The Non-surgical approach to treating Tarsal Tunnel Syndrome

Ross A. Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C.

The Non-surgical approach to treating Tarsal Tunnel Syndrome

In this article, we will discuss various treatment options for Tarsal Tunnel Syndrome including the non-surgical application of Nerve Release and Regeneration Therapy combined with Prolotherapy.

You have been limping around dealing with shooting and/or chronic pain on the inner side of your ankle. Sometimes it is a burning pain, sometimes there is an electric shock feel to it. Sometimes there is numbness. While the pain seems to be in the general ankle area, it is not really your ankle that you feel is causing your pain and discomfort, you have vague symptoms of pain in the arch, toes, and/or heel as well.

You have reached a point where you have tried many things on your own including recommendations that you may have found on the internet that include:

• Rest and staying off your feet or foot as best you can.
• A rotation of 20 minutes on 40 minutes off ICE therapy.
• Taking over-the-counter medications, such as Nonsteroidal anti-inflammatory drugs (NSAIDs), to reduce pain and inflammation.
• Getting an ankle brace or ace bandage which you have found did not really help and may create more pressure in your foot.

. . . and you have found that these remedies are not helping you at all. Worse, you are getting worse.

Like many of the problems we see in our office, not only does a patient have a primary problem, such as Tarsal Tunnel Syndrome, but they also have coexisting problems and a lot of the problems came from a surgery.

This is what we hear and see at our center:

A long journey with more pain at the end.

I have had foot pain for the last two years. I have been given one diagnosis after another. At first my doctor thought it was plantar fasciitis. But after a few months of treatment and pain that was getting much worse I decided on a second opinion. The second opinion turned into a third, fourth and fifth opinion. I saw an orthopedic specialist and physical therapist. One complaint I had was that the custom orthotics I had made was making my pain worse.

Finally I saw a doctor who diagnosed me with Tarsal Tunnel Syndrome. My treatments should include a cortisone injection, new and better shoe inserts and a walking boot or splint. I did not have a good reaction to the cortisone injection. My foot blew up. The pain on walking and standing became much more severe. I now walk as little as possible.

This story is an example. Many people do very well with cortisone, orthotics and physical therapy. It is however a story that you maybe able to relate to in your research of treatment options for your foot pain and you yourself are still looking for possible solutions.

Pain after Surgery

• I have peripheral neuropathy and Tarsal Tunnel Syndrome. This developed after an Achilles Surgery.
• I developed adhesive neuritis in the Tarsal Tunnel. My tunnel “has stenosis,” it is narrowed with scar tissue. This is causing other pains in my foot and ankle.
• I fell and broke my tibia. I was immobilized but my leg did not heal so I had surgery to place a rod in my tibia. I was sent for nerve conduction tests which showed that the pain I get when I walk is from the Tarsal Tunnel.

Tarsal Tunnel Syndrome or something else?

• You are getting unsteady on your feet and suffer from motor disturbances, which may include spasms, twitching, weakness, atrophy, numbness, and gait abnormalities.

It is very likely that if you are reading this article you found us through your own research on your symptoms and what you can do about it, or, you went to a health care provider and in some cases where the ankle was first suspect, then the Achilles tendon was suspect, you may have finally been introduced to the term Tarsal Tunnel Syndrome. Your health care provider is suspecting a nerve problem as he/she may believe you have pressure or impingement on the posterior tibial nerve that runs on the inside of the ankle into the foot. Posterior tibial nerve is the suspected cause of the numbness, pain, and the giving way or muscle weakness you may feel in your foot. It is also suspected if you had an acute injury.

You have the symptoms, numbness, pain on the inner side of the ankle into the foot, but you are not getting relief. Is the problem that you do not really have Tarsal Tunnel Syndrome? The process of elimination diagnosis.

This is one of the challenges facing doctors and patients when it comes to the diagnosis of Tarsal Tunnel Syndrome. Is this diagnosis accurate? As we mentioned briefly above, your doctor may have initially thought this to be an ankle problem or a tendon problem, it was probably a specialist who suspected Tarsal Tunnel Syndrome.

Often patients will come in and say things like:

• My doctors are not sure what this is, it actually started out as shin splints so everyone thought it was shin splints. I was told to stop running and the shin splints will go away. The shin splints did go away but not the burning ankle pain. So it wasn’t the shin splints.
• My doctor thought is was my Achilles tendon. Maybe tendinosis since there was no real swelling. I was booted up for a few weeks. The boot came off, the pain and burning was still there.

Foot specialists writing in the medical journal Foot (1) discussed the difficulties of making an accurate diagnosis of Tarsal Tunnel Syndrome and then what to do once you confirm it. Effective treatments can be a challenge. Let’s hear what the doctors of this study have to say:

• Tarsal tunnel syndrome is classified as a focal compressive neuropathy (a direct pressure) on the posterior tibial nerve (a branch of the sciatic nerve that runs into the heel. This is why it is also diagnosed as posterior tibial neuralgia or more simply as “ankle pain.”)
• The condition is rare and regularly under-diagnosed leading to a range of symptoms affecting the plantar (sole) of the foot.
• There are many intervention strategies for treating tarsal tunnel syndrome with limited robust evidence to guide the clinical management of this condition. The role of conservative versus surgical interventions at various stages of the disease process remains unclear.

So foot specialists are troubled by accurate diagnosis and accurate treatment. The non-surgical conservative care options are those discussed above, Rest, ICE, NSAIDs, etc. Remedies that you have probably found ineffective, that is why you went to the doctor.

Other foot specialists also wrote about the difficulties of making an accurate diagnosis of Tarsal Tunnel Syndrome and then what to do once you confirm it. Here is a study from university researchers in Italy published in Neurological Sciences.(2)

• (Tarsal tunnel syndrome) is a condition frequently underdiagnosed leading to controversies regarding its management and to an intense debate in the medical literature.
• Management of this entrapment neuropathy remains challenging because of many intervention strategies but limited robust evidence.
• Uncertainties still exist about the best conservative treatment, timing of surgical intervention, and best surgical approach.

Many things can cause a diagnosis of “Tarsal Tunnel Syndrome.”

Above you read the concerns of foot specialists in the diagnosis and treatment of Tarsal Tunnel Syndrome. In this section, we will try to provide information that you may be able to use to make sure that you have Tarsal Tunnel Syndrome or you do not have tarsal tunnel syndrome and that with this information you can help your health care providers guide your treatment.

Many things can cause a diagnosis of “Tarsal Tunnel Syndrome.”

The heading of this section specifically points out that many things can cause a diagnosis of  “Tarsal Tunnel Syndrome.” We hope here to point out that while your problem may look like Tarsal Tunnel Syndrome and get you a diagnosis of Tarsal Tunnel Syndrome, you may not have Tarsal Tunnel Syndrome.

What can cause true Tarsal Tunnel Syndrome?

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 (cysts, inflammation) may also contribute to compression neuropathy of the posterior tibial nerve. Bone spurs may be a causative factor. Valgus deformity of the hindfoot (ankle and heel) which may increase tension due to excessive eversion and dorsiflexion (unnatural rotation).

Ultimately, a patient needs to be properly evaluated for foot and ankle instability, as this is the cause of most nerve entrapment syndromes.

What can look like “Tarsal Tunnel Syndrome?”

Is it lumbosacral radiculopathy?

You may find it odd that in our clinic, if you come in with a diagnosis of Tarsal Tunnel Syndrome and a painful foot condition we may want to take a look at your lower back. What are we looking for? Spinal instability that may be causing pain down to your legs. We are going to bring in two different teams of surgeons to explain this to you.

First, we have a team of medical university surgeons from China who co-authored research with the Department of Physical Medicine and Rehabilitation, Upstate Medical University, State University of New York at Syracuse doctors. This research is published in the European Spine Journal.(3)

The concern here is that doctors will misdiagnose a back pain problem as Tarsal Tunnel Syndrome, or the similarities in both these conditions may confuse treatment. Here is what the research said:

• Tarsal tunnel syndrome and Lumbosacral radiculopathy share many of the symptoms occurring in Tarsal Tunnel Syndrome. Chinese and American researchers writing in the European Pain Journal 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 lumarsacral radiculopathy due to the possible existence of Tarsal tunnel syndrome, as their management strategies are quite different.

This is a serious concern for surgeons. Someone with numbness or burning pain in the feet may be diagnosed as having this pain from a problem with the nerves in the spine. This person is then sent off to surgery and after the surgery, they still have burning pain in their foot/feet.

Let’s bring in the second group of surgeons who were looking at 13 patients who had continued pain after lumbar disc surgery. This is from Japanese medical university surgeons writing in the Asian Spine Journal.(4)

“We evaluated and treated 13 patients with persistent or recurrent symptoms after lumbar disc herniated surgery. (Four patients had to have the surgery redone). The other nine patients manifested no radiological abnormalities that explained their persistent or recurrent symptoms. (In other words, the MRI of their spine showed nothing wrong). However, treatment for Peripheral Neuropathy resulted in symptom abatement in these patients, suggesting that factors other than lumbar disease were involved.”

In other words, the person in this group with foot pain suspected to come from the nerves got a spinal surgery. When they received a nerve block the doctors realized it was Tarsal Tunnel Syndrome all along.

Clearly, the treatment of Tarsal tunnel syndrome presents a challenge.

Is it plantar fasciitis?

We will often see patients who have been diagnosed with plantar fasciitis only later to be diagnosed with Tarsal Tunnel Syndrome when the “proven,” treatment for plantar fasciitis has failed. We will see patients who have been diagnosed with Tarsal Tunnel Syndrome only later to be diagnosed with plantar fasciitis when “proven,” nerve entrapment remedies failed.

What do these patients really have? Tarsal Tunnel Syndrome? The Plantar Fasciitis? Both? Neither?

Many readers of this article will know first hand of the confusion of diagnosis between Tarsal Tunnel Syndrome and Plantar Fasciitis and worse, the medical history of a lot of failed treatment. This is typical of a medical history we will hear:

I was treated for years for chronic Plantar Fasciitis. Nothing worked, stretching, exercises, massage, rollers, Active Release the one constant was plenty of anti-inflammatory medications. 

When someone comes into our clinic with this story, we start thinking nerve entrapment may be a possible answer. We also start thinking ligament damage may be an answer.

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.

• 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. The problems with a diagnosis are the problem of the sprain or weakening of the metatarsal, lateral collateral and medial collateral ligaments, ligaments which are causing the pain and are rarely examined by a family physician or an orthopedic surgeon.
• You may get a nerve release surgery that was not necessary and will not help.

Treatment of Tarsal Tunnel Syndrome – Is it nerve pain?

Tarsal Tunnel Syndrome Surgery

In this section, we are going to talk about the actual foot surgery. Surgery, too, can make the condition worse, especially when the condition has been misdiagnosed, which is often the case. This is not just a misdiagnosis as it relates to the lower spine causing issues, but misdiagnosis of other foot issues that can be masquerading as Tarsal Tunnel Syndrome or hiding the true diagnosis of Tarsal Tunnel Syndrome.

Since we are talking surgical failures, let’s bring in the surgical opinion.

In the medical journal Foot and Ankle Clinics,(5) John S. Gould, MD Division of Orthopaedic Surgery, Section of Foot and Ankle, University of Alabama at Birmingham wrote:

“Recurrence of tarsal tunnel syndrome after surgery may be due to inadequate release, lack of understanding or appreciation of the actual anatomy involved, variations in the anatomy of the nerve(s), failure to execute the release properly, bleeding with subsequent scarring, damage to the nerve and branches, persistent hypersensitivity of the nerves, and preexisting intrinsic damage to the nerve. Approaches include more thorough release, use of barrier materials to decrease adherence of the nerve to surrounding tissues to avoid traction neuritis, excisions of neuromas using conduits, and consideration of nerve stimulators and systemic medications to deal with persistent neural pain.”

More favorably but with reservation is a February 2020 study (6) in which six feet in five patients with Tarsal tunnel syndrome were treated surgically. The patients were aged 31-70 years (average age about 53), and all of them complained of pain or dysesthesia (numbness, pins and needles sensation) of the sole of the foot but not the heel.

• In the surgery, flexor retinaculum (the important laciniate ligament also called internal annular ligament) was dissected to free the posterior tibial nerve, (this is a neurovascular decompression procedure), and fascia of the abductor hallucis muscle (the big foot arch muscle) was excised to decompress the medial and lateral plantar nerve (releasing fascial of abductor hallucis muscle.)

Surgical decompression was beneficial in 5 feet. The recurrence of symptoms was found in one case within 1 postoperative month. In this small study 1 oin 6 feet had the symptoms return within one month of the surgery. So the surgery was likely not performed on the actual problem.  The case study also suggeted that some methods to prevent adhesion and granulation (car formation) in the reconstructed tarsal tunnel should be considered as this may be a problem.

Treating Tarsal Tunnel Syndrome with Prolotherapy and Nerve Release & Regeneration Injection Therapy
Caring Medication examination and treatment

The first step in our treatment plan is to make the determination that the patient is actually suffering from Tarsal Tunnel Syndrome. 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, Nerve Release & Regeneration Injection Therapy can typically be performed to free up and calm entrapped nerves. Surgical referrals are rare, as most of the chronic cases exhibit joint instability and the nerve entrapment is positional. When the nerve is freed up with NRRIT and the joint is stabilized with Prolotherapy, the condition resolves.

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 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.

Sometimes only one treatment is needed, but often, three to six visits are needed, especially in cases of severe joint instability where the nerve irritation is located. Patients suffering from nerve pain should not delay seeking medical care for these conditions. This cannot be overemphasized. Permanent nerve damage may occur. If the fear of surgery has prevented you from seeking help, please know that wonderful non-surgical treatment options now exist! Our team will be happy to help you! Please reach out to us to discuss your case. Let’s get you the help you need to restore your nerve function!

What is Nerve Release & Regeneration Injection Therapy? Non-Surgical Nerve Release

NRRIT is a nerve hydrodissection technique that is highly successful for releasing peripheral nerve entrapments. It is a quick, straightforward process injection procedure often providing instant relief results for the patient! In the procedure, the practitioner uses ultrasound guidance to identify the nerves being entrapped. Next, simple dextrose, like that used in H3 Prolotherapy,  is injected around the nerve to nourish the nerve and mechanically release it from the surrounding tissue, fascia, or adjacent structures.

Nerve Release Injection Therapy (hydrodissection) of an entrapped nerve. In this image dextrose solution is injected around the nerve which releases or separates it from the surrounding tissue. The nerve, which is the central circular object has a dark ring forming around it, as seen strongly in the B image. That is the dextrose solution from the needle, the straight image from the right of the screen. The nerve as seen in B is now surrounded by the nerve release fluid and therefore “released.”

If this article has helped you understand the problems of Tarsal Tunnel Syndrome and you would like to explore Prolotherapy as a possible remedy, ask for help and information from our specialists

1 McSweeney SC, Cichero M. Tarsal tunnel syndrome-A narrative literature review. Foot (Edinb). 2015 Dec;25(4):244-50. doi: 10.1016/j.foot.2015.08.008. [Google Scholar]
2 Doneddu PE, Coraci D, Loreti C, Piccinini G, Padua L. Tarsal tunnel syndrome: still more opinions than evidence. Status of the art. Neurological Sciences. 2017 Jun 29:1-5 [Google Scholar]
3. 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. [Google Scholar]
4 Yamauchi T, Kim K, Isu T, Iwamoto N, Yamazaki K, Matsumoto J, Isobe M. Undiagnosed Peripheral Nerve Disease in Patients with Failed Lumbar Disc Surgery. Asian Spine Journal. 2018 Aug;12(4):720. [Google Scholar]
5. Gould JS. Recurrent tarsal tunnel syndrome. Foot and Ankle Clinics. 2014 Sep 1;19(3):451-67. [Google Scholar]
5 Yunoki M. Analysis of Surgical Cases of Tarsal Tunnel Syndrome in Our Department: Case Series and Literature Review. Asian J Neurosurg. 2020 Feb 25;15(1):59-64. doi: 10.4103/ajns.AJNS_257_19. PMID: 32181174; PMCID: PMC7057884. [Google Scholar]

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• Surgery
• NSAIDs
• Cortisone Shots
• R.I.C.E.