Neurol Sci (2017) 38:1735–1739

DOI 10.1007/s10072-017-3039-x

REVIEW ARTICLE

Tarsal tunnel syndrome: still more opinions

than evidence. Status of the art
Pietro Emiliano Doneddu 1 & Daniele Coraci 2,3 & Claudia Loreti 2 & Giulia Piccinini 4 &
Luca Padua 1,2,5

Received: 27 March 2017 / Accepted: 17 June 2017 / Published online: 29 June 2017
# Springer-Verlag Italia S.r.l. 2017

Abstract Tarsal tunnel syndrome is an entrapment neuropa- Introduction

thy of the posterior tibial nerve or its terminal branches within
its fibro-osseous tunnel beneath the flexor retinaculum on the
medial side of the ankle. The condition is frequently
underdiagnosed leading to controversies regarding its epide-
miology and to an intense debate in the literature. With the
advent of nerve imaging techniques, the diagnostic confirma-
tion and the etiological identification have become more ac-
curate. However, management of this entrapment neuropathy
remains challenging because of many intervention strategies
but limited robust evidence. Uncertainties still exist about the
best conservative treatment, timing of surgical intervention,
and best surgical approach. In the attempt to clarify these
aspects and to provide the reader some understanding of the
status of the art, we have reviewed the published literature on
this controversial condition.
Keywords Tarsal tunnel syndrome . Nerve entrapments .
Literature review . Tibial nerve
* Luca Padua
luca.padua@unicatt.it
Tarsal tunnel syndrome (TTS) is an entrapment neuropathy of
the posterior tibial nerve or its terminal branches (medial plan-
tar, lateral plantar, and calcaneal nerves) within a fibro-
osseous tunnel beneath the flexor retinaculum on the medial
side of the ankle. Although there is a broad agreement regard-
ing the existence of the syndrome, there are still differences of
opinion regarding its epidemiology as an etiology for foot pain
and paresthesiae, particularly in patients with diabetes. These
uncertainties are mostly based on the poor diagnostic sensitiv-
ity of the instrumental exams classically used to diagnose
nerve entrapments (nerve conduction studies and electromy-
ography). Moreover, there is still confusion regarding the best
conservative treatment, timing of surgical intervention, best
surgical approach, and management of recurrences. These
controversies may explain why TTS is so frequently debated.
Indeed, as we previously reported [1], TTS is the fifth most
commonly published entrapment syndrome in the literature
(Table 1). In an attempt to clarify these controversial aspects,
we performed a review of the literature reporting evidence
(and opinions) around this nerve entrapment syndrome.

1
Department of Geriatrics, Neurosciences and Orthopaedics, Catholic
University of the Sacred Heart, Largo F. Vito 1, 00168 Rome, Italy
Search strategy and selection criteria
2
Don Carlo Gnocchi Onlus Foundation, P.le Morandi, 6,
20121 Milan, Italy
The methods used in this article have been previously described
3
in another review published by our group [1]. In the first phase,
Board of Physical Medicine and Rehabilitation, Department of
Orthopaedic Science, BSapienza^ University, Piazzale Aldo Moro 3,
in order to provide as much as possible evidence-based data,
00185 Rome, Italy we performed a comprehensive search of PubMed using the
4
Board of Physical Medicine and Rehabilitation Unit, Sant’Andrea
MeSH term, Btarsal tunnel entrapment neuropathy,^ with the
Hospital, BSapienza^ University, Via di Grottarossa, 1035/1039, following additional filters: article types (metanalysis; system-
00189 Rome, Italy atic review), text availability (abstract available), publication
5
Department of Neurorehabilitation, Don Carlo Gnocchi Foundation, dates (from 2006 January the 1st to 2016 June the 31st), spe-
Piazzale Morandi n.6, 20100 Milan, Italy cies (humans), and language (English). Following this
1736
Table 1 PubMed search results of the number of articles published on
each nerve entrapment syndrome (from 2006 January the 1st to 2016 June
the 31st). MeSH terms were used when available. From Doneddu PE
et al. Thoracic outlet syndrome: wide literature for few cases. Status of
the art. Neurol Sci. 2017 Mar;38(3):383–388. Epub 2016 Dec 16
Nerve entrapment syndromes Number of articles in PubMed
Carpal tunnel syndrome 2450 [MeSH]
Thoracic outlet syndrome 446 [MeSH], 658 [no MeSH]
Ulnar neuropathy at elbow 547 [no MeSH]
Ulnar neuropathy at wrist 142 [no MeSH]
Tarsal tunnel syndrome 134 [MeSH]
Superficial peroneal entrapment 24 [no MeSH]
MeSH MeSH terms, no MeSH without using MeSH terms
methodology, we found zero metanalysis and two systematic
reviews. Secondly, due to a lack of metanalysis on the topic,
other article types were included, i.e., Bclinical trials,^
Breviews,^ Bmulticenter studies,^ Bguidelines,^ and Bpractice
guidelines.^ Extending the search, 4 clinical trials, 28 reviews,
0 guidelines, and 0 practice guidelines were found. For each
article, pertinence was considered. Finally, 2 systematic re-
views [2, 3], 3 clinical trials [4–6], and 26 reviews [7–33] were
included. We also reported results from publications on the
basis of references.
Pathophysiology
A specific cause for TTS can only be identified in 60 to 80%
of patients [19, 32]. Causes of TTS are usually classified into
either intrinsic, extrinsic, or combinations of the two. Intrinsic
causes include the following: osteophytes, hypertrophic reti-
naculum tendonopathy, hypertrophic extensor hallucis brevis
muscle, lipoma, tumor, ganglion cysts, venous varicosities,
pseudoaneurisms [15], accessory muscles [2, 10], vascular
leyomiomas [23], and other space-occupying lesions.
Extrinsic factors include the following: trauma, tight-fitting
shoes, hindfoot varus or valgus, lower limb edema, systemic
inflammatory arthropathy, mucolipidoses [25], diabetes, and
iatrogenic causes. In runners and soccer players, repetitive
stress and hyperpronation associated with poor running me-
chanics can predispose to entrapment [9]. In athletes, how-
ever, TTS is an uncommon diagnosis [9]. Whether abnormal
pronation of the foot should be considered a pure etiologic
factor or only a contributory cause in the development of
TTS is a matter of debate in the literature [32]. Recently,
three other well-defined fascial septa (medial, lateral, and
intermediate), in addition to the flexor retinaculum, have
been described as potential sites of compression [9].
Compression of the branches of the tibial nerve has been
referred to as Bdistal tarsal tunnel syndrome.^ Distal TTS
is a common entity and is usually associated with chronic
Neurol Sci (2017) 38:1735–1739
plantar fasciitis [18]. The most commonly involved of the
branches is the lateral plantar but a combination of the three
branches is possible [18]. Traction neuritis is considered the
most common cause of distal TTS [18].
Clinical features
TTS is a clinical diagnosis based on a detailed history and
clinical examination [16, 32]. Adjunctive imaging and elec-
trophysiological studies provide additional information to
plan management. Symptoms depend on the branch involved,
but usually, patients complain of burning, tingling, and pain
along the foot plantar region. Sometimes, pain radiates to the
distal part of the medial region of the leg. Symptoms worsen
walking or after prolonged standing or using high-heeled
shoes. Symptoms are usually unilateral, so underlying system-
ic illness and polyneuropathy should be ruled out in those with
bilateral pain [17]. Rest and leg elevation often relieves symp-
toms [16]. Inspection is useful to reveal soft-tissue masses on
the tibial nerve course, varicosities, or hindfoot misalignment.
In severe cases, tibial innervated foot muscles may show at-
rophy and motor deficit, although these manifestations rarely
interfere with function [28]. Examination may reveal Tinel’s
sign [16]. A test similar to the Phalen test for carpal tunnel
syndrome is available: ankle and foot are kept in dorsiflexion
and eversion expecting the onset or worsening of symptoms
[16]. However, it should be noted that an entrapment of the
first branch of the lateral plantar nerve is exacerbated not by a
pronated foot, but by supinatory position [32]. The differential
diagnosis of TTS includes polyneuropathies, small fiber sen-
sory neuropathy, proximal tibial nerve injuries, L5-S1
radiculopathy, plantar fasciitis, bursitis, calcaneal stress frac-
tures, osteomyelitis, piriformis syndrome, compartment syn-
drome, gout, and arthrosis. Bilateral sensory symptoms (burn-
ing pain, paresthesiae) in the feet, particularly in a Bstocking
distribution,^ should raise suspicion of an underlying
polyneuropathy since TTS is usually unilateral. The presence
of low back pain should be enquired, as may be a red flag of
lumbar spinal stenosis or radiculopathy. Reflex findings and
the distribution of sensory and motor deficits are fundamental
in the process of differentiation [8]. Quality of pain and the
associated sensory symptoms should help the clinician in dif-
ferentiating TTS from other musculoskeletal disorders (i.e.,
bursitis, plantar fasciitis) where paresthesiae, hypoesthesia,
and spontaneous burning pain are always missing.
Diagnosis
Neurophysiology and neuroimaging may provide useful in-
formation and should be considered complementary. Indeed,
no gold standard test is available and, according to some
Neurol Sci (2017) 38:1735–1739
authors, the syndrome is regularly underdiagnosed [14, 16].
Neurophysiology should be performed to confirm the diagno-
sis [11, 33]. However, nerve conduction studies have a high
false-negative rate while EMG has been shown to have a high
false-positive rate [11]. Therefore, negative nerve conduction
study (NCS) findings do not exclude the diagnosis [16, 32,
33]. Moreover, although sensory NCS are more sensitive than
motor NCS, the true sensitivity and specificity of these tests
are unknown [34]. Because of the limitations of the studies
(inconsistent clinical criteria, non-blinded or retrospective
studies), only low quality evidence without definitive recom-
mendations was available. Lacking evidence, a consensus was
provided on neurophysiological findings to confirm TTS: in-
creased distal motor latency recorded over the abductor
hallucis and abductor digiti minimi, slowed medial and lateral
plantar mixed NCS across the tarsal tunnel, slowed medial and
lateral plantar sensory nerve conduction, or reduced amplitude
of evoked response [34]. Insufficient data were available on
the utility of needle electromyography of intrinsic foot mus-
cles [34], which should be interpreted with caution as false
positives are reported in a percentage of 10–43% [16].
Nerve ultrasound (US) is able to demonstrate the complex
anatomy of the tarsal tunnel and show the entire course of the
tibial nerve and its branches at the medial ankle. US is also
effective in the identification of space-occupying lesions with-
in the tarsal tunnel [21] and is increasingly used to detect
ganglia, varicose veins, lipomas, tenosynovitis, and
talocalcaneal coalition [16]. In the absence of a mass lesion,
fusiform thickening together with loss of the normal fascicular
pattern of the tibial nerve may be demonstrated in patients
with TTS [21]. A part from being reliable and cost-effective,
US has also the advantage of readily available comparison
with the contralateral side [21].
Magnetic resonance (MR) can be a helpful tool for identi-
fying the pathologic cause of symptoms and is considered by
some authors the modality of choice for detecting space-
occupying lesions responsible for TTS [8, 13]. In one study,
MR was able to identify the cause of TTS in 88% of patients
with symptoms of TTS [8]. The MR imaging were confirmed
at surgery in 90% of the patients. A part from space-occupying
lesions, MR may also show increased size and signal of the
tibial nerve and its branches (infrequent) and denervation ede-
ma of the plantar muscles of the foot [22]. However, it is more
likely that the nerve will appear normal on imaging when no
specific focal masses are present [19].
Therapy
Agreement on therapeutic approach is lacking. There is a con-
sensus that conservative treatment (rest, walking boot, shoe
wear modifications, physical therapy, ice application, anti-
inflammatory medication, anti-neuropathic pain medications,
1737
heat, and ultrasound) should be initiated before surgery [5, 8,
13, 16, 20, 28, 32]. Some authors recommend avoiding local
application of heat, cold, and vibrations believing these could
irritate the nerves [18], whereas some other authors think they
may be helpful for providing symptomatic relief [20].
Physiotherapy can include different techniques, such as tap-
ing, bracing, stretching, and massage, but evidence of its effec-
tiveness is lacking [16]. Custom foot orthosis may be used for
the initial conservative treatment of patients with TTS [14].
Some authors have advocated local corticosteroid injection into
the tarsal tunnel [35], but its use should be carefully considered
because of the potential for tendon rupture and intravascular
injection [13]. A recent randomized clinical trial, investigating
the contribution of nerve mobilization exercises to the conser-
vative treatment of TTS, concluded that neural mobilization
have a positive effect on two-point discrimination and light
touch and Tinel sign [5]. However, no significant difference
was found for pain, muscle strength, and range of motion com-
pared with the control group (treated with a program of phys-
iotherapy and supportive inserts) [5]. Limitations of this study
included the small number of patients and the unblinded design.
If conservative therapies give no benefit and a definite point of
entrapment is found, surgery is suggested and good results with
decompression in selected cases are reported [16]. The best
indication to perform surgery is the presence of a space-
occupying lesion, as was demonstrated by two different studies
[36, 37]. Open decompression is the standard surgical approach
for TTS [3, 16]. Reported success rates after tarsal tunnel de-
compression vary in the literature from 44 to 96% partly due to
different patient selection, timing of surgical intervention, and
technique of decompression among the studies [16]. However,
associated complications can be notable and periods of non-
weight bearing are required [3]. Some authors retain the pres-
ence of a positive Tinel’s sign, one of the most predictable
indicators of a favorable outcome following decompression,
while its absence with a sensory deficit is considered a negative
predictor of recovery after surgery [16, 32].
Timing of surgical intervention is also important, as chron-
ic nerve compression leads to axonal loss and intraneural fi-
brosis, which can be responsible of muscle wasting.
Recurrence of tarsal tunnel syndrome after surgery is possible
and may be due to inaccurate diagnosis, inadequate release,
variations in the anatomy of the nerve(s), failure to execute the
release properly, inadequate hemostasis with subsequent scar-
ring, damage to the nerve and branches, persistent hypersen-
sitivity of the nerves, and preexisting intrinsic damage to the
nerve [12]. Recurrent TTS (defined as continuing tarsal tunnel
syndrome following previous surgical decompression) is a
challenging condition and its treatment results are barely pre-
dictable. While for these cases, some surgeons believe that
prognosis for success of revisional surgery depends directly
upon the etiology of the recurrent problem [12], others disap-
prove revision surgery considering its results often worse [38].
1738
Endoscopic tarsal tunnel decompression is an alternative
procedure. A new endoscoping technique for treating patients
with TTS was evaluated in a clinical trial [6]. The selection
criteria were the following: classical nerve compression symp-
toms, failed conservative treatment, abnormal electrophysiolo-
gy, and a non-violated anatomic region. Mean follow-up was
10.1 months. Good or excellent outcomes were obtained in all
patients. Limitations of the study included the small number of
patients and the lack of a control group. A recent clinical study
evaluated the anatomical bases, safety, and outcome of endo-
scopic tarsal tunnel release using a modified trocar cannula and
a dilator system [4]. The technique was performed on 12 intact
adult lower limb specimens and 7 patients with idiopathic prox-
imal TTS. Preoperative and postoperative evaluation was done
by electrophysiological studies, US, and using Takakura’s rat-
ing scale. Excellent to good results were obtained in 85.7% of
patients and the technique has proved to be safe. Limitations of
the study included the small number of patients and the lack of a
control group. A 2013 systematic review on outcomes and
safety of endoscopic tarsal tunnel decompression concluded
that the endoscopic approach is safe and has a low rate of
recurrence or failure despite allowing for near immediate am-
bulation [3]. However, further studies comparing open and en-
doscopic approaches to tarsal tunnel decompression are needed
[3]. There is no agreement on the timing of intervention but
some authors suggest that nerve recovery is poor when decom-
pression is delayed greater than 10–12 months [16].
Conclusions
TTS is a complex nerve entrapment syndrome where many
different causes may play a role. Although is considered a
clinical diagnosis, ancillary tests may provide crucial informa-
tion both to confirm the diagnosis and to plan the manage-
ment. Contrary to other nerve entrapments (i.e., carpal tunnel
syndrome) where electrophysiology and nerve imaging tech-
niques are equivalent in terms of diagnostic accuracy, in TTS,
the latter seem to be more useful. A comparative study of the
diagnostic value of the two techniques is needed to clarify this
aspect. The mainstay of treatment is conservative manage-
ment, although there is still uncertainty regarding the best
pathway. In cases with a definite lesion, an excellent result
can be expected from decompression when carried out soon
after the onset of the condition. Randomized control trials
comparing open and endoscopic approaches to tarsal tunnel
decompression are warranted to determine the best surgical
approach and the treatment algorithm.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflicts of
interest.
Neurol Sci (2017) 38:1735–1739
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