Tarsal Tunnel Syndrome

An Overview of Tarsal Tunnel Syndrome

Tarsal tunnel syndrome, often referred to as tibial nerve entrapment, is a painful foot condition noted when the tibial nerve becomes trapped in the tarsal tunnel. The tarsal tunnel is named for the bones of the foot, the tarsal bones (as compared to the carpel bones of carpel tunnel syndrome found in the hand).

The tarsal tunnel is found on the inside of the ankle behind the medial malleolus (the bony bump on the inside of the ankle where the top of the shoe rests against this bone). There is a groove in the back of this bone that this nerve sits in. The outside of the tunnel is bound by a retinaculum. A retinaculum is a ligament, a thick band of non-stretchable tissue needed to hold the contents of the tunnel in place.

The tibial nerve is not alone in this tunnel. There is an artery (the tibial artery) and three tendons connected to the foot and the muscles of the lower leg that also run through this tunnel.

The tibial nerve splits into three separate nerves in the tarsal tunnel. These nerves travel to the heel and the bottom of the inside and the outside of the foot.

General Causes of Nerve Entrapment Syndromes

Most nerve entrapment syndromes are caused by mechanical and genetic problems. Genetics have to do with the size of the tunnel these nerves travel in. Some people have congenitally smaller tunnels and with aging, previous injury, degeneration (bone spurs) and inflammation, these tunnels become overcrowded. Mechanically, overuse syndrome can cause tendons to swell (tendonitis and synovitis) and crowd out the nerve.

There are genetic and metabolic disease processes that can contribute to nerve malfunction. These processes may increase the swelling (crowding) of the tunnel or make the nerve itself more sensitive. These disorders include rheumatoid arthritis, hypothyroidism, pregnancy, diabetes, acromegaly (too much human growth hormone) and CMT syndrome (Charcot Marie Tooth syndrome-a genetic condition).

(Click to Enlarge Image) Tarsal Tunnel Syndrome.

(Click to Enlarge Image) Tarsal Tunnel Pain Diagram.

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(Please keep reading below for more information on this condition.)

Symptoms of Tarsal Tunnel Syndrome

Tarsal tunnel syndrome symptoms include paresthesias (pins and needles) as well as pain radiating around the ankle and to the underside of the toes. Numbness and burning sensations can also be noted in this distribution. Standing will increase the symptoms and elevating the foot will reduce the symptoms.

Increasing nerve involvement can produce hot or cold sensations and electrical discharge symptoms (Tinel’s sign). Prolonged standing in any individual can increase the swelling of the foot in general and this swelling can worsen the symptoms of tibial nerve entrapment.

The tibial nerve moves in the tarsal tunnel with ankle motion. Plantar flexion (pushing the foot and toes to the floor) loosens the nerve and dorsiflexion (pulling the toes and foot to the nose) will stretch the nerve. Stretching the nerve will increase symptoms.

Diagnosis of Tarsal Tunnel Syndrome

History, examination and special testing confirm the diagnosis of this condition. The history is exactly like that noted above.

Testing essentially consists of one or two tests. The Tinel’s test has to do with the exquisite sensitivity of any nerve at an injury point. A nerve that is injured will fire an ectopic focus (a lightening bolt of electricity) down to the end of nerve when stimulated. Percussion of the injury area will elicit this “lightening bolt”. In the case of tarsal tunnel syndrome, the injury point is where the nerve wraps around the ankle. A positive test will cause an electrical “zap” into the foot with percussion of the nerve at the ankle.

Some physicians will perform a two-point discrimination test. This test uses the ends of monofilament fishing line on a tool that can separate these two points at a specific distance. This tool is used to determine the smallest distance that a patient can identify the distance between these two points. In tarsal tunnel syndrome, this distance will be larger than normal in bottom of the foot as the sensitivity of the skin here diminishes.

Finally, an electrical test called an EMG/NCV can be used to determine if there is conduction loss or muscle weakness. A negative test (no findings) would not preclude a diagnosis of tarsal tunnel syndrome.

Treatment of Tarsal Tunnel Syndrome

Treatment for tarsal tunnel syndrome depends upon the severity of the symptoms. Intermittent symptoms that do not bother the patient and do not wake them up at night generally do not need to be treated.

With increasing symptoms, medications such as NSAIDs (Motrin, Aleve) can be helpful. Injection of steroid into the tarsal tunnel can be effective to reduce symptoms.

If symptoms continue without relief or motor weakness occurs, surgical decompression of the nerve can provide long-term relief.

For additional resources on tarsal tunnel syndrome, or to determine treatment options for your case of tibial nerve entrapment, please contact Dr. Donald Corenman, back doctor and spine specialist offering diagnostic and surgical second opinions to patients in the USA and around the world.

Donald Corenman, MD, DC

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81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

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