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Tarsal
Tunnel Syndrome
478

129

190

62

7824

Original Editor - David Cameron

Top Contributors - Erin Locati, Chelsey Walker, David Cameron, Ashley Bohanan and Katie Schwarz

Contents
1 Definition/Description
2 Epidemiology/Etiology
3 Characteristics/Clinical Presentation
4 Differential Diagnosis
5 Outcome Measures
6 Examination [18]
7 Medical Management
8 Physical Therapy Management
9 Key Research
10 Resources
11 Clinical Bottom Line
12 Recent Related Research (from Pubmed)
13 Read 4 Credit
14 References

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Definition/Description
The tarsal tunnel is a channel between the medial malleolus, talus, calcaneus and the flexor retinaculum a
fibrous sheet that runs from the medial malleolus to the calcaneus. The tunnel contains[1][2]:
Tibialis posterior tendon
Flexor digitorum longus tendon
Posterior tibial artery & vein
Tibial nerve (yellow in image)
Flexor hallucis longus tendon
The tibial nerve divides into two terminal branches - the medial and
lateral plantar nerves - as it passes through the tarsal tunnel. The
medial calcaneal nerve branches from the tibial nerve at or superior to
the flexor retinaculum. [3][4][5][6]
Tarsal Tunnel Syndrome (TTS) is a rare compressive neuropathy of
the tibial nerve or one of its branches as they pass under the flexor
retinaculum.[6][7][2][8][9]
In the TTS literature, the tibial nerve is also referred to as the
posterior tibial nerve and TTS is also known as Posterior Tibial

Posterior-Medial Ankle: Tarsal Tunnel

(Google Body Screenshot)

Nerve Neuralgia[7]. Some authors [10][4] refer to compression of the

deep fibular nerve as anterior tarsal tunnel syndrome. This page is limited to the discussion of tarsal tunnel
syndrome as the entrapment of the posterior tibial nerve or its branches.

Epidemiology/Etiology
Incidence is unknown[2][8][11]. A higher prevalence is reported for women than men[2][8][9]. It can be seen at any
age.[8]
Causes of TTS include[7][2][8][12][4][9][13]:
Repetitive stress activities such as running, excessive walking or standing
Traumas such as fracture, dislocation or stretch injuries
Heel varus or valgus
Fibrosis
Excessive Weight
Space occupying lesions in tarsal tunnel region such as a ganglion, tumors, edema, osteophytes or
varicosities
Tendonitis
Systemic diseases that cause ankle inflammation or nerve compromise (ex: diabetes mellitus, arthritis)
Many cases (20%-40%) are idiopathic.[2][4]

Characteristics/Clinical Presentation
Common symptoms of TTS include paresthesia (burning, numbness or tingling) in the posterior tibial, lateral
plantar and/or medial plantar nerve distributions - see picture. Burning, tingling, or pain in the medial portion of
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the ankle and or plantar aspect of the foot, as well as local tenderness behind the
medial malleolus may be seen[14][6][15]. Symptoms usually worsen with forced
eversion and dorsiflexion of foot. When the medial plantar nerve is affected in
isolation patients can present with stabbing pain in the medial sole of the foot
upon walking, which is usually seen in middle aged runners. In a progressed or
chronic case muscle weakness of the toe abductors and flexors can be
demonstrated. In more serious cases muscle atrophy can be seen[4]. Patients can
also present with night pain that awakens them from sleep as well as
aggravation with prolonged walking[11].

Differential Diagnosis
TTS can present similarly to other lower extremity conditions with the most
common differential diagnosis being plantar fasciitis as these patients also
present with plantar heel pain[5]. In addition to Plantar fasciitis (in which TTS is
thought to be commonly misdiagnosed as), polyneuropathy, L5 and S1 nerve
root syndromes, Morton metatarsalgia, compartment syndrome of the deep
flexor compartment will have to be distinguished from tarsal tunnel syndrome

Distribution of Peripheral
Nerve Sensation to Plantar
Aspect of Foot

as well[4].

Outcome Measures
Foot and Ankle Ability Measure (FAAM)
The FAAM is a reliable, responsive, and valid measure of physical function for individuals with a broad
range of musculoskeletal disorders of the lower leg, foot, and ankle.[16]

Rating Scale for the Severity of Tarsal Tunnel Syndrome [17]

A normal foot scores 10 points
Absent Some Definite
Pain, spontaneous or on
2
1
0
movement
Burning pain
2
1
0
Tinel's sign
2
1
0
Sensory disturbances
2
1
0
Muscle atrophy or weakness

Examination [18]
It is important to take a thorough history. The physical therapist should inquire about the following:
Mechanism of injury (MOI) was there any trauma, strain, or overuse?
Duration and location of pain and parathesia?
Weakness or difficulty walking?
Back or buttock pain associated with more distal symptoms?
Pain getting worse, staying the same, or getting better?
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Key history Findings:

Parathesia or burning sensation in the territory of the distal branches of the tibial nerve
Prolonged walking or standing often exacerbates patients pain
Dysesthesia (an abnormal and unpleasant sensation) arises during the night and can disturb sleep
Weakness of muscles
Observation (observe in weight bearing and non-weight bearing):
Muscle atrophy of the abductor hallucis muscle may be seen
Check for arch stability
Position of the talus and calcaneous
Gait Analysis:
Assess for abnormalities (excessive pronation/supination, toe out, excessive inversion/eversion, antalgic
gait, etc.)
Sensory Testing
Test light touch, 2-point discrimination, and pinprick in the lower extremity
Deficits will be in the distribution of the posterior tibial nerve
Palpation:
Tender to palpation in between the medial malleolus and Achilles tendon
Painful in 60-100% of those affected[4]
Range of Motion (ROM):
Focus on ankle and toe ROM
Manual Muscle Testing (MMT):
Decreased strength generally occurs late in the progression of TTS
The phalangeal abductors are impacted first followed by the short-phalangeal flexors
Special Tests:
Tinels Sign:
Percussion of the tarsal tunnel results in distal radiation of
parathesias
Elicited in over 50% of those affected [4]
Dorsiflexion Eversion Test: [14]
Place the patients foot into full dorsiflexion and eversion and
hold for 5-10 seconds[18]
The results are that it elicits the patients symptoms
Dorsiflexion-Eversion Test

EMG studies:

[11]

The presence of an isolated tibial nerve lesion in the tarsal tunnel is confirmed by measurement of the
sensory and motor nerve conduction velocity (NCV).
Sensory conduction velocity of the medial and lateral plantar nerves. This is best done by recording from
the tibial nerve just above the flexor retinaculum and stimulating the nerves at the vault of the foot. When
surface electrodes are used, the responses to stimulation are of low amplitude.
Measurement of the motor NCV through recording of the distal motor latency at the abductor hallucis
brevis muscle is a much easier, but less sensitive method. The important finding on electromyography
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(EMG) is the demonstration of axonal injury when the EMG is recorded from the distal muscles supplied
by the tibial nerve.

Medical Management
PHARMACOLOGICAL MANAGEMENT
Pharmacological treatments are often used in combination with physical therapy management to optimize
recovery and decrease functional disability.[2][4][18]
NSAIDS
Corticosteroid Injections
Pain Medications
SURGICAL MANAGEMENT
Surgery is indicated for patients who have not benefited from
conservative treatments such as physical therapy and have symptoms
that significantly impact their daily life. Individuals with a space
occupying lesion tend to not to respond to conservative management
and often require surgery. Godges and Klingman have identified
several characteristics that have been associated with a successful
response to surgery. The charateristics include; younger age, short
history of symptoms, no previous history of ankle pathology, early
diagnosis, and a determined etiology.
Posterior Tibial Nerve Decompression[19]
- If there is a space occupying lesion, the lesion will be
removed
and decompression will not be done.
Cryosurgery[20]

TTS Surgical Incision (Antoniadis

2008) Used with permission

ALTERNATIVE MANAGEMENT
Acupuncture[21]

Physical Therapy Management

There is a lack of high level evidence concerning physical therapy management for tarsal tunnel syndrome.
Further research is needed to identify specific rehabilitation exercises for patients with tarsal tunnel syndrome.
Small randomized controlled trials would help analyze the effectiveness of specific treatments.[2][4]

CONSERVATIVE MANAGEMENT[22][23]

Physical Agents
Acute Stage
Goal: reduce pain
and swelling

Orthotics
Therapeutic Ex
-Ankle bracing
-Ice
-CAM walker
-Pulsed ultrasound
-Calf stretching
-Plantar arch taping
-Phonophoresis
-Nerve mobility
-Medial heel wedge
-E-stim
-Pt edu on footwear

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Manual Therapy
-Soft tissue
massage
-Tibial nerve
mobilization
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Subacute Stage
-See above
Goal: increase
flexibility and STR
Settled Stage
Goal: promote
symmetrical flexibility, -See above
STR, and functional
mobility

-See above

-Posterior tibialis
strengthening

-See above

-Posterior tibialis
-See above
strengthening in WB

-See above

One of the mechanical causes of tarsal tunnel syndrome is believed to be excessive calcaneal eversion leading to
collapse of the medial longitudinal arch (over pronation) which puts traction stress on the posterior tibial nerve
and compression by the flexor retinaculum. Scherer proposes that custom fit orthoses will correct the over
pronation and therefore decrease the stress on the posterior tibial nerve. Although there is no clinical outcome
studies documenting the effectiveness of orthotics, it may be an important technique to consider when treating
patients with tarsal tunnel syndrome.[24]

Several articles listed basic techniques for conservative management of tarsal tunnel syndrome as a guideline to
rehabilitation, but did not provide patient outcomes.[2][25][4][12]

POSTOPERATIVE TREATMENT[26]
Timeframe Goals

Phase I

1-3 wks

-Protect nerve, joint, and

incision site
-Control swelling
-Reduce pn

Phase II 3-6 wks

-Prevent contractures
-Prevent scar tissue adhesions
-Increase joint mobility

Phase III 6-12 wks

-Normal gait mechanics

-Increase ankle mobility
-Increase PF strength
-Specific skill development

Intervention
-Immobilization with NWB precautions
-Ankle passive ROM
-RICE
-Gait training with AD
-WBAT
-Gentle passive and active ankle stretching
-Begin tibial nerve glide with anti-tension
technique (foot PF and inverted)
-Gait training to tolerance with protective splint
-Aquatic therapy
-Gait training without splint
-Pain free theraband exercises
-Tibial nerve glide progression
(foot everted and dorsiflexed)
-Weight bearing exercises
-Resistive exercises (impairment approach)
-Balance/proprioceptive training
-Specific skill development in pain free range
-Cardiovascular fitness

CASE STUDIES
Romani et al reported their findings for a 22 year old male lacrosse player experiencing tarsal tunnel syndrome.
The player experienced a mild eversion ankle sprain that was successfully managed with conservative treatment.
Upon a second eversion ankle sprain, the patient made an executive decision to participate in the NCAA
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tournament causing aggravation of symptoms ultimately leading to surgical repair. Within a 13 week
rehabiliatation program, treatment consisted of RICE, ROM, balance, theraband exercises, aquatic therapy, and
walking which was eventually progressed to running. At the end of 13 weeks, the athlete returned to
intercollegiate lacrosse participating at an elite level. For specific postsurgical protocol, click the following link.
[25]

Dr. Karen Hudes conducted a single subject case study addressing a conservative approach to treating tarsal
tunnel syndrome. The 61 year old patient with diagnosed tarsal tunnel syndrome reported pain and discomfort
along the medial ankle with a Verbal Rating Scale of 9/10. Initial management included orthotics for the first ten
weeks after which the patient reported little to no change in her symptoms. After unsuccessful outcomes with
orthotics, treatment techniques such as cross friction massage, HVLA toggle board adjustments of the
talonavicular joint, and mobilizations of the cuboid were used twice per week. The patients symptoms began to
decrease at 3 weeks, resolved by 6 weeks with low pain intermittent recurrences, and completely resolved within
12 weeks. The patient reported no pain at a ten month follow up.[2]

Key Research
Conservative Management of a Case of TTS
Posterior TTS: Diagnosis and Treatment
Usefulness of Electrodiangostic Techniques in Evaluation of Suspected TTS
Tarsal Tunnel Release

Resources
TTS - American College of Foot & Ankle Surgeons
TTS - University Foot & Ankle Institute

Clinical Bottom Line

There is a lack of high quality research on effective management of tarsal tunnel syndrome. The physical
therapist should stage the patient based on swelling, pain, duration of symptoms and/or time since surgery.
Management should be impairment based to address specific strength, flexibility, gait and functional limitations
of a given patient.

Recent Related Research (from Pubmed )

Neurovascular Bundle Decompression without Excessive Dissection for Tarsal Tunnel Syndrome.

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References
see adding references tutorial.
1. Louisiana State University Health Sciences Center. Posterior Thigh Dissection Guide: Posterior leg Tarsal tunnel. Available at:
http://virtualhumanembryo.lsuhsc.edu/hs2412/laboratory/New_Lab_Guide/LowerLimb/TarsalTunnel.html .
Accessed July 5, 2011.
2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 Hudes, K. Conservative management of a case of tarsal tunnel
syndrome. J can Chiropr Assoc. 2010; 54(2): 100-106.
3. University Foot and Ankle Institute. Tarsal Tunnel Syndrome. Available at:
http://www.footankleinstitute.com/tarsal-tunnel-syndrome . Accessed July 5, 2011.
4. 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 Antoniadis G, Scheglmann K. Posterior tarsal tunnel
syndrome: Diagnosis and treatment. Dtsch Arztebl Int. 2008; 1-5(45): 776-781.
5. 5.0 5.1 Alshami AM, Babri AS, Souvlis T, Coppieters MW. Strain in the tibial and plantar nerves with
foot and ankle movements and the influence of adjacent joint positions. J Applied Biomechanics. 2008; 24:
368-376.
6. 6.0 6.1 6.2 Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. 6th ed. Philadelphia, Pa:
Lippincott Williams and Wilkins; 2010: 617-618, 666-667.
7. 7.0 7.1 7.2 National Institute of Health Office of Rare Disease Research. Tarsal tunnel syndrome.
Available at:
http://rarediseases.info.nih.gov/GARD/Condition/7733/QnA/21157/Tarsal_tunnel_syndrome.aspx .
Accessed on July 5, 2011.
8. 8.0 8.1 8.2 8.3 8.4 Llanos LF, Vila J, Nunez-Samper M. Clinical symptoms and treatment of the foot and
ankle nerve entrapment syndromes. Foot and Ankle Surg. 1999; 5: 211-218.
9. 9.0 9.1 9.2 Mondelli M, Morana P, Padua L. An electrophysiological severity scale in tarsal tunnel
syndrome. Acta Neurol Scand. 2004; 109: 284-289.
10. Zongzhoa L, Jiansheng Z, Li Z. Anterior tarsal tunnel syndrome. J Bone
& Joint Surg. 1991; 73: 470-473.
11. 11.0 11.1 11.2 Patel AT, Gaines K, Malamut R, Park A, Del Toro DR, Holland N. Usefulness of
electrodiagnostic techniques in the evaluation of suspected tarsal tunnel syndrome: An evidence-based
review. Muscle and Nerve. 2005; 236-240.
12. 12.0 12.1 American College of Foot and Ankle Surgeons. Tarsal tunnel syndrome. Available at:
http://www.foothealthfacts.org/footankleinfo/tarsal-tunnel-syndrome.htm . Accessed on July 5, 2011.
13. Toth C, McNeil S, Feasby T. Peripheral nervous system injuries in sport and recreation: A systematic
review. Sports Med. 2006; 35(8): 717-738.
14. 14.0 14.1 Kinoshita M, Okuda R, Morikawa J, Jotoku T, Abe M. The dorsiflexion-eversion test for
diagnosis of tarsal tunnel syndrome. Journal of Bone and Joint Surgery, American Volume. December
2001; 83A (12): 1835-1839.
15. Netter, FH. Atas of Human Anatomy. 5th ed. Philadelphia, Pa: Saunders Elsevier; 2011: 529.
16. Martin R, Irrgang J, Burdett R, et al. Evidence of Validity for the Foot and Ankle Ability Measure
(FAAM). Foot and Ankle International. 2006; 26(11):968-983.
17. Takakura Y, Kitada C, Sugimoto K, et al. Tarsal Tunnel Syndrome. J Bone Joint Surgery. 1991; 73B:125-128.
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18. 18.0 18.1 18.2 Huber L, Lombara A. Clinical Review: Tarsal Tunnel Syndrome. Rehabilitation Operations
Council: Glendale Adventist Medical Center. October 8, 2010.
19. Ward P Porter M. Tarsal tunnel syndrome: a study of the clinical and neurophysiological results of
decompression. Royal College of Surgeons of Edinburgh. 1998;43:35-36
20. Goldstein S. New technologies. Cryosurgery for the treatment of tarsal tunnel syndrom. Podiatry
Management. October 2006;25(8):163-170.
21. Smith S. Acupuncture in the treatment of tarsal tunnel syndrome. Journal of Chinese Medicine. February
2009;(89):19-25.
22. Godges J, Klingman R. Ankle Nerve Disorder: Tarsal Tunnel Syndrome. Loma Linda University DPT
Program.
23. Bond T, Lundy J. Physical Therapy Following Peripheral Nerve Surgeries. Clinics In Podiatric Medicine
and Surgery. 2006;23:651-666.
24. Scherer P, Waters L, Choate C, et al. Is There Proof In The Evidence Based Literature That Custom
Orthoses Work? Podiatry Management. September 2007;109-122.
25. 25.0 25.1 Romani W, Perrin D, Whiteley T. Tarsal Tunnel Syndrome: Case Study of a Male Collegiate
Athlete. Journal of Sport Rehabilitation. 1997;6:364-370.
26. Godges J, Klingman R. Tarsal Tunnel Release. Loma Linda University DPT Program.
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