Rethinking Tarsal Tunnel Syndrome
Podiatrists have been treating tarsal tunnel syndrome (TTS) conservatively for decades although there is no clinical outcome study to document the effectiveness of orthotics for this syndrome. Most podiatrists rely on the anecdotal evidence and their own experience to prescribe orthoses, which are intended to change the position of the foot and reduce the trauma and traction of the posterior tibial nerve at the flexor retinaculum. First defined by Keck in 1962, tarsal tunnel syndrome is a relatively common problem that podiatrists see in their practice and is frequently associated with extremely pronated feet and patients with standing occupations.1 The hallmark of the syndrome is pain in the proximal medial arch with paresthesias extending along the course of the medial and lateral plantar nerve. The thinking is the pathology is the result of traction on the tibial nerve and compression by the flexor retinaculum or occurs due to compression of the medial plantar nerve as it perforates the fascia and intrinsics at the porta pedis. Conservative treatment is always the first step. This includes strapping and orthotics to hold the foot in a less pronated position. One may use antiinflammatory or anesthetic injections in some areas to reduce concomitant symptoms. In cases of resistant pathology, podiatrists would proceed with surgical treatment by releasing the retinaculum at the medial malleolus or decompressing the nerve at the porta pedis.