Tarsal Tunnel Surgery

Tarsal tunnel syndrome causes an array of symptoms in the sole of your foot (including heel, arch, ball of foot, and toes). If you are experiencing issues in the top of your foot, you might have a different medical condition (possibly a compressed nerve in your ankle or foot). With that being said, it is certainly possible to have both tarsal tunnel syndrome and a second issue. In fact, this happens often with diabetic individuals or those who sustain ankle sprains and other ankle injuries.Tarsal Tunnel Surgery

If you have tarsal tunnel syndrome, you could experience problems like:

  • Severe burning pain in the bottom of the foot
  • Feeling as though fire ants are biting
  • Hypersensitivity in foot
  • Feeling as though stepping on shards of glass
  • Pain coming up into the inner ankle, especially behind the bone that sticks out (medial malleolus)
  • Feeling like someone plugged your foot into electrical socket
  • Foot falling asleep easily after activity
  • Cramping or curling toes

If you are experiencing any of those symptoms in the sole of your foot, it could be the result of a compressed nerve in your ankle, and you may need to have your tibial nerve (along with its medial plantar, lateral plantar, and calcaneal branches – each of which has their own respective tunnels) evaluated to determine if you might be a candidate for tarsal tunnel surgery. (Particularly if the symptoms are severe to the point they keep you up at night.) If you also have pain in the top of the foot, you may need to check out our common peroneal nerve webpage to see if this sounds like the problem you are experiencing.

Traditionally, it had been thought that the problem is directly related to the tibial nerve in the tarsal tunnel. A. Lee Dellon, MD, PhD, however, has pioneered recent changes in the field of tarsal tunnel surgery by discovering that the problem may be a matter of issues with the four tunnels (and not a single one) that need to be addressed for complete relief.

The condition arises when too much pressure is placed on the tibial nerve, or any of its three branches. The calcaneal nerve goes to the heel, the later plantar nerve goes to the outer half of the foot and toes, and the medial plantar nerve goes to inner half of the foot and toes. When there is too much pressure, it cuts off blood supply to the nerve(s), which then causes problems to develop.

As we look at this ailment, it should be noted there are nonsurgical treatment options that might be able to resolve the problem for you before it becomes serious. In fact, you probably should start your search for relief by visiting a podiatrist first. You may need orthotics, physical therapy, special footwear, or other nonsurgical care.

If symptoms are severe, have been present for a long time, and conservative treatment methods haven’t worked, surgery may be the best course of action. Dr. Eric H. Williams has extensive experience with and has been involved with research in this area since 2006.

Dr. Williams is passionate about taking away patients’ pain from this condition—it’s one of his favorite procedures to perform—and will be glad to help if you cannot find it elsewhere.

Tarsal Tunnel Syndrome

The best starting point for looking at this particular ailment is with a structure found on the inner edge of your ankle known as the tarsal tunnel. This is a narrow space covered by a thickened, fibrous connective tissue (the flexor retinaculum) which serves to protect the anatomical structures it contains – tendons, nerves, arteries, and veins. As it relates to this condition, an important nerve found within the “tunnel” is your tibial nerve.

The problem begins when there is a squeezing or compression on the tibial nerve (and its branches), and this is similar to the carpal tunnel syndrome that can occur in the wrist. In both cases, the root cause of pain and discomfort is compression on nerves found in confined spaces. Down in your tarsal tunnel (and the other tunnels), the source of that compression can come from any of several different possibilities, such as arthritic bone spurs, ganglion cysts, swollen tendons, and varicose veins.

Some cases of tarsal tunnel syndrome develop in response to injury (physical trauma), particularly ones that cause swelling or inflammation in or near your tarsal tunnel. In other instances, a systemic disease (like arthritis or diabetes) causes the swelling. In the case of arthritis, the swelling happens around the nerve, whereas a systemic disease like diabetes or hyperthyroidism causes the nerve itself to swell. Additionally, individuals who have flat feet also have higher risk, which can be attributed to an outward tilting of the heel as a result of the structural abnormality.

Persistent Tarsal Tunnel Symptoms

In the event you have recently had surgery on a tarsal tunnel and are not better, it’s possible that what you are experiencing—particularly with regards to tingling and burning sensations—is the result of an incomplete procedure. Your treating physician may have tried his or her best, but was unaware that the problem could be the result of issues in the branches downstream (or upstream) from the tarsal tunnel.

At other times, the surgery didn’t work because it’s not tarsal tunnel syndrome at all. Sometimes, when the problem is still present after surgery, it might be caused by pinched nerves upstream. The issue could be a pinched proximal tibial nerve (which is an area that Dr. Williams has pioneered himself) in the calf. As a final possibility, scar tissue pressing on the nerve or nerves entrapped in scar tissue could be a problem.

Tarsal Tunnel Surgery

Our current understanding of tarsal tunnel surgery has demonstrated that the condition is much more complicated than it was previously thought.

The tarsal tunnel is important. It is the starting point – but cannot be thought of as the endpoint for resolving this particular problem. If your current physician does not describe to you the four distinct nerves that may pinched, they are likely working from an outdated model of this particular disease process. We would be happy to evaluate your case and possibly often a second opinion.

Research done in our office and spearheaded by Dr. A Lee Dellon—pioneer of peripheral nerve surgery (and mentor and partner of Dr. Williams)—has shown that releasing the four tunnels is necessary to provide optimal relief in many cases. This work has redefined tarsal tunnel syndrome treatment. Much of the data has proven that issues can be downstream, and not entirely in the ankle. For this reason, those who previously had this medical condition basically only had half of the surgery they needed.

This surgery requires an incision to be made behind your ankle and extending down to the arch of your foot. From there, the connective tissue over the tibial nerve is carefully released, along with the tunnels for the lateral and medial plantar nerves. Finally, the calcaneal branch, which has its own tunnel is also released. In the event the ailment is caused by a growth, it will be removed.

Following the surgery, you will likely feel numbness in the affected foot or leg. This can be attributed to the long-acting anesthetic used to help with tarsal tunnel surgery postoperative pain. The soft, bulky dressing applied after the procedure will need to be kept on the repaired site before removal after one week. Most people will need crutches or a walker (depending on mobility) to assist with walking for the first week.

As with any procedure, it is important to control swelling. In this case, you will want to elevate your foot as much as possible, and also move your toes, ankle, knee, and hips periodically to prevent a nerve becoming stuck in scar tissue.

Walking will be limited based on the amount of weight your foot can comfortably handle. You may need to use crutches or a walker at first to decrease the amount of weight-bearing on your foot (however, many people switch to a cane after a week or two). With regards to driving after tarsal tunnel surgery, you definitely will not be able to drive home after the procedure (so arrange a ride to and from the surgery). Additionally, Dr. Williams will not allow you to drive for the first two to three weeks, if surgery was performed on the right foot. And you will definitely not be able to drive while you are on prescribed pain medication.

Once sutures have been removed, water walking is a valuable therapeutic exercise. This helps with gait, while allowing for self-directed physical therapy.

Other postoperative matters include performing range-of-motion exercises and using an elastic wrap to control swelling in the foot. Typically, we remove stitches about two to three weeks after the procedure, depending on how the surgical wound is healing. Full weight-bearing can be resumed once you feel comfortable. Depending on your particular case, Dr. Williams could recommend physical therapy.

Expert Surgical Care

This is a complex issue that requires careful, thoughtful care to resolve it. Dr. Williams has extensive experience with failed, persistent, and recurrent cases of tarsal tunnel syndrome, and he may be able to help you.

Dr. Williams’ tutelage under A. Lee Dellon, MD, PhD—who is widely-renowned as one of the pioneers in the modern field of peripheral nerve surgery—has provided him the most advanced training and experience possible for tarsal tunnel surgery. There are few peripheral nerve specialists who have had the opportunity to spend a full year of fellowship training under the guidance of Dr. Dellon, but Dr. Williams is one of them, and this means you can rest assured knowing you are in the hands of an expert surgeon.

Currently, Dr. Williams has been with the Dellon Institutes for Peripheral Nerve Surgery over ten years.

For additional information on tarsal tunnel surgery—or to request an appointment for consultation—simply give our Baltimore, MD office a call at (410)709-3868 and a staff member will be happy to assist you.

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