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Tarsal Tunnel Syndrome - Causes, Symptoms, Diagnosis and Treatment

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Tarsal tunnel syndrome is the squeezing of the tibial nerve (nerve of the leg and foot muscle), causing painful feet. Read the article to know more.

Written byDr. Deepiha. D

Medically reviewed byDr. Suman Saurabh

Published At May 23, 2022
Reviewed AtSeptember 19, 2024

Introduction:

The term tarsal in Latin means about the ankle. A narrow passage found between the bones and the soft tissue inside the ankle is called the tarsal tunnel. This tunnel is present near the bony bump on the inner side of the ankle. Few tendons, blood vessels, and tibial nerves pass through this tunnel to reach the foot. Damage to the tibial nerves is rare and is often caused by the entrapment or compression caused inside the tunnel.

What Is Tarsal Tunnel Syndrome?

Tarsal tunnel syndrome is a painful foot condition caused by compressive neuropathy of the tibial nerve. The syndrome is common in active adults, with a higher incidence in women. Sports activities involving more of the lower limb, like playing football, skating, snowboarding, and track and field events, have a higher risk of developing tarsal tunnel syndrome. This syndrome can occur in one foot or both feet.

What Causes Tarsal Tunnel Syndrome?

Tarsal tunnel syndrome can be idiopathic (without any underlying diseases) or secondary to any factor that compresses the tibial nerve. The common causes are

  • Injury: Trauma to the foot or ankle causes bone fractures or sprains that can put pressure on the tibial nerve.

  • Tumor: A lesion or a mass occupying the space can compress the tibial nerve.

  • Bony Growth: The bony lumps or bone spurs formed inside the tarsal tunnel following an injury can stress the tibial nerve.

  • Varicose Veins: The twisted and enlarged veins of the leg often pressurize the tibial nerve and surrounding structures during an action.

  • Inflammation: Inflammation of the tendons or the membranes creates pressure in the tarsal tunnel.

  • Debilitating Diseases: Common conditions like diabetes and arthritis can cause inflammation, swelling, and nerve compression.

  • Postural Disorders: Flat feet are a postural disorder where one or both feet have little to no arch. Typically, the upper tilt of the heel with fallen arches produces pressure over the tibial nerve.

  • Disc Hernia: The bulging of the disc in the lower back can pinch the nerve, leading to the double crush phenomenon (the nerve is pinched first in the lower back, and the same nerve is pinched in the tarsal tunnel).

Pathophysiology of Tarsal Tunnel Syndrome:

Tarsal tunnel syndrome occurs due to compression of the posterior tibial nerve or any one of its two branches. Branches are lateral or medial plantar nerves. These are situated within the tarsal tunnel. Around 43 % of individuals affected with tarsal tunnel syndrome show a history of trauma. History of trauma may include ankle sprains. An abnormal biomechanics is thought to be the reason for the disease progression.

The risk factors leading to tarsal tunnel syndrome include diabetes mellitus, hypothyroidism, gout, mucopolysaccharidosis, gout, and hyperlipidemia.

What Are the Symptoms of Tarsal Tunnel Syndrome?

  • Pain that occurs spontaneously or is aggravated during movements.

  • Tingling or numbness around the ankle, toes, and sometimes the leg.

  • Sharp shooting pain along the tibial nerve path.

  • Burning or electric shock-like sensation over the feet.

  • Pins and a needle prick type of feeling.

  • Rarely the pain may radiate up to the calf muscles.

  • Muscle damage or weakness in the bottom of the feet.

  • Severe tarsal tunnel syndrome causes a partial or complete loss of sensation and movement in the feet.

How to Diagnose Tarsal Tunnel Syndrome?

Diagnosis can be made by certain tests called tarsal tunnel syndrome tests; these include:

1. Physical Examination: Evaluating the patient’s history and physical examination are the first steps in the diagnosis of tarsal tunnel syndrome. Physicians may perform a simple, non-invasive test to check for nerve problems, which is called the Tinel’s sign.

  • Tinel’s Sign: This test involves tapping over the nerve, which will produce a tingling or pain sensation. The sensation is a positive sign of nerve damage or irritation. Tinel’s sign is a potential indication of tarsal tunnel syndrome.

2. Imaging Techniques:

  • X-rays are used to rule out fractures or any other medical conditions.

  • MRI (magnetic resonance imaging) can visualize soft tissue lesions and tumor masses.

  • Ultrasound can evaluate inflammation around the ankle.

3. Nerve Conduction Test:

The nerve conduction test is the gold standard in diagnosing secondary tarsal tunnel syndrome.

4. Electromyography (EMG):

Electromyography records and evaluates the electrical activity of skeletal muscles and the nerve cells that control them. Any abnormal result may indicate a suspected tarsal tunnel syndrome.

How to Treat Tarsal Tunnel Syndrome?

The treatment of tarsal tunnel syndrome depends on the severity of the condition and the intensity of pain elicited during activities.

Non-Surgical:

  • Rest, manipulation, physical therapy, muscle strengthening exercises, steroid shots, immobilization using a cast, alternative ice packs, and heating pads during sports are the conservative treatments for tarsal tunnel syndrome.

  • Over-the-counter medications like painkillers and anti-inflammatory drugs are used to relieve pain and swelling temporarily. Injection of local anesthetic may also provide pain relief.

  • Orthotics are specially designed shoes or soles used to improve the functional ability of the skeleton. An orthotic can reduce the pressure on the tibial nerve. Binders, braces, straps, and stents are also available for decompressing the tibial nerve.

  • In the case of cysts, aspiration of the fluid under the guidance of ultrasonography can be done.

Surgical:

  • Surgery is recommended when conservative management does not improve the condition. In the case of a tumor, surgical resection is the best choice of treatment to debride the tunnel and relieve the nerve.

  • An incision is made at the back of the ankle, and the nerve is traced and followed into the tunnel. The ligaments, fibrous band, and septum are the important structures in the tunnel that may compress the tibial nerve. Hence, these structures are released to relieve the tibial nerve.

  • Researchers devised a rating scale for the severity of tarsal tunnel syndrome to evaluate the treatment outcome, especially before and after surgery.

Tarsal Tunnel Syndrome

A result with a total score of ten points was judged as excellent, eight to nine points as good, six to seven points as fair, and below five as poor.

Complications of Tarsal Tunnel Syndrome:

Complications of untreated or refractory tarsal tunnel syndrome may include:

  • Neuropathies of the posterior tibial nerve and its branches.

  • Continuous pain.

  • Motor weakness and atrophy may develop subsequently.

Post-operative complications include:

  • Disturbed wound healing.

  • Development of infection.

  • Formation of scar.

Conclusion:

Tarsal tunnel syndrome is similar to carpal tunnel syndrome. However, the prevalence of tarsal tunnel syndrome is rare. Tarsal tunnel syndrome is a chronic condition of foot pain that may progress and result in nerve damage. It is very important to treat the symptoms at the earliest. Many patients have good treatment outcomes. If left untreated, tarsal tunnel syndrome can greatly impact the patient’s quality of life. Depending on the severity, proper pain management, counseling, and even surgery are considered.

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Frequently Asked Questions

The treatment for tarsal tunnel syndrome depends on the severity of the condition. Most of the patients feel better with rest and home remedies. But If it is left untreated, it can further worsen the nerve damage and could be more painful, making it difficult to walk and do regular activities.
If the underlying cause is found and treated accordingly, the tarsal tunnel syndrome symptoms will fade within a few weeks. The recovery time also depends on the severity of nerve compression. Post-treatment rehabilitation will help further with pain reduction and regaining the range of motion.
Tarsal tunnel syndrome produces pain that refrains one from walking or doing other physical activities involving the leg. Painkillers and supporting devices can help temporarily, but mild stretching and strengthening exercises must be practiced regularly to achieve muscle resistance.
Rest, medications like painkillers and anti-inflammatories, and supporting devices are the conservative method of managing tarsal tunnel syndrome. Steroid shots can also be used to reduce inflammation. Surgery may be needed if there is any presence of cysts or tumors compressing the tibial nerve.
Sharp shooting pain is the primary symptom of tarsal tunnel syndrome. In addition, there may be numbness, burning, and tingling sensations in the toe, ankle, and leg region. The pain can be like a pricking sense with muscle weakness that makes it difficult to move the leg.
Tarsal tunnel syndrome can be treated effectively, and leg activities can be resumed shortly after the treatment. But if the condition is not treated appropriately on time, the nerve can be damaged permanently, and the condition is irreversible restricting the movements of the foot during walking or other normal activities.
The tarsal tunnel is a narrow passage located at the inner side of the ankle, providing space for many blood vessels, nerves, tendons, and ligaments to pass through to serve their purpose. Tarsal tunnel syndrome occurs when the tibial nerve is compressed or pinched inside the tarsal tunnel, and hence the pain is located at the bottom inner sides of the foot and toes.
Physical examination, imaging techniques, nerve conduction tests, and electromyography are used to diagnose tarsal tunnel syndrome. Tinel’s sign is a test done by tapping the nerve. When there is pain or tingling sensation in the area of tapping, it is a potential indicator of tibial nerve compression.
Yes, MRI (magnetic resonance imaging) is a radiation technique that clearly visualizes the tarsal tunnel and its contents. MRI images are highly sensitive in demonstrating the soft tissue lesions, tumors (space-occupying), or any other condition causing nerve damage.
Supporting devices help in decompressing the nerve and give better posture for the foot, thus relieving pain. Some of them are compression socks, specially designed shoes, and soles that can potentially reduce the pressure on the tibial nerve and are recommended in the treatment of tarsal tunnel syndrome.
Alternative ice packs and heating pads during vigorous physical activity like sports can alleviate the pain and also can prevent nerve damage. Applying cold can reduce inflammation, thereby reducing swelling, and heat can improve circulation, thereby improving faster recovery.
Tarsal tunnel syndrome can be managed with simple home remedies if there is no underlying disease condition. But one has to check the reason for nerve compression. If the condition is left untreated, it may cause permanent nerve damage and can cause severe pain during walking.
Both ice and heat are helpful in treating tarsal tunnel syndrome, hence it is recommended to use them alternatively. Ice can reduce swelling, and heat can reduce the pain, both giving relief from the symptoms of tarsal tunnel syndrome.
Plantar fasciitis usually occurs below the ankle region while the tarsal tunnel syndrome is because by the compression of the tibial nerve in the tarsal tunnel, which is present above the ankle region. Both the conditions share some common symptoms, but tarsal tunnel syndrome is rare, and the pain is severe.
Most of the time, the condition is caused by injury to the foot or ankle region. Otherwise, patients with flat feet, varicose veins, diabetes, arthritis, and disk hernia are at the risk of developing tarsal tunnel syndrome due to inflammation, swelling, and nerve compression.
The pain from plantar fasciitis is more in the mid-bottom foot region and gets worse while walking, running, and in the morning. But, in the case of tarsal tunnel syndrome, the pain is located at the sides of the foot and ankle region and gets worse while standing and at night.
A Tinel test is performed to diagnose tarsal tunnel syndrome. The Tinel sign is the pain or tingling sensation perceived by tapping the injured or compressed nerve. A positive Tinel sign while percussing on the ankle region indicates tarsal tunnel syndrome.
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Dr. Suman Saurabh from iCliniq
Dr. Suman Saurabh

Orthopedician and Traumatology

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