Dynamic Chiropractic

Dynamic Chiropractic Facebook Twitter
Dynamic Chiropractic
Advanced Search
Wellness Blog
Dynamic Chiropractic PracticeINSIGHTS
Current Graphic
Dynamic Chiropractic – March 26, 1993, Vol. 11, Issue 07
Dynamic Chiropractic
Printer Friendly Email a Friend PDF RSS Feed
Share |
Dynamic Chiropractic

The Tarsal Tunnel Syndrome -- A Conservative Approach to Treatment

By R. Vincent Davis, DC, PT, DNBPM

The tarsal tunnel syndrome is represented clinically by a constellation of symptoms which affect the foot. Most commonly, it is the result of compression neuropathy of the posterior tibial nerve at the point of its passage through the fibro-osseous tunnel beneath the flexor retinaculum on the medial aspect of the ankle. The neurovascular bundle, in which it is housed, is bound to the tibia by a ligament, which contributes to the formation of the tunnel in conjunction with the fibro-osseous tunnel. Since this neurovascular bundle occupies a relatively fixed position within the tunnel, any additional tissue accumulation in the tunnel tends to compress the nerve. Also, by passively forcing the heel and forefoot into valgus, the flexor retinaculum and point of origin of the abductor hallucis tightens, compressing the nerve. Accordingly, the process of this compression neuropathy is similar to that of carpal tunnel syndrome involving the hand.

Early in this compression process, there may be recurring episodes of transient ischemia which results in burning pain and paresthesias. With prolonged, extreme compression, nerve demyelination with Wallerian degeneration may take place with resulting numbness, muscular weakness, and atrophy. At this point, nerve conduction velocity tests demonstrate a time delay.

A common symptom is nocturnal burning pain causing the patient to awaken and results in the patient hanging the leg over the edge of the bed and shaking it, massaging the foot, or walking to gain relief. The patient may also complain of intermittent burning pain, tingling or numbness, which is located in the toes and distal components of the foot. This latter form of complaint is usually a product of prolonged standing and/or walking and is relieved by rest and shoe removal. The sensory loss finding is characteristically in the region of distribution of the medial and lateral plantar nerves. There may be diminution of two point discrimination and hypoesthesias to pin prick, with a positive (+) Tinel's sign. Not uncommonly, there is tenderness over the nerve at the tarsal tunnel, and/or the medial aspect of the foot. Good recovery should not be expected with the presence of obvious motor weakness and muscle atrophy.

Diagnostic aids to be considered by the physician should include nerve conduction velocity tests, an electromyograph, and some authors propose a tourniquet test which involves inflating a sphygmomanometer cuff proximal to the tarsal tunnel lesion to produce venous congestion and attempt to reproduce the symptoms. Of course, these procedures are requested with a neurological consult. In this author's opinion, the patient should be referred for neurosurgical consult when the neurological report involves nerve demyelinization and/or Wallerian degeneration. Prior to the presence of such findings, conservative care should be the regimen used when symptoms are of a transient character.

At the earliest presentation of clinically confirmed symptoms, the use of cryotherapy may be applied using ice water by immersion for 15 to 20 minutes. In the presence of skin pallor, continue the treatment in the absence of other contraindications, but in the event of skin cyanosis, treatment must be interrupted to avoid damage to subcutaneous tissues. It may be recalled that the reduction of skin temperature by five to 10 degrees C. is capable of reducing the nerve conduction velocity sufficiently to relieve pain and spasm. Following this, and with future treatments as resolution of symptoms permit, application of 0.5 percent hydrocortisone and 2.5 percent lidocaine (xylocaine) ointment should be transferred by pulsed phonophoresis directly to the region of the tarsal tunnel using 0.50 W/cm2 energy for 10 minutes. Following this, if necessary to reduce the pain level, interferential current therapy may be applied to the lesion with careful attention to correct placement of the electrodes. It is recommended that the beat frequency be about 100Hz to avoid vascular ischemia, which is already a problem.

In the event that this conservative regimen does not prevent progression of this lesion to nerve demyelination and/or Wallerian degeneration, the patient must be referred for neurosurgical consultation. Clinically, this is demonstrated by the presence of numbness, muscular weakness, and atrophy; neurologically by delayed nerve conduction velocity test, and abnormal findings on electromyography.

In this author's experience, tarsal tunnel lesions which have progressed beyond the early stage in which transient symptoms are present, to a point wherein the symptoms have become marked by a history of relatively constant distress, should be referred for neurosurgical consultation.


Davis RV: Therapeutic Modalities for the Clinical Health Sciences, ed 1. Copyright -- Library of Congress, Card #TXU-389-661, 1983.

Griffin JE, Karselis TC: Physical Agents for Physical Therapists, ed 2. Springfield: Charles C. Thomas, 1982.

Krusen, Kottke, Ellwood: Handbook of Physical Medicine & Rehabilitation, ed 2. Philadelphia: W. B. Saunders Company, 1971.

Schriber WA: A Manual of Electrotherapy, ed 4. Philadelphia: Lea & Feibiger, 1975.

R. Vincent Davis, D.C., BSPT, DNBPME
Independence, Missouri

Dynamic Chiropractic

Dynamic Chiropractic
Printer Friendly Email a Friend PDF RSS Feed
Share |
Dynamic Chiropractic
Dynamic Chiropractic
Join the conversation
Comments are encouraged, but you must follow our User Agreement
Keep it civil and stay on topic. No profanity, vulgar, racist or hateful comments or personal attacks. Anyone who chooses to exercise poor judgement will be blocked. By posting your comment, you agree to allow MPA Media the right to republish your name and comment in additional MPA Media publications without any notification or payment.
comments powered by Disqus
Dynamic Chiropractic
Have you ever contacted a local employer about the possibility of directing their corporate wellness program?
Yes, contacted
Yes, directing
Thinking about it

Sign Up for Our Webinars
Receive Advanced Notice of Future Webinars


Generic Viagra Lowest Prices Pfizer Drugs Viagra No Prescription Order Viagra Online Viagra Non Prescription Deal Sale Prescription Viagra Uk Online Levitra Reviews Viagra Oysters In Australia Viagra Price Australia Cialis Pill Color Generic Viagra Canada Buy Cheap Viagra Viagra Katelaris P Viagra Australia Cheap Levitra Prescription Or Not Viagra Levitra Usual Dosage Buy Tadalafil Cialis Online Viagra And Daibetes Viagra Tablets Uk Viagra Online From Us Pharmacys Generic Money Viagra Cialis And Priligy Next Dat Delivery Generic Viagra Vigora 5000 Effect Viagra Drug Interactions Online Levitra Tablet Viagra Buy Online Levitra Drug Interaction Walgreen Viagra Per Pill Viagra Online Gr 4.26 Buy Cialis Lowest Price Viagra Online Cheap Mexico Viagra Buying Free Sale Viagra Cheap Kamagra Viagra Buy Generic Online Viagra Viagra Online Sales Brand Viagra For Get Viagra Without Prescription Viagra Side Effects Blood Pressure Cialis For Sale In Us Australia Viagra Online Cialis Cheap Visa Auk Cialis Sales Bravejournal Buy Levitra Member Levitra Buy Online Find Cheap Cialis Vardenafil 20 Mg Hcl