Tarsal tunnel syndrome (TTS) occurs when the posterior tibial nerve, which runs along the inside of the ankle and foot, becomes compressed and damaged, causing inflammation.

TTS may happen due to injury, such as an ankle sprain, or can result from a health condition such as arthritis or diabetes. Bone spurs, flat feet, or a swollen tendon may all cause nerve compression and result in TTS.

Fast facts on TTS

  • TTS is a relatively rare condition.
  • Severe or untreated cases may cause nerve damage.
  • Treatment may include exercises to stretch the affected tissues.

Click on the BodyMap above to interact with a 3D model of the posterior tibial nerve.

It is best for a doctor to assess and treat symptoms of TTS early, as this may result in better outcomes.

The American College of Foot and Ankle Surgeons recommends the following ways to treat and manage TTS:

  • Rest: People can avoid using and putting pressure on the affected area as much as possible to prevent further damage and promote healing.
  • Ice: A person can apply an ice pack wrapped in a cloth to the foot for 20 minutes. Leave the ice off for at least 40 minutes before repeating as necessary.
  • Over-the-counter pain and anti-inflammatory medications: These can help manage symptoms and may include ibuprofen and acetaminophen.
  • Full immobilization: For severe cases, especially those involving physical damage to the nerve, a cast may be necessary to restrict movement completely, allowing the nerve, joint, and surrounding tissues a chance to heal.
  • Injection therapy: For very painful or disabling symptoms, a doctor may inject anti-inflammatory medication, such as corticosteroids and local anesthetics, directly into the nerve.
  • Orthopedic devices and corrective shoes: Podiatrists can make specialized shoes and inserts that help support the arch and limit motions that further irritate the inflamed nerve and surrounding tissues. Shoes also exist to help prevent pronation or inward rolling of the foot.
  • Reducing foot pressure: In some cases, wearing supportive shoes and socks may help reduce pressure around the foot. People with flat feet, severe symptoms, or nerve damage may require a brace to reduce pressure on the injured foot.
  • Physical therapy: Physical therapy exercises may help reduce TTS symptoms by slowly stretching and strengthening the connective tissues, mobilizing the tibial nerve, and opening the surrounding joint space to reduce compression.

Types of physical therapy to treat TTS may include:

  • ultrasound therapy
  • acupuncture
  • manual therapy
  • taping or bracing
  • exercises to strengthen the tibialis posterior muscle

In severe cases of TTS or cases that do not respond to other therapies, people may require surgery.

Tarsal tunnel surgery

In some severe cases, or if other treatments are ineffective, people may require surgery to treat TTS. One procedure is tarsal tunnel release.

During tarsal tunnel release surgery, a surgeon will make an opening from the back of the ankle to the arch of the foot. A surgeon will then make a cut in the ligament to stop it from compressing the tibial nerve.

According to one source from 2021, surgery is successful in 44–96% of cases. People with no previous ankle problems, younger people, and people who receive an early diagnosis may have a better outcome with surgery.

In other cases, people may have endoscopic surgery, which is a less invasive procedure. They will have a local anesthetic, and a surgeon will make a small incision of around 1 centimeter in the inner ankle.

Using a push knife, a surgeon will release the flexor retinaculum, a band of tissues in the foot, from part of a muscle called the abductor hallucis.

Exercises such as calf stretching and nerve gliding may help relieve symptoms and strengthen the tibialis posterior muscle.

People can follow the advice of a doctor or work with a physical therapist to find exercises that are safe for them to do at each stage of their recovery. Exercises for the treatment of TTS may include:

  • balance exercises
  • heel to toe walking
  • single-leg stances on various surfaces
  • heel-toe raises

The following are descriptions of how to do a few exercises to strengthen the tibialis posterior:

Heel-toe raises

  1. Using the back of a chair or counter for support, lift the heels off the floor to stand on the toes.
  2. Hold for 5 seconds before slowly lowering back down to the floor.
  3. Repeat the exercise 15 times.
  4. Do two sets, with a 30-second rest between each set.
  5. As the injured foot becomes stronger, try standing on the injured foot only.

Balance exercise

  1. Stand beside a chair, using it for support if needed, with the injured foot furthest from the chair.
  2. Stand on the injured foot and slightly bend the knee.
  3. Bend forward from the waist and reach forward with the hand furthest from the chair.
  4. Repeat 15 times for two sets.
  5. Reach the hand furthest from the chair across the body, toward the chair.
  6. Repeat 15 times for two sets.

Calf stretch

  1. Stand and face a wall with the hands placed on the wall at eye level.
  2. Take a lunge position by placing the injured foot slightly behind with the heel flat on the ground and the other leg slightly forwards with a bent knee.
  3. Turn the back foot inwards slightly.
  4. Gently lean towards the wall until there is a stretch in the back calf.
  5. Hold in this position for 15–30 seconds.
  6. Return to the start and repeat 3 times.
  7. Repeat the entire exercise several times a day.

A strain or compression to the tibial nerve can cause TTS. This may include:

A doctor will typically diagnose and assess TTS by performing a physical exam of the entire foot and lower leg area and asking questions about symptoms.

Diagnostic tests a doctor may use to confirm and evaluate TTS include:

Certain factors may increase the risk of developing the condition. Risk factors for TTS include:

  • diabetes
  • hypothyroidism
  • gout
  • mucopolysaccharidosis, a condition where the body is unable to break down certain sugar molecules
  • hyperlipidemia, in which there are high levels of fats in the blood
  • flat feet or fallen arches
  • arthritis
  • ankle or foot injury
  • nerve disease
  • ganglion cyst
  • varicose veins
  • bone spur

Without treatment, TTS may lead to complications such as:

  • nerve damage to the posterior tibial nerve and surrounding nerve branches
  • persistent pain
  • motor weakness and atrophy

In some cases, surgery may not be successful in treating pain or other symptoms and may result in complications such as:

TTS is a rare condition when compression to the posterior tibial nerve in the foot occurs. TTS may happen from injury, flat feet, or health conditions such as diabetes.

Rest, applying ice, and physical therapy may all help treat TTS. In severe cases, people may require surgery to relieve nerve compression.

Seeking proper treatment is important to prevent complications such as nerve damage. People can contact a doctor if they suspect they have TTS.