Health condition · Clinically reviewed
Tarsal tunnel syndrome, posterior tibial nerve entrapment — orthoses, injection and decompression.
Compression of the posterior tibial nerve behind the medial malleolus. Causes burning medial foot pain — orthoses, physiotherapy and ultrasound-guided injections work for many; endoscopic release for refractory cases.
Why trust this guide
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Clinically reviewed
Written by our editorial team and reviewed by a registered UK clinician before publication.
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Sourced from guidance
Every claim is checked against BOFAS, NICE and peer-reviewed sources you can see at the end.
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Current for 2026
Reflects current UK guidance on orthoses, image-guided injection and endoscopic decompression.
Key facts
Tarsal tunnel syndrome at a glance.
The essentials, in plain English — what tarsal tunnel syndrome is, why it burns on the sole of the foot, and what the evidence says actually helps.
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Definition
Tarsal tunnel syndrome is entrapment of the posterior tibial nerve as it passes behind the medial malleolus, beneath the flexor retinaculum.
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Rare but missed
Rarer than carpal tunnel syndrome but frequently missed — burning medial foot pain is often attributed to plantar fasciitis instead.
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Tinel’s sign
Tapping over the tarsal tunnel at the medial malleolus reproducing shooting or tingling pain into the sole is the classic clinical sign.
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Confirming tests
MRI of the ankle and nerve conduction studies confirm the diagnosis and help identify any space-occupying lesion.
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Injection
Ultrasound-guided steroid injection into the tarsal tunnel is both diagnostic and often therapeutic for many patients.
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Surgery when needed
Endoscopic or open tarsal tunnel release is reserved for refractory cases or where a space-occupying lesion needs excision.
Why this guide matters
Diagnose it, then decompress it.
Tarsal tunnel syndrome is often mistaken for plantar fasciitis — this guide sets out how the diagnosis is made and what actually helps, in order.
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Tinel’s sign points the way
A positive Tinel’s sign at the medial malleolus is the single most useful bedside test — cheap, quick and specific.
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Image before you inject or operate
MRI identifies space-occupying lesions inside the tunnel that change treatment entirely — missed at your peril.
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Injection first, decompression second
Ultrasound-guided steroid injection is both diagnostic and often therapeutic — endoscopic release is reserved for refractory cases.
How the diagnosis is made
From burning foot to a clear plan.
The steps a UK GP and foot and ankle team will normally follow, in order — so you know what to expect and why.
Phase 1 · Recognising
Symptoms, Tinel’s sign and neurological examination
Phase 2 · Confirming
Nerve conduction studies and MRI of the ankle
Phase 3 · Managing
Conservative care first, decompression if refractory
- 01
Recognising
Symptom pattern
Burning, numbness or tingling on the medial foot and sole, often worse at night and after prolonged standing — the story does most of the work.
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Recognising
Tinel’s sign at medial malleolus
Tapping over the tarsal tunnel reproduces shooting or tingling pain into the sole — the single most useful bedside test.
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Recognising
Neurological examination
Sensory testing of the medial and lateral plantar nerve distributions, and assessment of intrinsic foot muscle bulk and power.
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Confirming
Nerve conduction studies
Electrophysiology helps confirm posterior tibial nerve entrapment and excludes a more proximal or generalised neuropathy.
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Confirming
MRI of the ankle
MRI shows the nerve and looks for any space-occupying lesion — ganglion, varicosity, lipoma or accessory muscle — inside the tunnel.
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Confirming
Rule out space-occupying lesion
A ganglion, varicose vein, lipoma or tenosynovitis inside the tarsal tunnel changes the treatment plan entirely and needs to be identified.
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Managing
Foot & ankle surgery consultation
For refractory cases, or where imaging shows a space-occupying lesion, referral to a foot and ankle surgeon for consideration of decompression.
Typical timeline: 3–6 weeks from first appointment to a settled plan.
Symptoms
What tarsal tunnel syndrome actually feels like.
The pattern is more telling than any single symptom — burning medial foot pain, plantar numbness and a positive Tinel’s sign at the medial malleolus.
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Burning medial foot pain
A burning, neuropathic pain along the medial foot and sole — classic for posterior tibial nerve irritation.
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Numbness plantar surface
Reduced sensation on the sole of the foot, often patchy across the medial and lateral plantar nerve distributions.
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Positive Tinel’s sign
Tapping over the tarsal tunnel at the medial malleolus reproduces shooting or tingling pain into the sole.
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Night pain
Symptoms often worsen at night, disturbing sleep — a common neuropathic pain pattern.
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Medial ankle pain
A dull ache or tenderness just behind and below the medial malleolus, where the nerve enters the tunnel.
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Pins and needles
Tingling and pins-and-needles across the sole and medial foot, sometimes radiating into the toes.
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Symptoms with prolonged standing
Long periods on your feet — standing, walking, running — reliably provoke or worsen symptoms.
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Red flag
Bilateral tarsal tunnel syndrome with systemic features — investigate diabetes, B12 deficiency, thyroid disease or generalised neuropathy.
Treatment
How tarsal tunnel syndrome is treated in the UK.
A staged approach — orthoses and physiotherapy first, then image-guided injection, with endoscopic or open decompression reserved for refractory disease or a space-occupying lesion.
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Medial arch support orthosis
A medial arch support reduces traction on the posterior tibial nerve — a simple, cheap and often effective first step.
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Physiotherapy (nerve gliding)
Nerve gliding exercises for the posterior tibial nerve, alongside calf and foot conditioning — the backbone of conservative care.
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NSAIDs
A short course of non-steroidal anti-inflammatory drugs can settle irritation around the nerve and calm background pain.
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Gabapentin / pregabalin for neuropathic pain
Neuropathic pain agents can help stubborn burning and tingling — prescribed and monitored by your GP or pain team.
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Ultrasound-guided steroid injection
An image-guided steroid injection into the tarsal tunnel is often both diagnostic and therapeutic in one step.
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Address space-occupying lesion
Where MRI shows a ganglion, lipoma, varicosity or accessory muscle, treating that lesion is often the definitive step.
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Endoscopic tarsal tunnel release
A minimally invasive endoscopic decompression of the tarsal tunnel — quicker recovery than open surgery in suitable cases.
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Open tarsal tunnel release with excision of mass
Open release allows full exposure of the nerve and excision of any space-occupying lesion — the definitive option in complex cases.
What this guide is based on
The sources behind every claim on this page.
UK and international specialist society standards, current at the time of last review.
Key references
Guidelines and standards we relied on.
A quiet reminder
This guide is for information, not medical advice.
Your GP, podiatrist or foot and ankle team knows your history and can tell you which parts apply to you. If in doubt, get seen.
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British Orthopaedic Foot and Ankle Society (BOFAS). Patient information and clinical standards.
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NICE CKS. Neuropathic pain — diagnosis and management.
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Peripheral Nerve Society. Guidance on entrapment neuropathies.
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American Orthopaedic Foot & Ankle Society (AOFAS). Clinical practice standards.
Red flags
When burning foot pain is not just tarsal tunnel.
Most cases are a local entrapment that settles with the right care. These are the situations where a different diagnosis needs to be considered.
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Systemic peripheral neuropathy
Symptoms in both feet with sensory loss elsewhere point to a systemic neuropathy — needs bloods and a neurology view rather than a local diagnosis.
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Diabetic neuropathy overlap
In people with diabetes, distal symmetrical polyneuropathy can mimic or coexist with tarsal tunnel — both need to be addressed.
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Post-op nerve injury
New neuropathic symptoms after ankle or foot surgery may reflect direct nerve injury — needs early review by the operating team.
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Complex regional pain syndrome
Disproportionate burning pain with skin, colour and temperature changes needs recognition and specialist pain management.
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Failed decompression
Persistent symptoms after tarsal tunnel release — consider incomplete release, scarring or misdiagnosis.
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Recurrent tarsal tunnel
Return of symptoms after initial improvement — imaging and specialist review to look for re-entrapment or missed lesion.
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Space-occupying lesion missed
A ganglion, lipoma or varicosity not identified before decompression is a common cause of surgical failure — always image first.
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Contralateral tarsal tunnel
New symptoms in the other foot broadens the differential — consider systemic causes rather than assuming bilateral entrapment.
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Lumbar radiculopathy differential
S1 nerve root pathology can mimic tarsal tunnel — a careful spine examination is part of the workup for atypical presentations.
Living with it
A slow condition, but a very manageable one.
Four things that make the biggest difference day to day — nerve glides, footwear, load management and patient review.
A quiet reminder
Consistency beats intensity, every time.
Small, steady changes — kept up for weeks — do more than a heroic burst that does not last.
- 01 Rehab
Do the nerve glides, daily
Nerve gliding and calf stretching done consistently over weeks — unglamorous but the biggest self-managed lever.
- 02 Footwear
Support your medial arch
A medial arch support in supportive shoes reduces traction on the nerve — avoid barefoot walking on hard floors.
- 03 Load
Manage standing time
Long days on your feet reliably flare symptoms — break up standing time and pace activity while the nerve settles.
- 04 Reviews
Reassess in weeks, not days
Conservative care takes weeks to work — reassess at 6–12 weeks, and consider injection or specialist review if things have not settled.
Frequently asked
Everything we get asked about tarsal tunnel syndrome.
Quick answers on diagnosis, orthoses, injection, endoscopic release and when to seek help.
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What actually causes tarsal tunnel syndrome?
Compression of the posterior tibial nerve as it passes behind the medial malleolus, beneath the flexor retinaculum. Causes include a ganglion, varicose vein, lipoma, accessory muscle, tenosynovitis, foot deformity, previous injury or a systemic neuropathy that predisposes the nerve to compression.
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How is tarsal tunnel syndrome diagnosed?
A clinical assessment focused on the burning medial foot pain pattern and a positive Tinel’s sign at the medial malleolus, supported by nerve conduction studies and an MRI of the ankle to look for any space-occupying lesion inside the tunnel.
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Do I need a scan?
Yes — MRI of the ankle is usually recommended once tarsal tunnel syndrome is suspected. It helps confirm the diagnosis and, importantly, identifies any ganglion, varicosity, lipoma or accessory muscle that would change treatment.
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Does an injection help?
An ultrasound-guided steroid injection into the tarsal tunnel is often both diagnostic and therapeutic. A meaningful response supports the diagnosis and can settle symptoms for many patients, particularly those without a fixed space-occupying lesion.
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When is surgery needed?
Endoscopic or open tarsal tunnel release is considered when conservative care and injection have failed, or where imaging shows a space-occupying lesion (ganglion, lipoma, varicosity) that needs excision at the same time as the decompression.
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What is the red flag I should not ignore?
Bilateral tarsal tunnel symptoms with signs of a wider neuropathy — investigate for diabetes, B12 deficiency, thyroid disease or another systemic cause, rather than assuming a local entrapment on both sides.
Related content
Keep reading.
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Foot MRI
MRI of the ankle and foot for nerve entrapment and lesions.
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Nerve conduction
Electrophysiology to confirm posterior tibial nerve entrapment.
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Joint injection
Image-guided steroid injection for refractory tarsal tunnel.
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