0196-6011/84/0601-0039$02.

00/0
THEJOURNAL OF ORTHOPAEDIC AND SPORTS PHYSICAL THERAPY
Copyright 0 1984 by The Orthopaedic and Sports Physical Therapy Sections of the
American Physical Therapy Association

Medial Tarsal Tunnel Syndrome: A

Review
SHIRLEY KUSHNER, BScPT, BPE,* DAVID C. REID, MD, MCh, FRCS(C)t

The medial tarsal tunnel syndrome is a compression neuropathy involving the tibial
nerve or its branches as they pass through the tarsal tunnel under the flexor
retinaculum. Medial tarsal tunnel syndrome is not recognized as readily as its
counterpart in the wrist. This syndrome can lead to a painful burning sensation in the
medial border of the foot and into the great toe. In its fullest extent medial tarsal
tunnel syndrome can involve sensory changes in the heel and the lateral part of the
sole of the foot as well as the remaining toes. In addition, it may lead to weakness of
the intrinsic muscles of the foot. This syndrome often goes unrecognized or
misdiagnosed particularly in the athlete. While medial tarsal tunnel syndrome may
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respond initially to nonoperative techniques of ultrasound and modification of

footwear, as it progresses surgical release of the nerve in the tunnel will be required
for optimal results. This paper reviews the anatomy, etiology, pathology, clinical
presentation, and treatment of the medial tarsal tunnel syndrome. In order to bring
more attention to this condition, our clinical experience is presented.
Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

The medial tarsal tunnel syndrome is a
compression neuropathy of the tibial nerve or its
terminal branches, the medial and lateral plantar
nerve^.'^^'^^'''^' This impingement occurs within
the boundaries of the fibro-osseous tarsal tunnel
or as it passes into the abductor hallucis mus-
Journal of Orthopaedic & Sports Physical Therapy
thorough knowledge of the condition, protracted
symptoms can be alleviated before permanent
motor or sensory damage ~ccurs.~.''
This paper will review the anatomy of the tarsal
tunnel as it pertains to the medial tarsal tunnel
syndrome, its etiology, pathology, clinical picture,

~ l e . ~ .Because
~ . ~ ' this syndrome is not as well
recognized as its counterpart at the wrist, there
may be a delay in diagnosi~.~,~.~.'
The first comprehensive report of: the tarsal
tunnel syndrome was presented by Keck15 in
1962, and later in the same year by
However both these authors credited earlier pass-
ing reference^.^, The tarsal tunnel syn-
'6317'2032529
drome has since been divided into the anterior
tarsal tunnel syndrome, which implicates
compression of the deep peroneal nerve at the
inferior extensor retinaculum, and the posterior or
medial tarsal tunnel syndrome. The latter is more
common and will be described in this paper.'-24
Physiotherapists should be aware of this syn-
drome, particularly if they are associated with
treatment of athletes, since they may be in a
position to make the initial diagnosis. With a more
Candidate for M.Sc.P.T., Department of Physical Therapy, Corbett
Hall, University of Alberta, Edmonton, Alberta.
t Associate Professor of Surgery. Division of Orthopaedics, University
of Alberta, Edmonton, Alberta.
39
differential diagnosis, and treatment. In addition,
details of the authors' clinical experience with this
condition will be outlined (Table 1).
ANATOMY
The tarsal tunnel is a descriptive space with
rather ill-defined limits. It begins a few centimeters
proximal to the tip of the medial malleolus where
the crural fascia starts to condense forming an
unyielding "roof," the flexor retinaculum (laciniate
ligament).7~8.20 It ends where the medial and lateral
plantar nerves enter or pass deep to abductor
hallu~is.~'
The tibial nerve enters the tunnel in the neuro-
vascular bundle lying just posterior and slightly
deep to the posterior tibial artery and vein. This
bundle lies behind the tibialis posterior and flexor
digitorum which are contained in their separate
fibro-osseous sheaths, and anterior to flexor hal-
lucis longus and its heath"^'^ (Fig. l ) .
Unlike the carpal tunnel, there is no sharp prox-
 KUSHNER AND REID JOSPT Vol. 6,No. 1

Med. Malleolus
Lat. Malleolus
Deltoid Lig.
Tibialis Post.
Flex. Digitorurn -Peroneus Brevis
Longus -Peroneus Longus
Post. Tibial Vei
Post. Tibial Art. ' /\A 'Flex. Retinaculum
Tibial Nerve
Flex. Hallucis Longus

Tendo ~ c h i l l e s ' ~ ~ ~

Fig. 1. A schematic horizontal cross-section through the ankle joint.

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imal border to produce entrapment, and much of \ >Post. Tibial N.

the pathology producing medial tarsal tunnel syn- Flex. Digitorurn Longus
drome occurs further in the canal where the tunnel Flex. Retinaculurn
narrows, reducing the space:content r a t i ~ . ~ . ~ . ' ' , ~ ' Flex.
Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

Hallucis Tibialis Post.

The anatomy is highly variable both as to the site Longus Abductor Hallucis
at which the tibial nerve divides into its terminal
branches and the method by which they exit from
the tunnel.
Cadaver dissections and surgical observations
have only served to emphasize the variability of Calcaneal N. Br
the anatomy in this area.26The nerve divides into Lat. Plantar N:
three terminal branches, the medial calcaneal, the Fig. 2. The posterior tibial nerve and its relationships (adapted
medial plantar, and the lateral plantar nerve either from Edwards et The flexor retinaculum is not always a
Journal of Orthopaedic & Sports Physical Therapy

within, immediately distal or, rarely, just proximal discreet structure, but is a condensation of the crural fascia.
The dotted lines indicate the extent recommended for surgical
to the The one or two very fine release.
sensory medial calcaneal branches arise from the
tibial nerve, or occasionally the lateral plantar
nerve. They supply the major portion of the medial
and plantar skin surface at the hee1.4~5.7~11~21*28 Saphenous M ~ e d Plantar
. N.

The medial and lateral plantar nerves exit from m ~ a tPlantar

. N.

the tunnel either through separate fibrous open- Ucalcaneal ~ r a n c h ( e s )

ings, or on occasion lie contiguously in one

cana15~7~11,13,16.26
(Fig. 2). The point of exit may be
further confused by the fact that the branches
may often exit by piercing the abductor mus-
Cle.4.8.21,26
The medial plantar nerve, the largest branch, is Sural
often compared to the median nerve in the
hand.7,'3,21It innervates the abductor hallucis,
flexor digitorum brevis, flexor hallucis brevis, and
the first lumbrical. Its sensory distribution is the
dorsal and plantar surface of the first, second,
third, and medial half of the fourth toe, and the Fig. 3. The sensory innervation of the medial and lateral plantar
medial aspect of the plantar surface of the foot nerves and the calcaneal branches (adapted from Edwards et
' ~ ~ 3).
anterior to the c a l ~ a n e u s ~ ~(Fig. a/.').
 JOSPT JulylAug 1984 MEDIAL TARSAL TUNNEL
The lateral plantar nerve, the smaller branch, is
homologous to the ulnar nerve in the hand.71'3 It
supplies the motor innervation to the remaining
intrinsic musculature of the foot (except the ex-
tensor digitorum brevis): quadratus plantae, ab-
ductor digiti quinti, flexor digiti quinti brevis, op-
ponens digiti quinti, adductor hallucis, three plan-
tar interossei, four dorsal interossei, and three
lateral lumbricals. It supplies sensory innervation
to the dorsal and plantar surfaces of the lateral
half of the fourth and the fifth toes, and the lateral
aspect of the plantar surface of the foot anterior
~ ~ ~3).
to the c a l ~ a n e u s (Fig. '
ETIOLOGY
The etiology will be discussed under the head-
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ings of anatomic, trauma, tumor, inflammatory,
and miscellaneous causes. Because of the great
variety of etiological factors and their anatomic
location in the canal, there may be a variety of
presenting symptoms contributing to a delay in
Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
diagnosis (Table 2).
Anatomic Factors
1) Septa. The fibro-osseous compartments for
the structure5 that pass within the tunnel are
formed by several deep fibrous septa comment-
ing at the undersurface of the retinacu!um and
blending with the periosteum of the medial calca-
n e ~ s . " ~ ' ~These
. ~ ' limit the capacity of the space
Journal of Orthopaedic & Sports Physical Therapy
to adjust to changing dimensions of its contents.
2) Areolar tissue. This tissue may be so dense
that it binds the structures under the retinaculum
and when combined with edema, especially at the
narrowest point in the tunnel, compression can
re~ult."*'~,~~
3) Retinaculum. The retinaculum may undergo
fibrous changes with trauma, aging, or disease
and may thereby compress the nerve and vessels
lying under
4) Fibrous openings. One of the nerve branches
may become compressed in its individual fibrous
opening in the abductor hallucis muscle.8v21
5) Vascular factors. The nerve or its branches
may become compressed by dilated and en-
gorged veins.5,8.15918.20 The presence of an arterial
arch over the lateral and medial plantar nerves
may add a compressive factor.28
6) Muscular factors. Variations in the size and
anatomy of abductor hallucis, including an anom-
alous or accessory muscle, may contribute to
entra~ment.~'~~
41
7) Valgus deformity. Valgus alignment of the
heel, with associated pronated forefoot changes
may tighten the flexor retinaculum or origin of the
abductor placing increased tension on the neuro-
vascular structures5 In addition, the calcaneonav-
icular ligament may compress the medial plantar
nerve if there is marked pronation of the forefoot.
This may play a particular role in the athletic
overuse type of presentation4*" (Table 1).
Trauma
Medial tarsal tunnel syndrome may occur fol-
lowing fractures of the tibia, calcaneus, or meta-
tarsals.3.11.14.20.21.28 In a review of 500 os calcis
fractures, 48 (10%) developed medial tarsal tunnel
syndrome of which 16 (28%) required operative
decompres~ion.~ It may also occur with ankle
sprains, crushing injuries, dislocations, or with
tightly fitting plaster casts.4~8.11320*22
Last, the syn-
drome is seen postsurgically following osteoto-
mies for hallux valgus, tendoachilles lengthening
or shorteni~g,or b u n i o n e ~ t o m y All
. ~ ~of~ these
~~
may have in common secondary fibrosis and
thickening of the retinaculum and fibrous
septa.4,5.6.10
Tumor
Any neoplastic swelling in the confines of the
narrow canal will place undue pressure on the
tibia1 nerve4112118s21328
(Table 2). As far as young
athletes are concerned, a ganglion or post-trau-
matic synovial cysts would constitute the most
common etiology in this group.
Inflammatory
Chronic tibialis posterior synovitis may precipi-
tate this syndrome. Other, more rare causes in-
clude rheumatoid arthritis, ankylosing spondylitis,
thrombophlebitis, leprosy, regional migratory 0s-
teoporosis, and diabetic n e ~ r o p a t h y . ~ ~ ~ ~ ~ - ' ~ ~ ~ ~
Miscellaneous
The combination of ill-fitting footwear, inappro-
priate training surfaces, and poorly graduated and
planned training may lead to pressure and swell-
ing in the tarsal tunnel. In addition, fluid retention,
recent weight gain, and aging may all play a minor
precipitating role.5~'0.20~28
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TABLE 1
Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.

Clinical data on 8 patients with medial tarsal tunnel syndrome

Age Sex Sport Occupation S~de monthsin Foot alignment Symptoms Sensory Motor EMG Consewative Findings at
Results
treatment' suraerv
Runner, 40 mi/ Student Normal Pain into great Hyperesthesia of None US Constriction by fi- Relief by 24 hr
wk toe after run- great toe and lnjection brous band in
ning medial foot superior tunnel
Tinel +ve
Runner, 60 mi/ Teacher Valgus heel Numbness and Impaired pin prick None us Thickening of Relief by 3 months
wk. Chronic te- Pronated forefoot paresthesia Tinel -ve TNS nerve and fibro-
nosynovitis of Nocturnal pain lnjection sis
tibialis poste-
rior over 3-yr
Journal of Orthopaedic & Sports Physical Therapy

period
Runner, 45 mk/ Student Valgus heel Burning sensation Hyperesthesia None US Fibrosis of nerve Relief in 1 month
wk Pronated forefoot in great toe Tinel +ve Orthototic
Runner, 65 mi/ Lawyer Valgus heel Burning sensation Impaired pin prick None Orthotic Fusiform thicken- Relief by 36 hr
wk Pronated forefoot Tinel -ve ing of nerve PostoP
Skater (skate Student Prominent calca- Burning sensation lmpaired pin prick None Modificationof Normal appear- Relief in 24 hr
pressure?) neous Tinel -ve skates ance
Soccer (postcon- Phys. Ed. Normal lntense burning Decreased pin None US Dense scarring Relief at 1 month
tusion) teacher Nocturnal pain prick over en- SWD
tire medial plan- lnjection
tar nerve dis- Mobilization
trib.
Tinel -ve
Ice hockey (post- Construction Broadened heel lntense burning Paresthesia in None Wax baths Dense scarring Relief at 6 wk
fractured calca- worker Noctural pain foot and toes US Neuroma
neus) Tinel +ve lnjection
Mobilization
Runner, 80 mi/ Student Valgus heel lntense burning Decreased tactile None Orthosis Scarring near ab- Relief at 24 hr
wk Pronatedforefoot after running sensation US ductor hallucis
Tinel -ve muscle
- --

US, ultrasound, TNS, transcutaneous nerve stlmulatlon, SWD, shortwave diathermy.

Journal of Orthopaedic & Sports Physical Therapy
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Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
 KUSHNER AND REID
used as a therapeutic test to localize the patho-
logical process and to give temporary relief.4.5.14
An inflated sphygmomanometer cuff provides
temporary occlusion and, when applied to both
lower limbs, produces symptoms much sooner in
the affected ~ i d e . ~ ~Lam''
~ ~ " has
* ' ~ found that
holding the foot in forced inversion and medial
rotation reproduced the symptoms within 30 sec.
The anatomical relationships within the tunnel
would suggest that lateral rotation and eversion
should evoke the symptoms even more readily;
however, this test has not been documented.
Mann2' reproduced the pain by taking the patients
leg into a straight leg raise position and dorsiflex-
ing the foot. He explained that the nerve was so
firmly adherent in the tarsal tunnel that stretching
it reproduced the symptoms.
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DIFFERENTIAL DIAGNOSIS
A high index of suspicion must be maintained
in order to make an early diagnosis of this condi-
tion. In our series, the average delay in diagnosis
Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
was 15 months (range 5-38).26 Misdiagnosis is
easy since pain or paresthesia in the foot may be
associated with numerous conditions including
radiculopathies, neuropathies, tendinitis, and
chronic ligamentous strain^'^.'^ (Table 3).
ELECTRICAL STUDIES
The definitive tests for this condition are nerve
conduction studies and electromyography. In-
Journal of Orthopaedic & Sports Physical Therapy
deed, surgical release should not be contemplated
until these studies are
Nerve conduction studies both to the abductor
digiti minimi and abductor hallucis are imperative,
as only one may be abnormal.*' Latencies of more
than 1 SD above the normal for the particular
laboratory carrying out the test is considered di-
agnostic. Possibly, evaluation of evoked sensory
and motor potentials may be a more sensitive
indication of this ~ o n d i t i o n . ~ ~ ~ - ~ ~ ' ~
TREATMENT
Nonoperative
a) Modification of activity. With the athlete in
particular, modification of activity is combined with
other therapeutic endeavors. This should include
advice regarding terrain, distance, and spacing of
training sessions.
b) Therapeutic modalities. Most therapeutic
modalities are directed at the reduction of edema
and fibrosis and may include a trial of ice, ultra-
sound, interferential current, intermittent
JOSPT Vol. 6,No. 1
TABLE 3
Differential diagnosis
Tra~ma~,'~,~~
Post-traumatic ligament pain
Stress fracture
Longitudinal arch strain
~europathies~,'~.
Peripheral neuritis (diabetic, toxic)
Plantar neurofibromatosis
Interdigital neuromas
Radic~lopathy"~'~~~~
Disc herniation
Tumor
lnflarnmat~ry~~~~'~~~~
Tenosynovitis
Collagen disease (rheumatoidarthritis)
Plantar fasciitis
Rheumatoid disorders
Miscellaneo~s~~~~
Reflex dystrophy
Medial arch strain
Metatarsalgia
Restless leg syndrome
Peripheral vascular disease
compression in elevation, faradic stimulation, con-
trast baths, microwave, and shortwave dia-
thermy. With recent onset of symptoms those
may prove valuable but, unfortunately, due to late
presentation, most therapeutic modalities give
limited success.
c) Footwear. In view of the associated valgus
heel and pronated forefoot, a trial of an orthosis
or heel wedge may be c o n ~ i d e r e dExtremely
.~~~~
tight lacing of shoes or skates may also exacer-
bate this condition. When the condition is associ-
ated with edema, support hose may help.4
d) Drugs. Oral nonsteroidal, anti-inflammatories
may be used where a coexisting inflammatory
condition is suspected. Occasionally, local admin-
istration of steroids may be warranted but care
should be taken not to inject the nerve itself. There
is always considerable danger of skin atrophy with
injection of steroid into this area and this may
~ ultimately
~~ prove a larger problem than the entrap-
ment syndrome. Caution is, therefore, urged.
Operative
Surgical release may provide complete allevia-
tion of the compression neuropathy as early as
24 hours post~peratively.'~~'~ A few patients will
have residual weakness and numbness following
surgery.' During surgery the laciniate ligament is
completely divided, the nerve is freed from encom-
passing fibrous tissue, the branches are explored
and, if possible, mobilized distal to the abductor
hall~cis.~~" Each fibrous hiatus for the medial and
lateral plantar nerves is checked and slit if nec-
 JOSPT JulylAug 1984 MEDIAL TARSAL TUNNEL
essary.*' If there is an accessory abductor hallu-
cis, it is excised.5314 Constricting fibrous bands
are released. Care must be taken not to disrupt
the fine calcaneal branch or branches, or heel
numbness will r e ~ u l t . ~ ~A ' segment
~ , ~ ' ~ of
~ ~the
tortuous veins, if present, may be removed follow-
ing high and low ligation.15 DiStefano et aL4 re-
ported that 24.3% of patients had no abnormali-
ties detected at surgery, but were nevertheless
cured by decompression.
Following surgery only the skin is closed.'' A
pressure dressing is placed over the wound and
early gentle ankle exercises encouraged followed
by partial weightbearing with crutches for 2
weeks. This is thought to be advisable over the
generally recommended cast immobilization since
it tends to limit adhesion formation.5321By 3
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weeks, more aggressive activities can be under-
taken including balance board work, balancing,
running and jumping on the mini-trampoline, and
resisted work on the ankle exerciser. Running,
Copyright 1984 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
jumping, skipping, and hopping can be added at
4 weeks, working within the limits of discomfort
and swelling. Results of surgery are usually last-
ing, with most individuals experiencing early re-
lief.5.101'8Early complications of wound infection
and dehiscence are uncommon. Late complica-
tions include rescarring of the nerve and, more
rarely, subluxation of the tibialis posterior ten-
don.''
Journal of Orthopaedic & Sports Physical Therapy
CONCLUSION
M a r i n a ~ c iin
, ~describing
~ the median nerve at
the carpal tunnel stated that "Almost every pe-
ripheral nerve, at some point along its course,
passes through a constricted zone or tunnel . . .
Here it becomes liable to any change in the sur-
rounding tissues, whether due to trauma,
compression by edema, inflammation, or arthritis."
The posterior tibia1 nerve is no exception. Be-
cause physiotherapists are often the first to ex-
amine the athlete they must be aware of this
syndrome as it may be more common than we
are presently aware." The authors have de-
scribed the syndrome, paying particular attention
to the clinical picture and treatment. It is hoped
that this will assist early recognition, thereby
bringing this condition into the realm of conserv-
ative therapy, rather than the operative treatment
which has been very much the rule.
The authors would like to thank Dr. John Kramer and Dr. Graham
Lowe for their advice and assistance.
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