Tarsal Tunnel Syndrome: Why and What to Do?

Have you been diagnosed with carpal tunnel syndrome, or do you think you may have it because of pain and sensory problems in your foot?

I’d like to come back to the essentials on the subject, drawing as always on my experience as a physiotherapist, and the academic literature on the subject!

♻️ Last update: September 1, 2024.
👩‍⚖️ Declaration of financial interests: amazon affiliate links. My complete declaration of links of interest is in legal mentions.
Written by Nelly Darbois, physiotherapist and scientific editor

How to tell if it’s tarsal tunnel syndrome: symptoms, examination

The tibial nerve runs through your foot. Near the ankle, it passes through a kind of canal: the tarsal canal.

If this canal is narrowed or compressed, your nerve may be affected. You may feel pain, numbness or tingling in your foot.

It’s called tarsal tunnel syndrome!

The 5 most common symptoms are :

1. pain at rest or when moving ;
2. burning sensation ;
3. Tinel’s sign: you have pain or tingling which radiates into the foot when a doctor or physiotherapist taps the area of the tarsal canal, behind the medial malleolus, on the inside of the foot);
4. sensory disorders ;
5. muscular atrophy (less muscle mass visible to the naked eye) or weakness (reduced strength in the foot).

The diagnosis is made on the basis of your feelings, a clinical examination and, if necessary, additional tests.

Complementary examinations such as imaging, electromyograms or blood tests are used only to rule out other causes that could explain the symptoms, in case of doubt.

What are the causes?

Tarsal tunnel syndrome can be triggered by a number of things.

Internal causes, involving the structures of the foot:

• Inflammation of tendons passing through the area (tendonitis, tendinopathy, tenosynovitis);
• osteophytes (bony outgrowths often associated with ankle osteoarthritis);
• varicose veins, cysts, lipomas, neoplasms or neuromas that compress the area.

And so-called external causes:

• a shoeing problem;
• foot deformities;
• generalized edema of the lower limbs;
• foot surgery scars;
• trauma to the foot;
• arteriopathy of the lower limbs.

Can the tarsal nerve be “unstuck”?

The term “unstuck” is often used in everyday language. Instead, we talk about decompressing the nerve.

Think of the nerve as a garden hose stuck under a stone. To get the water flowing again, you have to remove the stone or move it.

In the case of the tarsal nerve, this can mean :

• reduce inflammation,
• adjust the surrounding structures,
• consider surgical intervention to free the nerve from compression.

Let’s take a look at the treatments we can use to do just that.

How is tarsal tunnel syndrome treated?

There are two main approaches to treating the syndrome:

• simply seek to relieve symptoms, especially pain;
• attempt to decompress the nerve.

Treatments may include physiotherapy, anti-inflammatory drugs, orthotics, physiotherapy exercises or corticosteroid injections, and sometimes surgery.

Although there are around 800 academic publications on this syndrome, there are very few clinical trials comparing the efficacy of one type of management versus no treatment, or two types of management against each other.

Recommendations are therefore based on case studies or the experience of healthcare professionals.

Physical therapy, exercises, orthotics, insoles

After carrying out an assessment, physiotherapists can propose different types of treatment, depending on your general state of fitness, the discomfort you describe and your objectives.

Some treatments focus primarily on short-term pain relief (physiotherapy, shockwave, TENS, cryotherapy, etc.).

Serial splints may also be prescribed to rest the area. Often for the night, or at limited times during the day. These are usually compression socks of some kind (see amazon).

Your physiotherapist or chiropodist will also be able to discuss your footwear with you, and whether or not you should wear an insole or heel cup for better arch support.

For others, the main objective will be to enable you to perform all activities involving the foot despite the presence of the syndrome. This may involve progressive muscle-strengthening exercises or stretching, for example.

The idea is to rehabilitate your foot and, more generally, your various muscular, tendinous and bony structures, so that they can withstand greater and greater stress.

Massage

When massage is used, the aim is only to provide short-term pain relief.

Medicines

Traditional pain medications are often suggested: paracetamol, NSAIDs, or sometimes those more commonly prescribed for pain of neurological origin: gabapentin, pregabalin and tricyclic antidepressants.

They are generally taken orally, but can also be applied locally to the skin.

Infiltration

Corticosteroid injections directly into the tarsal tunnel are sometimes suggested.

Operation

When conservative treatment isn’t enough, your doctor or physiotherapist may suggest that you consult a surgeon to consider an operation.

Surgery involves cutting a band of tissue called the flexor retinaculum, which attaches near the inside of the ankle, to release the compressed nerve.

Depending on the study, 4 out of 10 to 9 out of 10 people are relieved or even cured following surgery (Kiel 2024).

According to the available data (which remains of low quality), the people most likely to respond better to surgery are those who :

1. have a positive Tinel sign before surgery;
2. are younger;
3. have been hurting for less time;
4. have no other ankle pathology.

For the last 3 points, however, we can imagine that these people have a better prognosis whatever they do, even without surgery.

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That’s all I wanted to say on the subject! Any questions or comments? See you in comments!