Because the symptoms of tarsal tunnel syndrome (TTS) can be confused with other conditions, proper evaluation is essential so that a correct diagnosis can be made and appropriate treatment initiated. That’s why the place to start is with one of the accomplished and highly skilled specialists at OCC – Advanced Orthopedic & Sports Medicine Specialists in Denver, Parker, or Aurora, Colorado. Without treatment, TTS can lead to nerve damage. If you develop nerve damage, it can be permanent and irreversible. You may have difficulty walking, exercising, or performing your daily activities. Delayed treatment often requires more aggressive interventions. That’s why you should see Advanced Orthopedics now.

OVERVIEW

Tarsal tunnel syndrome (TTS), otherwise known as tibial nerve dysfunction or posterior tibial nerve neuralgia, is a compressive neuropathy of the foot caused by entrapment of the tibial nerve as it passes through the tarsal tunnel. While nerve compression syndromes like carpal tunnel syndrome are common in the wrist, the same type of compression in the foot is less common. This makes tarsal tunnel syndrome somewhat rare and often underdiagnosed. Some facts include:

• Women are approximately 3 times more likely to develop it
• Peak age of onset is 40-60 years old
• More common in middle-aged women
• Contributing Factors for Female Predominance
• Women typically have smaller tarsal tunnels
• Hormonal influences (similar to carpal tunnel syndrome)
• Higher rates of inflammatory conditions
• More likely to have flat feet (pes planus)
• Higher prevalence of rheumatoid arthritis
• Occupational Factors
• Jobs requiring prolonged standing
• Professions with repetitive ankle movements
• Work that involves sustained plantar flexion
• Anatomical Considerations
• Higher rates of ankle instability
• Greater foot mobility/flexibility
• Prevalence and Risk Factors in Athletes:
• Most common in runners and athletes who do a lot of jumping or cutting movements
• More frequent in athletes with flat feet (pes planus) or high arches
• Can be triggered by overtraining, especially on hard surfaces
• Often seen alongside other conditions like plantar fasciitis or posterior tibial tendonitis

THE TARSAL TUNNEL

The tarsal tunnel – the source of tarsal tunnel syndrome – is a narrow space that lies on the inside of the ankle next to the ankle bones, known as the tarsal tunnel.  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. Specifically, the tarsal tunnel is formed by:

• Ankle bones: The tunnel is bordered by the medial malleolus (the bony prominence on the inside of the ankle) and the calcaneus (heel bone).
• Ligaments: The flexor retinaculum is the key ligament that forms the roof of the tarsal tunnel, covering and protecting the structures within.

Within the tarsal tunnel, the posterior tibial nerve branches out into smaller nerves that innervate the foot, providing sensation and motor function. The tunnel protects these nerves and structures, but when there’s swelling, inflammation, or other issues, it can lead to conditions such as tarsal tunnel syndrome, resulting in pain, numbness, or weakness in the foot.

The tarsal tunnel itself has four separate compartments, not just one continuous tunnel as often assumed. Each compartment has its own unique risk factors for compression. The tibial nerve helps carry sensory and motor function messages from your brain to 21 different muscles in the lower part of the leg.

WHAT IS TARSAL TUNNEL SYNDROME?

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. While nerve compression syndromes like carpal tunnel syndrome are common in the wrist, the same type of compression in the foot is less common. This makes tarsal tunnel syndrome somewhat rare and often underdiagnosed. Most common in runners and athletes who do a lot of jumping or cutting movements.

CAUSES

Tarsal tunnel syndrome can affect a variety of individuals, but certain situations and conditions predispose one to develop TTS. Some of the conditions or people who are more likely to experience tarsal tunnel syndrome include:

1. Anatomical Factors

• Flat Feet or Fallen Arches: Can increase pressure on the tibial nerve by flattening the tarsal tunnel.
• Bone Spurs or Bony Growths: Irregular bone formations can press on the nerve.
• Ankle Fractures or Dislocations: May narrow the tunnel or cause irritation.

2. Soft Tissue Issues

• Tendinitis or Tenosynovitis: Inflammation of tendons or their sheaths in the area can compress the nerve.
• Ganglion Cysts or Lipomas: Benign growths within or near the tunnel can create pressure.
• Varicose Veins: Swollen veins in the tarsal tunnel can compress the nerve.

3. Injury or Overuse

• Trauma: Direct injuries to the ankle or foot, such as sprains, can inflame surrounding tissues.
• Repetitive Stress: Activities that put prolonged or repetitive pressure on the feet (e.g., running or prolonged standing).

4. Systemic Conditions

• Diabetes: This can increase the risk of nerve compression due to neuropathy and swelling.
• Arthritis: Inflammatory arthritis, like rheumatoid arthritis, can cause swelling and nerve compression.
• Hypothyroidism: May lead to tissue swelling that affects the nerve.

5. Obesity

• Excess weight can increase the strain on the ankle and foot, exacerbating the condition.

6. Footwear

• Poorly fitting or overly restrictive footwear can aggravate pressure on the tarsal tunnel.

7. Nerve Conditions

8. Masses or Growths

• Ganglion cysts, lipomas, swollen blood vessels, or bone spurs within the tarsal tunnel can exert pressure on the nerve.

SYMPTOMS

Sometimes, the symptoms of the syndrome appear suddenly. They are often brought on or aggravated by overuse of the foot, such as in prolonged standing, walking, exercising, or beginning a new exercise program. 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. People with TTS can experience:

• Burning/tingling pain along nerve distribution
• Numbness in foot/toes
• Pain worse when standing/walking
• Symptoms may radiate into arch and heel
• Weakness
• Muscle damage
• Shooting pain

NON-SURGICAL TREATMENTS

Many treatments can be applied at home that may give relief:

• 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, and Naproxen help reduce 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.

WHEN IS SURGERY INDICATED?

Surgery for tarsal tunnel syndrome is typically indicated when conservative treatments like rest, physical therapy, and anti-inflammatory medications fail to alleviate symptoms, particularly if the pain is severe, persistent, or accompanied by noticeable muscle weakness, indicating significant nerve compression in the tarsal tunnel. This is usually confirmed by diagnostic tests like nerve conduction studies or imaging scans. The tibial nerve can become permanently damaged if compressed for a sustained period. A doctor may opt for tarsal tunnel release if the patient experiences the following symptoms:

• Pain and numbness in the affected foot
• Numbness that lasts hours
• Sleep disturbance caused by numbness
• Trouble pressing the gas or brake pedals
• Loss of balance
• Neurosensory testing shows degeneration of nerves

In tarsal tunnel release, the surgeon cuts along the nerve path, allowing the tissue to stretch and creating more space inside the tarsal tunnel. This increase in space relieves pressure on the tibial nerve. The surgeon will also examine the two main branches of the tibial nerve that travel to the heel and determine whether they also need compression relief.

GETTING THE RIGHT DIAGNOSIS.  GETTING THE RIGHT DOCTOR.

In every way, skill and experience matter. At Advanced Orthopedics in Denver, Parker, or Aurora, Colorado, you will work closely with a specialist who puts you first. After a thorough physical exam, advanced imaging studies may be ordered to evaluate nerve problems – electromyography and nerve conduction velocity (EMG/NCV,) a Tinel’s test, or MRI may all help measure nerve and muscle function or indicate a mass putting pressure on the tibial nerve. Some foot conditions have symptoms that are similar to TTS symptoms such as bursitis, compartment syndrome, plantar fasciitis, or Tendinitis. You can count on getting the best care at Advanced Orthopedics from doctors who have the deep technical expertise and deep understanding of complex ankle/foot anatomy needed to get the best results. Above all, they perform surgery with precise and exacting skill. If you want to get back to life with little or no pain, you want to get to Advanced Orthopedics right away.