Knee / Ankle / Foot

Tarsal Tunnel Syndrome

Definition

Tarsal tunnel syndrome is a neurological disorder characterised by pain in the forefoot and/or neurological deficit due to dysfunction or lesion of the tibial nerve in tarsal tunnel.

Aetiology

The cause is an entrapment of the tibial nerve by the flexor retinaculum in the tarsal tunnel, located between the medial malleolar bone and the achilles tendon.

Because a large number of patients have an ankle trauma in the medical history (17% - 43%), is posttraumatic aetiology the most frequent cause. In addition, a relation exists with diabetes, hypothyroid, gout and mucopolysaccharidose.

Muscle hypertrophy (abductor hallucis muscle) and thickened tendons (flexor digitorum longis muscle) can compress the tarsal tunnel resulting in a entrapment of the tibial nerve.

Acute tarsal tunnel syndrome is seen in marathon runners. In the so-called "jogger foot" repetitive irritation of the medial plantar branch of the tibial nerve causes a tarsal tunnel syndrome.

Signs and symptoms

Patients with tarsal tunnel syndrome complain of burning pain, sensory loss, hyperalgesia, and allodynia of the plantar forefoot, toes and heel. Walking and running can provoke the pain.

Diagnostics

Physical Examination

Neurological examination can be normal. However, sensory loss and motor deficit of the abductors and short flexors of the toes can occur.

Additional Somatic Diagnostics

  • Diabetes must be excluded.
  • EMG of the tibial nerve.
  • Referral, when there is suspicion of other aetiology.

Additional Psycho-cognitive Diagnostics

  • RAND-36 (quality of life)
  • VAS Pain (maximal, minimal, actual, average/week)
  • PCS (catastrophising)
  • HADS (fear and depression)

Multidisciplinary Treatment

Whether or not somatic treatment is indicated is based on the pain diagnosis. Based on the findings of the pain questionnaires, additional diagnostics and/or multidisciplinary treatment comprising various non-somatic treatments may be necessary.

Non-somatic Treatment

Somatic Treatment

Pharmacological treatment:

  • Tricyclic antidepressants
  • Anticonvulsives: carbamazepine, oxcarbazepine, gabapentine and pregabaline.

Other Treatments

Interventional Pain Treatment