Assess & Address: Tarsal Tunnel Syndrome by Whitney Lowe

Anatomical background Pathology Assessment & Evaluation Treatment Massage Techniques

Assessment and evaluation
The client with TTS is likely to report sharp, shooting pain around the medial ankle and along the plantar surface of the foot. In addition to pain there may also be reports of numbness or loss of sensation, motor weakness in the muscles of the foot, as well as other biomechanical problems in the foot or ankle. Symptoms are usually worse after long periods of standing or walking, but may also be aggravated during the night if the nerve is in a compromised position for a prolonged period. Find out if there has been recent trauma to the area involving sudden compressive or tensile loads on the nerve, as other recent injuries may be responsible for the symptoms.

While structural or mechanical causes are the most common causes of TTS, the practitioner should not overlook other systemic disorders that may either cause TTS or be related to it. Peripheral neuropathies like TTS are linked to conditions such as diabetes, rheumatoid arthritis and hyperthyroidism. Various medications may also cause sensitivity in the distal lower-extremity nerves and could be mistaken for compression pathologies in the tarsal tunnel.

Excess tensile stress on the tibial nerve is a common cause of TTS, especially in runners or dancers who have calcaneal valgus. Therefore, observation of the foot alignment during assessment may yield valuable clues to nerve pathology.

Examine the client from a posterior direction in a standing position to see if there is any natural valgus angulation of the calcaneus. It is evident with an apparent bowing of the Achilles tendon in a medial direction (Figure 5). Your client’s weight is another factor that may play a role in developing calcaneal valgus and tarsal tunnel syndrome. Excess weight often leads to overpronation of the foot, including calcaneal valgus. Once the valgus alignment is present, there is increased tension on the tibial nerve and TTS is more likely.

Pressure directly on the tarsal tunnel is one of the most valuable ways of identifying this condition. Sometimes this is called the tarsal tunnel compression test (Figure 6). If this reproduces the client’s primary pain, it is a good indication that TTS may be involved.

It is important to identify if the sensations are primarily neurological, as irritated tendon sheaths in the area may also cause pain with palpation. If nerve compression is the primary problem, symptoms are most likely to be felt in the medial ankle and along the plantar surface of the foot. If the only problem is tendon irritation, such as tenosynovitis, pain or irritation are most likely only in the medial ankle region where pressure is applied.

Neurological symptoms may be felt with some active or passive motion evaluation, but they are not likely to be increased except in the extremes of dorsiflexion. However, there are special orthopedic tests that may be helpful in identifying TTS. Tinel’s sign is commonly used to evaluate TTS, although it is not considered the most reliable test in terms of accuracy. It is performed by tapping directly over the tarsal tunnel to see if symptoms are reproduced each time the area is tapped. The tap produces sudden nerve compression and subsequently increases symptoms.

However, the dorsiflexion-eversion test has a better degree of accuracy in identifying TTS. In this procedure the ankle is in a position of maximum dorsiflexion and eversion while the toes are held in a hyperextended position (Figure 7). The position is held for 5-10 seconds to evaluate reproduction of symptoms. The tibial nerve is pulled taut within the tunnel in this procedure. Reproduction of symptoms indicates hypersensitivity of the nerve from compression or tension pathology.