Introduction

Tarsal Tunnel Syndrome causes pain, tingling, or burning sensations in the foot. This syndrome occurs when the posterior tibial nerve is compressed and causes burning symptoms under the foot and sometimes up to the legs. 

The compression of the tibial nerve causes pain ranging from moderate to severe and may even disrupt daily activities. Luckily, the symptoms can be managed with physiotherapy exercises, painkillers, and NSAIDs ( anti-inflammatory drugs). These medications play a huge role in managing the syndrome by reducing inflammation, relieving pain, improving mobility, and quality of life.

Tarsal Tunnel Syndrome

Tarsal Tunnel syndrome, also called posterior tibial neuralgia, is a disorder in which the Posterior Tibial nerve is compressed or squeezed either due to injury, flat feet, or overuse of the feet, causing stabbing pain. The posterior tibial nerve runs down the leg and passes behind the inner side of the ankle bone, through a space called the Tarsal Tunnel, unitl finally reaching the bottom of the foot.

Description: Tarsal tunnel illustration.

Author: Nicole Williams, Jake Willet, Damian Clark, David Ketteridge

Attribution: Nicole Williams, Jake Willet, Damian Clark, David Ketteridge, CC BY 4.0 <https://creativecommons.org/licenses/by/4.0>, via Wikimedia Commons 

Available from: https://commons.wikimedia.org/wiki/File:Tarsal_tunnel.png

Tibial nerves help to feel sensations such as temperature, touch, pain, and movement, such as standing, walking, or curling toes; sending signals to the brain for the interpretation of changes in the environment.

This condition is mostly found due to underlying conditions such as diabetes and arthritis,¹ It is mostly found in athletic people because of extensive strain on the foot.

Causes

• Chronic conditions such as Diabetes, arthritis 
• People with flat feet, which causes more compression of the tibial nerve
• Acute injuries
• Abnormal growths of tumours or cysts can also apply more pressure on the nerves and cause symptoms

Signs and symptoms

• Burning
• Numbness
• Tingling sensations in the bottom of the feet
• Stabbing Pain in severe cases
• Swelling of the ankle and feet

Role of inflammation and the development of symptoms 

Elevated pain sensitivity

Compression of the tibial nerves can cause inflammation and swelling, and it can also sensitise the nerves, which can cause sharp pain or tingling even at slight movements.

Restricted blood flow

Along with the tibial nerves, the blood vessels are sometimes also compressed, which can obstruct blood flow to the feet and cause numbness or loss of all sensations to the feet.

Anti-inflammatory drugs for Tarsal Tunnel Syndrome

NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)

The most common NSAIDs are Ibuprofen, Naproxen and Diclofenac. Ibuprofen is the most common over-the-counter drug as it is analgesic, antipyretic, and anti-inflammatory.

Ibuprofen

Ibuprofen is a very common drug used for treating a variety of conditions and diseases. It is a non-selective drug and works by inhibiting both the cyclooxygenase enzymes (COX-1) and (COX-2). The COX enzymes produce prostaglandin; hormone-like substance which causes inflammation, pain, and fever. In tarsal tunnel syndrome, prostaglandins are released, which causes the symptoms and makes the pain unbearable.²

Ibuprofen reduces the inflammation, pain, and swelling by blocking the COX enzyme and decreasing the production of prostaglandins.

Caution 

Since NSAIDS are non-selective, they also inhibit COX-1 enzymes, which release mucoprotective prostaglandins to protect the stomach lining from the acid in the stomach. Therefore, it must be used with caution in patients who suffer from gastrointestinal issues or ulcers.

Adverse effects include

• Abdominal pain
• Nausea
• Vomiting
• Lethargy
• Vertigo
• Hepatic Failure
• Renal Failure
• Convulsions

Naproxen and Diclofenac

Similar to Ibuprofen, they are also non-selective COX inhibitors and reduce the synthesis of prostaglandins. They also cause GI upset due to their activity on the COX-1 enzymes. Naproxen is more potent than diclofenac.³ You must consult your doctor or pharmacist on the dose and administration procedure.

Caution 

NSAIDs are risky for patients suffering from cardiovascular diseases; however, Naproxen has less risk of worsening the condition as compared to ibuprofen. If you are suffering from Tarsal syndrome and have underlying heart conditions, then you must inform your physician, as it can be life-threatening if ignored.

Corticosteroids

Corticosteroids are also called steroids or glucocorticoids. They decrease inflammation and swelling ⁴ by the suppression of the immune system. They include

• Cortisone
• Hydrocortisone 
• Prednisone

Corticosteroid injections are directly administered at the tarsal tunnel, close to the nerves which provide relief from tarsal tunnel syndrome for weeks or even months. The injections must not be administered more than 3 times a year.⁵

The corticosteroids don't treat the underlying problem, compressed nerves. It just provides temporary relief from the pain.

Side effects of Corticosteroids

• Pain at the site of injection
• Muscle weakness
• Diabetes
• Easy bruising
• Weight gain
• Osteoporosis
• Increased blood pressure

Pain relievers for Tarsal Tunnel Syndrome

Acetaminophen

Acetaminophen is non-opioid analgesic and antipyretic. It reduces pain signals in the nervous system by targeting the brain and spinal cord, and relieves pain associated with tarsal tunnel syndrome. Acetaminophen focuses only on relieving the pain, while NSAIDs can relieve the pain and reduce inflammation around the body. 

Acetaminophen can be given to patients to relieve the pain of tarsal syndrome. It is an OTC drug, but it must be used with caution as a toxic dose can cause liver damage and even death. Some side effects of the acetaminophen include:

• Nausea
• Dizziness
• Loss appetite
• Fatigue
• Yellow eyes and skin( indicating jaundice and liver damage)

Neuropathic pain medications

Gabapentin and Pregabalin

Neuropathic pain or simply called “damaged nerves pain”. The tingling pain symptoms are due to the compression of the tibial nerves; thus, medications such as gabapentin and pregabalin can reduce the nerve pain and sensitivity. These medications are mainly used to treat epilepsy by decreasing the excitatory neurotransmitters. They are not a primary treatment for the tarsal tunnel syndrome and are only prescribed if the pain is unbearable and the NSAIDS are ineffective.

You must consult your physician before administering this medication.

Opioids (Severe cases)

Opioids are only considered as the last option after all the therapies have failed to work, such as NSAIDs, ibuprofen, gabapentin, and pregabalin. Opioids are also called painkillers and narcotics; they are controlled drugs and are only available through a prescription. They bind to the receptors (mu, delta, kappa) present in the central nervous system and block the pain signals, reducing the sensitivity towards pain and increasing the pain tolerance.⁶

They are only prescribed if the pain is beyond tolerable and the person can barely function, and even after then, the dose is strictly monitored since it is very easy to develop dependence and addiction towards it. 

Additional considerations

Besides medications, some of the approaches to alleviate the symptoms are:

• Resting or simply lying down to reduce the pressure at the bottom of the foot and nerves
• Use of ice to reduce inflammation
• Physical therapy exercises to improve mobility and activity
• Supportive footwear to decrease the pressure 
• Use of topical lidocaine to relieve pain

FAQs

What support is best for tarsal tunnel syndrome?

Orthotics are specifically designed footwear for tarsal tunnel syndrome as they reduce the pressure on the tibial nerve and provide comfort while standing.

What is the home remedy for tarsal tunnel syndrome?

The simplest home remedy is to perform stretching exercises of the calf muscles and Achilles tendon. Make sure to do it gently with no swift movements and stop immediately when you feel pain.

How to sleep with a tarsal tunnel?

Splints can be worn at night to relieve the pressure as it maintains the foot in a stretched position, this allows faster recovery.

Summary

Tarsal Tunnel syndrome is a disorder of the tibial nerve present in the feet. This happens due to compression of the tibial nerve, which causes symptoms such as “burning” or “shooting pain” at the ankle or the bottom of the feet. It is not a fatal disease in most cases and can be treated with proper guidance. The first approach to manage the disease is simply resting and icing the feet to decrease the pressure on the nerve and to numb the pain. If these methods don’t resolve the pain, then it's best advised to use painkillers and anti-inflammatory medications. 

Anti-inflammatory medications, such as Ibuprofen, are effective in reducing the pain and inflammation at the site. It provides relief from swelling and redness at appropriate doses administered by a physician. Painkillers, such as Acetaminophen, Pregabalin, and Opioids, are used to reduce the pain associated with tarsal tunnel syndrome. These medications only provide temporary symptomatic relief and do not treat the disease because the underlying issue, the compression of the nerve, persists. You should not rely on pain killers for treatment and must consider other options, such as physical exercises and surgery, for complete rehabilitation.