Tarsal Tunnel Syndrome

Do you feel burning under your foot? Numbness extending up towards your ankle? That tingling sensation that appears when you walk for too long? These symptoms may indicate Tarsal Tunnel Syndrome.

As physiotherapists, we regularly evaluate and treat this condition. Tarsal Tunnel Syndrome is a compression of the tibial nerve inside the ankle. It causes pain, burning, and numbness under the foot. Physiotherapy effectively treats this condition without surgery in most cases.

What science shows:

• Conservative treatment works: 60 to 90% of cases respond well to physiotherapy.¹
• Trauma is a risk factor: 43% of affected individuals have had a previous ankle injury.²
• Surgery is rarely necessary: It is reserved for cases that do not respond to treatment.
• Early intervention matters: The sooner treatment begins, the better the results.

This guide explains this condition and how to treat it effectively. For an overview of ankle pain, consult our complete guide.

What is Tarsal Tunnel Syndrome?

Tarsal tunnel syndrome is an irritation or compression of the tibial nerve within the tarsal tunnel, located on the inside of the ankle. It's similar to carpal tunnel syndrome, but in the ankle instead of the wrist.

You might be familiar with carpal tunnel in the wrist. The tarsal tunnel works similarly, but in the ankle.

The tarsal tunnel is a passageway located under the bony bump on the inside of your ankle (the medial malleolus). This tunnel is formed by the ankle bones and a ligament that acts like a roof.

Structure	Normal role	Impact if compression
Bones (malleolus, talus, calcaneus)	Form the tunnel walls	Fixed, unchangeable space
Flexor retinaculum	Tunnel roof (ligament)	Can compress if thickened
Tibial nerve	Foot sensation and movement	Pain, numbness
Posterior tibial artery	Foot blood circulation	Possible ischemia
Flexor tendons	Toe movement	Inflammation can cause compression

When the space in this tunnel becomes too narrow, the tibial nerve gets compressed. This compression causes the nerve symptoms you experience.

Let's now look at the role of this important nerve.

What is the tibial nerve and what is its role?

The tibial nerve is one of the main nerves in the foot. It starts at the knee, goes down into the calf, and passes through the tarsal tunnel. It's responsible for 90% of the sensation in the sole of the foot and supplies the muscles that bend the toes.³

Think of nerves as electrical cables that transmit signals. The tibial nerve carries two types of signals:

Sensory signals (which travel up to the brain):

• Sensation in almost the entire sole of the foot
• Sensations of touch, temperature, pressure

Motor signals (which travel down to the muscles):

• Commands to the calf muscles
• Commands to the muscles that bend your toes

When this nerve is compressed, the electrical signals don't pass through properly. This is what causes abnormal sensations like burning, numbness, and tingling.

Let's now look at what can cause irritation to this nerve.

What are the causes of tarsal tunnel syndrome?

The syndrome is caused by a combination of compression and stretching of the tibial nerve. This reduces blood flow to the nerve. Up to 43% of affected individuals have a history of ankle trauma.²

The exact cause varies from person to person. Several factors can contribute:

Risk factor	Modifiable?	Explanation
Previous trauma	No	43% have had a sprain or injury
Repetitive overuse	Yes	Excessive walking, running, or jumping
Flat feet	Partially	Orthotics can help
Poor muscle control	Yes	Ankle or arch instability
Masses or cysts	Variable	Occupy space within the tunnel
Tendon inflammation	Yes	Flexor tendinitis

How do you know if you have this syndrome? Here are the symptoms to recognize.

What are the symptoms of Tarsal Tunnel Syndrome?

The main symptoms are pain on the inside of the ankle, below the malleolus. The pain can spread towards the arch of the foot or the entire sole. People often feel burning, numbness, or tingling in the foot and toes.

Symptom	Location	Characteristic
Pain	Inner ankle (below the bony bump)	Deep, dull, or sharp
Burning sensation	Sole of the foot	Sensation of warmth
Numbness	Foot and toes	Loss of sensation
Tingling	Foot and toes	Tingling sensation
Weakness	Foot muscles	Difficulty bending toes

Symptoms worsen	Symptoms improve
Prolonged walking or standing	Rest
Running or jumping	Foot elevation
In the morning upon waking	After moving around a bit

Don't confuse this with plantar fasciitis, which causes heel pain rather than pain on the inside of the ankle.

If these symptoms sound familiar, let's see how the diagnosis is made.

How is Tarsal Tunnel Syndrome diagnosed?

Diagnosis is made based on the symptom history and a clinical examination. An EMG can be helpful but isn't always necessary. The vast majority of cases are treated effectively without this test.³

Your healthcare professional will:

1. Asking you questions about your symptoms: location, onset, what worsens or relieves them
2. Examining your ankle and foot: mobility, strength, sensation
3. Performing specific tests: such as the Tinel's test (tapping on the tunnel to see if it reproduces your symptoms)

Is an EMG (electromyogram) necessary?

EMG measures electrical activity in your nerves and muscles. It can confirm nerve damage, but:

• It is not always necessary to start treatment
• Results can be falsely negative in early stages
• Most cases of tarsal tunnel syndrome are treated without this examination

Now that you know what it is, let's see when to consult a professional.

When should you consult a physiotherapist?

Consult if you have pain, burning, or numbness in your ankle or foot. You don't need to see a doctor beforehand. If your condition requires medical advice, your physiotherapist will guide you.

Consult promptly if you have:

• Persistent pain on the inside of the ankle
• Burning or numbness under the foot
• Symptoms that increase with activity
• Tingling in the toes

You don't need to wait. In Quebec, you can consult a physiotherapist directly without a medical prescription. If your condition requires further investigation, your physiotherapist will refer you to the appropriate professional.

The sooner treatment begins, the better the results. Don't wait for symptoms to become chronic.

Let's see what physiotherapy can do for you.

What treatments does physiotherapy offer?

Your physiotherapist will assess your joint mobility, nerve gliding, movement quality, and strength. Treatment includes mobilizations, stabilization exercises, and rehabilitation to optimize healing.

The complete evaluation includes:

• Mobility of your ankle and foot
• Nerve gliding test
• Assessment of your movement quality
• Measurement of your strength and stability

Intervention	Goal	What this involves
Joint mobilization	Improve movement	Manual techniques for ankle and foot
Neurodynamics	Release the nerve	Tibial nerve gliding exercises
Strengthening	Stabilize the foot	Progressive exercises for the muscles
Motor retraining	Correcting movements	Learning to better control your foot
Education	Making you independent	Advice on managing your activity levels

Treatment is personalized to your needs. Every person is different, and the causes can vary.

Between your sessions, here's what you can do at home.

What to do at home?

Temporarily reduce activities that cause too much pain and gradually reintroduce them. Opt for low-impact activities like swimming or cycling. Take frequent breaks if pain increases with prolonged standing.

Advice	How to apply it	Benefit
Reducing painful activities	Temporarily, not permanently	Allows the nerve to recover
Swimming or cycling	Replacing walking or running	Maintains your fitness without worsening symptoms
Frequent breaks	Sit for 5 minutes every hour	Reduces weight-bearing
Local ice application	15-20 minutes if swollen	Reduces inflammation
Good shoes	Adequate arch support	Reduces tension on the nerve

Important: Don't remain completely inactive. Movement is beneficial, but finding the right balance is key. When to seek further consultation: If you don't see any improvement after 10 days of following these steps, consult a physiotherapist. Professional treatment may be necessary to make progress.

Finally, let's talk about healing time.

How long does healing take?

Healing time varies depending on the severity and duration of symptoms. With physiotherapy treatment, most people see significant improvement within 6 to 12 weeks. Early treatment leads to better results.

Factors influencing healing time:

• How long you have had the symptoms
• The severity of nerve compression
• Your ability to follow recommendations
• The underlying cause of the problem

Good news:

• Conservative treatment (physiotherapy) is effective in 60 to 90% of cases¹
• Surgery is rarely necessary
• Most people return to their normal activities

When is surgery considered? Only after 3 to 6 months of unsuccessful conservative treatment. This is rare, as the vast majority of people respond well to physiotherapy.

Key points to remember

Tarsal tunnel syndrome is a compression of the tibial nerve at the ankle, causing pain, burning, and numbness. This condition is effectively treated with physiotherapy in most cases.

• Symptoms are caused by nerve compression, not by wear and tear
• Conservative treatment is effective in 60 to 90% of cases
• Early treatment yields better results
• Surgery is rarely necessary

If you have symptoms of tarsal tunnel syndrome, don't wait. Consult a physiotherapist for a complete evaluation and a personalized treatment plan. You do not need a medical prescription.

References

1. Ahmad M, Tsang K, Mackenney PJ, Adedapo AO. Tarsal tunnel syndrome: A literature review. Foot Ankle Surg. 2012;18(3):149-152.
2. Cimino WR. Tarsal tunnel syndrome: review of the literature. Foot Ankle. 1990;11(1):47-52.
3. Kiel J, Kaiser K. Tarsal Tunnel Syndrome. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023.
4. Lau JT, Daniels TR. Tarsal tunnel syndrome: a review of the literature. Foot Ankle Int. 1999;20(3):201-209.
5. McSweeney SC, Cichero M. Tarsal tunnel syndrome-A narrative literature review. Foot (Edinb). 2015;25(4):244-250.