Tarsal Tunnel Syndrome

Picture from Orthopaedia.com

A patient came in to our clinic declaring she has plantar fascia pain in her right foot. She had seen another physiotherapist a few years ago for plantar fascia pain in her left foot and had gotten better. This time she tried orthotics, lots of stretching and even shockwave (or ESWT) with the same physiotherapist, but there was no improvement.

This is how she described her foot pain. She said there was a burning, aching pain at the bottom of her foot and on the inner heel. She said it almost feels like an electric shock. Her pain gets a lot worse after prolonged standing and sometimes wakes her up at night. She also gets numbness in her toes. 

None of those symptoms sound like plantar fascia pain to me. Patients with plantar fasciitis usually have pain during the first few steps when they get out of bed in the morning. There is rarely numbness, burning or electric shock sensations in the toes.

Upon assessment, there was no pain on the posterior calcaneal tubercle (where the PF inserts) nor along the plantar fascia itself. 

I elicited her pain when I did a modified Straight Leg Raise test by holding her foot in full dorsiflexion and eversion. However, there was no tingling or zinging in the foot when I tap on the medial malleolus (over the tarsal tunnel) - also known as Tinel's test. Online articles often describe a positive Tinel's test.

I explained my findings to her. My patient actually has Tarsal Tunnel Syndrome. This is when the posterior tibial nerve gets 'trapped' and irritated in the tarsal tunnel at the inner part of the foot (pictured below). 

Picture from Teachmeanatomy

The tarsal tunnel is a space just behind and below the medial malleolus and serves as a passageway for the posterior tibial artery, nerve and what we call Tom Dick and Harry muscles (tibialis posterior, flexor digitorum longus and flexor hallucis longus). The 'roof' of this tunnel is covered by the flexor retinaculum. It is a thick and strong fibrous band that holds Tom, Dick and Harry in place.

Tom, Dick and Harry- back of R leg

Entrapment of the posterior tibial nerve in the tarsal tunnel caused my patient's foot pain, not plantar fasciitis.

Online or AI* searches always say that flat feet or severe overpronation can cause tarsal tunnel pain as it can stretch the nerve although my patient does NOT have flat feet.

My patient did have a severe right ankle sprain a few months ago that caused swelling and perhaps thickening in the connective tissue in the tunnel that eventually caused this. It was also not treated properly, causing her to compensate and stand and walk differently possibly 'tractioning' her posterior tibial nerve.

A ganglion cyst in the canal may also cause this since it reduces the space in the tunnel. I have never come across this though in the 27 years of being a physiotherapist.

When a patient complains of bottom of foot pain, plantar fasciitis is usually the diagnosis one thinks of. The symptoms of tarsal tunnel syndrome pain can be similar to lumbar radiculopathy, diabetic and peripheral neuropathy or plantar fasciitis. Hopefully this article will correct that. 

 (*All the articles in this blog are written by me not by AI).

Reference

Boers N, Haverkamp M, Eligh AM et al (2026). Differences in Diagnosing Tarsal Tunnel Syndrome Across The Literature: A Systematic Review And A Call For Standardization. JBJS Rev. 14(2): e25.00222. DOI: 10.2106/JBJS.RVW.25.00222

L flexor retinaculum

Picture from https://drjustindean.com/retinaculaofthefoot/