The New York State Workers Compensation Board has formulated guidelines to aid physicians, podiatrists, and other healthcare professionals in delivering suitable treatment for Tarsal Tunnel Syndrome. These guidelines are designed to support healthcare practitioners in determining the optimal level of care for individuals with ankle and foot disorders.
It’s important to note that these guidelines serve as a resource and should not replace the application of clinical judgment or the expertise gained through professional experience. The ultimate decision regarding patient care should be a collaborative process, with the patient actively involved in consultation with their healthcare provider.
Tarsal Tunnel Syndrome (TTS)
Tarsal Tunnel Syndrome (TTS) is a rare condition characterized by the entrapment of the tibial nerve or its branches beneath the flexor retinaculum, extending from the lateral and medial ends to the posterior and plantar calcaneal branches, which supply nerve fibers to the arch of the foot. TTS manifests as occasional tingling, numbness, or burning sensations, particularly on the toe and plantar surfaces of the foot, resulting in paresthesias.
In cases where neuropathic findings do not show sensory or motor involvement, a conservative approach of four to six weeks is typically recommended before considering more invasive interventions. Conservative treatments aim to alleviate pressure and pain and may include icing, taping, posterior tibial nerve stretching, exercises, pain medication, splints, orthotics, and supportive footwear.
It’s important to note that TTS lacks clearly defined and universally accepted diagnostic criteria. Clinicians should be vigilant for TTS in patients experiencing pain and plantar foot paresthesias that worsen with prolonged standing and walking, or disrupt sleep.
Diagnostic Studies for Tarsal Tunnel Syndrome in workers compensation patients
Nerve Conduction Studies (NCS) for the diagnosis and pre-operative assessment of TTS patients are recommended, particularly for cases that do not show improvement with conservative treatment or when considering surgical release after ruling out alternative causes such as polyneuropathy and radiculopathy. NCS plays a valuable role in confirming the diagnosis of tibial nerve entrapment at the ankle.
However, NCS for the initial evaluation of TTS patients is not recommended during the initial phase of conservative therapy (four to six weeks), as it does not significantly impact the management of the condition at this stage.
Electromyography (EMG) for the initial evaluation, diagnosis, or preoperative assessment of TTS patients is also not recommended. While NCS is advised for the diagnosis of tibial nerve impingement and pre-operative evaluation, there is limited reliable data supporting the use of electromyography in the diagnosis of TTS.
MRI for the diagnosis of Tarsal Tunnel Syndrome is recommended, particularly for pre-operative assessment and treatment of tibial nerve impingement at the ankle. This recommendation is in line with the use of Nerve Conduction Studies (NCS) for the diagnosis and pre-operative assessment of TTS patients.
However, MRI for the initial diagnosis of Tarsal Tunnel Syndrome is not recommended during the initial evaluation. The primary diagnostic approach during the early stages is advised to be NCS.
The use of ultrasound as an aid to NCS for Tarsal Tunnel Syndrome is recommended, as it can assist in identifying suspected tarsal tunnel space-occupying lesions. This is especially useful following ineffective conservative therapy or as an adjuvant to help direct interventional therapies.
Routine use of diagnostic ultrasound for the initial examination is not recommended. It is suggested that ultrasound exams be reserved for patients who have failed conventional therapy or used as a supplement to direct interventional therapy, offering additional guidance in specific cases.
Medications for Tarsal Tunnel Syndrome
Non-Steroidal Anti-inflammatory Drugs (NSAIDs) and Acetaminophen are recommended for the treatment of Tarsal Tunnel Syndrome (TTS) pain. NSAIDs, including over-the-counter (OTC) agents, are suggested as first-line treatments for TTS pain, with as-needed use being reasonable for many patients. The goal is to discontinue NSAID use upon resolution of foot/ankle pain, lack of efficacy, or the emergence of adverse effects.
For patients at high risk of gastrointestinal bleeding who also require NSAIDs, cytoprotective medications such as proton pump inhibitors, sucralfate, H2 blockers, and misoprostol are recommended. This is particularly important for individuals with a high-risk factor profile, including those with a history of prior gastrointestinal bleeding, the elderly, diabetics, and cigarette smokers. The frequency, dose, and duration of these medications should follow the recommendations of the manufacturer.
Patients at risk for cardiovascular adverse effects who need NSAIDs should also consider cytoprotective medications, especially if a prolonged course of treatment is required. Individuals with a history of cardiovascular disease or multiple risk factors for cardiovascular events should carefully weigh the benefits and drawbacks of NSAIDs for their cardiovascular health.
These recommendations aim to provide effective pain relief while minimizing potential risks associated with NSAID use in Tarsal Tunnel Syndrome patients.
Opioids for Tarsal Tunnel Syndrome
The routine use of opioids for the treatment of pain from Tarsal Tunnel Syndrome (TTS) is not recommended. Most TTS patients do not experience pain severe enough to warrant the use of opioids. Opioids are suggested for limited and selective use, primarily in postoperative patients, and nighttime use is the main time for such use.
However, for a selected group of patients postoperatively, opioids may be recommended for restricted use, not exceeding seven days. This is applicable to patients with extensive incisions who have recently undergone tarsal tunnel release, experienced serious consequences, and have pain that is uncontrollable by other means.
The routine use of diuretics for the regular management of TTS is not recommended, as edema or swelling of the lower extremities is not a common symptom in the majority of TTS cases.
Similarly, routine use of vitamins, including pyridoxine, is not recommended for the treatment of TTS.
Lidocaine patches are recommended for the treatment of a few TTS cases. This is indicated for patients with moderate to severe TTS who have eliminated all other curable reasons for their discomfort and report pain as their primary symptom. The frequency and duration of use should follow the advice of the manufacturer, and discontinuation may be considered in case of problem-solving, intolerance, negative impacts, or inability to deliver benefits after a trial period.
Treatments for Tarsal Tunnel Syndrome
Self-application of ice or heat for the treatment of Tarsal Tunnel Syndrome (TTS) is recommended, especially for more acute symptoms. Both ice and heat can be helpful in managing symptoms.
However, nocturnal splints for the treatment of TTS are not recommended. Nocturnal splinting involves the use of splints during the night, but it is not suggested for TTS treatment based on the provided information.
Rehabilitation for Tarsal Tunnel Syndrome (TTS)
Recovery from a work-related injury requires focused rehabilitation efforts to restore functional abilities, allowing the individual to meet daily and work responsibilities and ultimately return to their pre-injury status as much as possible.
Active therapy involves the patient actively engaging in specific activities, putting internal effort into completing tasks. In contrast, passive therapy relies on modalities administered by a therapist, minimizing the patient’s own exertion.
While passive therapies are recognized for expediting the active therapy program and achieving functional gains, emphasis should be placed on prioritizing active initiatives over passive interventions.
To maintain the achieved improvement levels, patients are encouraged to continue both active and passive therapies at home, extending the therapeutic process. Additionally, incorporating assistive devices into the rehabilitation strategy can contribute to enhancing functional gains.
Rest is suggested for managing more symptomatic cases of TTS, particularly when prolonged standing or walking worsens the condition. This ankle rest can be beneficial in such situations.
Engaging in regular exercise is recommended as part of TTS treatment. Incorporating workout routines may contribute to improved function and reduced pain.
The use of taping is discouraged for TTS treatment.
Similarly, magnets are not recommended for managing TTS.
Acupuncture is also not advised for treating TTS, as other proven therapies are more effective.
Manipulation and mobilization of the distal lower extremity are not recommended for TTS treatment.
The use of ultrasound is not recommended for managing TTS.
Iontophoresis is not recommended for TTS treatment due to the effectiveness of other therapies.
Phonophoresis is also not recommended for TTS treatment, as other forms of therapy have demonstrated efficacy and should be prioritized.
Injection Therapy for Tarsal Tunnel Syndrome (TTS)
Injection therapy is recommended as a part of a careful management plan for treating Tarsal Tunnel Syndrome (TTS).
The rationale behind this recommendation lies in the frequent mention of injections as a component of conservative therapy and as an additional method to confirm a TTS diagnosis. In cases where a more cautious approach proves ineffective, glucocorticosteroid injections may be employed to address the issue.
However, insulin injections are not recommended for TTS treatment.
Similarly, botulinum injections are not advised for the treatment of TTS.
Surgery for Tarsal Tunnel Syndrome (TTS)
When nonsurgical treatments prove ineffective and there is a presence of a space-occupying lesion, surgical release is recommended. In cases where the posterior tibial nerve at the tarsal tunnel is impinged by such a lesion, surgical intervention may be necessary. However, it’s crucial to note that surgical release for cases with a generalized etiology is expected to yield variable outcomes. Therefore, patients should be informed about the potential lack of benefit before considering surgery.
Other for Tarsal Tunnel Syndrome (TTS)
Orthotics are recommended for the treatment of select patients with TTS, especially for individuals whose TTS is believed to have a biomechanical etiology.
What our office can do if you have Tarsal Tunnel Syndrome.
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