EFFECTS OF NERVE MOBILIZATION EXERCISE AS AN ADJUNCT

TO THE CONSERVATIVE TREATMENT FOR PATIENTS WITH

TARSAL TUNNEL SYNDROME
Yasemin Kavlak, PT, PhD, a and Fatma Uygur b

ABSTRACT

Objective: This study was carried out with the aim of investigating the contribution of nerve mobilization exercises
to the conservative treatment of tarsal tunnel syndrome.
Methods: In this clinical trial, 28 patients were randomly allocated into 2 groups. The control group was composed of
14 patients who were treated conservatively with a program consisting of physiotherapy and supportive inserts,
whereas 14 patients in the study group were given nerve mobilization exercises in addition to the same treatment.
Allpatients were followed up for 6 weeks. Before treatment, subjects were evaluated for muscle strength, range of
motion, pain, sensory tests, and clinical manifestations of tarsal tunnel syndrome. The evaluations were repeated after
6 weeks.
Results: There was a significant difference in favor of posttreatment values for range of motion, muscle strength, and
pain in both groups (P b .05). Intergroup comparisons showed no difference between the groups for these parameters.
Significant results were attained in the study group for 2-point discrimination and light touch and Tinel sign after
treatment (P b .05).
Conclusion: Patients in both groups showed improvement from conservative treatment. The results of the study
group showed that nerve mobilization exercises have a positive effect on 2-point discrimination and light touch and
Tinel sign. (J Manipulative Physiol Ther 2011;34:441-448)
Key Indexing Terms: Tarsal Tunnel Syndrome; Tinel Sign; Nerve Mobilization Exercises

arsal tunnel syndrome (TTS) is an entrapment foot. Because the tibial nerve innervates the entire sole of

T neuropathy of the posterior tibial nerve and its

branches, including the medial calcaneal, medial
plantar, and lateral plantar nerves individually or collec-
tively under the flexor retinaculum behind and below the
medial malleolus of the ankle.1-3 Nerve entrapment may
occur at the distal portion of the posterior compartment of
the leg, the retromalleolar ligamentous coverage (flexor
retinaculum) at the ankle, and the anterior and posterior
fibro-osseous tunnels exiting to the plantar aspect of the
a
Assistant Professor, Prosthetics and Orthotics Unit, Health
Services Vocational Schools, Eskisehir Osmangazi University,
Eskisehir, Turkey.
b
Professor, Department of Physical Therapy and Rehabilita-
tion, Faculty of Health Sciences, Hacettepe University, Ankara,
Turkey.
Submit requests for reprints to: Yasemin Kavlak, PT, PhD,
Prosthetics and Orthotics Unit, Health Services Vocational
Schools, Eskisehir Osmangazi University, Meselik, 26480,
Eskisehir, Turkey (e-mail: ykavlak@hotmail.com).
Paper submitted August 9, 2010; in revised form March 30,
2011; accepted April 4, 2011.
0161-4754/$36.00
Copyright © 2011 by National University of Health Sciences.
doi:10.1016/j.jmpt.2011.05.017
the foot, the symptoms are usually spread throughout the
sole of the foot and not localized to the heel.3,4 The varied
clinical presentation of TTS may occur because of varied
sites of entrapment of the individual branches of the
posterior tibial nerve.3,5
The symptom triad of pain, paresthesia, and numbness is
the most common clinical presentation.6 Patients typically
complain of poorly localized, burning pain and paresthesia
along the plantar surface of the foot and toes.2 Typically,
pain is worse during or after weight-bearing activities and
improves with rest.7,8
Some of the common manifestations of TTS are posi-
tive Tinel sign, pain felt on provocation using passively
maximally dorsiflexing, and everting the ankle while all the
metatarsophalangeal joints were dorsiflexed and held in this
position for 5 to 10 seconds.9 In addition, the most common
and objective symptom is diminished sensation.10,11
The results of a study by Bracilovic et al12 support the
hypothesis that eversion and inversion of the foot and ankle
cause decreased compartment volume of the tarsal tunnel
and increased tarsal tunnel pressure that may contribute to
symptoms of posterior tibial nerve entrapment in TTS.
Neutral immobilization of the foot and ankle may relieve
symptoms of posterior tibial nerve entrapment in TTS by

441
442 Kavlak and Uygur
Nerve Mobilization in Tarsal Tunnel Syndrome
minimizing pressure on the nerve and maximizing tarsal
tunnel compartment volume available for the nerve. The
mean tarsal tunnel volume was significantly greater when
the foot and ankle were in neutral position (21.5 ± 0.9 cm3)
than in either full eversion (18.0 ± 0.9 cm3, P b .001) or
inversion (20.3 ± 1.0 cm3, P b .001).12
Conservative treatment of plantar heel pain may include
rest, nonsteroidal anti-inflammatory drugs, corticosteroid
injections, extracorporeal shock wave therapy, laser, local
anesthetic injections, heel pads and heel cups, night splints,
medial longitudinal arch supports, strapping, foot orthoses,
soft-soled shoes, stretching exercises for the Achilles
tendon and plantar fascia, ultrasound, and casting.8
Management of these patients include treatments directed
toward reducing pain, inflammation, and tissue stress as well
as restoring muscle strength, flexibility, lower-extremity
mobility, and restoring soft tissue mobility of the lower
extremities. Neural mobilization may be used for restoring
soft tissue mobility. Nerve-gliding (NG) exercises have been
used to attain neural mobilization for the treatment of carpal
tunnel syndrome with contradicting results.13-16
There are a limited number of case studies that have
applied nerve mobilization techniques in the treatment for
patients with plantar heel pain of neural origin. Shacklock17
used knee extension movements in supine position in a
patient with a neuropathy of the medial calcaneal nerve and
tibial nerve at the tarsal tunnel. Meyer et al18 performed
knee extension movements in a slump position in a patient
with a possible entrapment of the medial calcaneal nerve
and tibial nerve at the ankle and/or at the arch of the soleus
muscle. Both case studies reported positive outcomes with
no adverse effects.
At present, there is no randomized clinical study in the
literature investigating the effectiveness of nerve mobiliza-
tion exercises in the conservative treatment of TTS. This
preliminary study was carried out with the aim of
investigating the contribution of nerve mobilization exer-
cises on outcome measures for the conservative treatment
for patients with TTS.
METHODS
The study was carried out at the Orthotic Rehabilitation
Department of Hacettepe University, Ankara. The clinical
trial registration number was received from the Eskisehir
Osmangazi University Ethical Committee, its protocol
number is PR-10-11-02-01, and its approval number is
2010/266. Forty-three patients who were diagnosed as
having TTS by an orthopedic surgeon were assessed for
eligibility during a period of 16 months. Patients were
considered eligible if they met inclusion and exclusion
criteria. Inclusion criteria were as follows:
1. to be classified by the orthopedic surgeon as not
having an indication for surgery;
Journal of Manipulative and Physiological Therapeutics
September 2011
2. to be at a cooperative to understand the aim of study,
to give informed consent, and to understand and
follow the directions of the exercise protocols;
3. to be able to attend therapy and follow-up sessions;
and
4. to be older than 18 years.
Exclusion criteria were as follows:
1. having comorbidities or orthopedic or postural
problems that could confound the outcomes;
2. having other entrapment neuropathies;
3. having undergone surgery related to the lower
extremity or lumbar spine;
4. regularly taking alcohol every evening; and
5. smoking addiction.
The subjects of the study consisted of 28 consecutive
patients who were allocated to the study or control group by
randomization of even and single numbers in sealed
envelopes carried out by a colleague unaware of the nature
of the study. However, after this allocation, although the
patients were blind to which group they were in, the
assessor was not blind. After allocation, there were no
dropouts from the study. The same physiotherapist carried
out all the assessments. The assessor was experienced in
treating and assessing foot and ankle problems and did not
require undergoing a particular training for consistency.
The study was reviewed and approved by the University
Dissertation Review Committee, and informed consent was
obtained from all the patients.
A home exercise program of 6 weeks duration was given
to all the patients in both groups. This program included
gastrocnemius stretching, strengthening the weak muscles,
ice application, bandaging, medial arch supports, and
wedges as necessary. The weak muscles were strengthened
starting from 5 repetitions and adding 2 repetitions each
week and giving incremental resistance by means of
changing the color of therabands. Medial arch supports
were given to patients who had a low navicular tubercle,
and medial wedges were given to patients with pronation
deformities. Bandaging was given to patients who had
edema and pain in their ankles. All the patients came in for
controls every 10 days for 6 weeks. During these control
visits, compliance with and correct application of therapy
program were checked. In addition to this program, the
patients in the study group were given tibial nerve
mobilization exercises as described by Meyer et al18 to be
carried out each day. The physiotherapist assisted the
patient with nerve mobilization exercises during the first
week, after which the patients continued on their own.
The patients were instructed to perform exercises in
positions that enhance nerve mobilization in a slow,
controlled manner. As described by Meyer et al,18 neural
mobilization was performed in a slump position with
Journal of Manipulative and Physiological Therapeutics
Volume 34, Number 7
sustained ankle dorsiflexion and eversion. Knee flexion and
extension movements were used as the mobilizing
components. The patients were seated at the edge of the
treatment table and were instructed to slump forward to a
comfortable position with their hands placed behind their
backs. The ankle was then taken into end-range dorsiflexion
and eversion in an attempt to apply more tension to the
tibial nerve. With the ankle maintained in this position,
the patient's knee was extended and then returned to its
resting flexed position. This sequence was performed
10 times. Each flexion-extension maneuver took approxi-
mately 4 seconds. When the patients extended their knees,
the tibial nerve was stretched, and knee flexion relaxed the
stretch, resulting in mobilization of the tibial nerve. If the
patients in the study group felt discomfort in the form of
sharp pain, burning, or numbness during nerve mobilization
exercises, they were asked to stop the exercises at that point
and resume after discomfort was relieved. In all of our
patients, the discomfort was transient and did not cause
cessation of treatment.18
Each patient was given written material explaining all
the exercises in detail.
The following assessments were carried out initially and
after 6 weeks for the patients in both groups:
1. Pain was assessed using the visual analog scale on a
10-cm line where 0 represents no pain and 10
represents excruciating pain.19
2. Range of motion of the ankle and subtalar joints were
measured using a universal goniometer. The design of
the universal goniometer and the procedures for its use
have been described in detail in numerous
publications.20,21 To measure inversion and eversion
range of motion (ROM), with the patient positioned
prone, the subtalar neutral joint position, where the
therapist is able to palpate the head of the talus equally
both medially and laterally, is maintained, and the
goniometer is used to measure the angle formed by the
longitudinal midline of the posterior calcaneus and the
vertical line drawn on the posterior lower leg with the
heel in maximum inversion and eversion.22 To
measure plantar and dorsiflexion, the goniometer
should be placed with its fulcrum over the lateral
aspect of the lateral malleolus. The proximal arm of
the goniometer is aligned with the midline of the
fibula using the head of the fibula as a reference
point, and the distal arm is placed parallel to the
lateral aspect of fifth metatarsal. The angle formed
during plantar and dorsiflexion is measured.23
3. The strength of the foot muscles, which were
innervated by tibial nerve and its branches (M tibialis
post, M gastrocnemius, M lumbricalis, M flexor
hallucis brevis, M flexor hallucis longus, M flexor
digitorum brevis, M flexor digitorum longus, dorsal
interosseal muscles, M abductor hallucis, M abductor
Kavlak and Uygur 443
Nerve Mobilization in Tarsal Tunnel Syndrome
digiti minimi, palmar interosseal muscles, and M
abductor hallucis) were manually evaluated accord-
ing to Kendall and McCreary,24 and total muscle
strength was computed for each patient.
4. For sensory measurement, an esthesiometer was
used for determining 2-point discrimination by
moving the prongs into contact with the portion of
the body part and then pressing until the patient
felt a sensation. As advocated by Periyasamy et
al,25 the test was carried out with the patient in a
comfortable reclining position with eyes closed.
The 2 prong tips of an esthesiometer were made
to touch the body part at the same instant. The
subject orally stated whether he/she perceived the
touch as a single point or as 2 separate points.
Occasionally, without the subject's knowledge, the
subject was touched with only 1 prong. This
prevented the subject from knowing whether a 2-
point stimulus was always delivered. When the
subjects consistently perceived 1 point rather than
2 points, this was recorded in the datasheet.25,26
5. For the measurement of light touch, Semmes-
Weinstein monofilaments were used on the 3
different areas of the foot representing medial
calcaneal, lateral plantar, and medial plantar nerves.
Measurement was started with the monofila-
ment, which corresponded to normal touch; if the
patient did not feel this, the monofilament corre-
sponding to diminished light touch with a larger
diameter was tested. If this was not sufficient, we
progressed to the monofilaments that represented
diminished protective sensation and loss of sensa-
tion, respectively.25,27
6. The provocate symptoms of tibial nerve entrapment:
provocation tests make use of the fact that a deranged
nerve is sensitized or is hyperalgesic to any manual
stimulus applied along its length.18
a. Tinel test consists of tapping the area below the
medial malleolus; if it resulted in a tingling along the
nerve distribution, the Tinel sign was considered
positive.7,18 Sensibility of the Tinel sign has been
reported to range from 38 to 100 and specificity from
55 to 100 for carpal tunnel syndrome (CTS). In a
2002 study, sensibility was found to be 67% and
specificity 68%.28
b. For the tibial nerve stretch test (TNST), the ankle
was passively maximally everted and dorsiflexed,
whereas all of metatarsophalangeal joints were
maximally dorsiflexed and held in this position for
5 to 10 seconds so that the tibial nerve was stretched
and compressed beneath the lacinate ligament. The
patients were asked if they felt pain, numbness, and/
or tingling at the plantar surfaces of the foot.9,29
7. Existence of paresthesia was inquired in all patients.
444 Kavlak and Uygur Journal of Manipulative and Physiological Therapeutics
Nerve Mobilization in Tarsal Tunnel Syndrome September 2011

Table 1. Demographic characteristics and comparison of groups

Study group (n = 14) Control group (n = 14)
Mean ± SD Mean ± SD P
Age (y) 40.71 ± 12.84 43.64 ± 14.72 N.05
Height (cm) 163.07 ± 9.47 163.35 ± 9.60 N.05
Weight (kg) 69.92 ± 12.28 76.35 ± 10.95 N.05
Education level (y) 13.14 ± 5.06 9.07 ± 5.37 N.05
Duration of symptoms (y) 3.40 ± 5.06 2.54 ± 2.43 N.05

Table 2. Cause of tarsal tunnel, affected side, and distribution of sex

Study group (n = 14) Control group (n = 14)
n % n %
Cause of tarsal tunnel
Idiopathic 8 57.1 9 64.3
Trauma 6 42.9 5 35.7
Affected side
Right 7 50 9 64.3
Left 7 50 5 35.7
Sex
Female 12 85.7 12 85.7
Male 2 14.3 2 14.3

Table 3. Within-group comparisons of pretreatment and posttreatment values for limitations of ROM, muscle strength, and pain
Pretreatment, mean ± SD Posttreatment, mean ± SD t P
Study group (n = 14)
ROM (deg) 32 ± 11.73 26.64 ± 8.11 2.16 .05
MS 37.73 ± 2.08 39.66 ± 2.21 −2.67 .02
PS (mm) 55.54 ± 18.86 28.70 ± 11.34 6.64 .00
Control group (n = 14)
ROM (deg) 36.14 ± 12.9 29.07 ± 10.4 3.82 .01
MS 37.68 ± 2.30 39.22 ± 2.28 −2.86 .01
PS (mm) 53.44 ± 18.33 37.45 ± 19.1 4.93 .00
MS, total muscle strength; PS, pain severity (in millimeters); t, paired t test.
Statistical significance was defined as a value of P b .05.

Statistics
Power calculations performed by a biostatistician
showed that for a clinical trial with a study and control
group, a total of 28 patients showed α N .667, and
confidence interval for difference of mean values was 95%.
Statistical evaluation was performed using IBM Statistical
Package for Social Sciences (PASW) 18.0 (Chicago, IL) for
Windows and Sigmastat 3.5 (DUNDAS Software LTD,
Erkrath, Germany). First, normal distribution was evaluated
by using Shapiro-Wilk test, and if data showed normal
distribution, we used paired samples t test to compare the
pretreatment and posttreatment values. When data did not show
normal distribution, we used Wilcoxon signed rank test to
compare the pretreatment and posttreatment values. Indepen-
dent-samples t test was used for comparisons between groups.
For dichotomous measures of Tinel sign, paresthesia, and
TNST, intergroup comparison were made using χ2 test, and
within-group comparisons by using McNemar test. Data were
summarized as mean ± SD and median (interquartile range).
Statistical significance was defined as a value of P b .05.
RESULTS
The demographic characteristics of the subjects are
given in Table 1. Comparison between the groups shows
that the groups were homogeneous about age, height,
weight, education level, and duration of symptoms.
Distribution of sex, affected extremity, and cause of
tarsal tunnel are given in Table 2. From this table, it is seen
that the patients were predominantly idiopathic tarsal tunnel
in both groups.
Within-group comparisons of pretreatment and post-
treatment values for limitations of ROM, muscle strength,
and pain are seen in Table 3. There was a significant
difference in favor of posttreatment values for all assessed
parameters in both groups (P b .05). Intergroup compar-
isons showed no differences between the groups for neither
of the assessed parameters.
Within-group comparisons of pretreatment and posttreat-
ment values for 2-point discrimination are given in Table 4,
and light touch, in Table 5. A statistically significant
Journal of Manipulative and Physiological Therapeutics Kavlak and Uygur 445
Volume 34, Number 7 Nerve Mobilization in Tarsal Tunnel Syndrome

Table 4. Within-group comparisons of pretreatment and posttreatment values for 2-point discrimination
Sensibility evaluation 2-point
discrimination (cm) Pretreatment, mean ± SD Posttreatment, mean ± SD t P (exact)
Study group (n = 14)
MCN 1.75 ± 0.44 1.46 ± 0.30 2.80 .02
LPN 1.73 ± 0.33 1.65 ± 0.64 0.44 .66
MPN 1.80 ± 0.46 1.49 ± 0.42 2.39 .03
Control group (n = 14)
MCN 1.54 ± 0.46 1.39 ± 0.44 1.13 .28
LPN 1.57 ± 0.57 1.38 ± 0.47 1.85 .09
MPN 1.38 ± 0.40 1.32 ± 0.52 0.38 .71
MCN, medial calcaneal nerve; LPN, lateral plantar nerve; MPN, medial plantar nerve.
Statistical significance was defined as a value of P b .05.

Table 5. Within-group comparisons of pretreatment and posttreatment values for light touch
Sensibility evaluation on light touch Pretreatment, median (Q1-Q3) Posttreatment, median (Q1-Q3) Z P (exact)
Study group (n = 14)
MCN 4.31 (4.31-4.56) 4.31 (3.61-4.31) −2.69 .01
LPN 3.61 (3.61-4.31) 3.61 (3.61-3.61) −0.37 .87
MPN 3.61 (3.61-4.31) 3.61 (3.61-4.31) −1.08 .31
Control group (n = 14)
MCN 4.31 (4.31-4.56) 4.31 (4.31-4.31) −2.03 .06
LPN 4.31 (3.61-4.31) 3.61 (3.61-4.31) −1.27 .22
MPN 3.96 (3.61-4.31) 3.61 (3.61-3.61) −0.37 .73
Z, Wilcoxon signed rank test; Q1, first quarter; Q3, third quarter.
Statistical significance was defined as a value of P b .05.

Table 6. Intragroup pretreatment and posttreatment comparisons for paresthesia, Tinel sign, and positive TNST
Study group (n = 14) Control group (n = 14)
Pretreatment Posttreatment Pretreatment Posttreatment
Symptoms n % n % P n % n % P
Paresthesia
Positive 14 100 11 78.6 .25 14 100 14 100 1.00
Negative 0 – 3 21.4 0 – 0 –
Tinel sign
Positive 14 100 7 50 .02 14 100 13 92.9 1.00
Negative 0 – 7 50 0 – 1 7.1
TNST
Positive 10 71.4 3 21.4 .02 7 50 5 35.7 .50
Negative 4 28.6 11 78.6 7 50 9 64.3
Statistical significance was defined as a value of P b .05.

difference in favor of posttreatment values for 2-point
discrimination of medial calcaneal nerve and medial plantar
nerve (Table 4) and for light touch of medial calcaneal nerve
were seen only in the study group (Table 5). As can be openly
observed by looking at Table 4, although intergroup
comparisons of pretreatment values showed that the study
group had higher 2-point discrimination values for medial
plantar nerve (t = 2.58, P = .02), no difference was seen for
intergroup comparisons of posttreatment values. This result
shows the effectiveness of treatment in the study group.
Within-group pretreatment and posttreatment compari-
sons by dichotomous evaluation of the subjects for
paresthesia, Tinel sign, and positiveness of TNST are
given in Table 6. Although posttreatment values showed
no statistically significant differences in the control group
(P N .05), a statistically significant difference in favor of
posttreatment values were seen in the study group for Tinel
sign (P = .02) and TNST (P = .02).
Intergroup comparisons of pretreatment and posttreat-
ment values for paresthesia, Tinel sign, and TNST were
examined by using χ2 test. Although there was no
difference between the groups for pretreatment values,
posttreatment values showed a decrease in the Tinel sign of
the study group, and the difference between groups was
statistically significant (P = .03).
DISCUSSION
The results of the study have shown that conservative
treatment of CTS is effective in increasing ROM and muscle
446 Kavlak and Uygur
Nerve Mobilization in Tarsal Tunnel Syndrome
strength and alleviating pain; the addition of nerve mobilization
exercises to this treatment did not enhance the treatment effects
about these parameters. However, the decrease in Tinel sign
and 2-point discrimination values imply that sensory param-
eters may benefit from nerve mobilization.
Tarsal tunnel syndrome is an uncommon clinical entity,
with the most frequent symptoms being paresthesia, pain,
and sensory impairment.11,30,31 When significant symptoms
do not respond to conservative management, surgical decom-
pression may be beneficial in most patients with longstanding
TTS.32,33 However, there is a consensus that conservative
treatment should be initiated before surgery.1,34-37
In our study, there was a significant difference in favor of
posttreatment values in ROM, muscle strength, and pain
severity in both groups. It is obvious that our treatment protocol
consisting of gastrocnemius stretching, strengthening the weak
muscles, ice application, bandaging, medial arch supports, and
wedges, as necessary, was effective. The importance of
controlling excessive pronation, which is usually the cause of
decreased compartment volume of the tarsal tunnel, to relieve
the symptoms of TTS has been stressed in various studies.12,18
In the present study, we have tried to obtain neutral position of
the foot using medial longitudinal arch supports and heel and
sole wedges, as necessary.
In a 2010 case study on the conservative management of
TTS, Hudes1 states that TTS not complicated by muscle
atrophy might be managed conservatively and counts up to
16 methods for conservative treatment in which nerve
mobilization exercises are not mentioned.
Although clinical application and effectiveness of strength-
ening, stretching, and low-dye taping methods have been
described in the literature, little evidence exists for the
effectiveness of “neural mobilization” in the treatment of TTS.
Nerve-gliding exercises have been used to attain neural
mobilization for the treatment of tunnel syndromes of the upper
extremity. Oskay et al38 reported that in a series of 7 patients
with cubital tunnel syndrome who received nerve mobiliza-
tion, various long-term outcomes improved, such as pain and
Tinel sign; Disability of Arm, Shoulder, and Hand Index
scores decreased; and grip and pinch strength increased.
Rozmaryn et al13 found that, of the subjects with CTS who
did not perform NG and tendon-gliding exercises, 71.2%
underwent surgery compared with only 43.0% of patients
who did perform them. Akalin et al14 and Brininger et al15
compared subjects who wore splints with subjects who wore
splints and performed tendon and NG exercises and found no
additional improvement in the subjects who received NG
exercises. There are only 2 case studies in the literature that
have used neural mobilization in the lower extremity for the
tibial nerve; both case studies reported positive outcomes.17,18
In the present study, the group that carried out nerve
mobilization exercises showed no additional improvement
when compared with the control group about muscle
strength, ROM, and pain severity. This result is in
accordance with the results of Akalin et al14 and Brininger
Journal of Manipulative and Physiological Therapeutics
September 2011
et al15 who investigated the effect of NG exercises in carpal
tunnel syndrome.14,15
However, when we look at the sensory parameters, there
is a different picture; although there was no difference
between the pretreatment and posttreatment values in the
control group, a statistically significant difference in favor
of posttreatment values for 2-point discrimination of medial
calcaneal nerve and medial plantar nerve and for light touch
of medial calcaneal nerve were seen in the study group. In a
study by Gondring et al,3 it was shown that the least
improvement was seen in lateral plantar nerve regions
despite surgery. This result is consistent with our results.
When the groups were compared for paresthesia, Tinel
sign, and TNST, the number of patients with a decrease in
the Tinel sign and TNST was statistically significant when
compared with the number of subjects in the control group.
In a study investigating the effects of surgery for TTS,
although 72% of the cases were satisfied with the surgical
outcome and there was a significant improvement in 2-point
discrimination, half of the patients (and feet) continued to
have a positive Tinel sign and a residual nerve compression
test.6 Our results concerning Tinel sign and TNST are in
concurrence with this study. In spite of the fact that the
group practicing nerve mobilization exercises showed a
significant decrease in the number of patients with Tinel
sign and TNST, still, half of the patients showed a positive
Tinel sign, and one third showed a positive TNST.
Limitations of the Study
After randomized allocation, the outcome assessor knew
which group the patient was in. To blind the assessor to the
treatment alternative would have controlled bias. Nerve
conduction latency of patients who benefited and did not
benefit from the treatment would have given more objective
insight to the problem. There are many different types of
treatment of lower extremity conditions, and it is not clear if
one is superior to another.39 Because multiple approaches
were used in this study, it is difficult to identify the specific
type of care or that which influenced patient improvement.
Future studies should consider using a no-treatment control
group. Another limitation is the relatively small number of
patients. Therefore, more research is required to test our
results. The recommendation for future research is to
conduct larger randomized controlled trials to nerve
mobilization exercises for TTS to determine clinical effects.
CONCLUSION
The results of this pilot study imply that putting a controlled
amount of stress on the tibial nerve via nerve mobilization
exercises had no adverse effects and helped in reinforcing
sensory parameters such as 2-point discrimination and
alleviating the discomforting manifestations of TTS. However,
more research is needed to determine clinical effects.
Journal of Manipulative and Physiological Therapeutics
Volume 34, Number 7
Practical Application
• In this study nerve mobilization exercises had a
positive effect on 2-point discrimination and light
touch and Tinel's sign in patients with tarsal
tunnel syndrome.
ACKNOWLEDGMENT
The authors acknowledge the valuable contributions of
Assist Prof Cengiz Bal, PhD, for his assistance in statistical
analyses included in this study.
FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST
No funding sources or conflicts of interest were reported
for this study.
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