While heel pain and posterior tarsal tunnel syndrome are well recognised, anterior tarsal tunnel syndrome is a less common but important cause of chronic foot pain in athletes. This condition results from deep peroneal nerve entrapment as it passes under a tight structure on the top of the foot, leading to pain, burning, and altered sensation in the forefoot and toes. What is anterior tarsal tunnel syndrome, and how do we treat it?  

What Is Anterior Tarsal Tunnel Syndrome?

The deep peroneal nerve is a branch of the common peroneal nerve that supplies sensation to the first web space (between the big toe and second toe) and motor function to several foot muscles. In anterior tarsal tunnel syndrome, the nerve is compressed as it passes beneath the extensor retinaculum at the front of the ankle joint. The nerve splits into a medial and a lateral branch; sometimes, only one of these branches is compressed, leading to a partial tarsal tunnel syndrome. It is common for the long extensor tendon to the big toe to compress the medial branch at the level of the tarsometatarsal joint. 

Athletes such as footballers, ballet dancers and basketball players are particularly prone because of repetitive loading, footwear compression, and direct trauma around the ankle and midfoot. Previous ankle sprains can increase the risk of nerve entrapment at the extensor retinaculum due to scar tissue formation. 

Symptoms

The symptoms of deep peroneal nerve entrapment are:

  • Burning, tingling, or numbness in the first web space between the toes

  • Pain on the top of the foot or the front of the ankle

  • Symptoms aggravated by tight footwear, boots, or ankle straps

  • Weakness in toe extension in severe cases due to muscle weakness, although this symptom is rare

  • Wasting of the small muscle on the top of the mid-foot

Many patients describe nerve-type pain rather than mechanical pain, which helps distinguish it from conditions such as tendonitis or arthritis. Generally, exercise triggers nerve pain, and rest relieves it immediately. 

Clinical Assessment of Anterior Tarsal Tunnel Syndrome 

deep peroneal nerve supplying skin between the 1st and 2nd toes

On examination, your doctor may find: 

  • Local tenderness over the deep peroneal nerve as it crosses under the extensor retinaculum

  • Tinel’s sign (tingling when tapping over the nerve at the ankle)

  • Reproduction of symptoms with forced plantarflexion or tight shoelaces

  • No tenderness of other structures in the ankle and mid-foot, including the ankle joint, mid-tarsal joints and tendons

Investigations

Investigations support the diagnosis of deep peroneal nerve entrapment and help rule out conditions that mimic it.

  • Nerve conduction studies: may demonstrate delayed conduction of the deep peroneal nerve across the anterior ankle.

  • Ultrasound: can visualise the nerve, identify swelling, or detect compression from a ganglion or bony spur.

  • MRI: useful for identifying growths, synovitis, bony spurs or other structural changes causing compression.

Treatment Options for Anterior Tarsal Tunnel Syndrome

The management of anterior tarsal tunnel syndrome depends on severity and the underlying cause.

  • Activity modification: Avoiding footwear or lacing techniques that compress the front of the ankle.

  • Footwear changes and orthotics: Shoes with a wider toe box or padding over the extensor retinaculum can relieve pressure.

  • Physiotherapy: Stretching, strengthening, and mobilisation to reduce mechanical stress.

  • Medications: We use NSAIDs for pain and inflammation during the acute phase.

  • Ultrasound-guided injection: Local anaesthetic and corticosteroid or nerve hydrodissection around the deep peroneal nerve can provide targeted relief.

  • Surgical decompression: Considered for persistent or severe cases, mainly if caused by structural compression such as a cyst, growth or osteophyte.

Final Word from Sportdoctorlondon about Anterior Tarsal Tunnel Syndrome

Anterior tarsal tunnel syndrome, caused by entrapment of the deep peroneal nerve, is an uncommon but significant cause of chronic foot pain in athletes. Careful history and examination, combined with targeted investigations, allow for accurate diagnosis. Most athletes respond well to conservative treatment, although nerve hydrodissection or surgical release may be necessary in cases that are resistant to treatment. 

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