A cross-sectional study to assess the risk of tarsal tunnel syndrome among type 2 diabetes patients

 Corresponding author: Marjorie Miraclin K. Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution Liscense 4.0. A cross-sectional study to assess the risk of tarsal tunnel syndrome among type 2 diabetes patients Marjorie Miraclin K * and Mohammed Idris Faculty of Allied health Sciences, Dr MGR Educational and Research Institute, Chennai, India. World Journal of Biology Pharmacy and Health Sciences, 2025, 22(02), 192-211 Publication history: Received on 18 March 2025; revised on 29 April 2025; accepted on 01 May 2025 Article DOI: https://doi.org/10.30574/wjbphs.2025.22.2.0300 Abstract Aim: To assess the risk of tarsal tunnel syndrome among chronic diabetic patients. Objectives :1. Determine the risk of tarsel tunnel syndrome among chronic diabetic patients within the study population. 2. Investigate the relationship between diabetes – related variables (such as duration of diabetes, glycemic control) and the occurrence of tarsal tunnel syndrome.3. Associate the demographic variables with the risk of tarsal tunnel syndrome. Results: The prevalence of TTS in diabetic patients has been reported to range between 10% to 20%. Discussions: Tarsal tunnel syndrome (TTS) is an entrapment neuropathy affecting the tibial nerve, often underdiagnosed in diabetic patients. Diabetes-related peripheral neuropathy increases the risk of developing TTS due to nerve damage and metabolic changes. Several studies report a higher prevalence of TTS among individuals with longstanding diabetes and poor glycemic control. Early diagnosis and management are crucial to prevent chronic pain and improve quality of life in affected patients. Conclusion: Male diabetic patients are more commonly affected by Tarsal Tunnel Syndrome (TTS), with prolonged diabetes (16–20 years) increasing the risk. Poor glycemic control (high HbA1c) and pre-diabetic states are strongly linked to TTS development. Thyroid dysfunction, especially hypothyroidism, further contributes to nerve compression risk in diabetics. Early diagnosis and personalized treatment improve outcomes and help prevent long-term complications. Keywords: Tarsal Tunnel Syndrome; Diabetes Complication; Entrapment; Tinel Sign; Triple Compression Test 1. Introduction Tarsal Tunnel Syndrome (TTS) is a condition that results from the compression or irritation of the tibial nerve, which runs through a narrow passage in the ankle called the tarsal tunnel. This tunnel is located on the inside of the ankle, just behind the bony prominence of the medial malleolus. The tibial nerve, along with several tendons, blood vessels, and ligaments, passes through this tunnel, and when the nerve is compressed or entrapped, it can lead to symptoms such as pain, tingling, numbness, and weakness in the foot and ankle. TTS is often caused by factors that put pressure on the tibial nerve, such as injury, overuse, and systemic conditions like diabetes, flat feet, or abnormal foot mechanics. The symptoms are typically worsened with activities that involve prolonged standing, walking, or other repetitive movements. Treatment options for TTS include conservative measures like rest, ice, anti-inflammatory medications, physical therapy, and orthotics to reduce pressure on the nerve. In severe cases, surgery may be needed to relieve the World Journal of Biology Pharmacy and Health Sciences, 2025, 22(02), 192-211 193 compression. Early diagnosis and intervention are important for managing the condition and preventing further nerve damage 2. Material and methods 2.1. Aim To assess the risk of tarsal tunnel syndrome among chronic diabetic patients. 2.2. Objectives • Determine the risk of tarsal tunnel syndrome among chronic diabetic patients within the study population. • Investigate the relationship between diabetes – related variables (such as duration of diabetes, glycemic control) and the occurrence of tarsal tunnel syndrome. • Associate the demographic variables with the risk of tarsal tunnel syndrome. 2.3. Study type The cross-sectional study was conducted in the inpatient and outpatient department at A.C.S Medical College and Hospital. 2.4. Study population • Inclusion criteria All male and female in-patients admitted in General medicine and General surgery department; diabetic patients were included; patients with age of 30 and above are included irrespective of their genders • Exclusion criteria Any diabetic patients with diabetic foot ulcers 2.5. Sample size and population 569 participants were included in the study according to inclusion criteria and duration of the study was 6 months 3. Results and discussion Table 1 Gender Distribution Gender Frequency Percent Male 296 52.0 Female 273 48.0 Total 569 100.0 Table 1 shows the gender distribution of tarsal tunnel syndrome among chronic diabetic patients, which shows among female male has more frequency and higher percentage of cause, with a graph representation. Table 2 Duration Of Diabetes Years Duration Frequency Percent 1-5YRS 0 28 4.9 6-10YRS 1 250 43.9 11-15YRS 2 158 27.8 16-20YRS 3 74 13.0 Table 2 shows the duration of diabetes among diabetic patients in both male and female. Which shows 16-20 yrs. of duration has more frequency and higher percentage with graph representation World Journal of Biology Pharmacy and Health Sciences, 2025, 22(02), 192-211 194 Table 3 HbA1C Levels HBA1C LEVEL Frequency Percent Normal 0 4 0..7 Pre - Diabetic 1 101 17.8 Risk 2 463 81.4 Total 568 100 Table 3 shows the HBA1C level among diabetic patients in both genders, with the graphRepresentation which Shows high of risk in prediabetic condition with frequency and Percentage. Table 4 Recent Trauma (accident / injury/tendonitis) In the lower limb RECENT TRAUMA Frequency Percent Male 376 66.1 Female 193 33.9 Total 569 100.0 Figure 1 Recent trauma Figure 1 shows the RECENT TRAUMA (accident / injury/tendonitis) IN THE LOWER LIMB in diabetic patients in both male and female, to see any defect or injury in lower limb, which shows with a graphical representation. World Journal of Biology Pharmacy and Health Sciences, 2025, 22(02), 192-211 195 Table 5 Wearing tight shoes or sandals Frequency Percent Valid Percent Male 568 99.8 99.8 Female 1 .2 .2 Total 569 100.0 100.0 Figure 2 wearing tight shoes/ sandals to see any difficulty Figure 2 shows the wearing tight shoes/ sandals to see any difficulty in diabetic patients to see if their tarsal tunnel syndrome symptoms with graph representation Table 6 Atrophy of feet ATROPHY IN FEET Frequency Percent Male 342 60.1 Female 227 39.9 Total 569 100.0 World Journal of Biology Pharmacy and Health Sciences, 2025, 22(02), 192-211 196 Figure 3 Atrophy in feet Figure 3 Shows whether cause of atrophy in feet among diabetic patients, which Shows more Than females; males have high frequency and percentage with graph representation Table 7 Edema in feet Frequency Percent Male 220 38.7 Female 349 61.3 Total 569 100.0 Figure 4 Edema in feet Figure 4 Shows both tabular column and graph representation of Edema in feet among diabetic Patients in both genders, in which females have high percentage and frequency of cause of Edam more than males. World Journal of Biology Pharmacy and Health Sciences, 2025, 22(02), 192-211 197 Table 8 Inversion INVERSION Frequency Percent Free 284 49.9 Difficult 285 50.1 Total 569 100.0 Figure 5 Inversion sign Figure 5 Shows the Inversion sign in diabetic patients among both genders which Shows both Free and difficult movements in the leg with graph representation Table 9 Eversion EVERSION Frequency Percent Free 337 59.2 Default 232 40.8 Total 569 100.0 World Journal of Biology Pharmacy and Health Sciences, 2025, 22(02), 192-211 198 Figure 6 Eversion sign Figure 6 Shows the Eversion sign in diabetic patients among both genders which Shows both Free and difficult movements in the leg with graph representation Table 10 Dorsiflexion DORSI FLEXION Frequency Percent Free 199 35.0 Default 370 65.0 Total 569 100.0 Figure 7 Dorsiflexion World Journal of Biology Pharmacy and Health Sciences, 2025, 22(02), 192-211 199 FIGURE. 7 shows the dorsiflexion test which is a physical exam that helps diagnose tarsal tunnel Syndrome (TTS) by stretching and compressing the tibia nerve, with graph representation Table 11 Plantar Flexion Plantar Flexion Frequency Percent Free 180 31.6 Default 389 68.4 Total 569 100.0 Figure 8 shows planter flexion movement which is a test used to diagnose tarsal tunnel Syndrome, and it's performed by Placing the foot into maximum plantar flexion and inversion Holding for 10–15 seconds Returning the foot to neutral. It is represented with graph and its Frequency with its percentage Figure 8 Plantar Flexion Table 12 Numbness in the foot Numbness in the foot Frequency Percent Male 189 33.2 Female 380 66.8 Total 569`` 100.0 World Journal of Biology Pharmacy and Health Sciences, 2025, 22(02), 192-211 200 Figure 9 Numbness in the foot Figure 9 shows the numbness in the foot among diabetic patients in both genders in the leg Which is one the signs and symptoms of tarsal tunnel syndrome. This shows us that females Have higher percentage and frequency than males with the graph representation Table 13 Tingling in the foot TINGLING IN THE FOOT Frequency Percent Male 210 36.9 Female 359 63.1 Total 569 100.0 Figure 10 Tingling sign in the foot World Journal of Biology Pharmacy and Health Sciences, 2025, 22(02), 192-211 207 Table 32 Duration of diabetes * varicose vein in lower limb Years DURATION Male Female Total 1-5YRS 0 27 1 28 6-10YRS 1 249 1 250 11-15YRS 2 158 0 158 16-20YRS 3 74 0 74 Total 508 2 510 Table 33 Duration Of Diabetes * Recent Trauma Recent Trauma (Accident / Injury/Tendonitis) In The Lower Limb Years DURATION Male Female Total 1-5YRS 0 21 7 28 6-10YRS 1 155 95 250 11-15YRS 2 97 61 158 16-20YRS 3 55 19 74 Total 328 182 510 Table 33 shows the comparison between duration of diabetes and recent trauma in the lower Limb among diabetic patients with the given tabular column and represented pie chart in both Genders. Table 34 DURATION OF DIABETES * WEARING TIGHT SHOES/SANDALS WEARING TIGHT SHOES/SANDALS Years DURATION Male Female Total 1-5YRS 0 28 0 28 6-10YRS 1 250 0 250 11-15YRS 2 158 0 158 16-20YRS 3 73 1 74 Total 509 1 510 Table 34 shows the comparison between the duration of diabetes and wearing tight shoes / Sandals among diabetic patients with the given tabular column and represented pie chart in Both genders. Table 35 Duration of diabetes * edema in the feet EDEMA IN THE FEET Years DURATION Male Female Total 1-5YRS 0 18 10 28 6-10YRS 1 107 143 250 11-15YRS 2 33 125 158 16-20YRS 3 29 45 74 Total 187 323 510 World Journal of Biology Pharmacy and Health Sciences, 2025, 22(02), 192-211 208 Table 35 shows the comparison between the duration of diabetes and edema in the feet among the diabetic patients in the both genders with the given tabular column and represented pic chart. Table 36 DURATION OF DIABETES * - INVERSION INVERSION Total Years DURATION Male Female 1-5YRS 0 20 8 28 6-10YRS 1 148 102 250 11-15YRS 2 54 104 158 16-20YRS 3 30 44 74 Total 252 258 510 Table 36 shows the comparison between the duration of diabetes and inversion among diabetic Patients with the given tabular column and represented pie chart in both genders. Table 37 Duration Of Diabetes * Eversion EVERSION Years DURATION Male Female Total 1-5YRS 0 24 4 28 6-10YRS 1 171 79 250 11-15YRS 2 73 85 158 16-20YRS 3 34 40 74 Total 302 208 510 Table 37 shows the comparison between the duration of diabetes and eversion in foot among Diabetic patients with the given tabular column and represented pie chart in both genders. Table 38 Duration Of Diabetes * Dorsi Flexion DORSI FLEXION Years DURATION Male Female Total 1-5YRS 0 16 12 28 6-10YRS 1 87 163 250 11-15YRS 2 38 120 158 16-20YRS 3 30 44 74 Total 171 339 510 Table 38 shows the comparison between the duration of diabetes and the dorsiflexion in the Foot among the diabetic patients in both genders which is shown with the given tabular Column and represented pie chart. World Journal of Biology Pharmacy and Health Sciences, 2025, 22(02), 192-211 209 Table 39 Duration Of Diabetes * Plantar Flexion PLANTAR FLEXION Years DURATION Male Female Total 1-5YRS 0 18 10 28 6-10YRS 1 74 176 250 11-15YRS 2 30 128 158 16-20YRS 3 30 44 74 Total 152 358 510 Table 39 shows the comparison between duration of diabetes and the plantar flexion of the foot Among diabetic patients in both genders with the given tabular column and represented pie chart. Table 40 Durations of diabetes * numbness in the foot Crosstab Count NUMBNESS IN THE FOOT Total Years DURATION Male Female 1-5YRS 0 13 15 28 6-10YRS 1 87 163 250 11-15YRS 2 30 128 158 16-20YRS 3 31 43 74 Total 161 349 510 Table 40 shows the comparison between the duration of diabetes and numbness in the foot Among diabetic patients in both the genders with the given tabular column and represented Pie chart. Table 41 Duration of diabetes vs pain in the foot Crosstab Count P0IN IN THE FOOT Years DURATION Mild Moderate Severe Very Severe Total 1-5YRS 0 8 19 1 0 28 6-10YRS 1 18 114 108 10 250 11-15YRS 2 11 16 93 38 158 16-20YRS 3 29 2 11 32 74 Total 66 151 213 80 510 Table 41 The comparison between the duration of diabetes and pain in the foot among Diabetic patients in both the genders with the given tabular column and represented pie chart. World Journal of Biology Pharmacy and Health Sciences, 2025, 22(02), 192-211 210 4. Discussions The gender distribution of Tarsal tunnel syndrome among chronic diabetic patients, which shows among female male has more frequency and higher percentage of cause, with a graph representation. The duration of diabetes among diabetic patients in both male and female. which shows 16-20 yrs. of duration has more frequency and higher percentage with graph representation. The HBA1C level among diabetic patients in both genders, with the graph representation which shows high of risk in prediabetic condition with frequency a percentage. shows the frequency and percentage of thyroid [ whether hypo or hyperthyroidism among diabetic patients in both male and female, which shows male has more case of thyroid more than females with the graph representation The comparison between gender and thyroid among diabetic patients with pie chart representation. which shows males are more of than females. Research indicates that patients with diabetes have a higher risk of developing TTS compared to the general population. The prevalence of TTS in diabetic patients has been reported to range between 10% to 20%, though estimates may vary depending on the study population and diagnostic criteria used. A higher prevalence of TTS in diabetic patients can be attributed to several factors related to the pathophysiology of diabetes, particularly diabetic neuropathy and poor circulation. 5. Conclusion Research indicates that male diabetic patients are more frequently affected by Tarsal Tunnel Syndrome (TTS) compared to females. Despite the higher occurrence in males, the gender distribution often shows a similar percentage of affected individuals once adjusted for total population numbers. This could be due to the greater overall risk factors in men, such as a higher likelihood of associated complications like diabetic neuropathy, obesity, and lifestyle factors. The duration of diabetes plays a crucial role in the onset of TTS. Among chronic diabetic patients, those with a duration of 16-20 years tend to have the highest frequency and percentage of TTS cases, indicating that prolonged exposure to hyperglycemia and associated complications (like neuropathy and poor circulation) increases the risk of nerve compression in the tarsal tunnel. The level of HbA1c (glycated hemoglobin) serves as a marker for long-term blood glucose control. Pre-diabetic conditions, reflected by higher HbA1c levels (typically between 5.7% and 6.4%), are associated with a significant increase in the risk of developing TTS. Diabetic patients with poor glycemic control (i.e., HbA1c > 7%) show a higher risk for neuropathy, which can exacerbate TTS symptoms. Thyroid dysfunction, particularly hypothyroidism, is common in diabetic patients and can contribute to an increased risk of neuropathies such as TTS. Male diabetic patients tend to have a higher frequency of thyroid disorders compared to females. The reasons for this discrepancy are not entirely clear but may be related to hormonal differences or a higher prevalence of autoimmune thyroid disease in men with diabetes. Tarsal Tunnel Syndrome (TTS) is a neuropathic condition caused by the compression of the posterior tibial nerve, leading to symptoms like pain, tingling, numbness, and weakness in the foot. Early recognition and accurate diagnosis through clinical assessment, imaging, and electrodiagnostic tests are crucial for effective management. While conservative treatments such as rest, physical therapy, and orthotics can provide relief in many cases, more severe instances may require corticosteroid injections or surgery to decompress the nerve. The prognosis for TTS is generally favorable, especially when addressed early, though some patients may experience recurrent symptoms. Ultimately, a comprehensive, patient-specific approach to treatment is essential for restoring function and improving the quality of life for individuals affected by TTS. Compliance with ethical standards Disclosure of conflict of interest There is no Conflicts of Interest Statement of ethical approval The study was approved by Institutional Ethics Committee ACS Medical College and hospital (No.972/2023/1EC/ACSMCH Dt. 17.11.2023) Statement of informed consent Informed consent was obtained from all individual participants included in the study. World Journal of Biology Pharmacy and Health Sciences, 2025, 22(02), 192-211 211 References [1] Kinoshita, H., Okuda, R., Yasuda, T., Jotoku, T., Shima, H., & Abe, M. (2010). Tarsal tunnel syndrome in diabetic neuropathy: A comparison between diabetic patients and idiopathic cases. The Journal of Bone and Joint Surgery. 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