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Tarsal Tunnel Syndrome – Causes, Symptoms & Treatment

Tarsal tunnel syndrome is a nerve entrapment condition near the inner ankle where the tibial nerve is compressed, causing pain, numbness, and tingling in the foot.

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Things worth knowing about "Tarsal Tunnel Syndrome"

Tarsal tunnel syndrome is a nerve entrapment condition near the inner ankle where the tibial nerve is compressed, causing pain, numbness, and tingling in the foot.

What is Tarsal Tunnel Syndrome?

Tarsal tunnel syndrome is a nerve entrapment (compression) syndrome in which the tibial nerve becomes compressed as it passes through the tarsal tunnel – a narrow fibro-osseous canal located on the inner side of the ankle. The tunnel is formed by the ankle bones and a thick band of connective tissue called the flexor retinaculum. In addition to the tibial nerve, tendons and blood vessels also pass through this tunnel. When the space within the tunnel becomes reduced, the tibial nerve and its branches are irritated or damaged, leading to characteristic pain and sensory disturbances in the foot.

Causes

Tarsal tunnel syndrome can develop due to a variety of underlying factors:

Space-occupying lesions: Cysts, ganglia, benign tumors, or enlarged blood vessels within the tarsal tunnel
Trauma and scar tissue: Ankle injuries, fractures, or post-surgical scarring that narrow the tunnel
Foot deformities: Flat feet (pes planus) or overpronation increase pressure on the tibial nerve
Inflammatory conditions: Rheumatoid arthritis or other inflammatory joint diseases can cause swelling around the tunnel
Overweight and overuse: Excess body weight or intensive physical activity can raise pressure within the tarsal tunnel
Systemic diseases: Diabetes mellitus, hypothyroidism, or other metabolic conditions may additionally impair nerve function

Symptoms

Symptoms of tarsal tunnel syndrome primarily affect the inner ankle, heel, and sole of the foot:

Burning pain along the inner ankle, heel, and sole of the foot
Numbness and tingling (paresthesia) in the toes or the entire sole of the foot
Electric shock-like sensation when tapping over the tibial nerve at the inner ankle (positive Tinel sign)
Worsening of symptoms with prolonged standing, walking, or physical activity
Improvement of symptoms with rest or elevating the foot
In advanced cases: muscle weakness in the sole of the foot and difficulty spreading the toes

Diagnosis

The diagnosis of tarsal tunnel syndrome is based on a combination of clinical examination and technical assessments:

Clinical examination: The physician evaluates the Tinel sign at the inner ankle, assesses foot posture, and tests sensitivity of the foot sole
Nerve conduction studies (NCS) and electromyography (EMG): These neurophysiological tests measure the speed of nerve conduction and can identify damage to the tibial nerve
Imaging: Ultrasound and MRI (magnetic resonance imaging) help detect space-occupying lesions and identify the precise cause of nerve compression
X-ray: Used to rule out bony causes or foot deformities

Treatment

Conservative Treatment

For mild to moderate symptoms, non-surgical management is the first line of treatment:

Orthotic insoles: Custom-made insoles correct foot alignment and relieve pressure on the tibial nerve
Physical therapy: Targeted exercises for stretching and strengthening the foot muscles, as well as manual therapy techniques
Anti-inflammatory medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen for pain relief
Corticosteroid injections: Local injections of corticosteroids can reduce inflammation within the tarsal tunnel
Immobilization: Short-term offloading using braces or specially designed footwear

Surgical Treatment

If conservative measures are insufficient or a structural cause is identified, surgery may be recommended. During tarsal tunnel release, the flexor retinaculum is surgically divided to decompress the tibial nerve. Any space-occupying lesions such as cysts or ganglia are removed at the same time. The success rate of surgery is good when the indication is carefully established.

Prognosis

The outlook for tarsal tunnel syndrome depends on the underlying cause, the duration of symptoms, and the degree of nerve damage. When treated promptly, the prognosis is generally favorable. However, prolonged untreated nerve compression can lead to permanent nerve damage. Regular follow-up care, appropriate footwear, and the use of orthotic insoles can help prevent recurrence.

References

Dellon AL. - The four medial ankle tunnels: a critical review of perceptions of tarsal tunnel syndrome and neuropathy - Neurosurgery Clinics of North America, 2008.
Lam SJ. - A tarsal-tunnel syndrome - The Lancet, 1962; 2(7264): 1354–1355.
DiDomenico LA, Masternick EB. - Anterior tarsal tunnel syndrome - Clinics in Podiatric Medicine and Surgery, 2006; 23(3): 611–620.

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