Tarsal tunnel syndrome (TTS), sometimes called jogger’s foot, is a relatively common cause of pain along the inside (medial) portion of your ankle. TTS can be a repetitive strain injury or an entrapment (compression) type injury.
The tarsal tunnel is a fibrous tunnel that is not structurally flexible. There is limited room for swelling inside the tunnel. This can cause nerves and blood vessels to be “entrapped” and lead to pain and other symptoms.
TTS is often caused by repeated pressure that results in damage on the posterior tibial nerve. Similar to carpel tunnel in the hand, the tarsal tunnel is located just below the medial malleolus (the large bump to the inside of the ankle). Basically, the tibial nerve branches off of the sciatic nerve and travels down the inside of the leg. It eventually runs through the tarsal tunnel, which is a narrow passageway inside your ankle that is bound by bone and soft tissue called a retinaculum.
How to Self-Treat Tarsal Tunnel Syndrome
Symptoms of Tarsal Tunnel Syndrome (TTS) include:
- Pain can be felt anywhere along the tibial nerve, sole of the foot or inside of the ankle.
- Pain can be pin point or diffuse extending to the heel, calf, arch or toes of the foot.
- Pain can come on gradually or suddenly appear.
- Pain is often described as pins and needles or as sharp shooting pains.
- Pain may often feel as an electric shock sensation or a burning sensation.
- Paresthesia or loss of sensation or numbness may also be present.
TTS is often mistaken for Posterior Tibial Tendon Dysfunction (PTTD) because of the location and type of pain. In order to correctly diagnose TTS, other possible conditions should be ruled out first. You may have TTS if you are experiencing the symptoms listed above and they worsen with direct pressure or firm tapping over the tarsal tunnel. The only definitive way to diagnose TTS is to have a nerve conduction study performed by your physician.
Common Risk Factors for Tarsal Tunnel Syndrome (TTS) include:
- Direct trauma or injury (such as being kicked in soccer).
- Overuse of the foot and/or overtraining of the tendon that causes inflammation, swelling, and pain.
- Prolonged standing, walking, exercising or sudden increase in activity or exercise volume.
- Training overload. Performing too high of training intensities and volumes.
- Abnormal foot and ankle mechanics.
- Flat feet, which cause overpronation while running.
- Poorly fitting or worn out shoes.
- Weak ankle muscles (particularly, the posterior tibialis or the foot intrinsic muscles that help to support the arch of the foot).
- Weakness in the hip, pelvic, and/or core muscles causing faulty gait mechanics.
- A change in running surfaces or environments. This is most evident when transitioning from a softer running surface, such as dirt, to a concrete running track or running downhill.
- Running on cambered surfaces, such as the edge of a road, where overpronation can cause excessive and repeated stretch on the nerve. Alternately, a high arch can cause more compression particularly on the downhill side of the foot. Thus, compressing the tarsal tunnel and possibly leading to inflammation and symptoms.
- Excessive dorsiflexion (toes moving towards the shinbone) during running. Those who tend to excessively heel strike can develop TTS. If the terrain (such as hill running) forces excessive dorsiflexion, then the combination of landing on the heel while the ankle dorsiflexes can increase the tarsal tunnel compartment pressure. This can cause impingement of the artery, vein, and nerve and can lead to pain or neurologic symptoms.
Initial Treatment for Tarsal Tunnel Syndrome (TTS):
This condition typically begins as an overuse syndrome with an active inflammatory cycle occurring. The initial course of treatment includes PRICE, which stands for Protect, Rest, Ice, Compression, and Elevation.
- Protect. In more severe cases (especially those involving physical damage to the nerve), it’s necessary to protect the damaged area. This may be done through use of a walking boot or in some cases, a cast may be necessary to restrict movement completely which allows the nerve, joint, and surrounding tissues a chance to heal.
- Rest. In this case, rest would indicate tapering down from your regular exercise activity and discontinuing running (for the short term).
- Ice. Apply ice to the painful area. The rule for icing is to apply ice no more than twenty minutes per hour. Do not place the ice directly against the skin, especially if you are using a gel pack style. A bag of frozen peas can be ideal. Individuals with poor circulation or impaired sensation should take particular care when icing.
- Compression helps to prevent and decrease swelling. Swelling can cause increased pain and slow the healing response, so limit it as much as possible. A compression stocking can help to limit the amount of swelling and promote blood flow back out of the lower leg. This insures better nutrient exchange, waste removal, and limits the swelling. I particularly recommend wearing a pair during your rehabilitation phase and when tapering back into full activity. Although there are many different styles of compression stockings available, always be sure to choose a pair that is at least knee high.
- Elevation. Depending on your pain level and the amount of swelling present, this step may be more or less beneficial.
Depending on the severity you may also want to speak to your physician about utilizing anti-inflammatory medications such as NSAIDs (non-steroidal anti-inflammatory drugs). This class of medication can be used as a pain reliever as well as to reduce inflammation. Medications in this class include drugs such as over-the-counter Aleve and Ibuprofen or higher strength medications such as Meloxicam.
How to Self-Treat Tarsal Tunnel Syndrome (TTS):
Please refer to Tarsal Tunnel Syndrome Exercises for demonstrations of the following strategies that I recommend when self-treating TTS.
Self-mobilize the tissue. Be sure to mobilize the tissue in and around the upper leg, calf and shinbone (tibia). Take care not to be too aggressive when mobilizing right over the tarsal tunnel or you may make the pain worse. Instead, initially focus on any other mobility and myofascial restrictions in the lower legs. Utilize a foam roller to address any lower leg tightness or restrictions. I tend to use the foam roller for the larger parts of the leg including the thigh, back of the leg, calves, and buttock muscles.
Mobility bands, such as the Rogue Fitness VooDoo X Bands or EDGE Mobility Bands, are a novel way to self-mobilize the tissue of the calf, foot, and ankle. The use of mobility bands affects blood flow to the area and speeds up healing. Mobility bands also help reset some of the receptor cells in the muscle tissue that cause excessive muscle tightness. Application of the band starts at mid foot, and then wraps directly over the ankle. You will then pump your ankle back and forth for as much motion as possible in each direction. Typically, the mobility band is in place for 30-60 seconds. If you experience numbness or tingling or worsening of symptoms, please discontinue the treatment. (If you suffer from any form of blood clotting disorder or are on blood thinning medications, I would advise against utilizing mobility bands for any type of deep compression.)
Strengthen your foot and ankle complex. Weakness in the foot and ankle muscles is a major risk factor in developing TTS. I recommend initiating a complete ankle and foot strengthening protocol.
Improve your balance. Poor balance is often associated with muscle weakness in the foot and ankle as well as the knee and hip musculature. Weakness and balance deficits can lead to poor foot mechanics, which can lead to excessive strain on the foot/ankle complex. Practice balancing on one foot.
Gently stretch and “floss” the tibial nerve. You will need a belt or a towel to stretch the tibial nerve. Wrap the belt around the ball of your foot. Apply a forceful pull on the belt so that your foot and toes move toward your nose while tilting your foot slightly outward. While keeping this downward tension, slowly straighten your knee (as demonstrated). Repeat for 20-30 repetitions, and repeat twice a day.
Make sure you have normal range of motion in your ankle. In order to have proper foot mechanics, your ankle should have normal mobility. Your ankle should have range of motion in all directions. Also, be sure to stretch your calves so that they don’t restrict your ankle’s dorsiflexion. I typically advise at least two repetitions of holding for 60 seconds per calf stretch. Stretch both the gastrocnemius and soleus calf muscles (as demonstrated).
Address any sources of mechanical irritation and/or compression. Due to the location of the tarsal tunnel, it can be easily affected by poorly fitting shoes and/or socks. Avoid wearing socks or shoes that cause any type of rubbing or compression directly over the tarsal tunnel.
If you change running surfaces, progress slowly. If you typically run on softer surfaces, such as dirt or a running track, progress carefully and slowly to running on a harder surface (like concrete). If you run on roads, try to vary which side so that the natural camber of the road is not causing excessive strain on one foot versus the other. Overall, softer running surfaces are better for your body. If your job requires that you stand on a hard surface, adding a foam pad or rubber mat can decrease the strain on your foot and arch.
Avoid training overload. Don’t progress your training volume and/or intensity levels too quickly. TTS is most commonly diagnosed as an overuse injury. Proper training is very important to avoid overloading your body. Improper progression of training volume and/or intensity can easily lead an overuse injury like PTTD, Achilles tendinitis or other lower extremity injuries.
Add an orthotic. Additional foot control is often needed to normalize gait mechanics. Many running stores sell an over-the-counter orthotic such as Superfeet Blue Premium Insoles. The blue tends to fit most feet, but a variety of options are available for customization. In my experience, these insoles can last 1,000 to 1,500 miles easily.
If you continue to experience pain related to your foot or footwear, then you may need to consult with a physical therapist and/or podiatrist that specializes in feet and orthotics. A custom orthotic may be necessary to correctly support your foot and insure proper foot mechanics. Seek assistance from a professional such as a podiatrist or physical therapist who has experience with treating other runners.
Laser therapy. Laser therapy uses light to accelerate the body’s natural healing processes. It produces a photochemical, photothermal, and photomechanical effect. The photochemical effect is said to increase local energy production, activate enzymes, and decrease pain perception. The photothermal effect is said to increase circulation which will improve oxygen and nutrient delivery for healing. The photomechanical effect is said to increase lymphatic mobility and improve circulation as well.
Other treatments. When conservative measures fail, additional medical management may be necessary. This includes steroid injections to reduce the pain and inflammation in the area. This usually works best when you are actively working on rehabilitation to insure that the cause of TTS has been addressed. Surgery may also be needed. Tarsal tunnel surgery can be a complicated surgery. You will likely need an MRI to see what is causing the TTS. Sometimes, there are varicose veins or a cyst that are impinging on the nerve. If there is a cyst and removal is required, then the surgery should have a success rate of about 90%. If there isn’t a defined cause of the TTS (such as a cyst), then the chance of a successful surgery decreases. Surgery is best performed when there is a clear impingement in the tunnel which can be surgically fixed. Surgery is typically performed by a Doctor of Podiatry or an orthopaedic surgeon.
Ask for help. If you’re still experiencing pain after implementing these self-treatment strategies, then it may be time to seek additional help. Other medical conditions can mimic or be associated with TTS, including foot neuropathy and radiculopathy from the lumbar spine. Your medical physician or physical therapist can help to determine if your pain is associated with other conditions or other biomechanical related issues. Your physician could also prescribe a stronger anti-inflammatory medication if necessary. The American Physical Therapy Association offers a wonderful resource to help find a physical therapist in your area. In most states, you can seek physical therapy advice without a medical physician’s referral (although it may be a good idea to seek your physician’s opinion as well).
RETURN TO RUNNING
As you return to running and your normal training activities, insure the following:
- Your involved leg is as mobile and flexible as the other.
- Your involved foot and ankle is as mobile and flexible as the other.
- Your involved foot and ankle complex is as strong as the other leg.
- Your ability to balance is equal in both legs.
- You can jog, run, sprint, and jump without pain.
If you are not progressing after 3-4 weeks of implementing these treatment options, speak to your medical professional. Do not take this condition lightly. Be sure to properly address it so you don’t lose too much time with your training. As you taper back into your running program, follow these guidelines:
- Although you will need to progress and train on uneven ground and hills, initially start with level terrain only.
- Initially limit your running distance. I recommend starting with a distance approximately 50-75% of your pre-injury distance.
- Initially start with a slower pace. Don’t immediately progress back into very intense running activities, such as interval or hill training, until you have worked back up to your previous running distances and paces without pain.
Tarsal Tunnel Syndrome (TTS) most commonly starts out as an overuse injury, but it can be caused by a direct trauma or injury. If the condition is left untreated, the end result can be permanent nerve damage. When this condition is caught early, it can be self-treated. For additional information on common running injuries and how to self-treat, please visit www.thePhysicalTherapyAdvisor.com.
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