Posterior Tarsal Tunnel Syndrome

Aka: Posterior Tarsal Tunnel Syndrome, Tarsal Tunnel Syndrome, Tarsal Tunnel, Tibial Neuropathy, Posterior Tibial Nerve Entrapment

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II. Anatomy (See Ankle Anatomy)

  1. Posterior Tibial Nerve
    1. Behind medial malleolus and under flexor Retinaculum
  2. Flexor Retinaculum
    1. Arises from medial malleolus
    2. Insertion into medial Calcaneus
    3. Neurovascular encasement in combination with medial Calcaneus, distal tibia, posterior talus, medial malleolus
      1. Posterior tibial nerve
      2. Tibialis posterior tendon
      3. Flexor digitorum longus tendon
      4. Flexor hallucis longus tendon
      5. Posterior tibial artery
      6. Posterior tibial vein

III. Epidemiology

  1. Uncommon

IV. Pathophysiology

  1. Posterior Tibial Nerve compressed in flexor Retinaculum and Tarsal Tunnel

V. Associated Conditions

  1. Phlebitis
  2. Rheumatoid Arthritis
  3. Pes Planus
  4. Foot Fracture
  5. Foot traction injury
  6. Heel or foot deformity
  7. Foot or ankle mass lesion

VI. Symptoms

  1. Burning, numbness, or tingling Sensation
    1. Starts at posteromedial ankle and plantar heel
    2. May radiate into distal sole of foot to toes
    3. May radiate up into calf
    4. May result in cramping of medial longitudinal arch
  2. Provocative
    1. Worse with ambulation, standing or Running
    2. Worse at night
  3. Palliative
    1. Better with rest, foot elevation
    2. Better with loose fitting footwear

VII. Signs

  1. Sensory loss in posterior tibial nerve distribution
  2. Pes Planus may be associated
  3. Motor function usually intact
    1. Intrinsic Muscle Weakness and atrophy may be present
  4. Provocative maneuvers may elicit symptoms
    1. Tinel's Sign
      1. Percussion over Tarsal Tunnel (Flexor Retinaculum)
      2. Identify posterior tibial tendon
        1. Lies behind medial malleolus
        2. Find tendon by inverting foot against resistance
      3. Posterior tibial nerve lies behind tibial tendon
    2. Stretch, compress posterior tibial nerve
      1. Simultaneous dorsiflexion and eversion of foot
      2. Simultaneous plantar flexion and inversion of foot

VIII. Imaging

  1. Foot MRI (most diagnostic modality)
  2. Ultrasound
  3. Electromyography and Nerve Conduction Studies

IX. Differential Diagnosis

  1. Complex Regional Pain Syndrome
  2. Plantar Fasciitis
  3. Diabetic Neuropathy
  4. Lumbar Disc Disease (Lumbosacral Radiculopathy)
  5. Peripheral Neuropathy
  6. Posterior tibial dysfunction
  7. Exertional Compartment Syndrome

X. Management

  1. General measures
    1. Modify activities
    2. Stretching Program
    3. Medications
      1. NSAIDs
      2. Tricyclic Antidepressants (e.g. Amitriptyline)
      3. Gabapentin or Pregabalin
  2. Medial Heel wedge or Heel Seat
    1. Inverts heel
    2. Removes traction from tibial nerve
  3. Orthotics to correct foot Posture (e.g. Pes Planus)
  4. Tarsal Tunnel Injection (Corticosteroid Injection)
  5. Surgical release of entrapment
    1. Indicated for persistent symptoms

XI. References

  1. Del Toro in Frontera (2002) Essentials PMR, p. 453-6
  2. Mann in DeLee (2003) Orthopedic Sports Med, p. 2474-6
  3. Shapiro (2003) Med Clin North Am 87(3):663-96 [PubMed]
  4. Tu (2018) Am Fam Physician 97(2):86-93 [PubMed]

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