Introduction

Tarsal tunnel or tunnel syndrome is a neuropathy of the posterior tibial nerve associated with compression of structures in the tarsal tunnel. This syndrome has similarities to carpal tunnel syndrome of the wrist, although it is much less common.

The tarsal tunnel, also called the tarsal canal, is located on the inside of the ankle, behind the medial malleolus. It is formed by surrounding bones and tissues, creating a space through which several structures pass, including the posterior tibial nerve. This nerve is responsible for the innervation of certain parts of the foot and the plantar flexor muscle.

When there is excessive compression in the tarsal canal, the posterior tibial nerve can be compressed, resulting in tarsal tunnel syndrome. Causes of this compression may include trauma, foot deformity, tendon inflammation, or cysts.

Symptoms of tarsal tunnel syndrome usually include pain, numbness, tingling, or burning sensation along the posterior tibial nerve, usually on the inner side of the ankle and foot. These symptoms may extend to the sole of the foot, arch and toes. In more severe cases, foot muscle weakness may develop.

Diagnosis of canaltarsal syndrome usually involves a thorough clinical examination, nerve conduction tests, and possibly imaging tests such as X-rays or MRI to evaluate the structure of the tunnel.

Treatment for tarsal tunnel syndrome may include conservative approaches such as rest, elevation of the foot, application of ice, and use of suitable footwear. Orthotics or insoles may also be recommended to relieve pressure on the nerve. In more severe cases or cases resistant to conservative treatment, surgery to release nerve compression may be considered.

It is essential to consult a healthcare professional for an accurate diagnosis and appropriate treatment plan if tarsal tunnel syndrome is suspected.

Tarsal tunnel anatomy

  1. Location: The tarsal tunnel is located inside the ankle, on the inner (medial) side. It is formed by the bones of the foot, notably the navicular bone, the calcaneus, and the medial tarsal bones.
  2. Content: Important structures that pass through the tarsal tunnel include:
    • Posterior tibial nerve: This is the element most often affected in tarsal tunnel syndrome. The posterior tibial nerve divides into branches that provide sensation and muscular control to the sole of the foot.
    • Arteries and veins: The blood vessels that provide blood supply to the foot also pass through the tarsal tunnel.
  3. Ligaments: The tarsal tunnel is reinforced by several ligaments which maintain the stability of the ankle. These ligaments play an important role in preventing deformation of the tunnel and compression of the structures within.
  4. Soft tissues: The soft tissues surrounding the tarsal tunnel, such as the tendons of the surrounding muscles, can also influence compression of the posterior tibial nerve.
  5. Anatomical variations: Anatomical variations, such as congenital deformities, flat feet, or excessive pronation, can contribute to nerve compression in the tarsal tunnel.
Tunnel tarsian syndrome

Causes of tarsal tunnel syndrome

Tarsal tunnel syndrome, a painful foot condition, originates from compression of the posterior tibial nerve as it passes through the tarsal tunnel, a structure formed by the bones of the foot. The causes of this syndrome can be varied, often linked to anatomical factors, trauma, mechanical disorders, or underlying diseases.

A common cause of tarsal tunnel syndrome is the anatomy of the foot, including a variation in bone structure. Some individuals have a narrower tarsal tunnel naturally, increasing the likelihood of nerve compression. Likewise, variations in the shape of the bones of the foot can create uneven pressure points on the posterior tibial nerve, contributing to the development of the syndrome.

Trauma, such as sports injuries or foot fractures, can also lead to tarsal tunnel syndrome. When there is damage to the foot, it can cause swelling and changes in the dynamics of the surrounding tissues, thereby compressing the posterior tibial nerve.

Mechanical disorders of the foot may play a significant role in the development of tarsal tunnel syndrome. Flat feet, for example, can create instability which can lead to increased pressure on the nerve. Likewise, excessive pronation of the foot, where the ankle rolls inward, can contribute to compression of the posterior tibial nerve.

Using inappropriate shoes, especially those that are too tight or do not provide adequate support, can make tarsal tunnel syndrome worse. Shoes that compress the feet or place excessive pressure on the tarsal tunnel area can contribute to nerve compression, intensifying symptoms.

Repeated impact activities, such as running, can also be a potential cause of tarsal tunnel syndrome. Repetitive movements and constant stress on the foot can lead to tissue inflammation, putting increased pressure on the posterior tibial nerve.

Certain underlying medical conditions may increase the risk of developing tarsal tunnel syndrome. People with diabetes, for example, are more likely to develop peripheral nerve problems, increasing the risk of nerve compression. Likewise, arthritis in the foot region can contribute to changes in bone structure, putting pressure on the posterior tibial nerve.

It is essential to note that several factors can interact to cause tarsal tunnel syndrome. A combination of several causes, such as predisposing anatomy, previous trauma, and mechanical disorders, can lead to the development of this painful condition.

  1. Trauma: Traumatic injuries, such as ankle sprains, fractures, or soft tissue damage around the tarsal tunnel, can lead to compression of the posterior tibial nerve.
  2. Arthritis: Some forms of arthritis, including rheumatoid arthritis, can cause inflammation of the ankle joints, which can lead to nerve compression.
  3. Anatomical Deformities: Anatomical abnormalities, such as flat feet, excessive pronation (inward rolling) of the foot, or anatomical variations in the tarsal tunnel, can contribute to nerve compression.
  4. Tumors: Although rare, tumors or cysts near the tarsal tunnel can put pressure on the posterior tibial nerve.
  5. Swelling of the tendons: Inflammation or swelling of the tendons surrounding the tarsal tunnel can also lead to compression of the nerve.
  6. Systemic Diseases: Systemic medical conditions such as diabetes, rheumatoid arthritis, or posterior compartment syndrome may increase the risk of developing tarsal tunnel syndrome.
  7. Repetitive activities: Activities that involve repetitive movements of the foot and ankle, such as running, can contribute to irritation and compression of the posterior tibial nerve.

Symptoms of tarsal tunnel syndrome


Tarsal tunnel syndrome is characterized by a variety of symptoms that result from compression of the posterior tibial nerve as it passes through the tarsal tunnel, located inside the ankle and foot. Symptoms can be progressive and vary in intensity, but they usually manifest as painful and uncomfortable sensations.

One of the most common symptoms is pain along the posterior tibial nerve, which runs from the lower leg to the sole of the foot. This pain may feel like a burning, tingling, or electric shock. It can occur intermittently, often exacerbated by activities that involve flexion or inversion of the foot, such as walking, running, or even just standing for long periods of time.

Individuals with tarsal tunnel syndrome may also experience a shooting pain or burning sensation along the arch of the foot, sometimes radiating toward the toes. This pain may be more pronounced at night, disrupting the affected person’s sleep.

Another common symptom is the feeling of swelling or warmth in the ankle and foot. Although visible swelling is less common than in other conditions, the person may notice an increase in the size of their foot due to fluid buildup caused by the inflammation.

Symptoms of tarsal tunnel syndrome also include loss of sensation or numbness in the sole of the foot. Individuals may experience tingling or tingling, often concentrated in the inner part of the foot. These abnormal sensations may extend to the toes, affecting the overall sensitivity of the area.

Muscle weakness in the foot and ankle may be an associated symptom of tarsal tunnel syndrome. The muscles controlled by the posterior tibial nerve may be affected, leading to decreased strength and stability. This may manifest as difficulty walking properly or lifting your toes.

Symptoms of tarsal tunnel syndrome may get progressively worse over time, especially if nerve compression persists without treatment. They can also fluctuate depending on daily activities and foot position, for example, worsening during walking and decreasing when resting.

It is important to note that the symptoms of tarsal tunnel syndrome may be similar to those of other foot conditions, such as plantar fasciitis or peripheral neuropathy. Therefore, an accurate diagnosis requires a thorough medical evaluation, often supplemented by medical imaging tests such as X-rays or MRIs.

  1. Pain: Pain is one of the most common symptoms. It is often described as a shooting, burning, or tingling pain on the inside of the ankle and foot.
  2. Numbness and tingling: Patients may experience sensations of numbness, tingling, or tingling along the posterior tibial nerve, which may radiate to the sole of the foot.
  3. Muscle weakness: Some individuals may experience muscle weakness in the foot, which may lead to difficulty lifting the toes or performing foot movements in a normal manner.
  4. Nighttime pain: Symptoms, especially pain, may be more pronounced at night, disrupting sleep.
  5. Swelling: Mild swelling of the ankle can sometimes accompany tarsal tunnel syndrome.
  6. Change in gait: Due to pain and muscle weakness, sufferers may change the way they walk to reduce pressure on the affected area.

Pathophysiology

The pathophysiology of tarsal tunnel syndrome involves compression of the posterior tibial nerve as it passes through the tarsal tunnel, an anatomical structure located inside the ankle. This tunnel is formed by the bones and soft tissues surrounding the nerve, and it allows the nerve to pass from the back of the leg toward the sole of the foot.

When there is compression of the posterior tibial nerve, several pathological mechanisms can occur. Excessive pressure on the nerve can lead to inflammation, swelling and irritation of the nerve tissue. This can gradually cause symptoms such as pain, tingling, numbness, and weakness in the area of ​​the foot and ankle innervated by the posterior tibial nerve.

Factors that contribute to the pathophysiology of tarsal tunnel syndrome can include a variety of conditions such as edema (swelling), cyst formation, presence of scar tissue, or degeneration of surrounding tendons. Compression of the nerve can be exacerbated by activities that increase pressure inside the tarsal tunnel, such as wearing inappropriate shoes, participating in strenuous sports activities, or the presence of anatomical abnormalities.

The underlying pathophysiology often guides the choice of treatment options, whether through conservative approaches to reduce pressure on the nerve or, in some cases, surgical interventions to release the compression. Accurate diagnosis and a thorough understanding of the pathophysiology specific to each case are essential to developing an effective treatment plan.

Differential diagnosis of tarsal tunnel syndrome

  1. Plantar fasciitis: Inflammation of the plantar fascia, the connective tissue on the bottom of the foot, can cause pain in the heel and arch of the foot.
  2. Tarsal Tunnel Syndrome: This is a condition similar to TTTS, but with compression of the anterior tibial nerve in the midfoot region.
  3. Morton’s neuroma: A thickening of the interdigital nerve, usually between the third and fourth toes, can cause pain, tingling and numbness.
  4. Arthritis: Arthritis, especially rheumatoid arthritis, can affect the joints of the foot and cause pain and stiffness.
  5. Tendinitis: Inflammation of the tendons around the ankle, particularly the Achilles tendon, can cause pain in the heel and calf area.
  6. Stress Fracture: Stress fractures can occur in the bones of the foot and ankle, causing pain that may be similar to that of TTTS.
  7. Lumbar Nerve Compression: Problems in the lumbar spine can sometimes manifest as symptoms in the foot.
  8. Infections: Local infections, such as abscess or foot infection, can cause pain and swelling

Tarsal tunnel treatment

  1. Rest and activity modification: It may be recommended to reduce activity that aggravates symptoms and allow the foot to rest.
  2. Orthotics and special shoes: Using orthotics or special shoes can help reduce pressure on the nerve.
  3. Physiotherapy: Specific exercises may be prescribed to strengthen the muscles around the tarsal tunnel, improve mobility and reduce nerve compression.
  4. Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) may be prescribed to reduce inflammation and relieve pain.
  5. Injections: Corticosteroid injections may be used to reduce inflammation around the nerve.
  6. Change in activity: In some cases, it may be recommended to change activities that exacerbate symptoms.
  7. Surgery: If other treatments are not effective and the compression of the nerve is severe, surgery to release the posterior tibial nerve may be considered.

It is important to consult a healthcare professional, usually an orthopedist or podiatrist, for an accurate diagnosis and appropriate treatment plan.

Conclusion

In conclusion, tarsal tunnel syndrome represents a neuropathy of the posterior tibial nerve due to compression of structures in the tarsal tunnel. Although less common than carpal tunnel syndrome, it can cause painful and uncomfortable symptoms in the ankle and foot area.

Early diagnosis and a tailored treatment approach are essential to effectively manage tarsal tunnel syndrome. Conservative treatment options, such as rest, use of appropriate shoes, and orthotics, can often relieve symptoms. However, in some cases, surgery may be considered to release the nerve compression.

It is crucial for individuals experiencing symptoms to consult a healthcare professional to obtain an accurate diagnosis and develop a personalized treatment plan. By taking appropriate measures, it is possible to improve quality of life and prevent the progression of symptoms related to tarsal tunnel syndrome.

References

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