tarsal tunnel syndrome." Clinical orthopaedics and related research 181 (1983): 167-170.
- Takakura, Y., et al. "Tarsal tunnel syndrome. Causes and results of operative treatment." The Journal of bone and joint surgery. British volume 73.1 (1991): 125-128.
- Baba, H., et al. "The tarsal tunnel syndrome: evaluation of surgical results using multivariate analysis." International orthopaedics 21.2 (1997): 67-71.
- Raikin, Steven M., and John M. Minnich. "Failed tarsal tunnel syndrome surgery." Foot and ankle clinics 8.1 (2003): 159-174.
- Goldstein, S. H. "Cryosurgery for the Treatment of Tarsal Tunnel Syndrome." PODIATRY MANAGEMENT 25.8 (2006): 163.
- Wallach, D. M., and S. D. Katchis. "Tarsal tunnel syndrome." Disorders of the heel, rear foot, and ankle. Churchill: Livingston (1999): 125-34.