The Prolotherapy approach to treating Tarsal Tunnel Syndrome

Tarsal Tunnel Syndrome | posterior tibial neuralgia

In this article we will discuss various treatment options for Tarsal Tunnel Syndrome including the non-surgical application of Prolotherapy.

You have been limping around dealing with a shooting and/or chronic pain on the inner side of your ankle. Sometimes it is a burning pain, sometimes there is an electric shock feel to it. Sometimes there is numbness. While the pain seems to be in the general ankle area, it is not really your ankle that you feel is causing your pain and discomfort, you have vague symptoms of pain in the arch, toes, and/or heel as well.

You have reached a point where you have tried many things on your own including recommendations that you may have found on the internet that includes . . .

  • Rest and staying off your feet or foot as best you can.
  • A rotation of 20 minutes on 40 minutes off Rice therapy.
  • Taking over-the-counter medications, such as Nonsteroidal anti-inflammatory drugs (NSAIDs), to reduce the pain and inflammation.
  • Getting an ankle brace or ace bandage which you have found did not really help and may create more pressure in your foot.

. . . and you have found that these remedies are not helping you at all. Worse, you are getting worse.

Worse, you are getting worse

  • You are getting unsteady on your feet and suffer from motor disturbances, which may include spasms, twitching, weakness, atrophy, numbness, and gait abnormalities.

Tarsal Tunnel Syndrome or something else?

It is very likely that if you are reading this article you found us through your own research on your symptoms and what you can do about it, or, you went to a health care provider and you may have been introduced to the term Tarsal Tunnel Syndrome. Your health care provider is suspecting a nerve problem as he/she may believe you have pressure or impingement on the posterior tibial nerve that runs on the inside of the ankle into the foot.

You have the symptoms, numbness, pain on the inner side of the ankle into the foot, but do you really have Tarsal Tunnel Syndrome?

Foot specialists writing in the medical journal Foot (1) discussed the difficulties of making an accurate diagnosis of Tarsal Tunnel Syndrome and then what to do once you confirm it. Effective treatments can be a challenge. Let’s hear what the doctors of this study have to say:

  • Tarsal tunnel syndrome is classified as a focal compressive neuropathy (a direct pressure) on the posterior tibial nerve (a branch of the sciatic nerve that runs into the heel. This is why it is also diagnosed as posterior tibial neuralgia or more simply as “ankle pain.”)
  • The condition is rare and regularly under-diagnosed leading to a range of symptoms affecting the plantar (sole) of the foot.
  • There are many intervention strategies for treating tarsal tunnel syndrome with limited robust evidence to guide the clinical management of this condition. The role of conservative versus surgical interventions at various stages of the disease process remains unclear.

So foot specialists are troubled by accurate diagnosis and accurate treatment. The non-surgical conservative care options are those discussed above, Rest, ICE, NSAIDs, etc. Remedies that you have probably found ineffective, that is why you went to the doctor.

Other foot specialists also wrote about the difficulties of making an accurate diagnosis of Tarsal Tunnel Syndrome and then what to do once you confirm it. Here is a study from university researchers in Italy published in Neurological sciences.(2)

  • (Tarsal tunnel syndrome) is a condition frequently underdiagnosed leading to controversies regarding its management and to an intense debate in the medical literature.
  • Management of this entrapment neuropathy remains challenging because of many intervention strategies but limited robust evidence.
  • Uncertainties still exist about the best conservative treatment, timing of surgical intervention, and best surgical approach.

Many things can cause a diagnosis of “Tarsal Tunnel Syndrome.”

Above you read the concerns of foot specialists in the diagnosis and treatment of Tarsal Tunnel Syndrome. In this section we will try to provide information that you may be able to use to make sure that you have Tarsal Tunnel Syndrome or you do not have tarsal tunnel syndrome and that with this information you can help your health care providers guide your treatment.

Many things can cause a diagnosis of “Tarsal Tunnel Syndrome.”

The heading of this section specifically points out that many things can cause a diagnosis of “Tarsal Tunnel Syndrome.” We hope here to point out that while your problem may look like Tarsal Tunnel Syndrome and get you a diagnosis of Tarsal Tunnel Syndrome, you may not have Tarsal Tunnel Syndrome.

What can cause true Tarsal Tunnel Syndrome?

External traumas such as crush injuries, stretch injuries, fractures, dislocations and strains of the foot and ankle, can contribute to the development of Tarsal Tunnel Syndrome.

Intrinsic issues such as soft-tissue masses (cysts, inflammation) may also contribute to compression neuropathy of the posterior tibial nerve. Bone spurs may be a causative factors. Valgus deformity of the hindfoot (ankle and heel) which may increase tension due to excessive eversion and dorsiflexion (unnatural rotation).

What can look like “Tarsal Tunnel Syndrome?”

Is it lumbosacral radiculopathy?

You may find it odd that in our clinics you come in with a diagnosis of Tarsal Tunnel Syndrome and a painful foot condition and we may want to take a look at your lower back. What are we looking for? Spinal instability that may be causing pain down to your legs. We are going to bring in two different teams of surgeons to explain this to you.

First we have a team of medical university surgeons from China who co-authored research with the Department of Physical Medicine and Rehabilitation, Upstate Medical University, State University of New York at Syracuse doctors. This research is published in the European Spine Journal.(3)

The concern here is that doctors will misdiagnose a back pain problem as Tarsal Tunnel Syndrome, or the similarities in both these conditions may confuse treatment. Here is what the research said:

  • Tarsal tunnel syndrome and Lumbosacral radiculopathy share many of the symptoms occurring in Tarsal Tunnel Syndrome. Chinese and American researchers writing in the European Pain Journal  suggest that the prevalence of Tarsal tunnel syndrome is significant in patients with Lumbosacral radiculopathy. Thus, more caution should be paid when diagnosing and managing patients with lumarsacral radiculopathy due to the possible existence of Tarsal tunnel syndrome, as their management strategies are quite different.

This is a serious concern for the surgeons. Someone with numbness or burning pain in the feet maybe diagnosed as having this pain from a problem with the nerves in the spine. This person is then sent off to surgery and after the surgery, they still have burning pain in their foot/feet.

Let’s bring in the second group of surgeons who were looking at 13 patients who had continued pain after lumbar disc surgery. This is from Japanese medical university surgeons writing in the Asian Spine Journal.(4)

“We evaluated and treated 13 patients with persistent or recurrent symptoms after lumbar disc herniated surgery. (Four patients had to have the surgery redone). The other nine patients manifested no radiological abnormalities that explained their persistent or recurrent symptoms. (In other words the MRI of their spine showed nothing wrong). However, treatment for Peripheral Neuropathy resulted in symptom abatement in these patients, suggesting that factors other than lumbar disease were involved.”

In other words, the person in this group with foot pain suspected to come from the nerves got a spinal surgery. When they receievd a nerve block the doctors realized it was Tarsal Tunnel Syndrome all along.

Clearly the treatment of Tarsal tunnel syndrome presents challenge.

Is it plantar fasciitis?

Metatarsal ligament weakness is manifested by pain at the ball of the feet which often radiates into the toes. This is called metatarsalgia. Chronic metatarsal ligament weakness and arch weakness is known as plantar fasciitis. Fasciitis can cause numbness in the foot and toes in the same areas of pain. Pain and numbness in the foot can also be caused by ligament and tendon laxity in the knee. The lateral collateral ligament can refer pain and numbness down the lateral side of the leg and foot and the medial collateral ligament down the medial side.

  • It’s important to note that the pain experienced in the ankle with Tarsal Tunnel Syndrome is often referred pain and may be due to injured or weakened ligaments at the ball of the foot. The problems with diagnosis is the problem of the sprain or weakening of the metatarsal, lateral collateral and medial collateral ligaments, ligaments which are causing the pain and are rarely examined by a family physician or an orthopedic surgeon.

Treatment of Tarsal Tunnel Syndrome

Tarsal Tunnel Syndrome Surgery

In this section we are going to talk about the actual foot surgery. Surgery, too, can make the condition worse, especially when the condition has been misdiagnosed, which is often the case. This is not just a misdiagnoses as it relates to the lower spine causing issues, but a misdiagnosis of other foot issues that can be masquerading as Tarsal Tunnel Syndrome or hiding the true diagnosis of Tarsal Tunnel Syndrome.

Since we are talking surgical failures, let’s bring in the surgical opinion.

In the medical journal Foot and ankle clinics,(5) John S. Gould, MD Division of Orthopaedic Surgery, Section of Foot and Ankle, University of Alabama at Birmingham wrote:

“Recurrence of tarsal tunnel syndrome after surgery may be due to inadequate release, lack of understanding or appreciation of the actual anatomy involved, variations in the anatomy of the nerve(s), failure to execute the release properly, bleeding with subsequent scarring, damage to the nerve and branches, persistent hypersensitivity of the nerves, and preexisting intrinsic damage to the nerve. Approaches include more thorough release, use of barrier materials to decrease adherence of the nerve to surrounding tissues to avoid traction neuritis, excisions of neuromas using conduits, and consideration of nerve stimulators and systemic medications to deal with persistent neural pain.”

The Prolotherapy approach to treating Tarsal Tunnel Syndrome

Step 1: Determine if the patient’s diagnosis is actually Tarsal Tunnel Syndrome. We using EMG/NCV studies, which measure the rate of nerve conduction. Confirmation of the diagnosis as well as the stage of the syndrome is determined by the degree of slowing of the nerve conduction. If the syndrome is detected in the early stages, Neural Therapy treatment is performed. This is a gentle healing technique developed in Germany that involves the injection of local anesthetics into autonomic ganglia, peripheral nerves, scars, glands, acupuncture points, trigger points, skin and other tissues. If, on the other hand, the tarsal tunnel syndrome is at an advanced stage, surgery may be necessary.

If the symptoms of tarsal tunnel syndrome are found to be due to weakened ligaments, then strengthening of the weakened ligaments in the foot with Prolotherapy would be recommended.

How Prolotherapy works

Prolotherapy is a treatment that regenerates and strengthens the injured structures, such as the weakened ligaments discussed above. Prolotherapy solution stimulates the body’s own mechanism for healing. If the metatarsal, lateral collateral and medial collateral ligaments are found to be the source of injury, then these weakened ligaments would be injected with a Prolotherapy solution triggering a localized mild inflammation. This produces a wound healing response resulting in an increased blood supply and deposits of new collagen. Ligaments are made of collagen, so those weakened ligaments that are causing the pain and other symptoms, become stronger with the new and tighter collagen. As they repair, the symptoms abate.

The tissue strengthening and pain relief stimulated by Prolotherapy is permanent.  Individuals receiving Prolotherapy are also able to continue with sports, work, and other activities between treatments. Contrary to the postsurgical protocols that require extended time off of your feet; activity, walking, and movement would be encouraged.

Danielle Steilen-Matias, PA-C | Katherine Worsnick, PA-C | Ross Hauser, MD | David Woznica, MD

1 McSweeney SC, Cichero M. Tarsal tunnel syndrome-A narrative literature review. Foot (Edinb). 2015 Dec;25(4):244-50. doi: 10.1016/j.foot.2015.08.008. [Google Scholar]
2 Doneddu PE, Coraci D, Loreti C, Piccinini G, Padua L. Tarsal tunnel syndrome: still more opinions than evidence. Status of the art. Neurological Sciences. 2017 Jun 29:1-5 [Google Scholar]
3. Zheng C, Zhu Y, Jiang J, Ma X, Lu F, Jin X, Weber R. The prevalence of tarsal tunnel syndrome in patients with lumbosacral radiculopathy. Eur Spine J. 2016 Mar;25(3):895-905. doi: 10.1007/s00586-015-4246-x. Epub 2015 Sep 25. [Google Scholar]
4 Yamauchi T, Kim K, Isu T, Iwamoto N, Yamazaki K, Matsumoto J, Isobe M. Undiagnosed Peripheral Nerve Disease in Patients with Failed Lumbar Disc Surgery. Asian Spine Journal. 2018 Aug;12(4):720. [Google Scholar]
4. Gould JS. Recurrent tarsal tunnel syndrome. Foot and ankle clinics. 2014 Sep 1;19(3):451-67. [Google Scholar]


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