TARSAL TUNNEL SYNDROME

TARSAL TUNNEL SYNDROME

Introduction📝 :-

What is tarsal tunnel? 🤔

👉 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.

What Is Tarsal Tunnel Syndrome?

👉 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.

👉 Tarsal tunnel syndrome (TTS), is a compression neuropathy and painful foot condition in which the tibial nerve is compressed as it travels through the tarsal tunnel. This tunnel is found along the inner leg behind the medial malleolus (bump on the inside of the ankle). The posterior tibial artery, tibial nerve, and tendons of the tibialis posterior, flexor digitorum longus, and flexor hallucis longus muscles travel in a bundle through the tarsal tunnel. Inside the tunnel, the nerve splits into three segments. One nerve (calcaneal) continues to the heel, the other two (medial and lateral plantar nerves) continue on to the bottom of the foot. The tarsal tunnel is delineated by bone on the inside and the flexor retinaculum on the outside.

👉 Patients with TTS typically complain of numbness in the foot radiating to the big toe and the first three toes, pain, burning, electrical sensations, and tingling over the base of the foot and the heel. Depending on the area of entrapment, other areas can be affected. If the entrapment is high, the entire foot can be affected as varying branches of the tibial nerve can become involved. Ankle pain is also present in patients who have high level entrapments. Inflammation or swelling can occur within this tunnel for a number of reasons. The flexor retinaculum has a limited ability to stretch, so increased pressure will eventually cause compression on the nerve within the tunnel. As pressure increases on the nerves, the blood flow decreases. Nerves respond with altered sensations like tingling and numbness. Fluid collects in the foot when standing and walking and this makes the condition worse. As small muscles lose their nerve supply they can create a cramping feeling.

Symptoms:-

Patients with tarsal tunnel syndrome experience one or more of the following symptoms:

👉 Tingling, burning or a sensation similar to an electrical shock

👉 Numbness

👉 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.  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.

It is 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.

Some of the symptoms are:

👉 Pain and tingling in and around ankles and sometimes the toes Swelling of the feet and ankle area.

👉 Painful burning, tingling, or numb sensations in the lower legs. Pain worsens and spreads after standing for long periods; pain is worse with activity and is relieved by rest. 

👉 Electric shock sensations Pain radiating up into the leg, behind the shin, and down into the arch, heel, and toes Hot and cold sensations in the feet A feeling as though the feet do not have enough padding Pain while operating automobiles Pain along the Posterior Tibial nerve path Burning sensation on the bottom of foot that radiates upward reaching the knee "Pins and needles"-type feeling and increased sensation on the feet A positive Tinel's sign Tinel's sign is a tingling electric shock sensation that occurs when you tap over an affected nerve.

👉  The sensation usually travels into the foot but can also travel up the inner leg as well.

Causes:-

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 or 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.

👉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)

Diagnosis:-

👉The foot and ankle surgeon will examine the foot to arrive at a diagnosis and determine if there is any loss of feeling. During this examination, the surgeon 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.

👉 Advanced imaging studies may be ordered if a mass is suspected or if initial treatment does not reduce the symptoms. Studies used to evaluate nerve problems—electromyography and nerve conduction velocity (EMG/NCV)—may be ordered if the condition shows no improvement with nonsurgical treatment.

👉 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?

Key history Findings:

Parathesia or burning sensation in the territory of the distal branches of the tibial nerve Prolonged walking or standing often exacerbates patient’s 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

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:

Tinel’s Sign:Percussion of the tarsal tunnel results in distal radiation of parathesias Elicited in over 50% of those affected. 

EMG studies: 

👉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 (EMG) is the demonstration of axonal injury when the EMG is recorded from the distal muscles supplied by the tibial nerve. 

Prevention:-

The exact cause of Tarsal Tunnel Syndrome (TTS) can vary from patient to patient. However the same end result is true for all patients, the compression of the posterior tibial nerve and it branches as it travels around the medial malleolus causes pain and irritation for the patient.There are many possible causes for compression of the tibial nerve therefore there are a variety of prevention strategies. One being immobilization, by placing the foot in a neutral position with a brace, pressure is relieved from the tibial nerve thus reducing patients pain.

👉 Eversion, inversion, and plantarflexion all can cause compression of the tibial nerve therefore in the neutral position the tibial nerve is less agitated. Typically this is recommended for the patient to do while sleeping. Another common problem is improper footwear, having shoes deforming the foot due to being too tight can lead to increased pressure on the tibial nerve.Having footwear that tightens the foot for extended periods of time even will lead to TTS. Therefore, by simply having properly fitted shoes TTS can be prevented.

TREATMENT :-

Nonsurgical Treatment

Many 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.

When Is Surgery Needed?

👉 Sometimes surgery is the best option for treating tarsal tunnel syndrome. The foot and ankle surgeon will determine if surgery is necessary and will select the appropriate procedure or procedures based on the cause of the condition.

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.

CONSERVATIVE MANAGEMENT

Physical AgentsOrthoticsTherapeutic ExManual Therapy

👉Acute Stage👇

👉Goal: reduce pain and swelling-Ice

-👉Pulsed ultrasound

-👉Phonophoresis and Ankle bracing

👉 CAM walker

👉Plantar arch taping

-👉Medial heel wedge

-👉Pt edu on footwear-Calf stretching

-👉Nerve mobility-Soft tissue massage

Tibial nerve

👉mobilization

👉Subacute Stage👇

👉Goal: increase

👉flexibility 

👉strengthening

👉Settled Stage👇

👉Goal: promote

👉symmetrical flexibility,STR, and functional

POSTOPERATIVE TREATMENT

Phase1

 👉1-3 wks-Protect nerve, joint, and

 incision site

-👉Control swelling

-👉Reduce in-Immobilization with NWB precautions

-👉Ankle passive ROM

-👉RICE

-👉Gait training with AD

Phase II

👉3-6 wks-Prevent contractures

-👉Prevent scar tissue adhesions

-👉Increase joint mobility-

-👉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

Phase III

👉6-12 wks-Normal gait mechanics

👉-Increase ankle mobility

👉-Increase PF strength

-👉Specific skill development-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

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