Physical Therapy for Tarsal Tunnel Syndrome
Tarsal tunnel syndrome results from compression of the posterior tibial nerve as it passes through the tarsal tunnel. The tarsal tunnel is a narrow space located on the inside of the ankle, containing the tibial nerve which provides feeling to the heel and foot and aids in foot function. Tarsal tunnel syndrome can cause debilitating pain, numbness, and tingling in the foot and ankle and limit ankle and foot mobility and function. Physical therapy can play a critical role in improving the function and mobility of those with tarsal tunnel syndrome through a targeted strengthening, stretching, manual therapy, and nerve gliding treatment program.
Anatomy of the Tarsal Tunnel Structures
The tarsal tunnel is a narrow space located on the inside of the ankle and is formed by the ankle bones and a band of ligaments that stretches across the foot. Numerous blood vessels, nerves, and tendons that provide movement and flexibility to the foot travel through the tarsal tunnel.
The tibial nerve passes through the tarsal tunnel, dividing into three branches that give feeling to the heel and bottom of the foot and aid in foot function. The tibial nerve controls muscle movement and transmits sensory messages felt in the knee, foot, and ankle joints.
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What is Tarsal Tunnel Syndrome?
Tarsal tunnel syndrome (TTS) results from compression of the posterior tibial nerve as it passes through the tarsal tunnel. Tarsal tunnel syndrome can occur due to narrowing of the tarsal tunnel which can be caused by a variety of factors.
Potential causes of tarsal tunnel syndrome can include:
Foot anatomy: having flat feet or very high arches can contribute to TTS as flat feet or high arches can lead to over-pronation, which causes ankles to turn inwards, placing more pressure on the tibial nerve.
Varicose veins: bulging or enlarged veins in the lower legs can place pressure on the tibial nerve.
Ankle injury: Nearly 40% of those with TTS have a history of ankle injuries. An ankle sprain or fracture leads to inflammation and swelling around the ankle, which can compress the tibial nerve and narrow the space of the tibial tunnel.
Underlying medical conditions: medical conditions like type 2 diabetes, arthritis, or hypothyroidism can contribute to chronic inflammation and cause swelling in the feet and ankles that place pressure on the tibial nerve
Repetitive stress on the ankle, such as engaging in more exercise than the body is ready for, such as increasing running mileage too quickly, can contribute to tendinopathy and inflammation of the ankle.
Irregular growths or masses in the ankle area such as a ganglion cyst or bone spurs can narrow the tibial tunnel and compress the tibial nerve.
Weakness or tightness in muscles of lower leg and foot can also contribute to TTS.
Symptoms of tarsal tunnel syndrome include:
Pain, numbness, or tingling in the sole of the foot or ankle, which can radiate into the bottom of the foot, heel, and toes. Pain may be described as shooting, “electric shock”-like pain.
Weakness in the muscles of the lower leg, foot, and big toe
Swelling of the foot
Symptoms increase with prolonged standing or walking, but improve with rest
Increased sense of cold or warmth in the foot and ankle
Tarsal tunnel syndrome is not a common condition but is often underdiagnosed and is more commonly seen in women than men. When diagnosing the condition, the doctor or physical therapist may gently tap over the posterior tibial nerve to reproduce symptoms, perform a nerve conduction study, or do the Tinel test, which involves light tapping over the tarsal tunnel repeatedly; pain or tingling along the nerve is considered a positive test for TTS.
Physical Therapy for Tarsal Tunnel Syndrome
Physical therapy can play a critical role in improving the function and mobility of those with tarsal tunnel syndrome. The goal of the therapist is to reduce foot and ankle pain, improve mobility, strength, flexibility, and endurance in the lower leg, and help patients return to activity safely.
Physical therapy treatment for tarsal tunnel syndrome can include:
Pain management: rest from activities that place undue pressure on the ankle and tarsal tunnel can alleviate pain as well as the use of ice to manage swelling and inflammation around the ankle.
Muscle strengthening: targeted exercises to address any muscle weaknesses or tightness in the knee, hip, foot, and ankle muscles can help alleviate stress placed on the tarsal tunnel area. Exercises can include ankle resistance exercises like ankle inversion, dorsiflexion, plantarflexion, rotations, or heel raises.
Targeted flexibility training: stretching exercises, particularly of the calf muscles (soleus and gastrocnemius) and the hamstring muscles, can be effective in relieving symptoms and tight muscles.
Aerobic cross training: this can involve low-impact aerobic exercises like swimming, stationary biking, or using the elliptical to increase blood flow to the injured area without placing excessive stress on the ankle and foot.
Manual therapy: hands-on soft tissue and joint mobilizations to gently move the foot, ankle, and surround tissues to restore movement and reduce pain.
Nerve gliding: this involves gentle exercises the move and “glide” the nerves of the ankle and foot to reduce symptoms and improve function.
Balance, coordination, and gait training: as the patient regains strength and mobility in the ankle and foot, they can progress to balance and coordination training to improve and restore normal walking patterns. Exercises can include single-leg stances on various surfaces and heel-to-toe walking.
Orthotics, taping, and bracing: utilizing orthotics, taping, and bracing and prioritizing wearing supportive shoes can help properly position the foot, support the foot arch, prevent pronation, and limit movements that further irritate the tibial nerve.
Tarsal tunnel syndrome can cause debilitating foot and ankle pain and limit your activities. Work with a physical therapist today to relieve pain and restore function!
