Treatment of Tarsal Tunnel Syndrome
Tarsal tunnel syndrome is a fairly rare condition caused by abnormal pressure on the posterior tibial nerve or its associated branches as it passes through the tarsal canal.
This canal is formed by the flexor retinaculum on the outside and bone on the inside. The posterior tibial nerve is located behind the medial malleolus, the bump on the inside of the ankle, and runs under the flexor retinaculum, which is a band of fibrous tissue giving form to the tunnel. The tarsal tunnel contains the tibial nerve, the posterior tibial artery, tendon and veins that travel along its pathway. The tibial nerve splits into three different pathways, one to the heel, and the other two to the bottom of the foot.
How does tarsal tunnel syndrome develop?
External traumas such as crush injuries, stretch injuries, fractures, dislocations and strains of the foot and ankle, can contribute to the development of tarsal tunnel syndrome.
Intrinsic issues such as soft-tissue masses may also contribute to compression neuropathy of the posterior tibial nerve. Bony prominences may be causative factors, such as a valgus deformity of the hindfoot which may increase tension due to excessive eversion and dorsiflexion.
Tarsal tunnel syndrome is a compression neuropathy of the tibial nerve situated in the tarsal canal. Nerves are responsible for transmitting signals and nutrients along their length for proper functioning. If the flow is blocked, the nerve tissue that is distal to the site of compression is nutritionally deprived and more susceptible to injury. It’s important to note that the pain experienced in the ankle with tarsal tunnel syndrome is often referred pain and may be due to injured or weakened ligaments at the ball of the foot.
Symptoms of tarsal tunnel syndrome develop when the tibial nerve in the tarsal tunnel becomes dysfunctional due to excess pressure. Pressure causes the nerve in the tunnel to be squeezed against the flexor retinaculum, which is quite inflexible. This results in numbness in the nearby skin area, as well as muscle weakness and pain in the area of the pinched nerve.
Unfortunately, however, many people with ankle and foot pain have been misdiagnosed with tarsal tunnel syndrome! Chronic pain in these areas is most often due to a sprain or weakening of the metatarsal, lateral collateral and medial collateral ligaments, ligaments rarely examined by a family physician or an orthopedic surgeon.
What are the symptoms of tarsal tunnel syndrome?
Symptoms of tarsal tunnel syndrome vary from individual to individual, but typically present as vague symptoms of pain in the ankle, arch, toes, or heel. Foot pain is often in the plantar aspect of the foot. Sensory disturbances also vary. Some individuals experience a slight pain, burning or tingling in the sole of the foot.There may be sensitivity to touch and temperature along the course of the nerve. Sometimes there is sharp pain and other times a loss of sensation. As the condition worsens, motor disturbances, weakness, atrophy, numbness, and gait abnormalities of the foot and ankle may occur. If pressure is kept off the foot and ankle, the symptoms may decrease; likewise, they will get worse if the foot and ankle are strained excessively. Although symptoms may subside with rest, they typically do not disappear altogether.
Conventional approaches to Tarsal Tunnel miss the mark
A standard practice of modern medicine is to use steroids or to prescribe anti-inflammatory medications. Cortisone injections are also frequently recommended. These medications generally produce short-term pain benefit. However, they both have been shown to actually inhibit the healing process of soft tissues and accelerate cartilage degeneration.
Surgery, too, can make the condition worse, especially when the condition has been misdiagnosed (which is often the case). Metatarsal, lateral collateral and medial collateral ligament laxity should always be evaluated prior to making the diagnosis of tarsal tunnel syndrome. Surgery for this condition should not be done until a physician who understands the referral patterns of ligaments and is experienced in Prolotherapy performs an evaluation.
The Prolotherapy approach to treating Tarsal Tunnel Syndrome
We typically confirm an actual tarsal tunnel syndrome diagnosis using EMG/NCV studies, which measure the rate of nerve conduction. Confirmation of the diagnosis as well as the stage of the syndrome is determined by the degree of slowing of the nerve conduction. If the syndrome is detected in the early stages, Neural Therapy treatment is performed. This is a gentle healing technique developed in Germany that involves the injection of local anesthetics into autonomic ganglia, peripheral nerves, scars, glands, acupuncture points, trigger points, skin and other tissues. Vitamin B and other natural supplements may also be prescribed. If, on the other hand, the tarsal tunnel syndrome is at an advanced stage, traditional surgery may be necessary.
Since the same patterns exhibited in tarsal tunnel syndrome can be found in metatarsal, lateral collateral and medial collateral ligament weakness, it is very important that a correct diagnosis is made before any treatment begins. More often than not, what has been diagnosed as tarsal tunnel syndrome is actually ligament damage. These ligaments bear the bulk of the body weight when a person stands, walks, or runs. No wonder they are often the first to weaken! The ball of the foot, the metatarsal joints support half the body weight during walking. Metatarsal ligament weakness is manifested by pain at the ball of the feet which often radiates into the toes. This is called metatarsalgia. Chronic metatarsal ligament weakness and arch weakness is known as plantar fasciitis. Fasciitis can cause numbness in the foot and toes in the same areas of pain. Pain and numbness in the foot can also be caused by ligament and tendon laxity in the knee. The lateral collateral ligament can refer pain and numbness down the lateral side of the leg and foot and the medial collateral ligament down the medial side.
If the symptoms of tarsal tunnel syndrome are found to be due to weakened ligaments, then strengthening of the weakened ligaments in the foot with Prolotherapy would be recommended. Ligament weakness around the knee, hip, sacroiliac joint or pelvis can also cause radiating pain and numbness in the foot area. These areas might need to be treated with Prolotherapy as well. Prolotherapy is a treatment that regenerates and strengthens the injured structures, such as the weakened ligaments discussed above. Prolotherapy solution stimulates the body’s own mechanism for healing. If the metatarsal, lateral collateral and medial collateral ligaments are found to be the source of injury, then these weakened ligaments would be injected with a Prolotherapy solution triggering a localized mild inflammation. This produces a wound healing response resulting in an increased blood supply and deposits of new collagen. Ligaments are made of collagen, so those weakened ligaments that are causing the pain and other symptoms, become stronger with the new and tighter collagen. As they repair, the symptoms abate.
The tissue strengthening and pain relief stimulated by Prolotherapy is permanent. Individuals receiving Prolotherapy are also able to continue with sports, work, and other activities between treatments. Contrary to the postsurgical protocols that require extended time off of your feet; activity, walking, and movement would be encouraged.
Is it lumbosacral radiculopathy?
Tarsal tunnel syndrome and Lumbosacral radiculopathy share many of the symptoms occurring in Tarsal tunnel syndrome. Chinese and American researchers suggest that the prevalence of Tarsal tunnel syndrome is significant in patients with Lumbosacral radiculopathy. Thus, more caution should be paid when diagnosing and managing patients with LR due to the possible existence of TTS, as their management strategies are quite different.
1: Zheng C, Zhu Y, Jiang J, Ma X, Lu F, Jin X, Weber R. The prevalence of tarsal
tunnel syndrome in patients with lumbosacral radiculopathy. Eur Spine J. 2016
Mar;25(3):895-905. doi: 10.1007/s00586-015-4246-x. Epub 2015 Sep 25. PubMed PMID: