Tarsal Tunnel Syndrome (TTS) is a condition caused by compression of the tibial nerve as it passes through a narrow space called the tarsal tunnel, located behind the inner ankle bone. The tibial nerve supplies sensation and muscle control to the bottom of the foot. When it becomes compressed, patients may experience pain, tingling, numbness, or weakness in the foot and toes. If untreated, this condition can lead to lasting nerve damage and difficulty walking.
How Common It Is and Who Gets It? (Epidemiology)
Tarsal Tunnel Syndrome can affect anyone, but it is most common in adults with flat feet, ankle injuries, or swelling that puts pressure on the nerve. Both men and women can develop the condition, though athletes, runners, and dancers are at higher risk due to repetitive foot motion. Systemic conditions such as diabetes, arthritis, or thyroid disease can also increase susceptibility.
Why It Happens – Causes (Etiology and Pathophysiology)
The tarsal tunnel is a rigid space formed by bone and a fibrous structure called the flexor retinaculum. When pressure builds within this tunnel, the tibial nerve becomes compressed.
Common causes include:
- Swelling from ankle sprains, fractures, or inflammation
- Bone spurs or cysts near the tunnel
- Varicose veins or masses pressing on the nerve
- Flat feet or high arches that alter foot mechanics
- Systemic diseases such as diabetes or arthritis that affect nerve health.
How the Body Part Normally Works? (Relevant Anatomy)
The tarsal tunnel runs behind the inner ankle bone (medial malleolus). It contains the posterior tibial tendon, blood vessels, and the tibial nerve. The tibial nerve branches into smaller nerves that provide sensation to the sole and toes. When space inside the tunnel becomes restricted, the nerve is compressed, leading to the characteristic pain and numbness of TTS.
What You Might Feel – Symptoms (Clinical Presentation)
Patients often report:
- Burning, tingling, or shooting pain on the bottom of the foot
- Numbness in the arch, heel, or toes
- Worsening pain with walking, standing, or at night
- Weakness or cramping in the foot muscles
- Inability to curl the toes or loss of balance in advanced cases
Tapping over the nerve (Tinel’s test) may cause tingling that radiates into the foot, a classic finding for TTS.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis is based on a physical exam, medical history, and specialized tests:
- Nerve conduction studies (NCS) and electromyography (EMG) confirm nerve compression.
- Ultrasound or MRI can detect cysts, varicose veins, or swelling around the nerve.
- X-rays may show bone abnormalities such as spurs or fractures.
Blood tests may be ordered to rule out systemic conditions like diabetes or arthritis.
Classification
TTS can be categorized by severity:
- Mild: Occasional tingling or burning that occurs with activity.
- Moderate: Daily symptoms affecting function and comfort.
- Severe: Persistent numbness, weakness, or visible muscle wasting due to chronic nerve damage.
Other Problems That Can Feel Similar (Differential Diagnosis)
Conditions that mimic TTS include:
- Plantar fasciitis
- Diabetic neuropathy
- Lumbar spine nerve compression (radiculopathy)
- Morton’s neuroma
- Peripheral vascular disease
A careful exam and diagnostic testing help identify the correct cause.
Treatment Options
Non-Surgical Care
- Rest and ice: Reduce inflammation and swelling around the nerve.
- Medication: Nonsteroidal anti-inflammatory drugs (NSAIDs) help control pain and inflammation.
- Orthotic support: Custom inserts can correct flatfoot deformity and offload nerve pressure.
- Activity modification: Avoid prolonged standing, running, or jumping.
- Steroid injections: May temporarily relieve nerve inflammation.
- Physical therapy: Improves flexibility, strengthens the ankle, and enhances nerve mobility.
Surgical Care
If conservative care fails, Tarsal Tunnel Release surgery is performed. A small incision is made behind the inner ankle bone, and the flexor retinaculum is released to relieve pressure on the tibial nerve. If a cyst, vein, or scar tissue is causing compression, it is removed during the procedure.
Surgery usually provides long-term relief, especially when performed before permanent nerve damage occurs.
Recovery and What to Expect After Treatment
After surgery, the ankle is protected in a boot or soft dressing. Limited weight-bearing is advised for the first two weeks. Physical therapy begins after the incision heals to restore motion and nerve flexibility.
Most patients experience significant pain relief within weeks, though complete nerve recovery may take several months. Walking and light activity usually resume by six to eight weeks.
Possible Risks or Side Effects (Complications)
Potential complications include:
- Infection or delayed wound healing
- Persistent or recurrent symptoms
- Sensitivity at the incision site
- Nerve irritation or scar formation
- Incomplete decompression requiring revision surgery.
Long-Term Outlook (Prognosis)
With early diagnosis and proper treatment, most patients recover fully and regain normal nerve function. Surgical outcomes are excellent when the cause of compression is corrected. Untreated TTS can result in permanent numbness, chronic pain, or muscle weakness.
Out-of-Pocket Costs
Medicare
CPT Code 28035 – Tarsal Tunnel Release: $122.67
Medicare Part B covers 80% of the approved amount after the deductible. Supplemental insurance plans such as Medigap, AARP, or Blue Cross Blue Shield usually cover the remaining 20%.
Secondary insurance (such as TRICARE, employer-based coverage, or Veterans Health Administration) may act as a second payer to cover any remaining coinsurance or deductible, typically between $100 and $300 depending on the plan.
Workers’ Compensation
If the condition or surgery is work-related, Workers’ Compensation pays for all medical and surgical costs, including rehabilitation, leaving the patient with no out-of-pocket expenses.
No-Fault Insurance
When the injury is related to a motor vehicle accident, No-Fault Insurance covers the full cost of care, with only a small deductible or copayment based on policy terms.
Example
John required Tarsal Tunnel Release surgery for severe nerve compression. His estimated Medicare out-of-pocket cost was $122.67. Because he also had secondary insurance, his remaining 20% was fully covered, leaving him with no personal expense.
Frequently Asked Questions (FAQ)
Q. What is Tarsal Tunnel Syndrome?
A. Tarsal Tunnel Syndrome (TTS) is a condition where the posterior tibial nerve is compressed as it passes through the tarsal tunnel in the ankle, causing symptoms like tingling, numbness, and pain in the foot.
Q. How is Tarsal Tunnel Syndrome diagnosed?
A. Diagnosis involves a physical exam, assessment of symptoms, nerve conduction studies (NCS), and electromyography (EMG) to confirm nerve compression and rule out other conditions.
Q. What is Tarsal Tunnel Release surgery?
A. Tarsal Tunnel Release is a surgical procedure where an incision is made near the ankle to release the flexor retinaculum, relieving pressure on the posterior tibial nerve to reduce pain and improve function.
Q. When is Tarsal Tunnel Release surgery recommended?
A. Surgery is recommended when conservative treatments such as rest, physical therapy, and corticosteroid injections fail, or when there is clear evidence of nerve compression.
Q. What is the recovery process after Tarsal Tunnel Release?
A. After surgery, patients must rest and avoid putting weight on the affected foot for a period of time. Physical therapy may be recommended, and it’s important to monitor for complications like infection or nerve injury.
Q. What are the expected outcomes of Tarsal Tunnel Release surgery?
A. The success rate ranges from 44% to 96%, with better outcomes for those with a clear cause of nerve compression and those with a shorter history of symptoms.
Q. Are there any alternative surgeries for Tarsal Tunnel Syndrome?
A. Yes, alternative surgeries like triple arthrodesis or distraction calcaneocuboid arthrodesis may be considered, especially if there are additional foot deformities contributing to nerve compression.
Q. How does nerve tension play a role in Tarsal Tunnel Syndrome?
A. Increased tibial nerve tension, especially in patients with foot deformities like flat feet, can contribute to the development and worsening of TTS, which may require surgeries to reduce this tension.
Q. Can Tarsal Tunnel Release be done with other surgeries?
A. Yes, in some cases, Tarsal Tunnel Release can be combined with procedures like triple arthrodesis to address foot deformities and reduce nerve tension for better long-term results.
Q. What is the role of physical therapy after Tarsal Tunnel Release?
A. Physical therapy may help restore foot function and strength after surgery, aiding in recovery and ensuring proper movement of the foot.
Q. How long does Tarsal Tunnel Release surgery take?
A. The procedure typically takes about one hour, depending on the complexity of the condition and any additional procedures being performed.
Q. Is Tarsal Tunnel Release surgery done under general or local anesthesia?
A. Tarsal Tunnel Release is generally performed under local anesthesia with sedation, though general anesthesia may be used depending on the patient and the surgeon’s preference.
Q. What are the potential risks and complications of Tarsal Tunnel Release surgery?
A. Risks include infection, nerve damage, scarring, recurrence of symptoms, and blood clots. However, these complications are relatively rare with proper care and follow-up.
Q. Will I have any scarring after Tarsal Tunnel Release surgery?
A. There will be a small scar where the incision is made near the ankle. It usually heals well and becomes less noticeable over time.
Q. Can Tarsal Tunnel Release surgery be performed on both feet at the same time?
A. While it is possible to perform Tarsal Tunnel Release on both feet simultaneously, most surgeons prefer to treat one foot at a time to reduce the risk of complications and ensure better recovery.
Q. Is Tarsal Tunnel Release surgery painful?
A. Post-surgical discomfort is mild and easily managed with medication. Most patients notice rapid improvement in nerve pain.
Q. Will numbness go away after surgery?
A. Yes, sensation usually improves as the nerve heals, though full recovery may take several months.
Q. Can Tarsal Tunnel Syndrome come back?
A. Recurrence is rare if the source of compression is fully corrected and proper footwear is maintained.
Q. When can I walk normally again?
A. Most people return to regular walking within six to eight weeks, depending on healing progress.
Q. Is the procedure covered by insurance?
A. Yes, Tarsal Tunnel Release is covered under most insurance plans, including Medicare, Workers’ Compensation, and No-Fault Insurance.
Summary and Takeaway
Tarsal Tunnel Syndrome occurs when the tibial nerve is compressed near the ankle, leading to pain, tingling, and numbness on the sole of the foot. Conservative treatments such as rest, orthotics, and physical therapy often help, but surgery may be necessary for lasting relief. Tarsal Tunnel Release effectively decompresses the nerve, restoring comfort and preventing long-term damage.
Clinical Insight & Recent Findings
A recent study from Plastic and Reconstructive Surgery – Global Open introduced a minimally invasive Tarsal Tunnel Release technique, demonstrating significant benefits for patients, particularly those with diabetic foot ulcers (DFUs).
This study compared 34 minimally invasive surgeries to 22 traditional open procedures. The minimally invasive method showed equally effective results in restoring sensation and nerve function but offered key advantages: smaller incisions (2.3 cm vs. 5.8 cm), faster wound healing (15 days vs. 24 days), and no major complications.
These outcomes are especially relevant for diabetic patients, who often struggle with poor wound healing and high infection risks. The authors concluded that this minimally invasive technique offers a promising advancement in managing TTS, reducing recovery time while maintaining excellent neurological outcomes.
(Study on minimally invasive tarsal tunnel release for diabetic foot ulcers – see PubMed.)
Who Performs This Treatment? (Specialists and Team Involved)
Tarsal Tunnel Release surgery is performed by orthopedic foot and ankle surgeons or podiatric surgeons. The care team typically includes anesthesiologists, nurses, and physical therapists who manage anesthesia, recovery, and rehabilitation.
When to See a Specialist?
You should see a foot and ankle specialist if you experience persistent numbness, burning, or tingling in your foot that worsens with walking or standing. Early evaluation prevents long-term nerve injury.
When to Go to the Emergency Room?
Go to the emergency room if you develop sudden, severe foot pain, loss of sensation, or inability to move your toes, especially after injury or swelling around the ankle.
What Recovery Really Looks Like?
Mild swelling and soreness are normal during early recovery. Most patients can bear light weight in two to three weeks and return to regular walking within two months. Full nerve recovery may take several months. Wearing supportive footwear and attending physical therapy enhances outcomes.
What Happens If You Ignore It?
Ignoring TTS can result in chronic nerve compression, leading to permanent numbness, weakness, or muscle atrophy in the foot. It may also alter gait and worsen ankle alignment.
How to Prevent It?
Maintain proper foot support with orthotics or cushioned shoes, avoid prolonged standing, and manage swelling or ankle injuries promptly. Controlling diabetes and weight helps reduce nerve stress and inflammation.
Nutrition and Bone or Joint Health
Eat foods rich in vitamin B12, vitamin E, omega-3 fatty acids, and antioxidants to support nerve health. For those with diabetes, maintaining stable blood sugar levels helps prevent neuropathy.
Activity and Lifestyle Modifications
Limit prolonged standing, wear well-fitted shoes, and stretch regularly to maintain flexibility in the ankles. After surgery, resume activities gradually to avoid re-injury and preserve long-term results.
Dr. Mo Athar
