Can mild compression of the right tibial nerve cause mild idiopathic pruritus of the right heel in the absence of dermatological abnormalities?

From the Guidelines

Mild compression of the right tibial nerve could potentially cause mild idiopathic pruritus of the right heel without visible dermatological abnormalities. The tibial nerve provides sensory innervation to the heel, and compression of this nerve can lead to paresthesias including itching, burning, or tingling sensations, as described in the British Association of Dermatologists' guidelines for the investigation and management of generalized pruritus in adults without an underlying dermatosis, 2018 1. This condition may represent a mild form of tarsal tunnel syndrome, where the tibial nerve is compressed as it passes through the tarsal tunnel behind the medial malleolus.

Key points to consider in the management of this condition include:

• Conservative measures such as rest, avoiding tight footwear, and using cushioned insoles to reduce pressure on the nerve
• Over-the-counter NSAIDs like ibuprofen (400-600mg three times daily with food) for any associated inflammation
• Physical therapy focusing on gentle stretching exercises for the foot and ankle to relieve pressure on the nerve
• Consideration of referral to neurology or podiatry for further evaluation if symptoms persist beyond 2-3 weeks, which might include nerve conduction studies to confirm the diagnosis, as neuropathic pruritus can be caused by pathology affecting the peripheral nervous system, including nerve fibre compression and degeneration 1.

The mechanism involves compression-induced aberrant nerve signaling that can manifest as pruritus without actual skin inflammation, explaining the absence of dermatological findings. It is essential to address this condition promptly to prevent further nerve damage and alleviate symptoms, prioritizing the patient's quality of life and minimizing potential morbidity.

From the Research

Neurological Causes of Pruritus

• Pruritus can be caused by neurological disorders, including neuropathic itch, which is transmitted to the central nervous system via unmyelinated C-type nerve fibers 2.
• Neurogenic itch can be caused by compression or damage to nerves, including the tibial nerve 3, 4.

Compression of the Tibial Nerve

• Compression of the tibial nerve near the knee can cause tibial neuropathy, which may lead to symptoms such as pain, numbness, and tingling in the foot and ankle 3.
• The soleus sling has been identified as a site of compression of the tibial nerve, resulting in soleal sling syndrome 3.
• Compression of tibial nerve branches in the foot can also occur, particularly in the areas where the nerve passes through or near the abductor hallucis muscle 4.

Relationship between Tibial Nerve Compression and Pruritus

• While there is no direct evidence linking mild compression of the right tibial nerve to idiopathic pruritus of the right heel, it is possible that nerve compression or damage could contribute to the development of pruritus 2, 5.
• Gabapentin and pregabalin, which are used to treat neuropathic pain and epilepsy, have been shown to be effective in relieving chronic pruritus, including neuropathic or neurogenic itch 2, 6, 5.

Potential Mechanisms

• The exact mechanism by which tibial nerve compression could contribute to pruritus is unclear, but it may involve the transmission of abnormal nerve signals to the central nervous system, leading to the sensation of itch 2.
• Further research is needed to fully understand the relationship between tibial nerve compression and pruritus, and to determine the potential effectiveness of treatments such as gabapentin and pregabalin in this context 2, 5.