Injury Spotlight: Tarsal Tunnel Syndrome

 The tibial nerve, posterior tibial artery, tendons of the tibialis posterior, flexor digitorum longus, and flexor hallucis longus travel in a bundle along this pathway.

The tibial nerve, posterior tibial artery, tendons of the tibialis posterior, flexor digitorum longus, and flexor hallucis longus travel in a bundle along this pathway.

What is Tarsal Tunnel Syndrome?

Tarsal Tunnel Syndrome - A condition in which the tibial nerve is irritated as it travels through the tarsal tunnel (along the inner leg behind the medial malleolus).

Inside the tunnel, the nerve splits into three different segments. One nerve (calcaneal) continues to the heel, the other two (medial and lateral plantar nerves) continue on to the bottom of the foot. 

Symptoms of Tarsal Tunnel Syndrome

Patients with tarsal tunnel syndrome typically present with numbness and pain in the foot radiating to the big toe and the first three toes. If the muscles of the foot have a compromised blood-flow, it may create a cramping feeling.

A positive Tinel sign on the medial side or symptoms during a straight leg raise test may be indicative of tarsal tunnel syndrome.

Massage Therapy for Tarsal Tunnel Syndrome?

The responses to massage therapy are multifactorial - physiological and psychological factors interplay in a complex manner. The biopsychosocial model provides a practical framework for investigating the complex interplay between massage therapy and clinical outcomes.

Based off the biopsychosocial model, investigation into mechanisms of action should extend beyond local tissue changes and include peripheral and central endogenous pain modulation. An observed favorable outcome may be explained by a number of overlapping mechanism in the periphery, spinal cord, and brain  represented in the image below.

mechanism of action 8.png

Structures To Be Aware of When Treating Tarsal Tunnel Syndrome

A treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. Structures to keep in mind while assessing and treating patients suffering from tarsal tunnel syndrome may include neurovascular structures and investing fascia of:
• Plantar Fascia
• Tibialis Posterior
• Flexor Digitorum Longus
• Flexor Hallucis Longus
• Flexor Hallucis Brevis
• Triceps Surae (gastrocnemius, the soleus, and the plantaris muscle)
• Ankle Joint (the talocrural joint, subtalar joint and the distal tibiofibular joint)


More to Explore

Abouelela, A.A., Zohiery, A.K. (2012). The triple compression stress test for diagnosis of tarsal tunnel syndrome. Foot (Edinb).
https://www.ncbi.nlm.nih.gov/pubmed/22405941

Alshami, A.M., Souvlis, T., Coppieters, M.W. (2008). A review of plantar heel pain of neural origin: differential diagnosis and management. Man Ther.
https://www.ncbi.nlm.nih.gov/pubmed/17400020

Basson, A., Olivier B, ... Mudzi, W. (2017). The Effectiveness of Neural Mobilization for Neuromusculoskeletal Conditions: A Systematic Review and Meta-analysis. J Orthop Sports Phys Ther.
https://www.ncbi.nlm.nih.gov/pubmed/28704626 

Ferkel, E., Davis, W.H., Ellington, J.K. (2015). Entrapment Neuropathies of the Foot and Ankle. Clin Sports Med.
https://www.ncbi.nlm.nih.gov/pubmed/26409596

Kavlak, Y., Uygur, F. (2011). Effects of nerve mobilization exercise as an adjunct to the conservative treatment for patients with tarsal tunnel syndrome. J Manipulative Physiol Ther.
https://www.ncbi.nlm.nih.gov/pubmed/21875518 

Kinoshita M, Okuda R, Morikawa J, Jotoku T, Abe M. The dorsiflexion-eversion test for diagnosis of tarsal tunnel syndrome. J Bone Joint Surg Am.
https://www.ncbi.nlm.nih.gov/pubmed/11741063

Kinoshita, M., Okuda, R., Yasuda, T., Abe, M. (2006). Tarsal tunnel syndrome in athletes. Am J Sports Med.
https://www.ncbi.nlm.nih.gov/pubmed/16567455

Meadows, J.R., Finnoff, J.T. (2014). Lower extremity nerve entrapments in athletes. Curr Sports Med Rep.
https://www.ncbi.nlm.nih.gov/pubmed/25211617

Pomeroy, G., Wilton, J., Anthony, S. (2015). Entrapment neuropathy about the foot and ankle: an update. J Am Acad Orthop Surg. 
https://www.ncbi.nlm.nih.gov/pubmed/25538131

Tu, P. (2018). Heel Pain: Diagnosis and Management. Am Fam Physician.
https://www.ncbi.nlm.nih.gov/pubmed/29365222