Evolutions | Health | Fitness | Wellness

Peripheral Entrapment Neuropathy #6

on September 25, 2013 by Dr. John Michie

Tarsal Tunnel Syndrome!

Tarsal Tunnel Syndrome is a painful nerve condition known as Posterior Tibial Neuralgia and is due to compression of the tibial nerve as is passes through the tarsal tunnel in the foot.  This “tunnel” is located along the inner lower leg behind the medial malleolus (ankle bone) and the nerve courses through this tight area known as the tarsal tunnel.


Patients will present with numbness in the foot radiating to the big toe and the adjacent three toes.  Burning, electrical sensations and tingling over the base of the foot and heel.  Ankle pain, inflammation and swelling can occur.  The Flexor Retinaculum, a retaining ligamentous band that encases the ankle region, has a very limited stretch capacity so increased pressure will lead to compression as well.  As pressure increases, blood flow decreases and nerves will be adversely affected.  Fluid can collect and worsen symptoms leading to diminished innervation and blood supply to the small muscles of the foot.

  • Swelling in foot
  • Pain worsens with prolonged standing and with activities and relieves with rest
  • Pain can radiate up into leg, arch, heel and toes
  • Feet can feel as though there is not “enough padding”


  • Patient history – this component of Tarsal Tunnel Syndrome is significant as mechanisms of cause may uncover specific athletic, trauma, lifestyle connections to this painful condition
  • X-Ray is typically an initial diagnostic tool to rule out architectural issues and/or bone spurs that may irritate the tibial nerve
  • MRI is the next choice of imaging as the soft tissues are highlighted and if space occupying lesions, tearing of the involved tissues or inflammation is present, findings will be revealed
  • Diagnostic Ultrasound is a commonly applied diagnostic tool as it is an excellent modality for revealing synovitis and/or a troubling ganglia interfering with the tibial nerve
  • Nerve Conduction Velocity is a decent tool as well but will will essentially confirm that there is tibial nerve irritation/compression and where
  • Tinel’s Sign is a quick, accurate diagnostic tool done right in the office with a neurological reflex hammer to tap over the tibial nerve and if electric shocks are ilicited, Tarsal Tunnel is most likely the offending pathology


As with all lower extremity neuro-musculo-skeletal conditions, there are typically multiple mechanisms of insult.

Varicosities in the lower extremities can lead to TTS

Foot pronation and loss of longitudinal arch can promote TTS

Lumbar spine, specifically, L4, L5, S1 nerve irritation and/or disc disease can create what is known as “Double Crush” neuropathy.  Lumbar nerves get irritated/compressed and this is the same nerve pathway that passes through the tarsal tunnel

Athletic and repetitive stress from endurance events can activate the tibial nerve in the tarsal tunnel from hypertrophy and friction

Multiple sprained ankles can evolve into TTS


Manual manipulation of kinetic chain – foot, ankle, knee, hip, lumbar spine

Myofascial release therapy to soft tissues from foot to lumbar spine to open up and release fascial and muscle planes for more compliance and minimize adhesive binding sites that may lead to nerve entrapment

Myofascial Dry Needling therapy for more progressive myofascial release along the myofascial planes

Strengthen the tibialis anterior, posterior, peroneus longus and toe flexor group muscles

Kinesiotape and custom orthotics for biomechanical support

Surgery to recalcitrant cases and/or decompression if space occupying lesions exist such as ganglion cysts, spurs and other lesions compressing delicate nerve tissue

Natural anti-inflammatory support such as proteolytic enzymes (Protrypsin), natural COX-@ Inhibitors (Inflavonoid), Omega Three Fatty acids (Omega Pure 600), Vitamin B6 for nerve transmission and Magnesium (OptiMag 125) for muscular compliance – apply this protocol for 30-90 days.

Sports/Athletic activity modification such as pool work and quasi weight bearing exercise to allow healing of the affected region

Often times a walking boot is recommended to allow the injured tissues to heal as well – this can be worn for 4-6 weeks.