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Tarsal Tunnel Syndrome (TTS)

Last updated Jan. 5, 2019

Approved by: Krish Tangella MD, MBA, FCAP


Placing the foot in Eversion (top left), Inversion (bottom left), or Plantar flexion(right) all put strain on the tibial nerve. These positions should be avoided to prevent the development of Tarsal Tunnel Syndrome and can be done so by using a brace to place the foot in a neutral position.

What are the other Names for this Condition? (Also known as/Synonyms)

  • Entrapment Neuropathy of Distal Tibial Nerve
  • Posterior Tibial Nerve Neuralgia
  • Tarsal Tunnel Entrapment Neuropathy

What is Tarsal Tunnel Syndrome? (Definition/Background Information)

  • The tarsal tunnel is a small rigid passageway surrounded by bones and ligaments that lie on the inside of the ankle. This passageway protects an important central nerve in the ankle, called the tibial nerve
  • Tarsal Tunnel Syndrome (TTS) refers to the compression of the tibial nerve as it passes through the tarsal tunnel
  • Overall, middle-aged women are more likely to develop Tarsal Tunnel Syndrome than men
  • Both nonsurgical and surgical methods are available to treat the condition. The prognosis of Tarsal Tunnel Syndrome is usually excellent with appropriate and early intervention

Who gets Tarsal Tunnel Syndrome? (Age and Sex Distribution)

  • Tarsal Tunnel Syndrome is most common between the ages of 30 to 40 years old. However, individuals of all ages can develop the condition
  • TTS is more common in women than men
  • No ethnic or racial preference is seen
  • The condition is also predominately seen in athletes who participate in sports that cause repetitive stress on the ankles

What are the Risk Factors for Tarsal Tunnel Syndrome? (Predisposing Factors)

Common risk factors of Tarsal Tunnel Syndrome include:

  • Any sport that requires repetitive overuse of the ankle joints, such as tennis, basket ball
  • Women have a higher incidence of TTS
  • Chronic inflammatory disorders (such as rheumatoid arthritis)
  • High blood glucose levels that result from either an insulin secretion deficiency (diabetes type II) or an insulin resistance (diabetes type I) in the body
  • Abnormal pressure on the tarsal tunnel due to excessive body weight (obesity)
  • Hormonal or metabolic changes, due to pregnancy or thyroid imbalance, can increase an individual’s risk of developing the condition
  • Factors such as vitamin deficiency and alcoholism can also increase an individual’s risk of Tarsal Tunnel Syndrome 

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases ones chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Tarsal Tunnel Syndrome? (Etiology)

Currently, the underlying cause of Tarsal Tunnel Syndrome is unknown. However, several contributing factors that researchers believe are linked to Tarsal Tunnel Syndrome include:

  • Individuals with flat feet
  • Individuals who participate in sports that require repetitive overuse of the ankle joints, such as tennis or baseball
  • High blood glucose levels that result from an insulin secretion deficiency (diabetes type II)
  • Proteinaceous deposition around the ankle due to hypothyroidism
  • Chronic inflammatory disorder (such as rheumatoid arthritis)
  • Swelling caused by a sprained ankle, which can compress nerves in the ankle
  • Structural abnormalities, such as varicose veins, ganglion cyst, inflamed tendon, lipoma, or bone spur, all may compress the nerve

What are the Signs and Symptoms of Tarsal Tunnel Syndrome?

Symptoms of Tarsal Tunnel Syndrome are usually observed on the inside of the ankle, heel, and bottom of the foot. In some cases, symptoms may occur in one place. In other cases, symptoms may extend to the heel, arch, and toes.

Additional signs and symptoms of Tarsal Tunnel Syndrome include:

  • Radiating pain in the ankle
  • Tingling sensation, noticeable numbness of the ankle
  • Burning sensation on the bottom of the ankle

How is Tarsal Tunnel Syndrome Diagnosed?

Diagnostic methods that a physician may use to help diagnose Tarsal Tunnel Syndrome include:

  • Physical examination: A thorough physical examination is important in determining if an individual has Tarsal Tunnel Syndrome.
    • During this exam, a physician will apply pressure to the tibial nerve for sensation and the strength of the muscles in the ankle, which can be affected by TTS
    • Individuals may be asked the list of activities that one may be performing, which cause repetitive motions around the ankle joint
    • Individuals are also expected to provide an explanation of the circumstances that led up to the injury. In addition to this, a complete medical history will aid in arriving at a definitive diagnosis
  • Blood tests, such as fasting blood glucose, thyroid function test, and tests for rheumatoid arthritis, may be performed
  • X-ray of the ankle: X-rays use radiation to produce images of the ankle. It can also help the physician rule out other possible causes of ankle discomfort, such as arthritis or a fracture
  • Electromyography (EMG): An EMG shows the electrical activity of the muscle during rest and during muscle contraction. Examining the electrical activity may help a physician identify any injury to the tibial nerve in the ankle
  • Nerve conduction velocity (NCV) study: Nerve conduction velocity study shows the speed at which electrical signals move through a nerve. Slowing of nerve conduction speed may indicate tibial nerve damage

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Tarsal Tunnel Syndrome?

If Tarsal Tunnel Syndrome is properly treated, a high percentage of individuals usually do not experience any serious complications. However, a common complication associated with TTS includes a permanent injury to the tibial nerve. This can result in:

  • Permanent loss of strength of the ankle muscles
  • Permanent loss of sensation in the ankle region

How is Tarsal Tunnel Syndrome Treated?

The treatment measures for Tarsal Tunnel Syndrome include nonsurgical and surgical methods.

Nonsurgical treatment measures for Tarsal Tunnel Syndrome include:

  • Any activity that aggravates the ankle condition should be avoided. The physician may advise the individual to refrain from participating in any physical activities, till the pain or symptoms get better
  • Application of ice/cold pack to the ankle, so as to reduce pain and swelling
  • Complete immobilization of the ankle with a cast may be required to restrict movement
  • Non-steroidal anti-inflammatory oral medications, such as indomethacin and naproxen, may be used to treat Tarsal Tunnel Syndrome. These medications can help decrease the pain and swelling
  • Corticosteroid injections help provide temporary relief of symptoms and in improving the range of motion. It is important to note that corticosteroid injections only give temporary relief. Prolonged episodes of such injections may injure the joints in the long run
  • A well-fitted brace may help relieve pressure on the ankle for individuals with flat feet or severe nerve damage
  • A well-fitted ankle brace may help individuals with severe nerve damage or flat feet to reduce the amount of pressure on the foot
  • A well-padded custom-made shoe insert may be used to help the arch and limit excessive motion that can cause nerve compression
  • Physical therapy or ultrasound therapy may help decrease symptoms

Surgical treatment measures Tarsal Tunnel Syndrome include:

  • Tarsal Tunnel Syndrome Release: It is a minimally invasive surgical procedure that allows a physician to examine certain structures within the ankle, such as the laciniate ligament (a strong fibrous band in the foot), using an orthopedic device (called an endoscope). During this procedure, the laciniate ligament is cut, which decreases any abnormal pressure on the tibial nerve, thereby reducing the signs and symptoms that the individual is experiencing

How can Tarsal Tunnel Syndrome be Prevented?

Currently, there are no definitive methods available to prevent Tarsal Tunnel Syndrome. However, certain measures that may be helpful in preventing abnormal pressure on the tibial nerve include:

  • Minimize participation in any sports or physical activities that require repetitive overuse of the ankle; also learn the correct technique to minimize stress
  • Stretch before exercising or taking part in sports activities, which can help prevent injuries to the structure around the nerve and decrease the possibility of compression
  • Wearing proper fitting and appropriate footwear, such as shoes that provide an adequate cushion for the heel, may help reduce stress on the ankle
  • Perform exercises to strengthen the supporting muscles of the lower leg, which can also decrease leg and ankle injuries
  • Proper treatment of type I diabetes and type II diabetes can help prevent TTS in such individuals
  • Proper treatment of underlying conditions such as rheumatoid arthritis (RA)
  • Maintaining a healthy body weight can help reduce abnormal pressure on the ankle joints

What is the Prognosis of Tarsal Tunnel Syndrome? (Outcomes/Resolutions)

  • Tarsal Tunnel Syndrome can range in severity from being a minor condition to a serious and disabling condition
  • The long-term prognosis of Tarsal Tunnel Syndrome is usually good in a majority of the individuals
  • If detected and treated early, signs and symptoms of TTS can be controlled; in many instances, they may completely disappear
  • If left untreated, severe cases of the disorder may result in permanent muscle strength and sensation loss, leading to a decreased ability of the individual to participate in any athletic, professional, or recreational activity

Additional and Relevant Useful Information for Tarsal Tunnel Syndrome:

Tarsal tunnel release (surgical procedure) decreases the symptoms of Tarsal Tunnel Syndrome in about 85-90% of cases.

What are some Useful Resources for Additional Information?

References and Information Sources used for the Article:

Helpful Peer-Reviewed Medical Articles:

Reviewed and Approved by a member of the DoveMed Editorial Board
First uploaded: May 27, 2015
Last updated: Jan. 5, 2019