3 Patient presentation 7
4 Objective evidence 8
5 Epidemiology 10
6 Differential diagnosis 11
7 Red flags 12
10 Miscellany 16
11 Key terms 17
12 Skills 18
Tarsal tunnel syndrome
1 Description
Tarsal tunnel syndrome (TTS) refers to compression of the posterior tibial nerve in the tarsal
tunnel. This can be due to many etiologies, including masses, trauma, and peripheral
neuropathies. Tenderness of the tarsal tunnel, shooting pain, numbness, and tingling or burning
sensations in the foot are common signs of TTS.
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traction on the nerve, there are also cases where a physical mass, such as a bone spur or a
ganglion, can press and injure the tibial nerve or its branches. Rarely the structures around the
nerve are swollen or diseased such as inflamed tendons coursing along the tibial nerve and
can also affect the nerves similarly.
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3 Patient presentation
Patients with TTS typically complain of numbness in the foot radiating to the big toe and the
first 3 toes, pain , burning, electrical sensations, and tingling over the base of the foot and the
heel. If the nerve entrapment is more proximal, the entire foot can be affected as varying
branches of the tibial nerve can become involved. Ankle pain is also present in patients who
have high level entrapments. Inflammation or swelling can occur within this tunnel for a number
of reasons. The flexor retinaculum has a limited ability to stretch, so increased pressure will
eventually cause compression on the nerve within the tunnel. As pressure increases on the
nerves, the blood flow decreases. Nerves respond with altered sensations like tingling and
numbness. Fluid collects in the foot when standing and walking and this makes the condition
worse. As small muscles lose their nerve supply they can create a cramping feeling.
Patients with this condition present with pain in the inside of the ankle or heel region that
radiates into the sole of their foot (Figure 2). This pain can have a sharp, shooting, dull, or
burning feeling and may be associated with numbness. The pain is often worse with activity
and towards the evening. Excessive walking and increased body weight can exacerbate the
patients symptoms.
Figure 2: Location of pain in patient presenting with tarsal tunnel syndrome.(from footeducation.com
http://www.footeducation.com/wp-content/uploads/2010/08/tarsal-tunnel-syndrome-Figure-1-300x235.png
)
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4 Objective evidence
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Figure 3: MRI showing fluid-filled ganglion (arrow) that is compressing the posterior tibial nerve. (from
footeducation.com http://www.footeducation.com/wp-content/uploads/2010/08/Figure-3-Tarsal-Tunnel-
Syndrome-Ganglion-Panchbhavi-04-19-2014.png)
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5 Epidemiology
Though TTS is rare in commonality, causality can usually be determined in 70% of reported
cases. According to a May 2014 OSHA report, in the workplace, TTS is considered a
musculoskeletal disorder and accounts for 1.8 million cases a year, which accumulates to
about $15$20 billion a year ( Jeffress, Charles N. "Work-related Musculoskeletal Disorders
(MSDs)." Work-related Musculoskeletal Disorders (MSDs). Occupational Safety & Health
Administration, n.d. Web. 11 May 2014). TTS occurs more dominantly in active adults, with a
higher pervasiveness among women.
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6 Differential diagnosis
It is important to attempt to determine the source of the problem.
Trauma
Space occupying lesion: ganglion cyst, benign tumors, swollen tendon, varicose veins
Ankle deformities: pes planus (flat foot)
Peripheral neuropathy: diabetes (if pain follows "stocking distribution")
Herniated lumbar disk: back pain in L4, L5, S1 regions, leg/thigh pain, "double crush"
one nerve pinch in the lower back, and the second in the tarsal tunnel.
Complex regional pain syndrome: if regional discoloration, swelling, temperature
changes, allodynia, hyperesthesia
Neurofibromatosis: formation of pigmented, cutaneous neurofibromas can invade tarsal
tunnel and create pressure.
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7 Red flags
It is important to rule out nerve compression in the low back area. There is a fairly high
correlation between nerve compression in the spine region (ex from a disk or spinal stenosis)
and tarsal tunnel-type symptoms. If this is the case, then local treatments may not be effective
if the real problem is at the level of the low back.
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neurolysis of the tibial nerve, which requires identifying and freeing up the tibial nerve as it
passes the inside of the ankle and hindfoot. This is done by releasing any tight structures and
removing any obvious scar on the outer aspect of the nerve. If there is a positive Tinel sign,
then there is an 80% chance that decompressing the tarsal tunnel will relieve the symptoms of
pain and numbness in a diabetic with TTS. It has been suggested that TTS in conjunction with
a mass effect, such as a bone spur or ganglion cyst, may do better. In theory, removing the
mass should help the patients symptoms. In practice, this is not always proven to be the case,
because scarring can occur around the nerve during surgery, which may unfortunately also
cause compression. Furthermore, by operating around the nerve, any postoperative bleeding
will have a tendency to scar the nerve further. Thus the main potential surgical complication
specific to tarsal tunnel release is hypersensitivity in the area of surgery, due to failure to
eradicate the symptoms and in some cases, making the symptoms worse. Other potential
complications that are not specific to tarsal tunnel surgery include wound healing problems,
infection, deep vein thrombosis (DVT), pulmonary embolism (PE), and complex regional pain
syndrome.
Figure 4: Schematic of tarsal tunnel release (from Wikipedia: Tarsal tunnel syndrome)
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10 Miscellany
Tarsal tunnel is quite different than carpal tunnel syndrome. Carpal tunnel syndrome is seen in
the wrist, where direct compression of the nerve produces the chronic injury and subsequent
symptoms.
Mnemonic for structures coursing through the tarsal tunnel (from anterior to posterior): Tom,
Dick, and very nervous Harry. (Tibialis posterior tendon, flexor Digitorum longus tendon,
posterior tibial Artery, posterior tibial Vein, tibial Nerve, flexor Hallucis longus tendon)
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11 Key terms
posterior tibial nerve, Tinel's sign, terrible triad, adult acquired flatfoot deformity, pes planus,
plantar fasciitis, tarsal tunnel release
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12 Skills
Recognize the Tinel's sign
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