From the Guidelines
Treatment for tarsal tunnel syndrome should start with conservative approaches, including rest, ice, and elevation to reduce inflammation and pressure on the tibial nerve, as well as orthotic inserts or supportive shoes to correct foot positioning and reduce nerve compression. When considering treatment options, it's essential to prioritize morbidity, mortality, and quality of life as the primary outcomes.
- Key considerations include:
- Reducing pressure on the area with open-backed shoes or orthoses
- Using NSAIDs for pain management, as seen in the american college of foot and ankle surgeons guidelines 1
- Decreasing activity and incorporating stretching exercises to alleviate symptoms
- Weight loss, if indicated, to reduce pressure on the foot and ankle
- In terms of specific treatment,
- Custom orthotic inserts or supportive shoes with good arch support are crucial to correct foot positioning and reduce nerve compression
- Physical therapy exercises focusing on stretching the calf muscles and strengthening the foot muscles can provide significant relief
- Night splints can help maintain proper foot position during sleep
- It's also important to note that local injections of corticosteroids are not recommended as an initial treatment option, according to the american college of foot and ankle surgeons guidelines 1
- If conservative treatments fail after 4-6 weeks, surgical decompression of the tibial nerve may be necessary to prevent permanent nerve damage.
From the Research
Tarsal Tunnel Treatment Options
- Conservative management is often the first line of treatment for tarsal tunnel syndrome, and may include activity modification, heat, cryotherapy, non-steroidal anti-inflammatory drugs, corticosteroid injections, opioids, GABA analog medications, tricyclic antidepressants, vitamin B-complex supplements, physical therapy, and custom orthotics 2
- Surgical treatment is typically reserved for patients with refractory symptoms that do not respond to conservative treatment, and involves releasing the flexor retinaculum from its proximal attachment near the medial malleolus down to the sustentaculum tali 3
- Minimally invasive treatment options, such as pulsed radiofrequency and neuromodulation, are being investigated, but more research is needed to fully understand their effectiveness 4
Indications for Surgical Treatment
- Failure of conservative treatment 3
- Clear identification of the cause of the entrapment 3
- Presence of a positive Tinel sign before surgery, which is a strong predictor of surgical relief after decompression 3
- Young patients, those with a clear aetiology, a short history of symptoms, an early diagnosis, and no previous ankle pathology tend to have better surgical outcomes 3
Important Considerations
- Early diagnosis and intervention are key to avoiding permanent nerve injury and maximizing the benefits of treatment, whether conservative or surgical 5
- Identifying the causative factor of the nerve compression and eliminating it is important to obtain excellent results 6
- A differential diagnosis should be made with other conditions, such as plantar fasciitis, lumbosacral radiculopathy, rheumatologic diseases, metatarsal stress fractures, and Morton's neuroma 3