Tibial Nerve Compression

Background

The tibial nerve functions to control plantar flexion of the ankle and toes and provide sensation to the lower leg, ankle and foot. The tibial nerve may be compressed in several areas, commonly the soleal sling in the back of the calf, and the tarsal tunnel at the ankle.

Causes

Compression of the tibial nerve can be due to inflammation, tumors, tight fascial bands, abnormally large muscles that lead to dynamic compression of the nerve, and sometimes due to changes in the nerve itself than can thicken and become pinched when it dives underneath various structures, most commonly fascial bands that occur everywhere in the body.

Symptoms

Patients with tibial nerve compression will often experience pain, numbness and tingling. Depending on the site of the compression, weakness may be present too. Lack of sensation in the feet can be problematic since it can lead to unrecognized ulcers that can become quite large and become limb-threatening.

Diagnosis

The diagnosis is often clinical, based on the history and physical examination. Nerve tests are often obtained but can be normal, especially in dynamic compressions. MRI and ultrasound can be helpful in visualizing the nerve and its compression, but can also identify muscles that are undergoing denervation changes from lack of normal nerve electrical signals into the muscle. Diagnostic injections can be considered.

One particular challenge is differentiating tibial nerve compression from exertional compartment syndrome and popliteal artery entrapment syndrome. As a matter of fact, these conditions can be present at the same time and require specialized testing such as measurement of exertional compartment pressures, and dynamic ultrasound or MRI scan.

Treatment

The treatment is customized to the site of compression, its cause and severity. Physical therapy to promote nerve gliding can be helpful. Gait analysis and retraining with a focused physical therapy regimen can help in high level athletes. Botulinum toxin injections can be considered if the compression is dynamic. Surgical release is recommended for more severe cases and does not involve cutting the nerve like some patients think, but actually involves releasing it from the surrounding structures so that it can recover. Depending on the severity of the compression, there may be abnormal changes in the nerve fibers themselves. These take a lot longer to recover, possibly years. This is the case with any severe nerve compression.