Physical Examination Techniques for Detecting Tarsal Tunnel yndrome

Physical Examination Techniques for Detecting Tarsal Tunnel Syndrome

Tarsal tunnel syndrome is often the unsung villain behind foot pain and discomfort. The tarsal tunnel is a canal-like structure formed by the bones, ligaments, and tendons within the ankle. It's similar in concept to the carpal tunnel in the wrist. Within this tunnel, the tibial nerve, along with some blood vessels, tendons, and other structures, passes from the lower leg into the foot.

Tarsal tunnel syndrome (TTS) is a condition that involves compression or irritation of the tibial nerve as it passes through the tarsal tunnel, a narrow space located on the inside of the ankle. The tibial nerve is one of the main nerves that supplies sensation and motor function to the foot.

Understanding the Symptoms: Listen to Your Feet

As a physiotherapist, it is important to assess the signs and symptoms properly because patients themselves dismiss early symptoms sometimes.

• Pain - experienced along the inside of the ankle or the sole of the foot.
• Numbness and Tingling - radiate from the inside of the ankle toward the toes and even extend up into the calf.
• Burning Sensation - may worsen with certain activities.
• Radiating Pain - radiate along the course of the tibial nerve, affecting the lower leg as well.
• Increased Symptoms During Activity - involve prolonged standing, walking, running, or activities that require flexing of the foot, such as driving.
• Foot Weakness - affects ability to walk, stand on tiptoes, or perform other foot movements.
• Pain at Night - might disrupt sleep or awaken you from sleep.
• Swelling - mild swelling around the ankle and foot

Causes of Tarsal Tunnel Syndrome

• Anatomical Variations
• Injuries or Trauma
• Flat Feet - experience increased tension on the tibial nerve as it passes through the tarsal tunnel.
• Systemic Conditions - diabetes can lead to neuropathy
• Inflammatory Conditions - rheumatoid arthritis
• Varicose Veins: Swollen and enlarged veins can increase pressure within the tarsal tunnel
• Repetitive Stress or Overuse
• Occupational Factors - prolonged periods of standing or activities that put strain on the feet and ankles
• Footwear Choices - contribute to improper foot
• Pregnancy - Hormonal changes and weight gain during pregnancy

Diagnosing the TTS

Physiotherapists ensures an accurate diagnosis thorough physical examination, often complemented by nerve conduction studies and imaging techniques like MRI, paints a comprehensive picture of the condition's scope and severity. Remember, a precise diagnosis is the cornerstone of effective treatment.

Tinel's Sign:
Tap lightly over the tarsal tunnel to check for the Tinel's sign. If the patient experiences tingling or electric shock-like sensations radiating into the foot, it could indicate nerve irritation.
 
Compression Test:
Gently compress the tarsal tunnel for about 10 seconds. If this leads to the reproduction of the patient's symptoms, it could suggest tarsal tunnel syndrome.
 
Sensory Testing:
Assess the patient's sensory perception in the affected area. A decrease in sensation or abnormal sensations can indicate nerve involvement.
 
Muscle Strength and Reflexes:
Evaluate muscle strength and reflexes of the foot and ankle to check for any motor nerve involvement.

Provocative Tests:

Tarsal Compression Test: 

Compress the tarsal tunnel by pressing the ankle into dorsiflexion and eversion. This can help elicit symptoms if the nerve is compressed.

Ankle Range of Motion:

Assess for any limitations in ankle range of motion, which could result from nerve irritation.

Differential Diagnosis

• Plantar Fasciitis
• Achilles Tendinopathy
• Lumbar Radiculopathy

The Physiotherapy Approach

As a physiotherapist the goal is to empower patients with exercises and techniques that not only alleviate pain but also improve his overall foot health.

Stretching Exercises

Calf Stretch

Stretching the calf muscles can help relieve tension in the posterior leg compartment and alleviate pressure on the tibial nerve.

1. Stand facing a wall with your hands against the wall at shoulder height.
2. Step one foot back, keeping the heel on the ground and the knee straight.
3. Lean forward, feeling a gentle stretch in the calf of the back leg.
4. Hold the stretch for 20-30 seconds and repeat on both sides.

Plantar Fascia Stretch

This stretch targets the plantar fascia and can help reduce strain on the tibial nerve.

1. Sit down and cross one ankle over the opposite knee.
2. Gently pull your toes back towards your shin until you feel a stretch in the sole of your foot.
3. Hold the stretch for 20-30 seconds and repeat on both sides.

Strengthening Exercises

Toe Raises

1. Stand with feet hip-width apart, holding onto a stable surface for balance if needed.
2. Slowly rise onto the balls of your feet, lifting your heels as high as possible.
3. Lower your heels back down with control.
4. Perform 2-3 sets of 10-15 repetitions.

Ankle Alphabet

1. Sit down and lift one leg off the ground, keeping the knee straight.
2. Use your ankle to trace the letters of the alphabet in the air.
3. Perform this exercise slowly and deliberately, ensuring full range of motion.
4. Switch to the other ankle and repeat.

 

Thera Band Exercises

1. Attach thera band to a sturdy surface and loop the other end around your foot.
2. Perform exercises like ankle dorsiflexion, eversion, and inversion against the resistance of the band.
3. Perform 2-3 sets of 10-15 repetitions for each direction.

Mobilization Method: Nerve Glide Techniques

This maneuver delicately mobilize the compressed nerves, easing their passage through the tarsal tunnel.

Tibial Nerve Gliding Exercise

Starting Position:

1. Sit on a chair or the edge of a bed with your back straight and feet flat on the floor.
2. Keep the leg that you'll be working on comfortably extended in front of you.

Toe Point and Ankle Dorsiflexion:

1. Start by pointing your toes downward, flexing your foot so that your toes move away from your shin.
2. Simultaneously, gently bend your ankle to bring your toes closer to your shin, creating a stretch in the back of your lower leg.
3. Hold this position for a few seconds, feeling a gentle tension along the back of your calf and into your foot.

Toe Flexion and Ankle Plantarflexion:

1. From the previous position, slowly begin to flex your toes towards your shin while simultaneously pointing your foot down, as if you're pushing the gas pedal in a car.
2. You should feel the stretch now moving from the front of your ankle and lower leg down into your foot.

Repetition:

1. Perform the toe point and ankle dorsiflexion movement, followed by the toe flexion and ankle plantarflexion movement, in a smooth and controlled manner.
2. Aim for around 10-15 repetitions of the full cycle, gradually increasing repetitions over time as tolerated.

Frequency:

Perform this exercise 2-3 times a day, gradually working up to this frequency if it's well-tolerated.

Steady Progression: Gradual Weight-Bearing Exercises

Gradual weight-bearing exercises are introduced to rebuild your confidence and stability. 

Proprioceptive Neuromuscular Facilitation (PNF) exercises

Proprioceptive Neuromuscular Facilitation (PNF) exercises can be effective in improving flexibility, strength, and coordination for individuals with tarsal tunnel syndrome. PNF techniques involve alternating between contracting and relaxing muscles to enhance their performance. Here are some PNF exercises that can be beneficial for tarsal tunnel syndrome:

 

Dorsiflexion and Plantar Flexion PNF Stretch

This exercise enhances ankle range of motion and flexibility.

1. Sit comfortably with your legs extended.
2. Using a resistance band or a towel, loop it around the ball of your foot.
3. Gently pull your foot towards your body (dorsiflexion) while resisting the movement with your ankle muscles.
4. Hold the contraction for a few seconds.
5. Then, gently press your foot away from your body (plantar flexion) while resisting with your foot.
6. Repeat this pattern for several repetitions, gradually increasing the stretch each time.

Inversion and Eversion PNF Stretch

This exercise focuses on the side-to-side movements of the foot.

1. Sit or lie down with your leg extended.
2. Loop a resistance band or towel around your forefoot.
3. Gently turn your foot inward (inversion) against the resistance while holding for a few seconds.
4. Next, gently turn your foot outward (eversion) against the resistance and hold.
5. Perform multiple sets of this alternating pattern.

 

PNF Ankle Strengthening

This exercise improves the strength of ankle muscles and the muscles surrounding the tarsal tunnel.

1. Sit on a chair with your leg extended.
2. Loop a resistance band around your forefoot and anchor the other end to a sturdy object.
3. Begin by pushing your foot away from your body (plantar flexion) against the resistance, holding for a few seconds.
4. Then, pull your foot towards your body (dorsiflexion) against the resistance, also holding for a few seconds.
5. Perform several sets of this pushing-pulling pattern.

 

PNF Toe Spreading and Squeezing

This exercise targets the muscles that support the arch of the foot.

1. Sit with your feet resting on the ground.
2. Spread your toes apart as if you're trying to fan them out.
3. Place your fingers between your toes and squeeze them together, resisting the movement with your fingers.
4. Hold the contraction for a few seconds and then release.
5. Perform multiple repetitions of this toe spreading and squeezing action.

Physiotherapists provide personalized guidance and ensure that the exercises are safe and appropriate for individual needs.