Dr. Douglas Pepple joined hosts Shannon O’Kelley, Physical Therapist and President of Integrated Rehabilitation Group, and Maury Eskenazi, radio personality from Fox Sports radio on Health Matters radio, KRKO 1380am, with thanks to Integrated Rehabilitation Group physical and hand therapy. He talked about tarsal tunnel
Read the transcript of Dr. Pepple's talk on tarsal tunnel on Health Matters radio or listen here
Health Matters: So, now, joining us is Allister Brookes. He is physical therapist from Snohomish Physical Therapy, and we also are joined by Dr. Douglas Pepple. He is a sports medicine and family medicine physician from The Everett Clinic in Lake Stevens. He has extensive experience treating athletes of all levels, including NCAA Division 1 athletes, gymnasts from the USA gymnastics team and Chicago area runners, marathon runners. The topic is tarsal tunnel syndrome. So, doc, welcome.
Health Matters: What actually is tarsal tunnel?
Dr. Pepple: Tarsal tunnel syndrome is a disorder that involves too much swelling inside the tarsal tunnel itself. It is on the inside of your ankle, the big toe side of your foot. The inside of your ankle we call the medial malleolus and then the heel we call the calcaneus and then overlying those two bones is the roof of the tarsal tunnel, the flexor retinaculum. So, that flexor retinaculum, that is supposed to keep everything in place, keep tendons in place, protect arteries and nerves, but, if you have swelling in that confined space, then it compresses the posterior tibial nerve and then gives you some pretty significant pain, numbness, even weakness in some cases.
Health Matters: It is always hard to kind of describe anatomically body parts on the radio. So, if you were to reach down and touch that bone on the inside of your ankle there, the tarsal tunnel is right underneath that, right in that area?
Dr. Pepple: Definitely. Underneath the inside bump of your ankle.
Health Matters: Allister, being a physical therapist, particularly this time of year, the weather is kind of changing and people are going to naturally kind of migrate outdoors and you start seeing increased activity, running, particularly. Is this kind of one of these things that you see with running activities, a little bit higher incident, both it is for Allister and Dr. Pepple.
Allister: Definitely. One of the major factors we have here is we are trying to keep a tunnel that is in a very confined space without very good blood supply open. Typically, runners that are over pronators or have flat feet can be prone to this, but there are many other causes, but that would be one of the things we would look at. People tend to run on the roads that have a little bit of an angle or a canter to it, and that can also make them prone to this because one end of the foot or one side of the foot is being compressed, but there are many other reasons that can cause this. Dr. Pepple, you want to expand on that?
Dr. Pepple: I would say amongst runners, certainly the hyper pronation can contribute having a flat foot. If you have a high arch that can cause, if anything, tilting the heel the other way. Instead of having the heel collapse inward and stretch out that nerve too much, you can have the heel fall too much outward and compress the nerve as it is in that small tunnel on the inside of your ankle.
Health Matters: Just out of curiosity, how would I know if I had flat feet or a high arch. Would there be pain involved.
Dr. Pepple: Not necessarily. From my experience, I get a sense for, I can fit my fingers under your arch to a normal degree or I can really slide in almost all the way to the outside of your foot, that is a really high arch.When you are standing.
Dr. Pepple: Or, I can hardly fit my fingertips underneath, that is a really flat foot.
Health Matters: And sometimes people talk about the footprint you leave. If the bottom of your feet are wet, if you leave just the outside trace of your feet, you have probably a high arch or the whole foot is kind of footprinted in the water left behind, you have a flat foot.
Health Matters: You've got this nerve that is rolling through this tunnel, and anytime that nerve gets compressed, irritated, pinched, squeezed, whatever, you are going to have nerve symptoms. Aside from running, could you have kind of bony changes from a fracture or arthritis or something going on there that could cause that compression, too?
Dr. Pepple: You could have inflammation of a joint, synovitis, if that swells up inside the tunnel, that can cause it.
Health Matters: If there is a compression on a nerve, what kind of symptoms would you see?
Dr. Pepple: In a milder case, it could be just pain at the heel. More classically, it would be pain and tingling and even numbness along the entire bottom of the foot in a severe compression that could even shoot up the leg. For the most part, it is pain and tingling and numbness in the bottom of the foot.
Health Matters: Who tends to get this? More athletes or runners or football players?
Dr. Pepple: If you are a person who is running or dancing, that is repetitive weight-bearing on the foot, that can cause it, and, certainly, if you do not have the proper shoe support, either you have that flat foot or that high arch, you are a hyper pronator and you are in the wrong shoe, that can certainly cause it. Someone who gains weight suddenly. Someone who is pregnant can have swelling that can cause that, but then, of course, that resolves when the pregnancy is over. But, I would say, you can either have it in a person who is fit improperly or maybe someone who goes from sedentary lifestyle to go run 10 miles and give yourself tendinosis and you have swelling inside that space.
Health Matters: These, what we term, peripheral neuropathies or peripheral impingement, nerve impingements are kind of hard from a diagnostic standpoint to detect and track down. So, if someone is suspected with these symptoms, what would be some best test to prescribe to rule this in or rule this out?
Dr. Pepple: I would say probably what would help the most would be the physical exam. You can tap directly on the tunnel. If that reproduces symptoms, that is suggestive. You can press the tunnel with your thumb, hold it there for a while. That can reproduce it. You can put a blood pressure cuff on the calf and if that reproduces the symptoms, maybe you have a varicose vein in there that is compressing it and causing it.
Health Matters: Kind of neat doctor detective work there.
Dr. Pepple: Like many things in life, it really is the thinking and the doing that matters more than just ordering a test. Doing nerve conduction testing, electromyogram testing, that can help. But if you had a normal nerve conduction study, that would not make you say, nope, it is not tarsal tunnel, we are done here. Maybe you could do an MRI to try to see is there a neuroma, a fibroma, some sort of growth that is pressing in there, is it just tendinosis all along, certainly MRI could find it. If the usual treatment isn't helping, then maybe you do some more extensive testing.
Health Matters: We are talking to Dr. Douglas Pepple from The Everett Clinic in Lake Stevens and our good friend, Allister Brookes. He is from Snohomish Physical Therapy. Allister, what do you do if somebody comes to you diagnosed with tarsal tunnel? What step do you do as a physical therapist?
Allister: That Tinel test or the tapping test that he talked about is the best test to determine a nerve problem compared to a tendon problem because there are some tendons in terms of the posterior tibial tendons and the flexors of your foot and the flexors of your big toe that also pass through this area. So, are you reproducing pain with what I call a muscle contraction or are you reproducing symptoms, neuralgia, numbness and tingling with a tapping test are probably the two best tests for a physical therapist to use. Then if we suspect it further, the EMG or the nerve conduction test that he was talking about which would not be done by a physical therapist.
Allister: In terms of what we do for it, you kind of have to figure out what is blocking the tunnel. If it is related to a bone spur or a ganglion or something like that, it is going to be hard to treat from a physical therapy standpoint. If the compartment is swollen, if it is coming on after a severe sprained ankle where there is a lot of swelling in the compartment, if there is tenosynovitis or the tendons are inflamed, those are physical therapy things we would work on.
Health Matters: When you say ganglion and when you say bone spur, those are anatomical things that at times if you rule out and attempt all of the conservative measures, there are situations sometimes where this needs to be cleaned up maybe?
Health Matters: That is surgical intervention and usually done by an orthopedic surgeon.
Dr. Pepple: If you find the correct cause and you treat it early, you should have good results. Certainly, if you deal with it for months or years, the longer you have it, the less likely it is to fully recover.
Health Matters: Now, months or years, does it come back? Is it something that you'll always get?
Dr. Pepple: I think it depends on whether or not you get good physical therapy early. If you get your strength back. If you not only solve the tendon overuse, tendon inflammation that was causing it, but strengthen all of the surrounding muscles so that tendon never has to overwork again, that is going to keep you from having it come back.
Health Matters: Allister and I have experienced this and I am sure Dr. Pepple also experienced this. Sometimes you look at a person and they have a very flat foot and you recommend a certain type of shoe and they go into that shoe and they are great because that shoe has a built-in counter. That shoe re-supinates the foot. Again, it is all about alleviating the pressure of the nerve and hopefully you can do that conservatively. There are times where, as a physician, you might consider injecting to calm this area down. Would that be a possibility?
Dr. Pepple: If you are not responding within the first month or two then injecting it would help have a higher likelihood of success. You never want to let that just smolder.
Health Matters: Allister, if you are going to treat these symptoms, as a therapist, you are going to maybe get 6, 8, 10 visits in and you should see some results by the time you get those treatments in?
Allister: Definitely. The one thing on this type of injury, it is a do-not-wait type of injury.
Allister: Because a nerve that is injured, is going to heal a lot slower than an injured tendon or an injured muscle just due to the vascularity of the nerve. So, if you notice numbness or tingling come on in your heel or on the mediolateral aspect of your foot, because the nerve splits into three places. Any time you get nerve symptoms, it is important to hop on that quick with your doctor and make sure you get a proper diagnosis because nerves are much more difficult to treat.
Health Matters: Yeah, and like you said, difficult to treat but also difficult sometimes to diagnose those symptoms based on nerves because there could be compression up in your thigh. Dr. Pepple, what is a nerve conduction test and what is the tester doing?
Dr. Pepple: The nerve conduction study is something where you place electrodes on the skin, measuring the electricity. Does it travel at the normal speed or does it slow down? And, if so, where precisely is it slowing down. If you see it slow farther down from the tarsal tunnel, that is very suggestive. If it is slow higher up from the tarsal tunnel then that tells you that it is something like the thigh.
Health Matters: You know, as long as we are talking about ankles and feet, you know plantar fasciitis, every athlete seems to have it. How do you get rid of this? It just kind of lingers.
Dr. Pepple: Plantar fasciitis can get better as long as you are faithful about what you do. Massage it out as best you can, ice it down as cold as you can, stretch out that foot. If you get out of the habit of doing that on a daily basis while it is still going on, then it is probably going to come back. Health Matters: So, if something does not go away like a week or two after you get it, you should probably have it checked out.
Dr. Pepple: I would say no more than a week.
Allister: Most of these things, too, there is some like what we call objective impairments there that are causing these problems. So, whether it is the position of your foot, it is the tightness of your calf, it is the weakness in the muscles, if you catch these things early it is an easy fix. If they go on and on that is when both the sports medicine doctor’s and the physical therapist's job gets pretty tough.
Health Matters: The most important thing is if you have something like that, get in and get it checked, get the treatment started right away because it is going to be more effective early on versus becoming chronic. Thanks guys.