Chiropractic Treatment of Tarsal Tunnel Syndrome
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What is Tarsal Tunnel Syndrome?
Tarsal tunnel syndrome is a common compressive neuropathy of the posterior tibial nerve as it passes through the tarsal tunnel. Tibial nerve compression results in pain and paresthesia radiating into the plantar arch and heel. Tarsal tunnel syndrome may be underdiagnosed as it sometimes mimics plantar fasciitis or heel pad syndrome.
The flexor retinaculum (FR) defines the tarsal tunnel, which extends posteriorly and inferiorly from the medial malleolus. The tarsal tunnel houses the tendons of the flexor hallucis longus, flexor digitorum longus, and tibialis posterior, in addition to the posterior tibial artery and nerve (TN). As the posterior tibial nerve traverses the tunnel, it divides into three branches: the lateral plantar nerve (LPN), the medial plantar nerve (MPN), and the calcaneal nerve (MCN).
Recognizing Tarsal Tunnel Syndrome
Numbness, pain, burning, or paresthesia in the plantar arch or heel
Symptoms increase with prolonged standing, running, or exercise
Forty-three percent of patients report pain that is worse at night (1)
Symptoms may present as part of the "Heel Pain Triad": the combination of plantar fasciitis, posterior tibial tendon dysfunction, and tarsal tunnel syndrome. Researchers postulate that a failure of the "static" plantar fascia combined with a "dynamic" failure of the posterior tibial tendon results in a traction injury to the tibial nerve. (2)
Confirming the Diagnosis of Tarsal Tunnel Syndrome
Physical Exam
1. Tenderness to palpation over the tarsal tunnel and manual compression for 30 seconds sometimes reproduces the chief complaint. A positive Tinel sign posterior to the medial malleolus may be present.
2. Diminished sensitivity to pinwheel or light touch in the tibial nerve distribution.
3. The loss of two-point discrimination on the plantar surface of the foot is the first and most sensitive sensory assessment and may be used to monitor progress. Two-point discrimination can help determine which branch of the plantar nerve is affected.
Orthopedic Exam
The Dorsiflexion-Eversion Test is a valuable assessment for tarsal tunnel syndrome. (3) As the name implies, this test places the patient's foot into dorsiflexion and eversion for 15 seconds while maintaining extension of the metatarsophalangeal joints. Reproduction of plantar paraesthesia during this test, although not pathognomonic, is an overwhelmingly positive sign of tarsal tunnel. (4)
The Triple Compression Stress Test is another reliable assessment to help define tarsal tunnel syndrome. (5) The test is performed by applying manual pressure over the posterior tibial nerve while performing the Dorsiflexion-Eversion test.
Electrodiagnostic testing is not generally required unless motor involvement is suspected. If necessary, EMG/NCS can help to differentiate nerve entrapment from radiculopathy or peripheral neuropathy. If a stress fracture, osseous lesion, or exostosis is suspected, perform radiographs.
How Can You Manage Tarsal Tunnel Syndrome?
The goals of management are first to reduce pain and inflammation. Initial treatment may include reassurance, rest, ice, anti-inflammatory modalities, and NSAIDs. Early correction of overpronation is critical. Individual needs vary from over-the-counter arch supports to custom orthotics. Consultation about footwear should include advice to discontinue wearing high heels (although a slight heel may improve symptoms) and consideration of a motion control shoe to prevent pronation.
1. Instrument-assisted soft tissue manipulation or myofascial release techniques may release adhesions in or near the tarsal tunnel, although some discretion is necessary to avoid further trauma to the nerve. Nerve mobilization is a helpful adjunct for improving nerve function. (6)
Nerve Release- Posterior Tibial Nerve at the Ankle
2. Myofascial stripping can help ease hypertonicity and trigger points in the gastroc and soleus. Stretching of the tibialis posterior and the plantar fascia can also be implemented as dorsiflexion becomes more tolerable.
STM- Posterior Tibialis
3. Strengthening the tibialis posterior will help support the arch. Patients may accomplish this by sitting with the affected ankle crossed at the knee, placing a resistance band over the affected forefoot-secured beneath the other foot, and moving the affected foot "up" into inversion and slight dorsiflexion.
Resisted Posterior Tibialis Strengthening
4. Manipulation may be beneficial to re-establish normal motion to fixations in the cuboid and talonavicular joint (7) and associated spinal segments.
Did You Know: Foot Pronation Affects Tarsal Tunnel Syndrome?
The tarsal tunnel has a variable volume, dependent upon the foot's position. A valgus deformity of the foot causes diminished cross-sectional area and increased tensile load to the tibial nerve. (8) Trepman et al. measured pressures within the tarsal tunnel in various foot positions and found an almost 30-fold increased pressure with pronation compared to neutral. (9) Since overpronation is often present bilaterally, tarsal tunnel syndrome commonly affects both feet.
Keep in mind
NEUROPATHIES
Co-existing polyneuropathies like alcoholism, diabetes, and thyroid disorders may superimpose entrapment neuropathies. Tarsal Tunnel Syndrome is almost twice as prevalent in people with diabetes. (10) Systemic neuropathies often present bilaterally, are not provoked by movement, and progress slowly.
FIBROMYALGIA
"Tarsal tunnel syndrome is statistically more frequent in patients with fibromyalgia than the normal population. The potential comorbidities of tarsal tunnel syndrome and paresthesia of the foot should be carefully examined in fibromyalgia patients." (11)
RHEUMATOID ARTHRITIS
"Bilateral Tarsal Tunnel Syndrome [TTS] was detected in 10 of the patients (33.3%) with rheumatoid arthritis...in correlation with TTS, foot and ankle joint were the first involved joints at the beginning of RA disease ...Tarsal tunnel syndrome is commonly seen in RA and its incidence increases in patients with primary foot involvement. Therefore, caution should be taken against the entrapment neuropathies in these patients" (12)
Evidence-based chiropractors strive to identify the proper diagnosis to save time and improve patient satisfaction. In the case of tarsal tunnel syndrome, we must differentiate between lumbar spine radiculopathy, heel pad syndrome, and plantar fasciitis. Each one of these diagnoses carries a much different management strategy.
Your patients deserve the absolute best care. And YOU are the right provider for that mission. Now that you have learned how to master Tarsal Tunnel Syndrome, it’s time to sharpen your clinical skills for another 100+ conditions with ChiroUp.
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1. Mondelli M, Morana P, Padua L. An electrophysiological severity scale in tarsal tunnel syndrome. Acta neurologica scandinavica. 2004 Apr;109(4):284-9
2. Labib SA, Gould JS, Rodriguez-del-Rio FA, Lyman S. Heel pain triad (HPT): the combination of plantar fasciitis, posterior tibial tendon dysfunction and tarsal tunnel syndrome. Foot & ankle international. 2002 Mar;23(3):212-20
3. Alshami AM, Babri AS, Souvlis T, Coppieters MW. Biomechanical evaluation of two clinical tests for plantar heel pain: the dorsiflexion-eversion test for tarsal tunnel syndrome and the windlass test for plantar fasciitis. Foot & ankle international. 2007 Apr;28(4):499-505.
4. Kinoshita M, Okuda R, Monkawa J. A new test for TTS. J Bone Joint Surg Am. 2002:1714-5.
5. Abouelela AA, Zohiery AK. The triple compression stress test for diagnosis of tarsal tunnel syndrome. The Foot. 2012 Sep 1;22(3):146-9
6. Kavlak Y, Uygur F. Effects of nerve mobilization exercise as an adjunct to the conservative treatment for patients with tarsal tunnel syndrome. Journal of manipulative and physiological therapeutics. 2011 Sep 1;34(7):441-8
7. Hudes K. Conservative management of a case of tarsal tunnel syndrome. The Journal of the Canadian Chiropractic Association. 2010 Jun;54(2):100
8. Daniels TR, Lau JT, Hearn TC. The effects of foot position and load on tibial nerve tension. Foot & ankle international. 1998 Feb;19(2):73-8.
9. Trepman E, Kadel NJ, Chisholm K, Razzano L. Effect of foot and ankle position on tarsal tunnel compartment pressure. Foot & ankle international. 1999 Nov;20(11):721-6.
10. Abouelela AA, Zohiery AK. The triple compression stress test for diagnosis of tarsal tunnel syndrome. The Foot. 2012 Sep 1;22(3):146-9.
11. López Solà M, Pujol J, Wager TD, Garcia Fontanals A, Blanco Hinojo L, Garcia Blanco S, Poca Dias V, Harrison BJ, Contreras Rodríguez O, Monfort J, Garcia Fructuoso F. Altered functional magnetic resonance imaging responses to nonpainful sensory stimulation in fibromyalgia patients. Arthritis & rheumatology. 2014 Nov;66(11):3200-9
12. Ünan MK, Ardçolu Ö, Ta NP, Baykara RA, Kamanl A. Assessment of the frequency of tarsal tunnel syndrome in rheumatoid arthritis. Turkish Journal of Physical Medicine & Rehabilitation (2587-1250). 2021 Oct 1;67(4).
