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Tarsal Tunnel Syndrome

From WikiSM

Other Names

  • Entrapment neuropathy of the posterior tibial nerve
  • Tarsal Tunnel Syndrome (TTS)
  • Posterior tibial neuralgia

Background

History

  • First clinical description in 1918 by Von Malaise (need citation)
  • Named by Keck and Lam in 1962 in two separate reports[2][3]

Epidemiology

  • Relatively rare condition; epidemiology is not well described in the literature

Introduction

Illustration of the contents of the tarsal tunnel[4]
illustration of the tarsal tunnel with underlying structures; the tibial nerve, posterior tibial artery and tendons of the tibialis posterior, flexor digitorum longus and flexor hallicus longus muscles, passing deep to the flexor retinaculum[5]
Entrapment sites of the tibial nerve in tarsal tunnel syndrome (A), medial plantar neuropathy at the abductor hallucis tunnel (B), lateral plantar neuropathy (C), Morton's neuroma at the metatarsal heads (D), Joplin's neuroma at the medial side of the great toe (E), medial calcaneal neuropathy (F), and inferior calcaneal neuropathy (G)[6]
Schematic diagram of the tarsal tunnel anatomy[7]

General

  • 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

Etiology

  • Intrinsic
    • Osteophytes from Ankle Arthritis
    • Hypertrophic retinaculum
    • Tendonopathy
    • Space-occupying lesions such as enlarged veins, ganglia, lipoma, tumour and neuroma
    • Haemorrhage secondary to trauma can lead to scarring, fibrosis
    • Tarsalcalcaneal Coalition[8]
  • Extrinsic
    • 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
  • Mixed
    • Can be due to more than one intrinsic or extrinsic cause
  • Idiopathic

Anatomy of the Posterior Tibial Nerve

  • Bifurcates into Medial Plantar Nerve, Lateral Plantar Nerve at the level of tarsal tunnel
  • About 5% of patients bifurcate proximal to tarsal tunnel[9]
  • Both the medial and lateral plantar nerves supply autonomic, sensory and motor fibres to the plantar foot[10]

Anatomy of the Tarsal Tunnel

Risk Factors

Differential Diagnosis

Differential Diagnosis Ankle Pain

Clinical Features

Clinical demonstration of the dorsiflexion-eversion test[12]

History

  • 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 [13]
  • 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: pain radiating proximally to the tarsal tunnel may be present
  • Recommended to test two point discrimination on plantar surface[13]

Special Tests

Evaluation

CT showing accessory tarsal ossicle causing tarsal tunnel syndrome[14]
MR imaging of tarsal tunnel syndrome. a , b Axial T1WI ( a ) and spin-echo T2WI ( b ) demonstrate a lipoma ( arrowheads ) in the upper tarsal tunnel, compressing the posterior tibial nerve ( arrows ). c , d Axial T1WI ( c ) and spin- echo T2WI ( d ) demonstrate a ganglion ( arrowheads ) in the lower tarsal tunnel, possibly compressing the lateral plantar nerve ( short arrow ). The medial plantar nerve is not well visualized. The medial calcaneal nerve ( long arrow ) is well depicted. Both patients had a tingling sensation in the foot. AH abductor hallucis muscle[15]

Radiology

MRI

  • General
    • Highly accurate (83%) when investigating space-occupying lesions[10]
    • Frey found 88% of symptomatic tarsal tunnel patients had significant findings[16]

Ultrasound

  • May provide evidence of direct nerve compression
    • Hypoechoic and never enlargement proximally to entrapment [17]
    • Numkarunarunrote found it may provide evidence of nerve compression by demonstrating nerve enlargement, changes in echogenicity[18]
    • 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[19]
    • 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[20]
  • Can be used to evaluate for[21]
    • Ganglia
    • Varicose veins
    • Lipomas
    • Tenosynovitis
    • Talocalcaneal coalition

CT

  • Can be considered if osseous abnormalities found in plain xray

EMG/NCS

  • General
    • 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% [22]
  • Useful to distinguish patients with TTS and more proximal lesions

Classification

  • Not applicable

Management

29-year-old male, right ankle medial, tarsal tunnel syndrome): (A) Intraoperative, ganglion cyst led to entrapment of both plantar nerves at the bifurcation of the tibialis posterior nerve (arrow). (B) Intraoperative, after resection of ganglion cyst and decompression/neurolysis of both plantar nerves[23]

Nonoperative

  • Indications
    • 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
  • NSAIDS
  • Activity modification
  • Physical Therapy
    • Consider taping, bracing
    • Stretching and strengthening of the calf, tibialis anterior and posterior, peroneal and short toe-flexor muscles
  • Orthotics
    • Orthotic shoes may decrease pressure over the nerve[24]
    • Also consider night splint, removal boot walker
    • Custom orthoses to support the medial and lateral longitudinal arches of the affected foot
  • Procedures

Operative

  • Indications
    • Failure of conservative management
    • Definitive indications of entrapment
  • Technique
    • Tarsal tunnel release [25]
    • Cryosurgery

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/ Work

  • Needs to be updated

Complications and Prognosis

Prognosis

  • Surgical release
    • May improve and resolve the overall symptoms of tarsal tunnel syndrome in up to 85–90% of cases[26]
    • Surgical outcomes are better if the etiology is a space occupying lesion[27]
  • Predictors of good surgical outcome[28]
    • 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[27]
  • Predictors of poor relief from surgery[29]
    • 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
  • Cryosurgery
    • May be an effective alternative to standard surgical interventions[30]

Complications

See Also

Internal

External

References

  1. ↑ Luis Beltran, J. B. (2010). Entrapment Neuropathies III: Lower Limb. Seminars in Musculoskeletal Radiology, 501-511
  2. ↑ Keck C. The tarsal-tunnel syndrome. J Bone Joint Surg Am. 1962;44:180-2.
  3. ↑ Lam, S. J. S. "A tarsal-tunnel syndrome." The Lancet 280.7270 (1962): 1354-1355.
  4. ↑ McSweeney, Simon C., and Matthew Cichero. "Tarsal tunnel syndrome—a narrative literature review." The Foot 25.4 (2015): 244-250.
  5. ↑ Williams, Nicole, et al. "Tarsal tunnel syndrome in the mucopolysaccharidoses: A case series and literature review." JIMD reports 46.1 (2019): 16-22.
  6. ↑ Oh, Shin J. "Neuropathies of the foot." Clinical neurophysiology 118.5 (2007): 954-980.
  7. ↑ Kim, Jahyung, and Jaeho Cho. "Tarsal Tunnel Syndrome: A Narrative Review." The Nerve 10.1 (2024): 1-6.
  8. ↑ Lee, M. F., et al. "Tarsal tunnel syndrome caused by talocalcaneal coalition." Clinical imaging 26.2 (2002): 140-143.
  9. ↑ Havel PE, Ebraheim NA, Clark SE. Tibial branching in the tarsal tunnel. Foot Ankle 1988;9:117–9.
  10. ↑ 10.0 10.1 Reade BM, Longo DC, Keller MC. Tarsal tunnel syndrome. Clin Podiatr Med Surg 2001;18(3):395–408.
  11. ↑ Lau, John TC, and Tim R. Daniels. "Tarsal tunnel syndrome: a review of the literature." Foot & ankle international 20.3 (1999): 201-209.
  12. ↑ M Kinoshita, R. O. (2001). The Dorsiflexion-Eversion Test for Diagnosis of Tarsal Tunnel Syndrome. The Journal of Bone and Joint Surgery, 1835-1839
  13. ↑ 13.0 13.1 John Lau, T. D. (1999). Tarsal Tunnel Syndrome: A Review of the Literature. Foot & Ankle International, 201-209
  14. ↑ Sweed, Tamer Ahmed, Seyed Asghar Ali, and Surabhi Choudhary. "Tarsal tunnel syndrome secondary to an unreported ossicle of the talus: a case report." The Journal of Foot and Ankle Surgery 55.1 (2016): 173-175.
  15. ↑ Kim, Sungjun, et al. "Role of magnetic resonance imaging in entrapment and compressive neuropathy—what, where, and how to see the peripheral nerves on the musculoskeletal magnetic resonance image: part 2. Upper extremity." European radiology 17 (2007): 509-522.
  16. ↑ Frey, Carol, and Roger Kerr. "Magnetic resonance imaging and the evaluation of tarsal tunnel syndrome." Foot & ankle 14.3 (1993): 159-164.
  17. ↑ Jon Jacobson, T. W. (2016). Sonography of Common Peripheral Nerve Disorders With Clinical Correlation. The American Institute of Ultrasound in Medicine , 683-693.
  18. ↑ 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.
  19. ↑ Therimadasamy, A., et al. "Combination of ultrasound and nerve conduction studies in the diagnosis of tarsal tunnel syndrome." Neurology India 59.2 (2011): 296.
  20. ↑ 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.
  21. ↑ Nagaoka M, Matsuzaki H. Ultrasonography in tarsal tunnel syndrome. J Ultrasound Med 2005;24:1035–40.
  22. ↑ Troy Watson, R. A. (2002). Distal Tarsal Tunnel Release With Partial Plantar Fasciotomy for Chronic Heel Pain: An Outcome Analysis. Foot & Ankle International.
  23. ↑ Schmidt, Ingo. "Ledderhose’s Disease-What do We Know and What do We not know."
  24. ↑ Gessini L, Jandolo B, Pietrangeli A. The anterior tarsal syndrome. J Bone Joint Surg 1984;66A:786–7.
  25. ↑ Eric Ferkel, W. D. (2015). Entrapment Neuropathies of the Foot and Ankle. Clinics in Sports Medicine, 791-801
  26. ↑ Radin, Eric L. "Tarsal tunnel syndrome." Clinical orthopaedics and related research 181 (1983): 167-170.
  27. ↑ 27.0 27.1 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.
  28. ↑ Baba, H., et al. "The tarsal tunnel syndrome: evaluation of surgical results using multivariate analysis." International orthopaedics 21.2 (1997): 67-71.
  29. ↑ Raikin, Steven M., and John M. Minnich. "Failed tarsal tunnel syndrome surgery." Foot and ankle clinics 8.1 (2003): 159-174.
  30. ↑ Goldstein, S. H. "Cryosurgery for the Treatment of Tarsal Tunnel Syndrome." PODIATRY MANAGEMENT 25.8 (2006): 163.
  31. ↑ Wallach, D. M., and S. D. Katchis. "Tarsal tunnel syndrome." Disorders of the heel, rear foot, and ankle. Churchill: Livingston (1999): 125-34.
Created by:
John Kiel on 14 June 2019 08:40:12
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Last edited:
1 October 2025 19:00:49
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