What is Tarsal Tunnel Syndrome? 1,2
Tarsal Tunnel Syndrome is a dysfunction involving the tibial nerve, a distal branch of the sciatic nerve, at the medial aspect of the ankle known as the tarsal tunnel. TTS is commonly found in the literature as Tibial Nerve dysfunction. The tibial nerve provides innervation to, and allows for movement and sensation in the calf and foot muscles. TTS may be caused by a number of different mechanisms, however, direct trauma, pressure on the nerve for prolonged periods, and pressure on the tibial nerve from nearby structures are the most common mechanisms leading to Tarsal Tunnel Syndrome. Abnormal mechanics/postures of the foot such as excessive pronation is often seen in patients with Tarsal Tunnel Syndrome. Symptoms commonly seen to be caused by Tarsal Tunnel Syndrome include: burning sensation, numbness, tingling or other abnormal sensations, pain, weakness of the foot muscles, toes, or calf: musculature innervated by the Tibial nerve. Symptoms may present at the site of the Tarsal Tunnel, proximally in the posterior compartment of the lower leg, or distally in the plantar surface of the foot. Patients with TTS may benefit from nonoperative management if the nerve entrapment/compression is caused by tenosynovities and flexible foot deformities whereas operative management may be indicated in the event of space occupying lesions such as ganglias, lipomas, chronic thrombophlebitis, and varicosities. Physical Therapy management will depend upon the patient specific course of treatment.
Guide to Physical Therapist Practice 3
Deduction by way of a thorough Physical Therapy examination will classify patient's with Tarsal Tunnel Syndrome under the Preferred Practice Pattern: 5F: Impaired Peripheral Nerve Integrity and Muscle Performance Associated With Peripheral Nerve Injury. The findings from the examination (history, systems review, and tests and measures i.e. Tinel’s Sign, Extreme Range of Eversion and Dorsiflexion, etc.) may indicate the presence or risk of pathology/pathophysiology (disease, disorder, or condition), impairments, functional limitations, or disabilities or the need for health, wellness, or fitness programs.
Goals of Conservative/Non-Surgical Treatment for Patients with TTS4,5,6
- Optimal Tibial nerve integrity
- Return to prior level of function in home, work, school, community and leisure activities
| Intervention | Method |
|---|---|
| P. R. I. C. E. | prevention of further injury, allow for healing of current dysfunction |
| Education | Resources for understanding the pathophysiology and anatomy of TTS, proper footwear for patient specific activity level |
| Balance, coordination, and agility training | motor function (control and motor learning), gait analysis, neuromuscular education for the recruitment of appropriate musculature at certain phases of gait, posture awareness: foot posture, mechanics, sensory training/retraining: regain normal sensory innervation to the plantar surface of the foot, task specific: What does your patient enjoy? |
| Body Mechanics and Postural Stabilization | single leg stance while maintaining appropriate foot posture with the help of appropriate footwear, orthotics, etc. |
| Flexibility Exercises | stretching of shortened musculature secondary to compensations adopted secondary to tibial nerve dysfunction: ACSM Guidelines for Stretching: at least 4 repetitions per muscle group, of 15-60 second holds, 2-3days/week |
| Gait Training | Gait analysis on treadmill with mirror for visual feedback to the patient; biofeedback to promote activation of weakened muscles during various phases of gait |
| Strength, power and endurance training | posterior compartment of the lower leg: Posterior Tibialis, & foot musculature: FHL, FDL as tolerated by patient and progressing with improvement of symptoms, i.e. aquatic-to-land-based-to-resisted therapeutic exercise. |
| Manual Therapy | soft tissue mobilization of fascial and myofascial structures potentially causing entrapment; neural mobilization: sciatic nerve glides |
| Modalities | |
| Medication | corticosteriod injection; inflammatory reducing agents: NSAIDS: Ibuprofen |
| Electrical Stimulation | NMES (reeducation of impaired musculature), TENS (pain relief) |
| Cryotherapy | Coldpack, ice massage |
| Hydrotherapy | Whirlpool therapy |
| Compression, Bracing | taping to maintain ideal foot biomechanics |
| Orthotics | maintain the arch, limit excessive motion that may compress branches of the Tibial nerve |
Where's the evidence? Research says… 7,8,9,10.
How do we know which intervention to choose? Practicing Evidence Based Medicine is the goal so here is some to help in your clinical desicion making!
- From an issue in Podiatry Today, Paul R. Scherer considers some recommendations relating to the role of orthotics in TTS managment.
- lack of longitudinal arch support causes traction injury to the tibial nerve
- pronation of the foot produces symptoms in a test secondary to increased pressure on the tibial nerve
Plantarflexion and inversion decrease tarsal tunnel pressure and therefore an orthotic device that supports the longitudinal arch, decreases pronatory motion and plantarflexes the ankle joint will have a positive effect.
- Range of motion and strength deficits of the components of the Tarsal Tunnel: flexor hallicus longus, posterior tibialis, flexor digitorum longus, may lead to over compensation of certain muscles or entrapment along the tibial nerve. Addressing strength and flexibility will promote symmetrical strength, flexibility, and functional mobility.
- According to a study by Kavlak and Uygur from the Journal of Manipulative Physiological Therapeutics 2011 studied 2 groups of randomly allocated patients: 14 in a control group recieving only conservative management consisting of physical therapy and supportive inserts and 14 in a study group receiving nerve mobilization exercises. Conservative management included lower leg posterior compartment strength and flexibility, icing, medial arch taping in cases of a low navicular tubercle, medial wedges were given to patients with pronation deformities. Both groups showed improvement from conservative management given to both the control and the study group, however, the study group given tibial nerve mobilization exercises displayed improvements in 2-point discrimination, light touch, and Tinel Sign.
- From American Family Physician, a peer reviewed journal from the American Academy of Family Physicians, corticosteroid injections may be utilized upon the conclusion of interventions such as strengthening, stretching, rest and orthotic devices to assist in improving chronic symptoms in patients with burning sensation, pain, and other paresthesias caused by compression of the tibial nerve.
The above interventions are to be tailored case-specifically. TTS may present in a number of different ways, to varying degrees of severity. In determining appropriate stretching and strengthening interventions, it is important to identify the patient's exact impairements and causes of functional limitations. Pre-test, Post-test measures will help in identifying patient specific best-practice.
Physical Therapy Implications Post-Surgical Management of Tarsal Tunnel Syndrome 11
In the event that TTS cannot be managed conservatively, in the presence of a space occupying lesion, a Tarsal Tunnel Release may be indicated. The following are guidelines for post-surgical management. Again, post-surgical management will be tailored on a case-specific basis.
Phase I for Immobilzation and Rehabilitation: Weeks 1-3
Goals:
- Protect joint/nerve integrity
- Control Inflammation
- Control pain/edema
| Intervention | Method |
|---|---|
| Immobilzation | non-weigh bearing precautions to protect the nerve and overstretching of the surgical incision |
| Passive Range of Motion (PROM) | hallux, phalange, and ankle PROM in order to prevent fibrosis of the Flexor Hallucis Longus, Flexor Digitorum Longus and Posterior Tibialis tendons as they traverse through the tarsal tunnel |
| Education: Wound Care | Instruct in surgical site protection and infection prevention strategies |
| Edema Management | Hands On Treatment for Tarsal Tunnel Syndrome: The following techniques may be helpful in reducing symptoms of tarsal tunnel syndrome. They may be in the order below, or in a different order with different emphasis depending on the clinical situation. Milking fluid from the tarsal tunnel, releasing the flexor retinaculum, milking fluid from the ankle joint, milking fluid from within the tibial nerve, releasing the abductor hallucis muscle, neural sliding and gliding of the tibial nerve relative to the flexor retinaculum, stretching the tibial nerve at the tarsal tunnel to release adhesions within the nerve. SOURCE: http://www.nervemobilization.com/tarsal-tunnel-syndrome |
| Education: Precautions | Monitor Non-Weight Bearing ambulation with appropriate assistive device |
Phase II for Immobilization and Rehabilitation: Weeks 3-6
Goals:
- Prevent contractions and formations of scar tissue adhesions
- Maintain soft tissue and joint mobility
| Intervention | Method |
|---|---|
| Weight Bearing Progression | non-weight bearing to weight bearing as tolerated |
| PROM, Active Assisted Range of Motion (AAROM), and Active Range of Motion (AROM) | Ankle ROM out of splint; passive dorsiflexion with towel or strap progressing to gentle, pain free, weight-bearing dorsiflexion stretching |
| Fibrosis, Adhesion Prevention | Initiate tibial nerve glides: start with anti-tension techniques of the tibial nerve(plantar flexion and inversion) moving from the hip or knee. Progress to mobilization of the foot into dorsiflexion and eversion as irritability decreases |
| Gait training | Introduce walking wearing protective splint as patient tolerates |
| Aquatic Therapy | walk or run under buoyant conditions to achieve appropriate gait with partial weight-bearing status |
Phase III for Immobilization and Rehabilitation: Weeks 6-12 to 24
Goals:
- Normal gait mechanics for walking and running on level surfaces
- Symmetric ankle mobility and single-leg proprioception
- Ability to perform repeated single leg heel raises pain free
- Initiate sport-specific or job-specific skill development exercises
| Intervention | Method |
|---|---|
| Gait training | Progress to walking without splint to pain free tolerance |
| Strengthening | Pain free resistive ankle exercises using theraband progressing to body weight exercises: partial-to-full weight bearing progression; evaluate compensations and muscular weakness |
| Flexibility | Progress to initiate body weight stretching over incline as tolerated |
| Balance and Proprioception | progress training from single to multi-planar unstable conditions (BOSU, 1/2 roll, foam) to single leg balance activities |
| Task specific training | According to patient's goals, prior level of function, begin pain-free sport-specific, job-specific interventions) |
| Health and Wellness Promotion | Cardiovascular conditioning on stationary bicycle to pain free tolerance progressing to greater impact, patient's choice, activities as tolerated |
Special Instructions
Differential diagnosis is essential in patients with symptomatology paralleling Tarsal Tunnel Syndrome. Patients with Tarsal Tunnel Syndrome will present differently depending upon the site of nerve irritation. It is important to tailor the treatment and intervention techniques to the specific symptoms. Determining the cause of nerve irritation and avoiding the aggravating stimuli will benefit the patient in symptom management, long-term relief, and ultimately allow for return to prior level of function.
