Cassie Glodowski and Jessica Wagstaff

MSAT 6451

October 9, 2013

Tarsal Tunnel Syndrome is an entrapment of the Posterior Tibial Nerve1-3

Tunnel formed by:3

Flexor Retinaculum

Posterior Talus

Medial Malleolus

Medial Calcaneus

Tom, Dick AN Harry4

Tibialis Posterior

Flexor Digitorum Longus

Posterior Tibial Artery

Posterior Tibial Nerve

Flexor Hallucis Longus

Burning Pain in heel and medial arch on the plantar aspect of the foot5

Local Tenderness posterior to medial malleolus

Increased pain with walking

Toe Flexion Weakness

Symptoms worsening at night 3,5

Loss of two point discrimination3

Tingling and Numbness (Sensory Disturbances) Usually poorly localized3

Anterior vs. Posterior Tarsal Tunnel6

Anterior: deep peroneal nerve

Posterior: posterior tibial nerve

Dorsiflexion + Eversion Increase Sx

Plantarflexion + Inversion Alleviate Sx

Tinels Sign

Posterior Tibial Nerve3,7

Plantar Fasciitis, Lumbar Radiculopathy3,5,8

Diagnosis determined through

examination and history2

Conservative treatments Reduce activity

Reduce pain and inflammation Ice, NSAIDs, cortisone injection, ultrasound

Ankle strengthening, flexibility and balance2,4,5,9-12

Nerve mobilization13

Nerve-gliding exercises to restore soft tissue mobility.

Slump position, hip flexed, ankle dorsiflexed and everted, knee moves into flexion and extension 10x

Orthotics and taping Correct hyperpronation, pes planus

Wider shoes3,4,13

Gait training Normal biomechanics of spine, hip, knee, ankle, foot

Deep friction massage Release adhesions in flexor retinaculum3

Timing is important because chronic nerve Compression can be related to atrophy13

Before surgery: Physical exam Hindfoot alignment (valgus vs. varus) in weight-bearing,

tarsal tunnel palpation, Tinels sign

Weight-bearing radiographs Identify bony abnormalities, further hindfoot alignment

assessment

MRI May show cause of TTS

Electrodiagnostic studies13

Confirm diagnosis, differentiate TTS from other radiculopathy or neuropathy

Surgical success rates are between 44-96%13

Surgery

Incision 6-8 cm proximal to tip of medial

malleolus, extends distally along course of

nerve, 1-2 cm posterior to tibia and

medial malleolus

Crural fascia divided, tibial nerve

identified

Flexor retinaculum divided/released

Posterior tibial nerve decompressed

Plantar nerves may also be decompressed

Nerve decompression: relieves pressure on the

entrapped nerve, make space for nerve

Abductor hallucis muscle belly often

removed2,10,11,13,14

Reduce painful activity for 3-4 weeks

Week 1 AROM 4-way ankle

Gastrocnemius and soleus stretches

Nerve mobility15,16

UBE

Weeks 2-3 4-way ankle with Theraband

Ankle circles and alphabet

Pool exercises partial weight-bearing Calf raises, mini-squats, step-ups and step-downs, single

leg stand

Gait training4,16

Recumbent bike

Weeks 4-6

Full weight-bearing

Calf raises, squats, step-ups and step-downs, single leg

stand

Gait training

Treadmill walking, jogging

Recumbent bike

Weeks 7-8

Calf raises, squats, step-ups and step-downs with weight

Single leg stand with eyes closed or on uneven surface

Cutting through cones, Z drill

Agility hurdles, ladder drill

Sled/parachute run

Running, sprinting4

Week 1-2: Immobilization vs. Mobilization17

Non-weight bearing

Ice

UBE

Week 3: Ice

Gentle AROM/PROM

Isometric resistance (4-way ankle)

Gradually increase to 50% weight bearing on crutch

Gastrocnemius and soleus stretching

Week 4: cast removed, full weight bearing Full AROM exercises (4-way ankle, circles, alphabet), toe curls

with towel, towel stretch to dorsiflexion

Weight shift between parallel bars, pool exercises (mini squats, aqua jogging, forward/backward walking, single-leg stand)

Gait training

Scar mobility (cross friction massage)8

Recumbent bike

Week 5: Single-foot balance Pool exercises: carioca, lateral shuffle, single-leg calf raises

Theraband: 4-way ankle

Discontinue isometrics, 4 inch box mini squats, step-overs and step-downs

Week 6-7: Walking (forward/backward) Carioca, lateral shuffle

Treadmill: speed walking at 2% grade

Jogging at week 7

Plyometrics

Weeks 8-12: Running progression and agility8

Jogging every day, increase by 2 min. per week

Backwards jogging

Figure 8s, Z drill, T drill

Agility hurdles, ladder drill, cutting cones by week 10

Full speed/sprinting by week 12

1 Joshi S. Anatomy of Tarsal Tunnel And Its Applied Significance. Journal of the Anatomical Society of India. 2006;55:1-7.

2 Ahmad M, Tsang K, Mackenney PJ, Adedapo AO. Tarsal tunnel syndrome: A literature review. Foot and Ankle Surgery. 2012;18:149-152.

3 Danchick J. Tarsal tunnel syndrome and orthotic support. The American chiropractor. 2003;25(3):59-60.

4 Godges J, Klingman R. Ankle Nerve Disorder: Tarsal Tunnel Release. Loma Linda U DPT Program, KPSoCal Ortho PT Residency.

5 Jackson D. Tarsal tunnel syndrome in athletes. Case reports and literature review. The American Journal of Sports Medicine. 1991;19(1):61-65.

6 Borges L, Hallett M, Selkoe D, Welch K. The anterior tarsal tunnel syndrome: a report of two cases. Journal of Neurosurgery. 1981;54:89-92.

7 Kinoshita M, et al. Tarsal Tunnel Syndrome in Athletes. The American Journal of Sports Medicine. 2006; 34:1307-1312

8 Romani W, Perrin DH, Whiteley T. Tarsal tunnel syndrome: Case study of male collegiate athlete. Journal of Sport Rehabilitation. 1997;6:364-370.

9 Krause KH, Witt T, Ross A. The Anterior Tarsal Tunnel Syndrome. Journal of Neurology. 1977;217:67-74.

10 Gondring WH, Trepman E, Shields B. Tarsal tunnel syndrome: Assessment

of treatment outcome with an anatomic pain intensity scale. Foot and

Ankle Surgery. 2009;15:133-138.

11 Antoniadis G, Scheglmann K.Posterior Tarsal Tunnel Syndrome. Deutsches

rzteblatt International. 2008;15(45):776-781.

12 Perera N, Liolitsa D, Scott C, et al. Surgical interventions for entrapment

and compression of the tibial and deep peroneal nerves including tarsal

tunnel syndrome (Protocol). The Cochrane Collaboration. 2013;7.

13 Singh SK, Wilson MG, Chiodo CP. The surgical treatment of tarsal tunnel

syndrome. The Foot. 2005;15:212-216.

14 Joubert M. Tarsal Tunnel Syndrome. South African Medical Journal.

1975;46:507-508.

15 Kavlak Y, Uygurb F. Effects of nerve mobilization exercise as an adjunct

to the conservative treatment for patients with tarsal tunnel syndrome.

Journal of manipulative and physiological therapeutics. 2011;34(7):441-

448.

16 Godges J, Klingman R. Ankle Nerve Disorder: Tarsal Tunnel Release. Loma

Linda U DPT Program, KPSoCal Ortho PT Residency.

17 Dellon LA. The Four Medial Ankle Tunnels: A Critical Review of

Perceptions of Tarsal Tunnel Syndrome and Neuropathy. Neurosurgery

clinics of North America. 2008.