What is the treatment algorithm for tarsal tunnel syndrome pain?

From the Guidelines

The treatment of tarsal tunnel syndrome should follow a stepwise approach, prioritizing conservative measures such as rest, ice, elevation, and over-the-counter NSAIDs like ibuprofen or naproxen for 1-2 weeks, before considering surgical intervention. When managing pain, it is essential to consider the type of pain, whether it is nociceptive, stimulant-dependent, or neuropathic, as well as any psychologic comorbidities that may be present 1. For acute pain management, topical analgesics such as lidocaine, oral acetaminophen, and oral nonsteroidal anti-inflammatory drugs are preferred 1. Some key considerations for the treatment of tarsal tunnel syndrome include:

• Custom orthotic inserts or supportive shoes with good arch support to reduce pressure on the tibial nerve
• Physical therapy focusing on stretching exercises for the calf muscles and foot intrinsics, performed daily for 4-6 weeks
• Corticosteroid injections, such as 40mg methylprednisolone with 1-2ml of 1% lidocaine, into the tarsal tunnel for temporary relief
• Night splints to maintain the ankle in a neutral position during sleep If conservative treatment fails after 3-6 months, surgical decompression of the tarsal tunnel may be necessary to address the underlying compression of the tibial nerve. It is crucial to approach chronic pain management with a multidisciplinary approach, sometimes in collaboration with pain specialists, and to consider the use of opioids judiciously, but they may be necessary in some cases 1. Alternative options, such as tramadol, can be considered for patients with cardiopulmonary compromise, and anticonvulsants like pregabalin and gabapentin can improve neuropathic pain, but should be used with caution 1.

From the Research

Tarsal Tunnel Pain Treatment Algorithm

The treatment algorithm for tarsal tunnel pain typically involves a combination of conservative and surgical management options.

• Conservative management is usually the first line of treatment and includes:
  • Activity modification
  • Administration of pain relief drugs
  • Physical and rehabilitation medicine
  • Corticosteroid injections into the tarsal tunnel 2
  • Orthoses, physical therapy, and nonsteroidal anti-inflammatory drugs (NSAIDs) 3
• Surgical treatment is considered when conservative management fails and the cause of the entrapment is clearly identified 2
• Surgical options include:
  • Releasing the flexor retinaculum from its proximal attachment near the medial malleolus down to the sustentaculum tali 2
  • Ultrasound-guided tarsal tunnel release 2
  • Standard open surgical decompression of the flexor retinaculum 4
• Minimally invasive treatment options are also being investigated, including pulsed radiofrequency and neuromodulation 5

Predictors of Treatment Outcome

Several factors can predict the outcome of treatment for tarsal tunnel pain, including:

• A positive Tinel's sign before surgery, which is a strong predictor of surgical relief after decompression 2, 4
• Abnormally slow nerve conduction through the posterior tibial nerve, which usually predicts failure of conservative treatment 2
• The presence of a clear aetiology, a short history of symptoms, and an early diagnosis, which are associated with better surgical outcomes 2

Patient Selection for Surgical Treatment

Surgical treatment is typically reserved for patients with refractory symptoms who do not respond to conservative or minimally invasive options 5

• Patient selection for surgical treatment should be based on a thorough evaluation of the patient's symptoms, medical history, and response to previous treatments 2, 5