Tarsal Tunnel Syndrome is described as numbness, tingling, and weakness on the medial ankle (inside part) and is similar in effect to what Carpal Tunnel Syndrome is in the wrist.  We have a piece of tissue, called a retinaculum, which is like a thin ligament, that holds certain structures and vessels in place. The retinaculum in the medial ankle is called the flexor retinaculum. When there is pressure or tension in the area and a particular nerve is compressed (in this case the tibial nerve), this creates the ‘syndrome.’  Regarding the wrist, the median nerve is compressed in the Carpal tunnel, causing tingling, numbness, and weakness.  In the medial side of the ankle, the tibial nerve is compressed in the Tarsal tunnel, causing tingling, numbness, and weakness in the medial foot/ankle and toes.

The Tarsal tunnel has more structures that course through the region and any/all of them can be affected by injury, repetitive use injury, or compression.

The silly acronym ‘Tom, Dick, and A Very Nervous Harry’ is an easy way to remember the structures that pass through the Tarsal tunnel.  So, what does this all mean?…

Tom = Posterior Tibialis muscle
Dick = Flexor Digitorum Longus muscle
And = Tibial Artery
Very = Tibial Vein
Nervous = Tibial Nerve
Harry = Flexor Hallucis Longus muscle

These structures lie in order from the medial malleolus (the bump on the inside of your ankle) to the Calcaneus bone. The Flexor Retinaculum (like a thin ligament) holds these structures in place.

Depending on which structures are affected, you can have a myriad of problems. The Posterior Tibialis has 9 attachment points on the bottom of the foot and damage to this muscle can lead to significant foot problems (we’ll touch on that in a bit).  The Flexor Digitorum Longus muscle is responsible for flexing the toes. Of course, any compression or damage to the tunnel can adversely affect the blood vessels and nerves and this can lead to significant injury.  The Flexor Hallucis Longus flexes your big toe.

It is important to be sure that your foot and ankle mechanics are proper.  Any injury to these areas should be evaluated quickly so as to avoid future issues. Once an injury to the Tarsal tunnel sets in, it can take significant time to rectify. Although Tarsal Tunnel Syndrome tends to be a slow and progressive condition, an eversion (when ankle turns out) sprain can also cause damage to the region. Unlike normal ankle sprains that tend to affect ligaments and muscles, this type of sprain would also lead to those pesky burning/tingling/numbing sensations due to the fact that the Tibial Nerve is affected in the tunnel.

In regards to damage to the Posterior Tibialis muscle, this can create serious issues.  Damage to this muscle plays a major part with plantar fascial pain. The arch in your foot is formed mostly by by the extrinsic muscles of the foot (the ones that start in the leg and go under the foot) and the plantar fascia itself is holding them together.  If the muscles that create the arch are damaged, such as the Posterior Tibialis, the plantar fascia will be put under additional stress and this leads to irritation, inflammation, and pain.  As a result, an injury to the Tarsal tunnel can help lead to plantar fasciitis.  There are many causes of foot and/or plantar fascial pain/plantar fasciitis, but all too often only the plantar fascia is evaluated. Failure to assess the entire region usually leads to improperly guided care and a poor resolution of the problem.

So, how do we deal with Tarsal Tunnel Syndrome? We assess the involved structures and see what is working well and what is not. Sometimes, we have to look at the individual muscles of the calf.  When we have compression in an area above the leg in addition to the leg, this is called a ‘double crush’ syndrome.   This means that if there was only one area of compression, the person would likely not have the symptoms.  The compression in both areas combined is why the problem exists.  We see this in Carpal Tunnel Syndrome also as the median nerve can be compressed in many places between the neck to the wrist.

Once we identify the problem structure(s), many treatment approaches can be used. Combinations of joint manipulation, Active Release, Dry Needling (amazing for this condition), Rapid Release, Graston, and more can be used to help resolve the problem. Rehabilitative exercises help to restore proper function to the area.  Only in rare cases will medical intervention be necessary.

If you have or know someone who has Tarsal tunnel like symptoms, be sure to get care from healthcare practitioners who have proper training with extremity and sports injuries.  A proper approach will lead to positive resolution.

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