Elsevier

Foot and Ankle Surgery

Volume 18, Issue 3, September 2012, Pages 149-152
Foot and Ankle Surgery

Review
Tarsal tunnel syndrome: A literature review

https://doi.org/10.1016/j.fas.2011.10.007Get rights and content

Abstract

Background

Tarsal tunnel syndrome (TTS) is an entrapment neuropathy of the posterior tibial nerve or its branches within its fibro-osseous tunnel beneath the flexor retinaculum on the medial side of the ankle. It is a rare but important condition which is regularly under diagnosed leading to a range of symptoms affecting the plantar aspect of the foot. Management of this entrapment neuropathy remains a challenge and we have therefore reviewed the published literature in an attempt to clarify aspects of initial presentation, investigation and definitive treatment including surgical decompression. We also assessed the continuing controversial role of electrodiagnostic techniques in its diagnosis.

Conclusion

Recommendations from literature:

  • Excellent results with decompression in selected patients.

  • To prevent nerve fibrosis, decompression should be performed early.

  • Remain aware of false negative NCS (under-diagnosing of those with symptoms but ‘normal’ NCS).

  • Role of NCS remains controversial with inability to predict which cases respond to decompression.

  • Poor outcome may be due to nerve fibrosis.

Introduction

Tarsal tunnel syndrome (TTS) is an entrapment neuropathy of the posterior tibial nerve or its branches (medial plantar, lateral plantar and calcaneal nerves) within its fibro-osseous tunnel beneath the flexor retinaculum on the medial side of the ankle. It is a rare but important condition which is regularly under diagnosed leading to a range of symptoms affecting the plantar aspect of the foot. Accurate diagnosis can be difficult as symptoms are similar to those associated with other lower limb conditions. In addition, controversy remains with false negative electrophysiological studies contributing to the under diagnosis. Surgical intervention may benefit cases where a definite point of entrapment is found.

Management of this entrapment neuropathy remains a challenge and we have therefore reviewed the published literature in an attempt to clarify aspects of initial presentation, investigation and definitive treatment including surgical decompression. We also assessed the continuing controversial role of electrodiagnostic techniques in its diagnosis.

Section snippets

Anatomy

The tarsal tunnel is a fibro-osseous tunnel beneath the flexor retinaculum, behind and inferior to the medial malleolus. The floor is formed by the medial wall of the talus, calcaneum and the medial wall of the distal tibia. The flexor retinaculum forms the superior and inferior margins as well as the roof.

The structures that course within the tarsal tunnel are, from medial to lateral, tibialis posterior tendon, flexor digitorum longus tendon, posterior tibial artery and vein, posterior tibial

Aetiology

Causes of TTS can be classified into either intrinsic, extrinsic, or combinations of the two. In a recent literature review it was estimated that in 80% of cases, the specific cause can be identified [1].

Intrinsic factors include: osteophytes, hypertrophic retinaculum, tendonopathy, space-occupying lesions such as enlarged veins, ganglia, lipoma, tumour and neuroma. Haemorrhage secondary to trauma may lead to adhesions and peri-neural fibrosis. Arterial insufficiency may lead to ischaemia of

Diagnosis

This is a clinical diagnosis based on a detailed history and clinical examination. Adjunctive imaging and electrophysiological studies provide additional information to plan management.

The predominant symptom is pain directly over the tarsal tunnel behind the medial malleolus with radiation to the longitudinal arch and plantar aspect of the foot including the heel. A sensation of tightness and to varying degree sensory symptoms of burning, tingling and numbness are usually present. Symptoms are

Investigations

Plain X-rays of the ankle are useful in demonstrating structural abnormalities such as hind foot varus/valgus, tarsal coalitions, osteophytes or evidence of previous trauma. Magnetic resonance imaging adds further detail and is highly accurate (83%) when investigating space-occupying lesions [2].

Diagnostic ultrasound is increasingly used to detect ganglia, varicose veins, lipomas, tenosynovitis and talocalcaneal coalition [6]. High frequency machines can demonstrate high divisions of the tibial

Management

To increase the rate of positive outcomes, management should be directed at the specific cause.

Surgical results

Reported success rates after tarsal tunnel decompression have varied in the literature from 44% to 96%. Handrix [10] discussed chronic intractable heel pain and presented successful outcome in 96% of patients with decompression of posterior tibial, medial and lateral plantar nerves, and the first branch of the lateral plantar nerve. Several papers have quoted low success rates: Pfeiffer and Cracchiolo [11] described a successful outcome in only 44% of cases and Kaplan [12] reported 21

Conclusion

The diagnosis of TTS is made by history and examination – not by nerve conduction studies. Appropriate use of electrodiagnostic and radiographic tests is necessary to confirm the diagnosis.

A review of the published literature highlights a lack of high quality evidence based research and suggests the role of nerve conduction studies remains controversial. A review article [23] evaluated the usefulness of electrodiagnostic testing in patients with TTS. The studies reviewed were retrospective and

Conflict of interest

No conflict of interest present for any of the above authors and no funding was received for this study.

References (28)

  • B.M. Reade et al.

    Tarsal tunnel syndrome

    Clin Podiatr Med Surg

    (2001)
  • C. Hendrix et al.

    Entrapment neuropathy; the aetiology of intractable chronic heel pain syndrome

    J Foot Ankle Surg

    (1998)
  • P.E. Havel et al.

    Tibial branching in the tarsal tunnel

    Foot Ankle

    (1988)
  • T.A. Park et al.

    The medial calcaneal nerve: anatomy and nerve conduction technique

    Muscle Nerve

    (1995)
  • M. Kinoshita et al.

    The dorsiflexion eversion test for diagnosis of tarsal tunnel syndrome

    J Bone Joint Surg

    (2001)
  • M. Nagaoka et al.

    Ultrasonography in tarsal tunnel syndrome

    J Ultrasound Med

    (2005)
  • A.M. Alshami et al.

    Strain in the tibial and plantar nerves with foot and ankle movements and the influence of adjacent joint positions

    J Appl Biomech

    (2008)
  • L. Gessini et al.

    The anterior tarsal syndrome

    J Bone Joint Surg

    (1984)
  • S.J.S. Lam

    J Bone Joint Surg

    (1967)
  • W. Pfeiffer et al.

    Clinical results after tarsal tunnel decompression

    J Bone Joint Surg

    (1994)
  • P.E. Kaplan et al.

    Tarsal tunnel syndrome: an electrodiagnostic and surgical correlation

    J Bone Joint Surg

    (1981)
  • A.L. Dellon

    Computed-assisted sensibility evaluation and surgical treatment of the tarsal tunnel syndrome

    Adv Podiatr Med Surg

    (1996)
  • M. Nagaoka et al.

    Tarsal tunnel syndrome caused by ganglia

    J Bone Joint Surg

    (1999)
  • G.J. Sammarco et al.

    Outcome of surgical treatment of tarsal tunnel syndrome

    Foot Ankle Int

    (2003)
  • Cited by (115)

    • Tarsal Tunnel Syndrome: Outcome According to Etiology

      2022, Journal of Foot and Ankle Surgery
    • Neurological Foot Pathology

      2022, Foot and Ankle Biomechanics
    • [Translated article] Tarsal tunnel syndrome: Clinical-imaging analysis of a case series

      2022, Revista Espanola de Cirugia Ortopedica y Traumatologia
    • Tarsal Tunnel Syndrome Associated with a Bipartite Talus

      2024, Journal of the American Academy of Orthopaedic Surgeons Global Research and Reviews
    View all citing articles on Scopus
    View full text