Burning, Tingling, or Numbness on the Inside of Your Ankle and Foot — Not All Nerve Pain Is the Same
Tarsal tunnel syndrome is an entrapment neuropathy — the tibial nerve being compressed as it passes through a narrow channel (the tarsal tunnel) on the inner side of the ankle behind and below the medial malleolus. When the nerve is compressed, it produces the characteristic symptoms of burning, tingling, shooting pain, and numbness that radiate from the inner ankle into the heel, arch, and sometimes the toes. It is the foot’s equivalent of carpal tunnel syndrome in the wrist.
Tarsal tunnel syndrome is less common than carpal tunnel syndrome and considerably less common than plantar fasciitis, which is why it is frequently either missed or misattributed. A patient with heel and arch pain who has been told they have plantar fasciitis but is not responding to treatment should be evaluated for tarsal tunnel syndrome — the two can coexist and are often confused because they share anatomical territory. Our podiatrists diagnose and treat tarsal tunnel syndrome at our Coon Rapids and Golden Valley offices, serving patients across the north and west metro including Maple Grove, Ham Lake, Andover, Champlin, Blaine, Plymouth, Wayzata, Minnetonka, St. Louis Park, and Edina.
The Tinel’s sign test: the most important clinical test for tarsal tunnel syndrome. A clinician taps or applies gentle pressure directly over the tibial nerve just posterior to and below the medial malleolus. A positive Tinel’s sign produces electric or tingling sensations that radiate into the heel, arch, or toes. If you have burning or tingling in the foot and this test has not been performed, ask for it at your evaluation. A positive Tinel’s sign in the right location is highly suggestive of tarsal tunnel syndrome.
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The Tarsal Tunnel — What Is It?
The tarsal tunnel is a fibro-osseous canal located on the posteromedial side of the ankle — behind and below the inner ankle bone (medial malleolus). Its floor is formed by the bones of the ankle and hindfoot (talus and calcaneus); its roof is a thick band of connective tissue called the flexor retinaculum that stretches from the medial malleolus to the calcaneus.
Running through this tunnel are the posterior tibial tendon, the flexor digitorum longus tendon, the posterior tibial artery and vein, the tibial nerve, and the flexor hallucis longus tendon. The tunnel is a confined space. Anything that increases pressure within it — swelling, a mass, scar tissue, or abnormal foot alignment that places traction on the nerve — can compress the tibial nerve and produce tarsal tunnel syndrome.
Inside or just past the tunnel, the tibial nerve divides into three branches: the medial plantar nerve (supplying the inner sole and medial toes), the lateral plantar nerve (supplying the outer sole and lateral toes), and the medial calcaneal nerve (supplying the inner heel). Depending on where within or below the tunnel compression occurs, different distributions of symptoms result.
Causes of Tarsal Tunnel Syndrome (TTS)
Tarsal tunnel syndrome has two broad categories of cause — structural/compressive causes, and mechanical causes from foot alignment. Identifying which is driving the compression is essential because treatment differs significantly:
Space-Occupying Lesions and Structural Causes
- Ganglion cyst: a fluid-filled cyst arising from a tendon sheath or joint capsule within or adjacent to the tarsal tunnel. One of the most common identifiable causes. Visible on MRI and sometimes palpable. Excision typically relieves symptoms definitively.
- Varicosities: dilated, tortuous veins within the tarsal tunnel compress the tibial nerve. Particularly symptomatic after prolonged standing when venous engorgement is greatest.
- Accessory muscles: anatomical variants such as the flexor digitorum accessorius longus, which is normally absent, can occupy space within the tunnel and compress the nerve.
- Post-traumatic fibrosis and scar tissue: scar tissue from prior ankle sprains, fractures, or surgery can tether the nerve or reduce tunnel volume. A common cause in patients with a history of ankle trauma and subsequent nerve symptoms.
- Lipoma or other benign mass: any soft tissue mass within or adjacent to the tunnel can produce TTS. MRI is the definitive diagnostic tool.
- Bone spur or coalition: a bony prominence from the talus, calcaneus, or a tarsal coalition can impinge on the tibial nerve at the tunnel entrance.
Mechanical Causes from Foot Alignment
- Flatfoot (pes planus) and ankle valgus: the most common mechanical cause. A flat, pronated foot stretches and applies traction to the tibial nerve as the foot collapses inward. This is a dynamic compression rather than a static space-occupying lesion, which is why it worsens with prolonged weight-bearing and activity and improves with rest.
- High-arched foot (pes cavus): a rigid, high-arched foot can create abnormal pressure patterns at the heel and along the tibial nerve course.
- Ankle instability: repeated sprains and chronic lateral ankle instability can place chronic traction on the tibial nerve as the ankle repeatedly inverts.
Idiopathic TTS: in a significant proportion of cases — estimates range from 20–50% — no identifiable cause is found despite thorough evaluation. These cases are most difficult to manage and have less predictable surgical outcomes.
Symptoms
- Burning, tingling, electric, or shooting pain on the inner side of the ankle, radiating into the heel, arch, and sometimes the toes
- Numbness or reduced sensation on the bottom of the foot
- Symptoms that worsen with prolonged standing, walking, and activity, and improve with rest
- A positive Tinel’s sign at the medial malleolus — tapping produces tingling or electric sensations into the foot
- In advanced or severe cases: weakness of the intrinsic foot muscles and persistent numbness in the plantar foot
Tarsal tunnel syndrome vs. plantar fasciitis: plantar fasciitis causes a localized aching pain at the heel, worse with the first steps in the morning, improving with walking. Tarsal tunnel syndrome causes neurological symptoms (burning, tingling, numbness) that worsen with activity and may be present at rest. The two can coexist. If you have heel pain with any neurological component — burning, tingling, or numbness — tarsal tunnel syndrome should be in the differential. See our Plantar Fasciitis page.
Diagnosis
Tarsal tunnel syndrome is a clinical diagnosis supported by imaging and electrodiagnostic studies. Examination includes:
- Tinel’s sign: tapping or percussion over the tibial nerve posterior to the medial malleolus. A positive test reproduces tingling or electric sensation into the foot. The most sensitive bedside test for TTS.
- Nerve compression test: sustained digital pressure over the tarsal tunnel for 30–60 seconds that reproduces symptoms — analogous to the Phalen’s test for carpal tunnel syndrome.
- MRI: the most important imaging study. Identifies space-occupying lesions (ganglion cysts, varicosities, accessory muscles, lipomas), evaluates the nerve itself (perineural edema, nerve enlargement), and assesses the surrounding structures. Mandatory when a structural cause is suspected.
- Ultrasound: can identify ganglion cysts and varicosities within the tunnel and can dynamically assess nerve compression with ankle movement.
- Nerve conduction studies and electromyography (NCS/EMG): measure the electrical conduction velocity of the tibial nerve across the tarsal tunnel. Can confirm the diagnosis and quantify severity but have limited sensitivity for early or mild TTS. Results are interpreted in clinical context, not in isolation.
Treatment at Family Foot & Ankle Clinic
Treatment approach depends critically on the underlying cause. Space-occupying lesion TTS responds well to surgical excision of the lesion; mechanical TTS from flatfoot responds best to orthotic correction; idiopathic TTS is the most challenging and has the most variable treatment response.
Conservative Management
Custom orthotics. For TTS caused by or aggravated by flatfoot and excessive pronation, a custom orthotic with medial arch support and heel valgus correction reduces the dynamic traction on the tibial nerve that occurs with every step. This is the most impactful conservative intervention for mechanical TTS and often produces significant symptom reduction. More on our Custom Orthotics page.
Immobilization. A walking boot or short-leg cast may be used for 4–6 weeks during acute or severe flares to unload the tibial nerve and reduce inflammation within the tunnel. Most effective as a short-term measure combined with longer-term orthotic management.
NSAIDs and ice. Anti-inflammatory medication and ice reduce acute perineural inflammation and provide symptomatic relief during flares.
Physical therapy. Nerve mobilization (neural gliding) techniques, tibialis posterior strengthening, and ankle stability exercises address the mechanical contributors to tibial nerve irritation. Particularly useful as an adjunct to orthotic management for flatfoot-related TTS.
Activity modification. Reducing prolonged standing and walking during acute episodes. Compression stockings may help with varicosity-related TTS by reducing venous engorgement in the tunnel.
Surgical Treatment — Tarsal Tunnel Release
Surgery is indicated when conservative management has been optimized without adequate relief, or when an identifiable structural cause (ganglion cyst, varicosity, accessory muscle) has been identified. Outcomes are most predictable when a specific compressible or excisable cause is identified.
- Tarsal tunnel release: The flexor retinaculum is divided under direct visualization to decompress the tibial nerve and its branches. Any scar tissue or space-occupying lesion contributing to nerve compression is addressed at the same time.
- Concomitant flatfoot correction: In some patients, a flexible flatfoot or hindfoot valgus contributes to chronic traction or compression of the tibial nerve. In these cases, tarsal tunnel release alone may not adequately address the underlying mechanical cause. Depending on the severity of the deformity, flatfoot reconstruction procedures may be recommended at the same time to improve alignment, reduce tension on the nerve, and optimize long-term outcomes.
Outcomes are best when a specific cause is identified and addressed — ganglion cyst excision through a tarsal tunnel release approach, for example, has excellent results. Idiopathic TTS without a structural cause has more variable outcomes, and this should be discussed before surgical decisions are made.
See our Foot & Ankle Surgery Overview for general information on surgical care at our clinic.
Frequently Asked Questions
Is tarsal tunnel syndrome the same as plantar fasciitis?
No, but they are frequently confused because both cause heel and arch pain. Plantar fasciitis is an inflammatory condition of the plantar fascia ligament that causes a localized aching pain at the heel, worst with first steps in the morning and improving after a few minutes of walking. Tarsal tunnel syndrome is a nerve compression that causes burning, tingling, and numbness radiating from the inner ankle into the heel and arch, typically worsening with activity and sometimes present at rest. The two can coexist in the same patient. If your heel pain includes neurological symptoms, both conditions should be evaluated.
How long does tarsal tunnel syndrome last?
This depends entirely on the cause. Tarsal tunnel syndrome from a discrete structural cause — a ganglion cyst, varicosity, or accessory muscle — often resolves completely after surgical excision. TTS from flatfoot mechanics that is managed with orthotics typically improves significantly over weeks to months and remains controlled as long as the orthotics are worn. Idiopathic TTS has the most variable course and may require an extended combination of orthotics, injections, and eventually surgery. Early accurate diagnosis and treatment is the most important factor.
My doctor said I have peripheral neuropathy, but the symptoms are mainly on the inside of one ankle and foot. Could it be tarsal tunnel instead?
Possibly — and this distinction is important because the treatments are different. Peripheral neuropathy typically affects both feet symmetrically and produces a diffuse, stocking-distribution of numbness and burning. Tarsal tunnel syndrome affects one foot (or affects one more than the other) and produces symptoms in the distribution of the tibial nerve specifically — the inner ankle, plantar heel, arch, and plantar toes. A positive Tinel’s sign at the medial malleolus and a response to a targeted tarsal tunnel injection strongly suggest TTS rather than systemic neuropathy. The two can coexist in diabetic patients, which further complicates the picture.
I had an ankle sprain a year ago and now have burning and tingling in my foot. Are they related?
Likely yes. Post-traumatic scar tissue and fibrosis within the tarsal tunnel is a well-recognized cause of TTS following ankle sprains, particularly severe or repeated sprains. Scar tissue from the original injury can tether the tibial nerve or reduce tunnel volume. MRI is the most useful diagnostic study in this scenario — it identifies perineural fibrosis and nerve changes that explain the persistence of neurological symptoms after what appeared to be an ankle ligament injury. If you have ongoing neurological symptoms following an ankle sprain, our Second Opinion / Foot Pain Not Improving visit is a useful starting point.
Burning or Tingling in Your Foot That No One Has Explained? Let’s Find the Source.
Tarsal tunnel syndrome is a specific, diagnosable condition with specific treatments. It should not be attributed to “nerves” or left undiagnosed. A clinical examination with Tinel’s testing, an ultrasound, and MRI when indicated give us a clear picture. Book an appointment at our Coon Rapids or Golden Valley office.
Call 763-421-7300 | Book online
Serving Coon Rapids, Golden Valley, Maple Grove, Ham Lake, Andover, Champlin, Blaine, Plymouth, Wayzata, Minnetonka, St. Louis Park, Edina, and all Twin Cities communities.