Time to discuss a clinical topic Section

Obscure Heel Pain – The Tarsal Tunnel Syndrome (TTS)

This month I wanted to feature a little more about heel pain. Previously in March, I discussed common heel pain known as fasciitis. Heel pain can become more resilient to treatment and if an injection fails it does not mean that all injections are bad, or should not be attempted. Outside the specialty of foot experts, the so called Triad Heel Pain is not well understood, so here is a brief but important overview.

On the inside of the ankle, that is the point under the  ankle bones (tibiae) a  thick nerve is routed into the foot where it divides. Close to this run two sets of veins which network with a strong artery. Just to complicate matters three major tendons run down the same anatomical space. We call this space the Tarsal Tunnel. As with any major road, many roads branch off. The nerve has branches and these run through muscles where they are both protected, but also supply  muscles. So we now have a picture of many different anatomical parts, nerves, veins, arteries, tendons and muscles. If the nerve (tibial) is trapped  pain can shoot not just into the foot, but also the heel. If the tendon lining is torn  inflammation pressure builds up in the tarsal tunnel. This causes pressure on the nerve. In some cases veins strangle the nerve causing pain especially on activity. As activity increases so does the fluid and with this comes increased pressure. I refer to this as a Triad (threesome) until I know exactly what the problem is. Some types of imaging tests like MRI and ultrasound can be helpful, sometimes I use a nerve conduction test. A carefully placed an injection of steroid into the region which can help reduce the inflammation, but, sometimes surgery is necessary to release the pressure. This is known as decompression.

If the tendon alone is affected this may lead to Post Tibial Tendon Dysfunction. This can cause TTS, but in most cases this can be managed conservatively. What you need to do is ask someone to undertake a careful tarsal tunnel examination exclusion test.


What to look out for?

If you have a foot which burns, feels tight and toes tingle, with or without heel pain. If the front of the feels as though it will explode with pressure then be sure to have a consultation with someone who knows feet. You will know because the more you exercise, the worse it becomes. At the end of the day it probably is not TTS, it could be post tibial tendon dysfunction, but that is another story.



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