Tarsal tunnel syndrome

1. Treatment
2. Exercises
3. Diagnosis
4. Risk factors
5. Complications
by. Dr.Anant patel

 Tarsal tunnel syndrome occurs when the posterior
tibial nerve, which runs along the inside of the ankle
and foot, becomes compressed and damaged, causing
inflammation.
 The condition, also known as TTS, is usually caused by
continual overuse of the foot and ankle, such as occurs
with strenuous or prolonged walking, running,
standing, or exercising.
 But TTS can also occur suddenly after traumatic injury,
or spontaneously, for no clear reason.

 Mechanism of injury (MOI) – was there any trauma, strain,
or overuse?
 Duration and location of pain and paraesthesia?
 Weakness or difficulty walking?
 Back or buttock pain associated with more distal
symptoms?
 Pain getting worse, staying the same, or getting better?
 Observation
 Gait Analysis
 Sensory Testing
 Palpation:
 Manual Muscle Testing (MMT):

i. Physio therapist will typically diagnose and
assess TTS by performing a physical exam of
the entire foot and lower leg area and asking
questions about symptoms.
ii. Diagnostic tests used to confirm and evaluate
TTS include:
iii. electromyography
iv. nerve conduction velocity (EMG/NCV)
v. magnetic resonance imaging or MRI
vi. X-ray

An examination may reveal Tinel’s sign over the tibial nerve at
the ankle, weakness, and atrophy of the small foot muscles or
loss of sensation in the foot.
Percussion of the tarsal tunnel results in distal radiation of
paraesthesias
Elicited in over 50% of those affected
Dorsiflexion – Eversion Test:
Place the patient’s foot into full dorsiflexion and eversion and hold
for 5-10 seconds
The results are that it elicits the patient’s symptoms
Tinel’s Sign:

• The first line of treatment for TTS is
RICE, which stands for rest, ice,
compression, and elevation.
• Over-the-counter non-steroidal anti-
inflammatory medications, or NSAIDs,
such as acetaminophen or ibuprofen,
can also help make symptoms more
manageable.
• For more severe or chronic cases, more
aggressive treatment options exist, such
as corrective devices, therapies, and in
some cases, surgery

Rest: The easiest and most immediate way to
reduce inflammation anywhere in the body is to stop
using and putting pressure on the affected area. How long
an individual should rest the foot depends mostly on the
severity of symptoms. For minor cases, rest may mean
replacing running with swimming. For more severe cases,
resting the nerve may require completely refraining from
exercise and activity.
Ice: An ice pack covered with a cloth or towel can be
applied to the inside of the ankle and foot for 20-minute
sessions to reduce inflammation. It is best to have the
foot elevated during this time. Icing sessions can be
repeated several times daily, as long as breaks of at least
40 minutes are taken.
Compression and elevation: Compressing the foot, and
keeping it raised above the heart, helps reduce blood flow
to the foot, and so reduces inflammation. Try wrapping
the foot with an ACE wrap, and resting it on a pillow while
sitting and sleeping.

 Over-the-counter pain and anti-inflammatory
medications: These can include ibuprofen and
acetaminophen.
 Full immobilization: For severe cases, especially
those involving physical damage to the nerve, a cast
may be necessary to restrict movement completely,
allowing the nerve, joint, and surrounding tissues a
chance to heal.
 Injection therapy: For very painful or disabling
symptoms, anti-inflammatory medication, such as
corticosteroids and local anesthetics, may be directly
injected into the nerve.
 Orthopedic devices and corrective
shoes: Podiatrists can make specialized shoes, and
inserts that help support the arch and limit motions
that can further irritate the inflamed nerve and
surrounding tissues. Shoes also exist to help prevent
pronation or inward rolling of the foot.

Physical therapy exercises can often help
reduce symptoms of TTS long-term, by
slowly stretching and strengthening the
connective tissues, mobilizing the tibial
nerve and opening the surrounding joint
space to reduce compression.

1. ultrasound therapy
2. acupuncture
3. manual therapy
4. taping or bracing
5. Ultimately, surgery may be performed for
very severe or chronic cases of TTS that
do not respond to any other form of
medical or physical therapy.
6. Exercises

 Exercises
As symptoms become less painful or easily irritated,
strengthening exercises should be done to help prevent
problems, including pronation or rolling of the foot, which
can worsen symptoms.
Common exercises recommended for the treatment of
TTS include:
Ankle pumps, circles, and eversion or inversion

1. Sitting down with the legs extended, slowly and
gently bend the foot at the ankles downward
towards the ground, and then upwards towards the
body, as much as possible, without pain. Repeat
several times.
2. Slowly and gently roll the ankles through their
circular range of motion as aggressively, as is
comfortable, several times.
3. Slowly turn the ankles inward and outward,
creating a windshield wiper motion, several times,
as far as is comfortable.
4. Repeat all three exercises several times daily.

1) Standing straight, slowly raise or flex the
toes upward, as far as possible, without
pain.
2) Slowly lower the toes and gently raise the
heels, putting gradual pressure on the ball
of the foot.
3) Repeat this exercise 10 times and perform
several times daily.

a. Sitting down with the legs fully extended, place a pencil
or pen on the floor directly below the toes and attempt
to pick it up using only the toes.
b. Once the pencil is fully grasped, hold for 10 to 15
seconds.
c. Relax the toes.
d. Repeat 10 times and perform several times daily.

 Standing straight slowly raise one leg and
rest the sole of the raised foot on the inner
calf of the other foot.
 Hold for at least 10 to 15 seconds or, as long
as is comfortable, without overstretching
the inner ankle and foot. If too wobbly, stop
by lowering the foot and restarting the
exercise.
 For a more intense version of this exercise,
gradually lift the raised leg further in the air,
away from the body.

i. Sitting down with the legs extended, as far as comfortable,
reach out and grasp the big toe and top of the sole, then
gently pull backward. This can also be done using a
stretching band, dishtowel, or sock.
ii. Stretch the foot backward until a stretch that runs from
the sole to the ball of the foot is felt.
iii. Hold for 30 seconds before slowly releasing the foot.
iv. Repeat the stretch at least three to five times, three times
daily for several weeks, even after initial symptoms have
greatly improved to reduce the chances of them returning.
v. The plantar fascia ligament can also be stretched by
rolling out the arch, sole, and heel in a gentle downward
motion on something round, such as a soup can, therapy
ball, tennis ball, or rolling pin.

i. Standing a small distance away from a wall, step one foot
forward, closer to the wall, and lean in, pressing the
hands into the wall while keeping the back leg straight.
This position should look somewhat similar to an
assisted lunge.
ii. Widen or deepen, the stretch as feels comfortable or
produces a notice, pain-free stretch along the full-length
of the back of the calf.
iii. Start by holding the stretch for 10 to 15 seconds,
gradually increasing holding time to reach 45-second
intervals.
iv. Repeat the stretch three to five times consecutively, three
times daily for several weeks.
v. For a more intense stretch, try standing on a step with
the foot halfway hanging off the edge, and then gently
push the heel downwards. Hold for as long as feels
comfortable, up to 10 times daily.

i. Repeat the steps of the gastrocnemius
stretch, except with the back leg being
stretched bent at the knee.
ii. To increase the stretch, place something
under the front or ball of the foot, or prop
the ball of the foot up on the wall.

i. Type 4 &7 laser machine
ii. tapping

•MAGGIE
•JOINT STRUCTURE AND FBY SYNTHIA
NORKINSUNCTINTION JSF
•PT IN ORTHO JAYANT JOSHI
•PT IN ORTHO MAHESWAR AND MAHASKAR

Tarsal tunnel syndrome

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