Tarsal Tunnel Syndrome: An Overview

Case Report

Austin J Musculoskelet Disord. 2015;2(3): 1022.

Tarsal Tunnel Syndrome: An Overview

Ellison T¹ and Saxena S¹*

¹Department of Family Medicine, Creighton University School of Medicine, USA

*Corresponding author: Saxena S, Department of Family Medicine, Creighton University, 601 N 30th ST, STE 6720, Omaha, NE 68131, USA

Received: April 30, 2015; Accepted: June 24, 2015; Published: June 25, 2015


Tarsal tunnel syndrome is an uncommon condition which can be painfully debilitating. This clinical diagnosis is often enhanced by electro diagnostic tests. Causes are both extrinsic and intrinsic. Initial treatment is usually non-operative, but at times surgical intervention is indicated at the outset. The surgery is difficult and the literature suggests patient selection is crucial for positive surgical outcomes. Surgical success rates are highest when cause is extrinsic and surgery is performed within 12 months of symptom onset.


Tarsal Tunnel Syndrome (TTS) is a type of compression neuropathy where the tibial nerve is compressed within the tarsal tunnel running along the inside of the ankle into the foot. Tarsal Tunnel Syndrome (TTS) is an uncommon condition that can become debilitating as a result of progressive pain. With TTS, pain originates in the ankle from entrapment of the posterior tibial nerve or its medial, lateral or calcaneal branches in the proximal and/or distal tarsal tunnel [1,2]. The flexor retinaculum serves as the roof of the fibroosseous tunnel connecting the medial malleolus to the calcaneous while the medial aspect of the talus, calcaneum and distal tibia form the floor [2,3]. The tarsal tunnel is posterior and inferior to the medial malleolus and holds, from medial to lateral, the tibialis posterior tendon, the flexor digitroumlongus tendon, the posterior tibial artery and vein, the posterior tibial nerve and the flexor hallucislongus tendon [1,4].The posterior tibial nerve can become compressed at the tarsal tunnel leading to proximal TTS [5]. Calcaneal branches from the posterior tibial nerve penetrate the flexor retinaculum to provide sensation to the posterior and medial heel [1-5]. Ninety-five percent of the time, the posterior tibial nerve bifurcates into the medial and lateral planter nerves distal to the tunnel [1]. The medial and lateral plantar nerves then enter their own distal tunnels [1,6]. Compression of either the proximal or distal tunnels can lead to TTS causing pain and hypoesthesia involving the heel and plantar surfaces of the foot [1,6]. Due to low incidence along with variations in pain, sensory and motor deficits, TTS can be difficult to diagnose. If TTS is suspected, differential diagnoses such as chronic plantar fasciitis with distal TTS or lumbar radiculopathy should be considered [1]. A variety of tests performed on physical exam as well as imaging studies improve the detection and diagnosis of TTS.

Classic Presentation

A 42-year-old female presented with pain and burning of three months duration in her left ankle and sole. She reported increasing discomfort now interfering with her recreational golfing [7]. She denied recent or past ankle trauma. Pain was localized posterior and inferior to her medial malleolus and she complained of numbness along her posterior and medial heel radiating to the plantar surface of the foot [8]. She denied pain upon first step, but reported intensifying pain with activity and “after burn” or lengthened time for pain dissipation post activity [2]. More recently, pain has occurred at rest, waking her at night [3]. She expressed concern over losing the ability to golf, or even walk, if the pain and numbness continued to progress.

On exam, no obvious ankle deformity, such as hindfoot varus or valgus, was appreciated. Ankle erythema and edema were absent. Point tenderness over the soft spot on the medial border of the abductor hallucis was present (Figure 1) [5]. There was a positive Valleix test (pain on deep palpation of the tarsal tunnel) as well as arch tenderness [9]. Neurological examination revealed positive Tinel’s sign and decreased two-point discrimination on the plantar surface of the foot.

Citation: Ellison T and Saxena S. Tarsal Tunnel Syndrome: An Overview. Austin J Musculoskelet Disord. 2015;2(3): 1022. ISSN : 2381-8948