Prefer to watch? 4-minute lesson13 slides · same content, shorter

1 · SNAPSHOT

Tarsal Tunnel Syndrome (Tibial Nerve) body chart — Illustrative, not diagnostic. Canva body chart for Tarsal Tunnel Syndrome (Tibial Nerve).

Who: Over-pronators, people with swelling, and anyone with a space-occupying lesion in the tunnel — a ganglion, varicosities, an accessory muscle. Diabetes and other systemic factors raise the risk.
What: Compression of the tibial nerve or its branches around the medial ankle.
How it behaves: Burning, tingling or numbness from the medial ankle into the plantar foot and toes. May wake them at night. Worse with prolonged standing, walking, and tight footwear. Sometimes relief barefoot or at rest.

The one thing to take from this page:

The territory overlaps with plantar fasciopathy and Baxter neuropathy. The QUALITY of the symptom is what separates them — and burning, tingling and numbness are not fasciopathy.

There is no single test

Every current review says it: no one test is definitive [1][2]. What you have is a combination —

The clinical picture	Neuropathic quality + tibial territory + night symptoms + a compressive reason
Provocation	Tinel's posterior to the medial malleolus · dorsiflexion-eversion [3]
Screen the chain	S1 radiculopathy and proximal entrapment — double crush is real
Investigate when	Atypical · progressive · surgical · lesion-driven

⚠️ No guideline exists, anywhere. The management literature is explicitly heterogeneous, and the conservative evidence is thinner than the surgical evidence — which is a publication pattern, not a verdict on what works.

2 · SE — THE SUBJECTIVE PATTERN (the 70%)

Five stages, in your course's order. The symptom QUALITY does most of the work — which is unusual, and it is why this gets missed by clinicians who only ask where.

MAIN PROBLEM

"It burns underneath, especially at the end of the day."
"My foot goes numb and I have to shake it."
"It wakes me — I hang it out of the bed."

Compare that to plantar fasciopathy: "It's agony for the first ten steps in the morning." Different sentence, different diagnosis.

BODY CHART

Map the tibial territory — medial ankle into the plantar foot and toes. Which branches?
Separate the medial heel specifically. That is Baxter's territory (Tedeschi 2025).
Mark numb areas as areas, and burning separately from ache.

BEHAVIOUR

	Fits tarsal tunnel	Points elsewhere
Quality	Burning, tingling, numb	Sharp, load-related ache → fasciopathy or tendon
Timing	Worse with prolonged standing and walking. Night symptoms	First ten steps in the morning → plantar fasciopathy
Footwear	Tight shoes worsen it; barefoot may relieve	Barefoot worsens it → fasciopathy
Rest	Often relieves	No change → screen wider
Severity	VAS 0–10 at best / at worst / right now	—

HISTORY

Foot posture — over-pronation, and whether it's changed.
Swelling — ankle, systemic, or after an injury.
A lump, a ganglion, previous trauma or surgery around the medial ankle.
Diabetes and systemic factors — both a risk factor and, later, an interpretation problem.
Back or proximal symptoms. Ask directly. Double crush is common and a lumbar source changes the whole plan.

SPECIAL / SCREENING QUESTIONS

Progressive weakness, toe clawing, difficulty spreading the toes — motor involvement, and it escalates the pathway.
Bilateral symptoms — think systemic neuropathy rather than bilateral tunnels.
Constitutional or vascular features — off this page.

Assessing this region? Download the Ankle & Foot assessment template →

3 · HYPOTHESIS RANKING

Competing pattern	The one discriminating feature
Plantar fasciopathy	First-step pain, focal calcaneal tubercle tenderness, normal neurological screen. No burning or numbness.
Tibialis posterior tendinopathy	Tender posterior to the medial malleolus with weak inversion and a failed single-leg heel raise. Tendinous, not neural.
S1 radiculopathy or proximal entrapment	Screen the chain. Double crush is common, and a lumbar source changes the whole plan.

The one that gets missed for years

Baxter neuropathy — entrapment of the first branch of the lateral plantar nerve. It causes medial heel pain, mimics plantar fasciopathy, and overlaps with tarsal tunnel reasoning [4]. Medial heel pain needs a nerve screen, not just a windlass test.

And the systemic one. Bilateral burning feet in someone with diabetes is more likely a peripheral neuropathy than two tarsal tunnels — and the ultrasound will not settle it, because the nerve may be enlarged for that reason (Senarai et al. 2022).

4 · RED FLAGS — DON'T MISS THIS

This section is free, on every pattern, forever. Safety is never gated.

Finding	What it suggests	What you do
Progressive motor deficit — intrinsic weakness, toe clawing, loss of toe abduction	Advancing compression	Surgical opinion
A palpable mass, or rapid onset with swelling	Space-occupying lesion	Imaging, then surgical opinion
Bilateral symptoms, or a stocking distribution	Systemic neuropathy	Medical referral, not local treatment
Progressive, unexplained, or multi-territory sensory loss	Beyond a focal entrapment	See the progressive neuropathy page
Diabetic foot with any skin breach, warmth or redness	Infection	🚑 See the infection page
Vascular features — cold, pale, absent pulses, rest pain	Vascular, not neural	Same-day vascular assessment; a cold, pale, painful foot of sudden onset goes to the emergency department now
No response to well-dosed conservative care over 3–6 months	Reconsider, or escalate	Investigate, then surgical opinion

The rule: sensory irritability that changes with position, footwear and load is yours. Progressive motor loss, a mass, or a bilateral stocking pattern is not.

Cross-links: Plantar fasciopathy · Tibialis posterior tendinopathy · Peripheral nerve entrapments

Members

The 4-minute lesson is for members

Twelve slides on this pattern: what you'll hear, what to examine, what to do. Free with an account.

Guideline anchor

No guideline exists for tarsal tunnel syndrome, in Australia or anywhere.

Anchored to the systematic review comparing conservative and surgical outcomes (Vij et al. 2022, PMID 36072502) and the scoping review of the management evidence (Haq et al. 2024, PMID 39101044), with the diagnostic position taken from the current reviews (Rodriguez-Merchan & Moracia-Ochagavia 2021, PMID 35839088; Fortier et al. 2022, PMID 35769658).

PubMed Source

There is no guideline and no consensus document. The management literature is explicitly heterogeneous, and the conservative evidence is thinner than the surgical evidence — which is a publication pattern, not a statement about what works. The staged approach on this page is drawn from the reviews and labelled as such.

Members

The evidence summary is for members

Verified diagnostic accuracy, where the evidence stands and what it doesn't settle. Free with an account.

Sources · 19

Show

Every source on this page resolves and title-verifies against PubMed. Newest first.

2021Rodríguez-Merchán & Moracia-Ochagavía (2021). Tarsal tunnel syndrome: current rationale, indications and results. EFORT open reviews, 6(12), 1140-1147. https://doi.org/10.1302/2058-5241.6.210031
2022Fortier et al. (2022). An Update on Posterior Tarsal Tunnel Syndrome. Orthopedic reviews, 14(4), 35444. https://doi.org/10.52965/001c.35444
2001Kinoshita et al. (2001). The dorsiflexion-eversion test for diagnosis of tarsal tunnel syndrome. The Journal of bone and joint surgery. American volume, 83(12), 1835-9. https://doi.org/10.2106/00004623-200112000-00011
2025Tedeschi (2025). Baxter's nerve: the hidden culprit of chronic heel pain. Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology, 46(9), 4685-4689. https://doi.org/10.1007/s10072-025-08253-0
2003Sammarco & Chang (2003). Outcome of surgical treatment of tarsal tunnel syndrome. Foot & ankle international, 24(2), 125-31. https://doi.org/10.1177/107110070302400205
2014Lareau et al. (2014). Plantar and medial heel pain: diagnosis and management. The Journal of the American Academy of Orthopaedic Surgeons, 22(6), 372-80. https://doi.org/10.5435/JAAOS-22-06-372
2021Vega-Zelaya et al. (2021). Ultrasound-Guided Near-Nerve Needle Sensory Technique for the Diagnosis of Tarsal Tunnel Syndrome. Journal of clinical medicine, 10(14). https://doi.org/10.3390/jcm10143065
2022Bouysset et al. (2022). Predictive factors of effective tibial nerve release in tarsal tunnel syndrome. Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons, 28(5), 610-615. https://doi.org/10.1016/j.fas.2021.06.009
2022Yammine et al. (2022). Tarsal tunnel syndrome secondary to accessory or variant muscles: a clinical and anatomical systematic review. Surgical and radiologic anatomy : SRA, 44(5), 645-657. https://doi.org/10.1007/s00276-022-02932-9
2022Khodatars et al. (2022). An update on imaging of tarsal tunnel syndrome. Skeletal radiology, 51(11), 2075-2095. https://doi.org/10.1007/s00256-022-04072-y
2022Vij et al. (2022). Clinical Results Following Conservative Management of Tarsal Tunnel Syndrome Compared With Surgical Treatment: A Systematic Review. Orthopedic reviews, 14(3), 37539. https://doi.org/10.52965/001c.37539
2022Kim et al. (2022). Magnetic Resonance Imaging Findings in Patients with Tarsal Tunnel Syndrome. Neurologia medico-chirurgica, 62(12), 552-558. https://doi.org/10.2176/jns-nmc.2022-0118
2022Senarai et al. (2022). Cross-Sectional Area of the Tibial Nerve in Diabetic Peripheral Neuropathy Patients: A Systematic Review and Meta-Analysis of Ultrasonography Studies. Medicina (Kaunas, Lithuania), 58(12). https://doi.org/10.3390/medicina58121696
2023Iborra et al. (2023). The role of ultrasound-guided perineural injection of the tibial nerve with a sub-anesthetic dosage of lidocaine for the diagnosis of tarsal tunnel syndrome. Frontiers in neurology, 14, 1135379. https://doi.org/10.3389/fneur.2023.1135379
2023Kumar et al. (2023). Nerve entrapment syndromes of the lower limb: a pictorial review. Insights into imaging, 14(1), 166. https://doi.org/10.1186/s13244-023-01514-6
2024Haq et al. (2024). The management of tarsal tunnel syndrome: A scoping review. Journal of clinical orthopaedics and trauma, 54, 102489. https://doi.org/10.1016/j.jcot.2024.102489
2025Bojovic et al. (2025). Overview of nerve entrapment syndromes in the foot and ankle. International orthopaedics, 49(4), 853-862. https://doi.org/10.1007/s00264-025-06469-5
2025Kim et al. (2025). Preoperative Magnetic Resonance Imaging Findings in Patients with Tarsal Tunnel Syndrome and Postoperative Outcomes. Neurologia medico-chirurgica, 65(9), 407-412. https://doi.org/10.2176/jns-nmc.2025-0115
2026Casares Tamayo et al. (2026). Functional Outcomes after Surgical Decompression for Tarsal Tunnel Syndrome. Revista brasileira de ortopedia, 61(1), s00461819577. https://doi.org/10.1055/s-0046-1819577

Mapped to this pattern

DN4
Douleur Neuropathique 4 Questions
neuropathic pain screening · 10 items · 4 min

Generic measures that also apply

Did this page do its job?

CliniStudy is in beta. One tap is enough — it decides what gets fixed first.