Tarsal Tunnel Syndrome
The tarsal tunnel is a narrow space that lies on the inside of the ankle next to the ankle bones. The tunnel is covered with a thick ligament (the flexor retinaculum) that protects and maintains the structures contained within the tunnel— arteries, veins, tendons, and nerves. One of these structures is the posterior tibial nerve, which is the focus of tarsal tunnel syndrome.
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Who does it affect?
Tarsal tunnel syndrome is caused by anything that produces compression on the posterior tibial nerve, such as:
- A person with flat feet is at risk for developing tarsal tunnel syndrome, because the outward tilting of the heel that occurs with “fallen” arches can produce strain and compression on the nerve.
- An enlarged or abnormal structure that occupies space within the tunnel can compress the nerve. Some examples include a varicose vein, ganglion cyst, swollen tendon, and arthritic bone spur.
- An injury, such as an ankle sprain, may produce inflammation and swelling in or near the tunnel, resulting in compression of the nerve.
- Systemic diseases such as diabetes or arthritis can cause swelling, thus compressing the nerve.
Why does it happen?
Tarsal tunnel syndrome is a compression, or squeezing, on the posterior tibial nerve that produces symptoms anywhere along the path of the nerve running from the inside of the ankle into the foot.
Tarsal tunnel syndrome is similar to carpal tunnel syndrome, which occurs in the wrist. Both disorders arise from the compression of a nerve in a confined space.
Patients with tarsal tunnel syndrome experience one or more of the following symptoms:
- Tingling, burning, or a sensation similar to an electrical shock
- Pain, including shooting pain
Symptoms are typically felt on the inside of the ankle and/or on the bottom of the foot. In some people, a symptom may be isolated and occur in just one spot. In others, it may extend to the heel, arch, toes, and even the calf.
Sometimes the symptoms of the syndrome appear suddenly. Often they are brought on or aggravated by overuse of the foot, such as in prolonged standing, walking, exercising, or beginning a new exercise program.
It is very important to seek early treatment if any of the symptoms of tarsal tunnel syndrome occur. If left untreated, the condition progresses and may result in permanent nerve damage. In addition, because the symptoms of tarsal tunnel syndrome can be confused with other conditions, proper evaluation is essential so that a correct diagnosis can be made and appropriate treatment initiated.
The foot and ankle consultant will examine the foot to arrive at a diagnosis and determine if there is any loss of feeling. During this examination, the consultant will position the foot and tap on the nerve to see if the symptoms can be reproduced. He or she will also press on the area to help determine if a small mass is present.
A variety of treatment options, often used in combination, are available to treat tarsal tunnel syndrome. These include:
- Rest. Staying off the foot prevents further injury and encourages healing.
- Ice. Apply an ice pack to the affected area, placing a thin towel between the ice and the skin. Use ice for 20 minutes and then wait at least 40 minutes before icing again.
- Oral medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation. Immobilization. Restricting movement of the foot by wearing a cast is sometimes necessary to enable the nerve and surrounding tissue to heal.
- Physical therapy. Ultrasound therapy, exercises, and other physical therapy modalities may be prescribed to reduce symptoms.
- Injection therapy. Injections of a local anesthetic provide pain relief, and an injected corticosteroid may be useful in treating the inflammation.
- Orthotic devices. Custom shoe inserts may be prescribed to help maintain the arch and limit excessive motion that can cause compression of the nerve.
- Shoes. Supportive shoes may be recommended.
- Bracing. Patients with flatfoot or those with severe symptoms and nerve damage may be fitted with a brace to reduce the amount of pressure on the foot.
Sometimes surgery is the best option for treating tarsal tunnel syndrome. The foot and ankle consultant will determine if surgery is necessary and will select the appropriate procedure or procedures based on the cause of the condition.
A 10 cm incision is made behind your ankle extending down to the arch of your foot. The ligament over the tibial nerve in the region of the tarsal tunnel is released. The nerve is followed in the foot, and the tunnels for the medial and lateral plantar nerves also are released. The calcaneal branch frequently has its own tunnel, which also is released. A long-acting anesthetic is used to help with postoperative pain, and because of this anesthetic, you likely will feel more numbness after surgery.
A soft, bulky dressing is applied. Two to three days following surgery, it will be removed. To control swelling, it is important to keep your foot elevated whenever possible, and moving your toes also will help decrease swelling. When you walk, you may put as much weight through your foot as comfort allows. A cane or crutches may be used at first to help decrease weight-bearing through your foot.
After the dressing is removed, you may begin range-of-motion exercises of your ankle, and an Ace wrap may be used to help control swelling in your foot. The stitches are removed two to three weeks after surgery depending on your wound healing. You may progress to full weight bearing as you feel comfortable and may use crutches or a cane for your comfort. In some cases with delayed wound healing, prolonged swelling or decreased ankle strength/range of motion, you may be sent to physical therapy.
- Delayed wound healing.
As the feeling comes back to your foot, you may feel more tingling or burning sensations as normal sensation returns.
Other surgical complications include injury to the small sensory nerves in the region or to the main nerve.