August 5, 2012 PT7549

Author: Brandon Plyler, Maiela Martinez, Caleb Melde, Matt Gieringer

Texas State University, Department of Physical Therapy PT7549, 2012  

Tarsal Tunnel Syndrome:

A Clinical Management Guideline

Etiology: Tarsal Tunnel Syndrome is caused by the entrapment and

compression of the posterior tibial nerve and its branches under the flexor retinaculum in the distal portion of the posterior compartment of the leg1, 2. Causes of nerve entrapment of can range from trauma (sprains, strains and fractures) to participation in repetitive or strenuous activities like running and jogging3. Prognosis:

Early diagnosis and intervention, as well as lower severity of traumatic insult, result in better prognoses. A positive Tinel Sign is indicative of intact nervous tissue, and thusly points to better outcomes post intervention4. Diagnosis of Tarsal Tunnel Syndrome:

The most common manifestation of tarsal tunnel syndrome is irritation of one or any combination of the peripheral nerve branches1, 5. Subjective information may include increased symptoms with prolonged standing or ambulation and increased symptoms at night, and a pes planus deformity may be noticed upon observation. In more progressed cases the patient may present with weakness in the abductors and flexors, typically starting with the great toe.

Some helpful clinical tests include palpation over the flexor retinaculum (Fig. 1) or Tinel Sign, which is performed by tapping over the nerve attempting to change or reproduce symptoms5. The dorsiflexion-eversion test and the inversion test may also both increase symptoms. When dorsiflexing and everting the foot tension is placed on the nerve, and when inverting the foot the volume of the tarsal tunnel is decreased; either of these tests can reproduce pain or increase symptoms.

Some differential diagnoses that should be considered include polyneuropathy, radiculopathy, deep flexor compartment syndrome, Morton’s Metatarsalgia, and plantar fasciitis5, 6. The most common and most probable misdiagnosis is plantar fasciitis.

Evidence-Supported Interventions7: • Conservative Management: pain medications, corticosteroids, non-steroidal anti-inflammatories (NSAIDs) • Physical Therapy Management

o In the acute stage:  Initially reduce inflammation, tissue stress, and pain using physical agents, orthotics and taping, therapeutic exercise and manual therapy

o In the subacute stage: Improve strength and flexibility of the posterior tibialis muscle o In the settled stage: Improve functional mobility, strength in weight bearing, and flexibility bilaterally in the

posterior tibialis muscle • Surgical management can include posterior tibial nerve decompression and cryosurgery

o Following surgery, post-surgical physical therapy will be needed.

Bottom Line Summary

The entrapment of the posterior tibial nerve leading to Tarsal Tunnel

Syndrome can be caused by a variety of intrinsic and extrinsic factors. Currently, management for TTS

includes conservative and surgical interventions that pose minimal

complications and positive outcomes. However, the prognosis of

TTS is still dependent on the identification of the mechanism of

peripheral nerve compression and the influence of comorbidities.

Figure 1. Palpation over the flexor retinaculum

August 5, 2012 PT7549

Author: Brandon Plyler, Maiela Martinez, Caleb Melde, Matt Gieringer

Texas State University, Department of Physical Therapy PT7549, 2012  

References

1. Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. 6th ed. Philadelphia, Pa: Lippincott Williams and

Wilkins; 2010: 617-618. 2. Kavlak Y, Uygur F. Effects of nerve mobilization exercise as an adjunct to the conservative treatment for patients with

tarsal tunnel syndrome. J Manipulative Physiol Ther. 2011; 34(7): 441-448. 3. Hudes K. Conservative Management of a Case of Tarsal Tunnel Syndrome. Journal of Canadian Chiropractic Medicine.

2010; 54(2): 100-106. 4. Ahmad M, et al. Tarsal tunnel syndrome: A literature review. Foot Ankle Surg (2011), doi: 10.1016/ j.fas.2011.10.007 5. Antoniadis G, Scheglmann K. Posterior tarsal tunnel syndrome: Diagnosis and treatment. Dtsch Arztebl Int. 2008; 1-5(45):

776-781. 6. Williams TH, Robinson AH. Entrapment neuropathies of the foot and ankle. Orthopaedics and Trauma. 2009; 23(6): 404-

411. 7. Godges J, Klingman R. Ankle Nerve Disorder: Tarsal Tunnel Syndrome. Loma Linda University DPT Program.