Anterior Tarsal Tunnel Syndrome

with Rehab

ExitCare ImageDeep peroneal nerve compression, or anterior tarsal tunnel syndrome, is a condition in which a nerve of the foot is damaged causing pain and a loss of feeling. This often occurs in the foot between the first and second toes or the upper outer foot by the ankle. The nerve that is affected is known as the deep peroneal nerve, and it is susceptible to being compressed by structures near it, such as the ligament-like tissue (retinaculum).

SYMPTOMS

  • Tingling, numbness, or burning in the foot between the first and second toes and occasionally in the upper outer foot by the ankle.

  • Pain and discomfort in the ankle and on top of the foot, occasionally radiating to the upper outer foot (near the ankle), and between the first and second toes.

  • Pain, usually with sports activities, and often felt at night.

  • Pain that is relieved by removing shoes and resting.

  • Possibly, weakness in extending the toes.

CAUSES

Anterior tarsal tunnel syndrome is caused by pressure being placed on the deep peroneal tendon. The pressure may be caused by a ligament-like tissue that covers the nerve, bone spurs, ganglion cysts, inflammation, or direct injury (ie. kicking or even from keys placed in the laces of jogging shoes).

RISK INCREASES WITH:

  • Recurrent ankle sprains.

  • Sports that involve kicking (ie. soccer).

  • External pressure placed on the peroneal nerve (ie. tight shoes or ski boots, tying a key in the lacing of shoes, or doing sit-ups with a foot hooked under a bar).

  • Poor strength and flexibility.

  • Arthritis or bone spurs of the ankle.

PREVENTION

  • Warm up and stretch properly before activity.

  • Maintain physical fitness:

  • Foot and ankle flexibility.

  • Muscle strength and endurance.

  • Cardiovascular fitness.

  • Ensure proper fitted equipment (ie. shoes or ski boots).

  • Taping, protective strapping, bracing, or high-top tennis shoes may help prevent ankle sprains and nerve-stretching injury.

  • Do not tie keys to shoelaces.

PROGNOSIS

If treated properly, then anterior tarsal tunnel syndrome is usually curable; some cases may resolve spontaneously. Occasionally, surgery is necessary.

RELATED COMPLICATIONS

  • Permanent numbness and weak toes in the affected foot.

  • Persistent pain in the foot or ankle.

  • Inability to compete due to pain.

TREATMENT

Treatment initially involves stopping and resting from any activities that cause symptoms to worsen. It may be beneficial for you to try wearing padding (ie. Moleskin) over the deep peroneal nerve to try and help relieve the pressure. Often times strengthening and stretching exercises are beneficial for reducing the negative symptoms. These exercises may be completed at home or with a therapist. If conservative (non-surgical) treatment is unsuccessful at eliminating the painful symptoms, then surgery may be necessary. Surgery involves freeing the compressed nerve by removing the source of pressure. Most patients who undergo surgery experience complete relief from symptoms.

MEDICATION

  • If pain medication is necessary, then nonsteroidal anti-inflammatory medications, such as aspirin and ibuprofen, or other minor pain relievers, such as acetaminophen, are often recommended.

  • Do not take pain medication within 7 days before surgery.

  • Prescription pain relievers may be given if deemed necessary by your caregiver. Use only as directed and only as much as you need.

HEAT AND COLD

  • Cold treatment (icing) relieves pain and reduces inflammation. Cold treatment should be applied for 10 to 15 minutes every 2 to 3 hours for inflammation and pain and immediately after any activity that aggravates your symptoms. Use ice packs or an ice massage.

  • Heat treatment may be used prior to performing the stretching and strengthening activities prescribed by your caregiver, physical therapist, or athletic trainer. Use a heat pack or a warm soak.

SEEK MEDICAL CARE IF:

  • Symptoms get worse or do not improve in 2 weeks despite treatment.

  • New, unexplained symptoms develop (drugs used in treatment may produce side effects.)

EXERCISES

RANGE OF MOTION (ROM) AND STRETCHING EXERCISES - Anterior Tarsal Tunnel Syndrome

These exercises may help you when beginning to rehabilitate your injury. Your symptoms may resolve with or without further involvement from your physician, physical therapist or athletic trainer. While completing these exercises, remember:

  • Restoring tissue flexibility helps normal motion to return to the joints. This allows healthier, less painful movement and activity.

  • An effective stretch should be held for at least 30 seconds.

  • A stretch should never be painful. You should only feel a gentle lengthening or release in the stretched tissue.

ExitCare Image RANGE OF MOTION- Ankle Plantar Flexion

  • Sit with your right / left leg crossed over your opposite knee.

  • Use your opposite hand to pull the top of your foot and toes toward you.

  • You should feel a gentle stretch on the top of your foot/ankle. Hold this position for __________ seconds.

Repeat __________ times. Complete __________ times per day.

ExitCare Image RANGE OF MOTION - Ankle Eversion

  • Sit with your right / left ankle crossed over your opposite knee.

  • Grip your foot with your opposite hand, placing your thumb on the top of your foot and your fingers across the bottom of your foot.

  • Gently push your foot downward with a slight rotation so your littlest toes rise slightly

  • You should feel a gentle stretch on the inside of your ankle. Hold the stretch for __________ seconds.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image RANGE OF MOTION - Ankle Inversion

  • Sit with your right / left ankle crossed over your opposite knee.

  • Grip your foot with your opposite hand, placing your thumb on the bottom of your foot and your fingers across the top of your foot.

  • Gently pull your foot so the smallest toe comes toward you and your thumb pushes the inside of the ball of your foot away from you.

  • You should feel a gentle stretch on the outside of your ankle. Hold the stretch for __________ seconds.

Repeat __________ times Complete this exercise __________ times per day.

STRENGTHENING EXERCISES - Anterior Tarsal Tunnel Syndrome

These exercises may help you when beginning to rehabilitate your injury. They may resolve your symptoms with or without further involvement from your physician, physical therapist or athletic trainer. While completing these exercises, remember:

  • Muscles can gain both the endurance and the strength needed for everyday activities through controlled exercises.

  • Complete these exercises as instructed by your physician, physical therapist or athletic trainer. Progress the resistance and repetitions only as guided.

  • You may experience muscle soreness or fatigue, but the pain or discomfort you are trying to eliminate should never worsen during these exercises. If this pain does worsen, stop and make certain you are following the directions exactly. If the pain is still present after adjustments, discontinue the exercise until you can discuss the trouble with your clinician.

ExitCare Image STRENGTH - Plantar-flexors, Standing

  • Stand with your feet shoulder width apart. Steady yourself with a wall or table using as little support as needed.

  • Keeping your weight evenly spread over the width of your feet, rise up on your toes.*

  • Hold this position for __________ seconds.

Repeat __________ times. Complete this exercise __________ times per day.

*If this is too easy, shift your weight toward your right / left leg until you feel challenged. Ultimately, you may be asked to do this exercise with your right / left foot only.

ExitCare Image STRENGTH - Towel Curls

  • Sit in a chair positioned on a non-carpeted surface.

  • Place your foot on a towel, keeping your heel on the floor.

  • Pull the towel toward your heel by only curling your toes. Keep your heel on the floor.

  • If instructed by your physician, physical therapist or athletic trainer, you may add weight to the end of the towel.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Ankle Eversion

  • Secure one end of a rubber exercise band/tubing to a fixed object (table, pole). Loop the other end around your foot just before your toes.

  • Place your fists between your knees. This will focus your strengthening at your ankle.

  • Drawing the band/tubing across your opposite foot, slowly, pull your little toe out and up. Make sure the band/tubing is positioned to resist the entire motion.

  • Hold this position for __________ seconds.

  • Have your muscles resist the band/tubing as it slowly pulls your foot back to the starting position.

Repeat __________ times. Complete this exercise __________ times per day.

ExitCare Image STRENGTH - Ankle Inversion

  • Secure one end of a rubber exercise band/tubing to a fixed object (table, pole). Loop the other end around your foot just before your toes.

  • Place your fists between your knees. This will focus your strengthening at your ankle.

  • Slowly, pull your big toe up and in, making sure the band/tubing is positioned to resist the entire motion.

  • Hold this position for __________ seconds.

  • Have your muscles resist the band/tubing as it slowly pulls your foot back to the starting position.

Repeat __________ times. Complete this exercises __________ times per day.