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/

What Supports The Medial Arch

I've been trying to keep myself busy during the circuit breaker and catch up on my reading and watching. Not watching Netflix, mind you. I don't have a Netflix account. At the risk of sounding like a dinosaur, I have never watched anything on Netflix.

Anyway, I've been trying to learn about the human body and how to best treat it when it's under duress. So here's sharing what I've learnt about the medial (or inner) arch and also by putting whatever I've learnt down, I can always refer back to this.

The human medial arch has a four muscles supporting it. Namely, Tibialis Anterior, Tibialis Posterior, Flexor Digitorum Longus  and Flexor Hallucis Longus (the last 3 are also known as Tom, Dick and Harry).

Back of R leg

Tom, Dick and Harry start from the back of the leg as seen in the picture above. Flexor Hallucis Longus (FHL), or Harry goes under the talus to the bottom of the big toe. This muscle carries the whole weight of the body while we push off while walking. This is also the same muscle that can cause bunions, as it puts undue pressure between the sesamoid bones under the big toe. But that will have to be another much longer post.

FHL goes in between the sesamoid bones under the big toe

I'm especially fascinated with the Tibialis Posterior muscle, especially how it attaches at the bottom of the foot in the picture below. See how wide and diverse the attachments are. It attaches to the calcaneus, the navicular bone, the 2nd - 4th metatarsals and also the cuboid.

Bottom of R foot

Other than the muscles, there is also the plantar fascia, helping to support the medial arch. Much more important than the muscles are the deeper arch support consisting of the Long Plantar Ligament (which attaches to the base of metatarsals and cuneiforms) and especially the Spring Ligament.

a = plantar fascia, b = long plantar ligament

The spring ligament is also known as the calcaneonavicular ligament (c in the picture above). It goes from the sustentaculum tali to the talus. It really acts like a trampoline to prevent your talus from flattening when you weight bear. This is most important for lifting or supporting our arches.

Typically, when we talk about arch support, we would think of taping the arch, changing our shoes, putting arch supports or orthotics into our shoes. But as you can see from the picture above that none of them can really help the spring ligament in supporting our arches.

We can really only affect/ or treat the muscles and the plantar fascia. Remember this. You may not need to buy anything fancy to support the spring ligament.

Another look at the dissected medial arch. 9 is the Long plantar ligament, 10 is the plantar fascia and 11 is the spring ligament.

Now you know.