Answering Post-Procedure Questions About Tarsal Tunnel Release

Eric H. Williams MD
Specializing in reconstructive surgery and pain relief in the Greater Baltimore area.

We want treatments to put a firm end to a story of pain and problems. Unfortunately, life does not always make that the case.

Plenty of questions can remain following a tarsal tunnel release procedure, and all of them are very important! This rings especially true if your questions are concerns about your health and comfort weeks or months following the operation.

As an office that performs many tarsal tunnel release procedures, including revisions on patients who had unsuccessful procedures performed elsewhere, we receive many questions from our own patients as well as patients of other doctors. We have compiled a few of the most common and crucial questions patients may have.

Please note that we can’t guarantee the answers below will apply to all cases. Each individual may vary, and answers may sometimes be unique. Each answer below is based on most common circumstances.

How long should I expect to still feel pain after a tarsal tunnel procedure? How long should I wait until I should be concerned?

Healing from most forms of surgery takes time, but there are points when you should reasonably expect to feel improvement.

Most people will recover from the trauma of tarsal tunnel surgery itself within 4-6 weeks of an uncomplicated operation. However, depending on the general health of the patient, factors such as diabetes, morbid obesity, smoking, and poor conditioning may increase healing time for a surgical wound.

But what about the pain of the tarsal tunnel issue itself?

Some patients may report immediate relief of their tarsal tunnel symptoms (e.g. numbness, tingling, burning, shooting sensations) following surgery. Others may take up to 6 months to a year to see the same improvements. This depends on the severity of the disease and the length of time it has been present.

Patients who have a more severe disease can expect a longer recovery of nerve function. We start to get worried, however, if symptoms do not resolve after 6 months. At this time, we usually begin to look for other reasons why recovery has not happened.

A good general rule of thumb is that, if you have not started to feel improvement 4-6 weeks following your surgery, you should call the office of the surgeon who operated on you. The surgeon will naturally have the most direct knowledge of your condition and can perform an assessment to gauge your progress.

If they do not identify any problems and pain persists, it may then be time to contact us.

In some cases, pain may be resolving, but numbness is still present. It may sometimes take up to a year for sensation to come back depending on how severely the nerve was injured. Certain conditions, such as diabetes (once again), can also complicate things.

When should I be able to drive again after tarsal tunnel surgery?

This is a frequent question, but by no means a silly one. Many of us need to get around, and may not have the right access to public transportation to do so.

The answer to this question does depend on a few factors, though. Is it the right or left foot? Do you have an automatic vehicle or a manual?

If you use the foot that has been operated on for driving (i.e. using the clutch with the left, or using the right foot for gas and brake), the necessary requirements are:

  • You are still not taking narcotic pain pills, or other medications that may impair your ability to drive. If you have not been taking any, then there should be no problem here.
  • You must be able to comfortably step on a brake pedal or clutch without pain. This often takes 3-4 weeks, but sometimes longer if you have had a revision surgery or more complicated standard procedure. We don’t care how fast you go—it’s how fast you stop. If you can’t hit a brake hard and fast enough to save either your life or the life of someone in front of you, do not drive.
  • Your friends and family should be comfortable letting you drive. We sometimes try to delude ourselves into being more capable than we are at a given time. If they do not want to get in the car with you, take their advice and give yourself more time.

Will I have a cast on or be immobilized?

There are different schools of thought on this matter.

Our philosophy is not to immobilize patients, because we want the nerves we have operated on to move and glide while scar tissue is forming around them.

If you wanted to create steel-reinforced concrete, you put metal rebar in concrete and leave it there, unmoving. We don’t want that, however; we want the nerve to be mobile and not trapped in scar tissue. We see far more problems with nerves being stuck in scar tissue than we do with wounds reopening.

All said, we do like to put patients in soft, bulky dressings for one week. You will be able to walk on it (gingerly), and bear weight on it as tolerable 48 hours after surgery. Most people will also use crutches for around 3 weeks following surgery, and be off them by then.

Why does it still hurt after my surgery?

If your tarsal tunnel procedure has not resulted in as much pain relief as you expected or were told there would be, why would that be?

You might be surprised to know this happens more often than you might expect.

Dr. Williams has been trained under Dr. A. Lee Dellon, a surgeon who has studied why tarsal tunnel procedures sometimes have poor outcomes, and what can be done to both find correction and prevent such outcomes from happening in the first place.

The most common cause for failure of a tarsal tunnel procedure is that we believe it has been largely taught incorrectly or inadequately. Most doctors have been trained to release the tibial nerve in the tarsal tunnel (above the ankle) only. However, other potential compression points often affect the medial plantar, lateral plantar, and calcaneal nerves downstream of the tarsal tunnel and are either not addressed or incompletely addressed. Each one of these nerves travels through their own individual tunnel and frequently need to be completely released.

This is not an individual surgeon’s fault, but rather something that stems from education. There has been a concerted effort in recent years to provide updated and more comprehensive training in this field.

Another potential cause of lasting pain after tarsal tunnel release (even if it does include a release of all nerves mentioned above) may come from immobilizing patients in casts or boots. This is often a standard procedure, but, as we have previously mentioned, the nerve may not move or glide as it is meant to when the foot and ankle are confined. This can lead it to become entrapped in scar tissue, causing pain.

A similar situation can happen if there was extensive bleeding, signified by heavy bruising. Significant bleeding within the site can also create more scar tissue and entrap a nerve.

There is also the possibility that tarsal tunnel surgery was not the operation you needed. The diagnosis could have been wrong and the underlying problem not properly addressed. Compression of the proximal tibial nerve at the soleal sling in the upper calf can mimic tarsal tunnel syndrome rather well, and may be one misleading factor.

Finally, there are rare circumstances where the nerve compression is so severe that the nerve simply will not recover. If all other factors have been ruled out, this may be the potential cause. This is most likely in patients who have had years of pain or numbness.

Why is my pain worse?

Still having pain following a tarsal tunnel procedure is one thing. Having worse pain or unexpected problems (such as numbness) is another!

If pain and numbness have worsened it may mean that a nerve had been damaged during the procedure. It may have been a major nerve, such as the tibial nerve itself or one of its branches (medial plantar, lateral plantar, or calcanel nerve). It may also have been a minor nerve branch within the inner arch or heel.

If it was a minor nerve, they can be notoriously difficult to see. The medial calcaneal nerve, for example, is about 0.5-1 mm in size. Magnification is helpful to allow the surge to see it and. And even when you look for it, it may still end up injured.

A full evaluation is naturally required to determine what may be wrong. This starts by determining whether the whole foot feels worse or just a specific area that correlates well to one of the major nerve branches (medial plantar, lateral plantar, or calcaneal nerves).

It is important to understand that there is always a possibility for complications to occur with any operation, even in properly trained hands. The only surgical team that has no complications is a surgical team that does not operate.

What if I need revision surgery? What does that mean?

If pain still remains from a tarsal tunnel procedure, the plan of treatment may involve a second surgery to address any issues that may have been caused or are remaining from the original. About one-quarter to one-third of our tarsal tunnel procedures are revision surgeries.

Before a revision surgery, we typically recommend waiting about 6 months from the first procedure before returning to the site. Individual cases may vary but, in general, tissues must have time to recover and heal, and going back in too soon can cause further complications.

Waiting is naturally not ideal if you are currently experiencing pain. What do you do in the meantime?

  • Maximize nutrition. Eat healthy.
  • Work on non-impact exercises, like water walking, to help the affected nerves move and glide and help with desensitization. Formal physical therapy may be necessary.
  • Pain management may be needed, depending on severity.

Each case is different, and we will be sure to provide full recommendations and plans following an examination and diagnosis.

Have More Questions? We Can Help!

If you have questions that have not been addressed here, or have been in pain for a significant time following a tarsal tunnel procedure, our office can help.

Give us a call at (410) 709-3868. If you prefer to contact us electronically, you are also welcome to fill out our online contact form.

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