How to fix tarsal tunnel syndrome: find the cause, then release the nerve

Burning, tingling or numbness spreads across the sole of your foot. It gets worse the longer you stand or walk, and sometimes it keeps you up at night. If that is tarsal tunnel syndrome, you want to know how to fix it, not just how to live with it.

The tarsal tunnel is a narrow passage behind and below the bone on the inside of your ankle. The tibial nerve, which gives feeling to the sole, runs through it under a band of tissue called the flexor retinaculum. Tarsal tunnel syndrome means the nerve is being squeezed in that space.^[8]

How do you fix tarsal tunnel syndrome?

You fix it by matching the treatment to the cause. In one older surgical series, most people who needed an operation had something taking up space in the tunnel.^[1] When surgeons compared results by cause, people with a structure pressing on the nerve improved more than people with no clear cause.^[4]

That is why the first job is finding the cause. The second job is removing it. Tarsal tunnel release is surgery that opens the tight band over the tunnel, frees the nerve and its branches, and takes out whatever is pressing on it. Dr. Efe Ozturk, a double board certified Foot and Ankle Surgeon and podiatrist, performs tarsal tunnel release for appropriate patients.

Which causes of tarsal tunnel syndrome can surgery fix?

• Ganglion cysts. A ganglion is a fluid-filled sac, often from a nearby joint. In 50 feet treated surgically, ganglia were the most common cause.^[1] In another series, 29 people had their cyst removed, and the result was satisfactory in all but one.^[5] In eight people with a ganglion, the three who had surgery within 10 months of their first symptoms reported favorable results.^[9]
• Enlarged veins. Swollen veins (varicosities) can press on the nerve. In 18 people with long-standing symptoms, surgeons found varicose veins trapping the nerve in six.^[2]
• Extra or unusual muscles. Some people are born with an extra muscle in the tunnel. A systematic review of 39 such patients found that releasing the nerve and removing the muscle were the most common treatments.^[3]
• Bony problems. A bony bump from a talocalcaneal coalition, an abnormal bridge between two foot bones, was the second most common cause in one series. People with a coalition or a tumor did better than those with no clear cause.^[1]
• Tight tissue and scar. Bands of tissue, scarring and small blood vessels wrapped around the nerve are common findings at surgery.^[7,2]

For a lesion like these, one surgical team wrote that an excellent result can be expected when surgery is done soon after the problem begins.^[1]

How well does tarsal tunnel release work?

A 2022 systematic review described surgical results in the published studies as good.^[10]

• In 62 people followed for almost five years, foot scores rose from an average of 61 to 80 out of 100. The authors found improvement predictable even when no cyst or other lesion was found, and even after more than a year of symptoms.^[7]
• In 18 people with symptoms for a median of five years, all symptoms went away in 61%.^[2]
• In 13 people with a space-occupying lesion, average pain fell from 6.4 to 2.2 out of 10.^[11]
• In 41 people whose nerve tests matched tarsal tunnel syndrome, reported improvement after release averaged 92%.^[12]

Our main practice explains peripheral nerve surgery (external site) in more detail.

What predicts a good result?

• A clear cause. Structural compression did better than enlarged veins that come and go or no cause at all.^[4]
• Shorter symptoms. Less than a year of symptoms before surgery gave higher scores.^[7]
• Matching nerve tests and symptoms. Nerve test findings in the tunnel and nerve-type symptoms in the sole predicted improvement.^[12]
• Foot alignment. Results tended to be better without an alignment problem, especially a heel that tilts inward.^[6]

Do you need an MRI or ultrasound for tarsal tunnel syndrome?

Often, yes. Imaging, especially MRI, can help find a cause and guide surgery.^[13] It matters because many cysts can’t be felt through the skin.^[5,9]

• MRI showed where the nerve was squeezed in 82% of sides in one study. It missed enlarged veins and small vessels that surgeons later found.^[14] In another study, a bright signal in the nerve on MRI went with greater improvement after surgery.^[15]
• Ultrasound is widely available, can scan you while you stand, and uses Doppler to show blood flow in veins.^[16]

Imaging and nerve studies are arranged with another specialist, and we review the results with you. See ultrasound or MRI for nerve pain in the foot and nerve testing for foot pain.

What should you try before surgery?

Supportive shoes, orthotics, activity changes and sometimes an injection come first for most people. In the five-year study, 65% of feet did well with this care alone.^[6] Think of it as the first step. If it hasn’t worked by about six months, release is the next step.^[6] If a cyst or other mass is clearly pressing on the nerve, there is less reason to wait.^[9] See tarsal tunnel syndrome.

What are the limits?

Tarsal tunnel release doesn’t help everyone. In one older series, only 44% of feet had a good or excellent result, and 13% had wound problems.^[17] Even when pain scores fell after removing a lesion, only 54% of people were satisfied.^[11] People with a past injury did worse in one study.^[2] Return to usual activity averaged nine months.^[7] High-quality evidence is limited, and the right balance of surgery and non-surgical care is still debated.^[18]

Common questions

Why is tarsal tunnel syndrome worse at night?

In a lab study of cadaver feet, pressure in the tunnel rose sharply when the foot turned in or out. That may explain night pain, and why keeping the ankle in a neutral position helps some people.^[19]

Can tarsal tunnel syndrome cause swelling?

Sometimes. A cyst or an extra muscle can show up as swelling at the inner ankle. In the review of extra muscles, about a quarter of patients had swelling.^[3]

How do you choose a tarsal tunnel surgeon?

Look for a surgeon who looks for the cause before operating and examines the whole nerve. They should arrange imaging and nerve testing when needed and also treat symptoms that come back. See revision nerve surgery.

When to see a specialist

See us if burning or numbness in your sole lasts more than a few weeks, wakes you at night or keeps you from walking. We see patients in Lyndhurst, Paramus and Millburn. Please call our office at 908-215-5953 to inquire about your insurance.