TARSAL TUNNEL SYNDROME: UNDERSTANDING THE PAIN BEHIND YOUR ANKLE

Medically Reviewed by Dr. Rosmy Barrios

Tarsal tunnel syndrome (TTS), otherwise known as posterior tibial neuralgia, causes a compression of the tibial nerve at the point of the tarsal tunnel, a narrow space inside the ankle. It is more prevalent among women and can occur at any age.

This article illustrates the anatomy of the tarsal tunnel, the causes and symptoms of tarsal tunnel syndrome, and the available treatment options.

Anatomy of the Tarsal Tunnel

The tarsal tunnel is a narrow channel inside your ankle, precisely behind the inner ankle bone (medial malleolus). It is formed by the foot bones and a thick ligament called the Flexor Retinaculum, stretching from the inner ankle to the heel bone (calcaneus). Several vital structures pass through this tunnel, including tendons (like the tibialis posterior and flexor digitorum longus), blood vessels, and, most importantly, the tibial nerve.^[1]

The tibial nerve, which runs from the back of the knee to the foot, supplies feeling to the sole of the foot and governs the muscles that flex the toes. When the nerve is compressed or damaged, it can lead to an assortment of symptoms, with common ones including pain, numbness, and weakness.

What Causes Tarsal Tunnel Syndrome?

A variety of factors can induce tibial nerve compression, including:

• An injury to the ankle or foot
• Foot surgery and surgical scarring
• Microtrauma (damage) due to repetitive stress to the ankle and foot
• Any swelling or cause of inflammation in the tarsal tunnel
• A cyst or tumor in the tarsal tunnel
• Ankle fibrosis
• The tarsal coalition, where two or more bones in the foot fuse together
• Valgus hindfoot (the foot maintains an outward angle)
• Varus hindfoot (the foot maintains an inward angle)
• Arthritis or other conditions that cause inflammation in the ankle
• Diabetes or other conditions that affect nerve function

20-40% are idiopathic, which occurs spontaneously without a known cause.

Risk Factors for Tarsal Tunnel Syndrome

Below are several factors that can elevate your risk of acquiring tarsal tunnel syndrome:

• Ankle injuries or fractures
• Diabetes
• Rheumatoid arthritis
• Gout
• Hypothyroidism
• Hyperlipidemia
• Obesity
• Pregnancy
• Foot deformities
• High arches or flat feet
• Poorly fitting shoes
• Varicose veins affecting the area
• Arterial insufficiency
• Extra muscles in the feet that may compress the tibial nerve
• Activities that place the feet under pressure due to repetitive stress, such as running or standing for long periods

Can Tarsal Tunnel Syndrome Be Hereditary?

While there is no direct evidence that tarsal tunnel syndrome is hereditary, some studies have shown that specific foot and ankle conditions, such as flat feet and high arches, can run in families. These conditions can increase the risk of developing tarsal tunnel syndrome.

Symptoms of Tarsal Tunnel Syndrome

TTS symptoms typically include pain, numbness, and tingling in the ankle or foot.

Other common symptoms include^[2]:

• Difficulty with foot flexion
• A burning sensation in the foot
• Pain that deepens with activity
• Pain that is worse at night or when the foot is plantarflexed (pointed downward)
• Weakness in the foot or toes
• In severe cases, muscle wasting in the foot

Does Tarsal Tunnel Ever Go Away?

Tarsal tunnel syndrome can be chronic, meaning it may not go away independently. Treatment can help to keep the symptoms well under control.

What Are the Long-Term Effects of Tarsal Tunnel Syndrome?

If left untreated, tarsal tunnel syndrome can lead to enduring nerve damage and muscle weakness in the foot. This can affect walking ability and make it challenging to perform daily activities.

Diagnosis of Tarsal Tunnel Syndrome

If you are experiencing TTS symptoms, your doctor will perform a physical exam. The hallmark symptoms of the condition can go a long way towards differentiating it from other conditions. Your doctor may mandate additional tests to verify the diagnosis and eliminate other possibilities.^[3]

These tests may include:

• Tinel's Test: Your doctor will tap on the tarsal tunnel to see if it causes numbness or a tingling sensation in your foot.^[4]
• Nerve Conduction Study: This test measures the speed and intensity at which electrical signals travel through the tibial nerve.
• MRI or Ultrasound: These imaging tests can help identify any abnormalities in the tarsal tunnel, such as a cyst or tumor.

What Conditions Mimic Tarsal Tunnel Syndrome?

Other conditions that cause pain in the foot or ankle may resemble TTS.

Differential diagnosis for tarsal tunnel syndrome comprises:

• Plantar Fasciitis
• Achilles Tendinitis
• Stress Fractures
• Compartment syndrome of the deep flexor compartment
• Degeneration of the structure in the ankle and foot
• Heel spurs
• Retrocalcaneal bursitis
• Intersection syndrome
• L5 and S1 nerve root compression
• Polyneuropathy
• Morton metatarsalgia

Tarsal Tunnel Syndrome vs. Plantar Fasciitis: How to Tell the Difference

Tarsal tunnel syndrome usually causes pain and numbness on the inside of the ankle, while plantar fasciitis leads to pain in the sole of the foot. Additionally, tarsal tunnel syndrome is usually worse at night or when the foot is pointed downward, while plantar fasciitis is usually worse in the morning and improves with activity.

Treatment Options for Tarsal Tunnel Syndrome

The treatment for tarsal tunnel syndrome relies on symptom severity and the underlying cause. In most cases, conservative measures are recommended as the first line of treatment.

A standard approach for foot injuries and conditions like tarsal tunnel syndrome includes RICE. This abbreviation stands for:

• Rest the concerned foot and avoid any activity that aggravates the symptoms
• Apply ice packs to lessen inflammation
• Use compression to minimize swelling
• Elevate the foot to promote circulation and reduce pain

These measures can prevent further damage, help alleviate symptoms, and support the healing process.

Other conservative measures that can help include:

• Taking over-the-counter pain relievers
• Wearing supportive shoes or orthotic inserts

Nonsurgical Treatments

If conservative measures do not offer relief, your doctor may recommend other nonsurgical treatments to you^[5], such as:

• Steroid Injections: These can block inflammation and alleviate pain.
• Custom Orthotics: These specially designed shoe inserts can help support the foot and reduce pressure on the tibial nerve. For some, a foot brace may support the foot and alleviate symptoms better than an insert.^[6]
• Physical Therapy: A physical therapist can assist with learning exercises and stretches to relieve your symptoms and prevent future flare-ups.

Tarsal tunnel syndrome exercises can help relieve the symptoms and prevent future flare-ups. These exercises may include^[7]:

• Ankle rotations, 5-10 times in both directions
• Calf stretches, which involve pushing against a wall with the calf of the injured foot stretched out behind and bending the other leg forward.
• Heel stretches, achievable by standing "tip-toed" for a few seconds while holding onto something for support.

A physical therapist can provide more comprehensive exercises to help strengthen the foot.

Surgical Interventions

In extreme cases, surgery may be necessary to relieve pressure on the tibial nerve. Surgical treatment may involve releasing the Flexor Retinaculum or removing cysts or tumors compressing the nerve. Following nerve release or the removal of tissue compressing the nerve, the surgeon may flex and extend the ankle to confirm that the nerve moves freely without any impingement, ensuring that no other structures are compromised.^[8]

Living with Tarsal Tunnel Syndrome

If you have a TTS diagnosis, there are a few lifestyle modifications that can help you manage your symptoms and avert future flare-ups. These may include:

• Resting the feet and avoiding activities that strain them
• Sustaining a healthy weight to diminish pressure on the foot
• Performing regular foot stretches and exercises

What Kind of Shoes Should I Wear if I Have Tarsal Tunnel Syndrome?

When choosing shoes to wear with tarsal tunnel syndrome, looking for shoes with good arch support and a wide toe box is essential. This will help reduce pressure on the tibial nerve and support the foot. Avoid high-heeled shoes or shoes with a narrow toe box, as these can aggravate the symptoms.

How Long Does Tarsal Tunnel Syndrome Last?

The duration of tarsal tunnel syndrome will depend upon the cause, severity, and effectiveness of treatment. With conservative measures, symptoms may improve and never return in some cases. In other instances, TTS may require ongoing management or surgery.

Research and Advancements

Research is ongoing to understand better the causes and treatment options for tarsal tunnel syndrome. Some recent advancements include using ultrasound-guided injections and surgery^[9] to target the tibial nerve more accurately and using stem cell therapy to repair nerve damage^[10].

The use of Wharton's Jelly is also currently under investigation to treat Tarsal Tunnel Syndrome. Wharton's Jelly (WJ) is a human umbilical cord tissue that does not elicit an immune reaction. Studies have shown that WJ is safe and effective for treating connective tissue defects surrounding nerves in the tarsal tunnel. It has been shown to improve pain and restore function in patients who have failed standard care treatments.

These emerging therapies require further research and clinical trials to determine their effectiveness and safety. Always discuss any other treatment options you wish to try with your doctor so that they can assess their suitability for your case.

Conclusion

In conclusion, tarsal tunnel syndrome is an often debilitating condition, yet with proper treatment and lifestyle modifications, it can be managed effectively. If you are experiencing tarsal tunnel syndrome symptoms, book an appointment with your doctor for a proper diagnosis and treatment plan. The right approach can help provide relief from the pain behind your ankle and get you back on your feet.

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