Hi guys! This video is about tarsal tunnel syndrome, and it's a common cause of pain over the
inside of your ankle as well as under your foot. In this video, I'll discuss what tarsal tunnel
syndrome is. I'll take a look at what causes it, what it feels like when you have it. We'll
take a look at what tests you can do to make sure that it is that that you've got. And then lastly,
we'll take a look at the treatments for it. My name is Maryke. I'm the physiotherapist
from sports-injury-physio.com, where you can get online physiotherapy assessment as well as
treatment for your injuries. Have a look at my ... link for my website is in the description
of this video. Excellent! So, if you've got any questions as I go along, just ask them in
the comments. If you want to message me or email me, that's also absolutely fine. Excellent! So,
let's look at tarsal tunnel syndrome. Now, what is it – what's the tarsal tunnel? So, I don't
know if you've heard of carpal tunnel syndrome – it's a similar thing that you get in your wrists,
in this area. But the tarsal tunnel is on the foot, and it's the inside of the ankle that
you can see there. So, if I can show you my foot at the same time, it may make more sense. Okay,
so, there we go! If we look at the inside of the foot, the tarsal tunnel runs in this area,
and it is formed by the bones of the foot on the inside. And then there's the flexor retinaculum,
which I'm hoping I'm saying in the right way, which is a thick fibrous band that runs from this
bone down to your heel and kind of under your foot as well. And the function of that band is
to keep all your tendons and arteries and things that run behind this bone in place. So, what have
we got that's running in that tarsal tunnel? You have got your tibialis posterior tendon,
you've got your flexor digitorum tendon, basically muscles of the foot or that control the foot,
as well as your hallucis tendon, and then you've got your posterior tibialis vein as well as
artery. And you've got your posterior … you've got your posterior tibial nerve as well, and that's
the important one that I want you to concentrate during this video. So, tarsal tunnel syndrome is
when that posterior tibial nerve is compressed and causes symptoms that refer under your foot
and sometimes even up your leg. The posterior tibial nerve also divides into two branches,
the medial and lateral plantar nerves, and they go to different parts of your foot. Now, we all
differ with regards to anatomy. So, what they've seen when they've looked at various people,
and for some of these people, the nerve will split before it enters the tarsal tunnel, for others it
splits inside the tarsal tunnel, and for others it splits a little bit lower, and it can have quite a
few different number of branches even. So, people with this condition, their pain can really vary,
and you'll see on that picture, those little ... the yellow bits are the nerves that's running
down. So, that's what the tarsal tunnel is, and anything ... So, if we move on to what causes it:
It's basically, anything that causes more pressure to build inside that tunnel will
cause compression of the nerves. So, what do we think about? We're thinking about things like,
if the foot bones have changed shape. So, say for instance your foot arch has flattened, or
your foot’s turning in more, or a little bone has pushed out a bit – that will cause less space and
compression of the nerve. But it can also be the way that you move. Say, for instance, your foot
may have really good posture when it's at rest, but it could be that it turns in excessively when
you're walking or just when you wear certain types of shoes, it can turn in excessively. Of course,
also external pressure. So, shoes that push on that area can cause it, and also shoes that really
press in hard into that bit can cause compression of that nerve. You can get with chronic overuse
injuries, you can get thickening of the tendons and the flexor retinaculum, which means that
there's less space as well. So, we're thinking of things like tibialis posterior tendinopathies,
where the tendon actually thickens so there's less space for the other things, like the nerves,
in there. You can also have little growths inside the … Oops! Let me just stop this from dying on
me … You can also have little growths inside the tunnel, like cysts or neuromas, that can cause the
space to narrow down, and that can cause tarsal tunnel syndrome. So, what does it feel like? Again
like I've said, because our anatomy varies and where the nerve splits varies between people, some
people can have pain under the feet, some people can have a bit more pain on the lateral side,
and for some people it can even shoot up the leg. It can be in the form of tingling, it can have a
burning sensation, there can be a numbness and change in sensation, funny sensations, or it can
just be a throbbing pain that feels very similar to plantar fasciitis, for instance. And it can
often also be misdiagnosed as plantar fasciitis, because it can cause pain in the same area. But
there are certain things that will kind of make you think or suspect that maybe it's not plantar
fasciitis, things like … Let me just get this out of the way as well …If you think of ... plantar
fasciitis is typically more painful when you … first thing in the morning, when you get up
out of bed or when you've sat down for a while – those first few steps really hurt. If that's
not the case and actually your pain gets better when you rest it, it may not be plantar fasciitis;
it can be this condition. Or if there's tingling or funny sensations involved as well, then that
usually indicates that there's a nerve compression of some sorts or nerve irritation of some sorts
going on. So, it's definitely worth looking into it. Of course, you can have both conditions at the
same time as well. You can have plantar fasciitis and you can have tarsal tunnel syndrome. So,
it's worth having it investigated and seeing somebody who can help you identify what things
are the right things to do. Let me just make sure I'm not leaving anything out here. The other thing
that can feel very similar to that is if you have L 4 or 5 nerve root irritation in your back. Now,
the funny thing about nerve roots is that you can have the irritation in your back but have
absolutely no symptoms in your back. So, no back pain or anything, but the pain can be in your
foot. So, that type of pain, when it's those nerves in your back that's irritated, can feel
very similar to tarsal tunnel syndrome, and that's why it's always worth whichever clinician you see,
they have to test your lower back and all of that as well, because you can distinguish
between the two through certain tests. And then, of course, you can have double crush syndrome,
which is pretty much what the name says: It means that you can have an issue with the nerve up here,
but then because that causes neural tension in the leg and the nerve isn't free to slide, it can then
compress the nerve around the ankle. Because as you move, your sciatic nerve and the tibial nerve
are meant to slide gently forwards or backwards in your leg as you give steps. Now, say for instance
you've got a back injury, and your nerve's not free to move because it's stuck up here – when
you take your leg forwards that nerve can't slide. So, now it's stretching around the ankle, so it
can cause a compression injury or tarsal tunnel syndrome at the ankle secondary to an injury that
you've got higher up in your body. Let me know if this doesn't make sense. So, how do you test
for this? I hope from what I've just said, it's clear that you have to … any patient that you get,
you have to test all the way from the lumbar spine down, even if they don't complain about lumbar
symptoms, because so many times I get people to do the slump test or straight leg raise and things,
and then you notice that no, no, there is neural involvement all the way from up here. So,
I would always test the full body from the middle down. And then, specifically for tarsal tunnel,
you've got three main tests that people do. These tests aren't 100% accurate, so you can
get false negatives and positives. So, it may look as if it's not showing up, but still be it,
or it can show up as positive, but actually not be it. So, again, it's useful to see somebody about
it. But let me talk you through this, through the tests quickly. First one is Tinel's test,
where you basically just go and tap over the nerve. So, when nerves are irritated,
if you give extra pressure on that nerve and tap on it like that, that will set it off. So, you can
get a tingling, or you can get your pain, or you can get a numbness – sometimes not while you're
doing it, sometimes it's when you then get out of the position, then you go, ‘Oh! That's quite sore
now!' I would say that's also kind of a positive test. So, for the tarsal tunnel, if I did Tinel's,
it would be ... Come on, focus! ...It would be in this area of the tunnel that you tap it along the
area where the nerve would be running, and you see if you can elicit your pins and needles or
funny sensations or whatever symptoms it is that you get. Now, the second test is, if we think of
the nerve running behind here – under the foot – it's when you take the foot into dorsiflexion
and turn it out, because you're stretching the nerve all around that leg then, and that can be
quite painful in somebody who has tarsal tunnel syndrome. I would probably do it with the leg
extended, that you put the nerve at the top of the leg also – a little bit under pressure. But
interestingly enough, the opposite also closes the tarsal tunnel down and causes compression,
which is plantar flexion and inversion, because then you're closing the tunnel down and that bit,
and that can be painful for some people. And then also, if you read the research,
often if you take it into those stretch positions and then do the tapping,
it can make those tests more sensitive, or you can feel more pain with that. So, there's no one test
that will give you a definitive answer; it's usually about the symptoms a patient tells me,
plus the tests I do with them online that give me a good indication of what it is. But it has to be
the holistic thing that you look at. So ... moves us on to treatment. And of course, as you've seen,
there are quite a few different things that can cause this syndrome. So, you've got to make the
treatment specific to your cause. So, you've first gotta identify why you have this. Things
like massage can be really effective as long as you massage the correct bits. So, for instance,
if you think of ... Say, for instance, it's really tight calf muscles, or your buttocks that's tight
may even have an influence on it. So, massaging those areas, self massage or going to somebody
else who can help you with that, can be effective. Dry needling can be effective to loosen off the
muscles and allow the nerve to move more smoothly. For some people doing things like calf stretches
can be really useful, whilst for others, if it's really … if it's the foot shape that's causing
the issue, then doing a calf stretch can often aggravate it. Because if you're gonna do a strong
calf stretch, and actually because of the shape of the foot that nerve is really squashing around
that area, you will make it worse, whereas if it's purely because of your calf being tight that the
nerve can't move, doing the calf stretch can be quite useful. So, it's worth seeing a clinician
to guide you with that. What I would say is, I tend to give people flexibility exercises, again
from the lumbar spine down, even if the lumbar spine doesn't look like the main culprit, just
to be holistic with it all and allow everything to slide, because your nerves have to run through
your glutes, through your hamstrings, through your ... or close to your calves, and it's best to keep
all of that flexible. Orthotics, supportive shoes, can be useful for some people if it is
that your foot is pronating too much or turning in too much and that's causing the compression.
Giving a bit of support there can be useful. Just be careful – if you've got a really flat foot and
you're gonna get an off-the-shelf orthotic, it may be too hard or it may be too high,
and it can squash that nerve further. So, when you use orthotics, they have to be comfortable.
If they're uncomfortable when you've got them on, really, really uncomfortable, it's probably
not the right type of orthotic for you, or maybe you've just worn it too long at the beginning.
You've got it ease into it. But yeah, chat to somebody who can help, to advise you about that.
What else is available? So, spoke about stretches. Strength creating exercises? Yes, but look further
away from just the foot, and it depends on what's causing your tarsal tunnel. So, if it is that
your leg is turning in too much and all of that's causing the issue, then strengthening the butt can
actually be quite effective, because your glute muscles have to control how your knees move, or
your leg pointing forwards when you're running or walking. So, if it turns in too much when you're
doing that, you've got to strengthen your bum up. You can strengthen your feet as much as you like,
but if you don't give it support from the top, you're gonna still struggle with that. So,
look further than just the calf muscles or the foot muscles. And if your tarsal tunnel is really,
really irritated, I would probably wait with the strength training exercises until it's calmed down
a little bit, because otherwise you may make it feel worse. Cortisone injections can help for
some, and for others it doesn't work that well, but for some people that can work quite well if
there's a lot of inflammation or swelling in that tarsal tunnel. Immobilizing the foot in a boot or
support for a period of time, that can give some people quite good relief that they then can get
on with other things. Surgery is an interesting thing. I found a research study where they looked
at why decompression surgery, where they go in and loosen the flexor retinaculum and things and just
trim things away to give them more space. So, for some people it works really well and for others it
doesn't work, or it actually makes it worse. And what they've identified it, is it's all about the
reason why you have the tarsal tunnel syndrome. So, for instance, for other people who's got
other issues in the body, like the lower back is maybe contributing to why the nerve is so tight,
they didn't react very well to surgery, whilst other people, where it was purely there was
something just blocking the space in the tarsal tunnel, they really reacted well to creating more
space in there. So, it really depends on your case of tarsal tunnel syndrome why or whether surgery
will help or not. And when it comes to surgery on feet, it's always good to go see a consultant
who really specializes in feet and ankles, because it's quite a finicky area to have surgery in. So,
make sure you see somebody who's experienced in it. Excellent! That's everything about
tarsal tunnel. So, let me know if you've got any questions, and you can find a link to my website
in the description of this video if you would like more help with any specific injuries. Take care!