What is Tarsal tunnel Syndrome?

ATTS is a chronic entrapment neuropathy that affects the deep peroneal nerve beneath the thin inferior extensor retinaculum at the front of the ankle, or more distally as the lateral and medial terminal branches across the talo-navicular and calcaneo-cuboid joint. 

Anatomy:

At the ankle, the inferior extensor retinaculum forms the roof of the anterior tarsal tunnel, which protects the deep peroneal nerve. Its floor is the fascia, which covers the talus and navicular bones. 

Causes:

As a result, the source of nerve compression is frequently associated with edema on the tunnel floor. Another Dilatation of the venous vessels (anterior tibial veins) that accompany the dorsalis pedis artery can produce nerve compression. This is a unique source of nerve compression that may occur in a variety of places.

Several variables may have a role in the development of ATTS.

The most common cause of compression is either acute or micro-trauma to the dorsum of the foot, which can result in local fibrosis or change the structure of the "tunnel." ATTS may also be associated with talo-navicular bone spurs, which are caused by wearing tight-fitting shoes, localized edema, long-standing aberrant posture, and ganglions.

Symptoms:

ATTS, an apparently under-diagnosed cause of dorsal foot pain, involves a dull pain, numbness, and paresthesias on the dorsum of the foot that radiates to the first interdigital region. These symptoms may worsen in specific situations (plantar flexion of the foot) or due to inactivity, or they may have nocturnal aggravation and proximal radiation. Motor symptoms are often moderate due to muscular redundancy, which allows numerous muscles to execute comparable motor functions. The anterior tarsal tunnel syndrome accounts for around 5% of instances of foot numbness that pass electromyographic and nerve conduction testing.





Diagnostic Test

The dorsiflexion-inversion test consists of passively dorsiflexing and inverting the ankle to the end of its range of motion and holding it for 10 seconds. Reproduction of symptoms is a good indicator since the posterior tibial nerve is compressed in this posture. This test is positive in 82% of tarsal tunnel syndrome patients.




Tinel test:

Tinel's test of the ankle is conducted by tapping the tibial nerve directly over the flexor retinaculum posterior to the medial malleolus with fingers or a reflex hammer.




Treatment:

Nerve gliding & Stretch

Gentle exercises that move and "glide" the nerves may help reduce symptoms and improve function. 




Taping


Week 1:

  1. Initial Assessment:
    • Evaluate the patient's medical history, symptoms, and functional limitations.
    • Perform a thorough physical examination, including range of motion, muscle strength, sensation, and gait analysis.
    • Assess any contributing factors, such as footwear, activities, or postural habits.
  2. Pain Management:
    • Educate the patient about pain management techniques, such as rest, ice, compression, and elevation (RICE).
    • Advise on the use of over-the-counter pain relievers, if necessary.
    • Suggest modifications to activities that exacerbate symptoms.
  3. Rest and Immobilization:
    • Encourage the patient to avoid activities that worsen symptoms, including high-impact exercises.
    • Recommend the use of supportive footwear or orthotics to reduce stress on the affected area.
    • Provide education on proper rest and immobilization techniques, such as gentle stretching and avoiding prolonged weight-bearing activities.

Week 2-3:

  1. Manual Therapy and Modalities:
    • Perform hands-on techniques like soft tissue mobilization, joint mobilization, and myofascial release to address muscle imbalances and improve tissue extensibility.
    • Utilize modalities such as ultrasound, electrical stimulation, or low-level laser therapy to help manage pain and promote tissue healing.
  2. Stretching and Strengthening:
    • Prescribe specific stretching exercises to improve flexibility and reduce compression on the tibial nerve.
    • Develop a strengthening program focusing on intrinsic foot muscles, ankle stabilizers, and lower limb muscles to enhance overall support and stability.

Week 4-6:

  1. Neuromuscular Re-education:
    • Implement proprioceptive and balance exercises to enhance neuromuscular control and stability.
    • Incorporate activities that challenge coordination and weight shifting to restore normal movement patterns.
  2. Gait Training:
    • Assess the patient's walking pattern and address any abnormalities or compensations.
    • Provide gait retraining, emphasizing proper foot and ankle alignment, weight distribution, and stride mechanics.
  3. Progression of Exercise:
    • Gradually increase the intensity, duration, and complexity of stretching and strengthening exercises.
    • Incorporate functional activities and sports-specific movements, if applicable.

Week 7 and beyond:

  1. Maintenance and Prevention:
    • Emphasize the importance of ongoing exercise and stretching to maintain strength, flexibility, and nerve mobility.
    • Educate the patient on proper footwear selection, foot hygiene, and ergonomics to prevent future flare-ups.
    • Provide home exercise programs and self-management strategies for long-term symptom control.

Remember, this protocol is a general guideline, and the actual treatment plan may vary depending on the individual's specific condition, response to treatment, and healthcare professional's assessment. It's essential to consult with a physiotherapist or healthcare provider for a personalized approach.