Tarsal Tunnel Syndrome
- David Tollafield
- Sep 18
- 6 min read
Updated: 19 hours ago
Understanding Tarsal Tunnel Syndrome
Tarsal tunnel syndrome is a common cause of heel pain. A distinctive burning sensation often characterises the symptoms. However, it can also mislead us by causing pain in the ball of the foot. This condition creates a feeling of fullness, almost like an exploding sensation during exercise. The pain tends to worsen with activities such as standing, walking, or running. Sometimes, this type of pain arises as referred pain. This means that the source of the pain and its location may not match. For example, the pain may be felt in the front of the foot, but it actually relates to structures in the hind part of the foot.
Tarsal tunnel syndrome can be complex. It is essential to understand the underlying causes and how they affect our daily lives. The condition often causes discomfort and can significantly impact mobility.
What Causes Tarsal Tunnel Syndrome?
Several factors can contribute to the development of tarsal tunnel syndrome. These include:
Injury: Trauma to the ankle can lead to swelling and compression of the tibial nerve.
Inflammation: Conditions like arthritis can cause inflammation in the area, leading to increased pressure on the nerve.
Structural abnormalities, such as flat feet or other foot deformities, can alter the way pressure is distributed in the foot, potentially contributing to nerve compression.
Overuse: Repetitive activities, especially those that involve running or jumping, can lead to irritation and swelling.
Symptoms of Tarsal Tunnel Syndrome
The symptoms of tarsal tunnel syndrome can vary from person to person. Common signs include:
A burning sensation in the heel or arch of the foot
Tingling or numbness that radiates into the toes
Pain that worsens with activity and improves with rest
A feeling of fullness or pressure in the foot
If you experience these symptoms, it’s essential to seek professional advice.
Why is it called Tarsal Tunnel Syndrome?
A syndrome is a term used to describe a condition associated with another disease entity. This means that conditions like plantar fasciitis or tendon pain can become involved with tarsal tunnel syndrome. The diagram illustrates the tunnel under the ligament (green).
In this diagram, MM represents the medial malleolus, and MTC stands for the medial tubercle of the calcaneus. The blue horizontal line is Line A, which crosses the tip of the medial malleolus. The green oblique line (band) is Line B, with a width of 1 cm, spanning from the medial malleolus to the medial tubercle of the calcaneus. This axis also represents the inferior edge of the flexor retinaculum and, consequently, the tarsal tunnel.
Comparing Conditions
Tarsal tunnel syndrome shares similarities with the carpal tunnel syndrome in the hand. The green band in the diagram represents a ligament that crosses over the blood vessels and tendons.
The yellow line indicates the tibial nerve, which is the thickest nerve in the foot. Just as roads branch out, so do nerves and blood vessels. As the tibial nerve moves forward, it curves under the foot while sending higher branches out. If the nerve is compressed, damaged, or has fluid within the tunnel, it won't conduct signals correctly.
Inflammation can increase fluid in the area, leading to fluctuating pain, especially during activity. The fascia, which forms part of the arch of the foot, passes close to the tunnel and can influence pressure in some cases. If this happens, professional management of fascial pain is essential.
Once the fluid reduces, the nerve should return to normal. However, complications arise when the tendons are swollen, as they require relief from pressure and pain. Shin splints are often associated with tendon overpull. If the lining tears, the tendon sheath leaks, causing increased pressure.
True tarsal tunnel syndrome (TTS) may not have a single cause but several. Unlike the hand, surgery is not always the first option for the foot. Surgery may only be necessary if there is a growth on the nerve or if the nerve is clearly overwhelmed with fluid that needs to be released.
Compartment syndrome is another condition where fluid builds up and affects groups of muscles under pressure. It differs from TTS and poses a threat to the blood supply.
Increasing pain should always be investigated, particularly if it worsens during exercise. However, TTS typically does not involve a severe blood supply deficit.
Diagnosis of Tarsal Tunnel Syndrome
Diagnosing Tarsal Tunnel Syndrome (TTS) can be complex and may resist treatment. The process begins with taking a detailed history of symptoms and identifying when they arise.
A simple test known as the Tinel sign involves tapping the nerve around the inside of the ankle (percussed).
Finger-tapping can also be effective. The Valleix sign is another test where tapping causes signals to travel in two directions. Radiating tingling (paraesthesiae) suggests some restriction of the nerve, which may include scarring. The tibial nerve is around 3-5mm thick and very visible during surgery.
Veins can become engorged around the nerve, producing similar symptoms of tingling and burning. Typical imaging tests include ultrasound and MRI, but early signs can be challenging to detect.
Clinical Testing & Measurement
A useful test involves inflating a pressure cuff around the ankle and comparing the responses of both limbs. Discomfort below 100 mmHg should be followed up, especially if tingling is noted. If the pressure drops below 70 mmHg and notable symptoms arise, further imaging is warranted—MRI or ultrasound.
Patients usually tolerate 120mmHg unless the limb is compromised or has any associated rheumatological condition. Nerve conduction tests can also help measure the speed of nerve signals if symptoms persist. Slow values indicate obstruction.
One challenge for foot specialists is that a neuroma between the toes (Morton’s neuroma) can produce similar pain in the forefoot. It is possible to have TTS and Morton’s neuroma simultaneously, so both conditions must be managed separately.
Different Levels of Discomfort
Pain means different things to different people. Factors like gender, genetics, and age contribute to varying pain experiences. The impact of pain on daily life is significant. It affects sleep and emotions. Signs differ from symptoms.
To guide discussions about symptoms, a scale allows pain to be rated from none to worst, with 0-10 being the most common. Keeping a pain diary can enhance consultations with healthcare professionals. Diaries can take various forms: charts, electronic diaries (spreadsheets), calendar styles, or formal descriptive formats.
Timelines are crucial for tracking the origin of the problem. The longer pain persists, the more damage occurs, making it harder to reverse the condition. Referred pain may originate from nerves elsewhere or alter posture from the original site in the foot. Burning (causalgia) pain should not be allowed to become chronic.
Treatment Options
The use of medication for pain generally includes options like paracetamol (non-anti-inflammatory), aspirin or ibuprofen (anti-inflammatory), and codeine. It’s important to use drugs responsibly, typically for only 2-5 days before seeking help. The goal is to identify areas where pain can be alleviated. If medication fails, professional assistance is necessary, as nerve compression may not respond well to over-the-counter treatments.
When consulting a professional, such as a GP, having some prior knowledge of the condition can be beneficial. Many practices prioritise urgency through telecommunication. Keeping a pain diary can also be helpful.
True TTS requires support from professionals. Early signs of numbness in the toes, fullness in the forefoot, or pain during activity are key indicators. Remember, this is a syndrome. If you have plantar fasciitis, you might consider stretching. Pain is easily identified with specific pain points in the heel. If it relates to the tendon, you may feel deep aching behind the inside ankle bone. In extreme cases, ice can help, as can local gels like Voltarol or Ibulieve.
What Can Be Done?
General information on this condition can be accessed from several useful sites, such as FootEducation.com, which divides options into non-surgical and surgical choices.
The following article from the Marathon Training Academy (Ben Shatto, 2018) might also be helpful, covering other conditions associated with TTS. Use my tips on dealing with Morton’s neuroma.
Here are some practical tips to manage Tarsal Tunnel Syndrome:
Act early.
Check your shoes for proper fit and support.
Identify what exacerbates the pain and take action to prevent further irritation.
Consider orthoses for poor foot alignment – orthotic care can be beneficial.
Determine if the issue is plantar fasciitis or tendon pain (posterior shin splints).
Tap around the ankle (Tinel’s sign). If the nerve sends tingling to the toes, suspect TTS and seek help early.
Is this Morton’s neuroma – localised toe tingling?
Surgery is reserved for cases where pain does not subside.
For those interested in TTS surgery, refer to the FootEducation link.
Open surgery is an option, and some surgeons may use minimal surgery with optical scopes. Always seek professional advice from a podiatric surgeon or dedicated orthopaedic foot surgeon.
Thanks for reading Tarsal Tunnel Syndrome by David R. Tollafield.
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