Tarsal tunnel syndrome (TTS), sometimes called jogger’s foot, is a relatively common cause of pain along the inside (medial) portion of your ankle. TTS can be a repetitive strain injury or an entrapment (compression) type injury.
The tarsal tunnel is a fibrous tunnel that is not structurally flexible. There is limited room for swelling inside the tunnel. This can cause nerves and blood vessels to be “entrapped” and lead to pain and other symptoms.
TTS is often caused by repeated pressure that results in damage on the posterior tibial nerve. Similar to carpel tunnel in the hand, the tarsal tunnel is located just below the medial malleolus (the large bump to the inside of the ankle). Basically, the tibial nerve branches off of the sciatic nerve and travels down the inside of the leg. It eventually runs through the tarsal tunnel, which is a narrow passageway inside your ankle that is bound by bone and soft tissue called a retinaculum.
How to Self-Treat Tarsal Tunnel Syndrome
Symptoms of Tarsal Tunnel Syndrome (TTS) include:
- Pain can be felt anywhere along the tibial nerve, sole of the foot or inside of the ankle.
- Pain can be pin point or diffuse extending to the heel, calf, arch or toes of the foot.
- Pain can come on gradually or suddenly appear.
- Pain is often described as pins and needles or as sharp shooting pains.
- Pain may often feel as an electric shock sensation or a burning sensation.
- Paresthesia or loss of sensation or numbness may also be present.
TTS is often mistaken for Posterior Tibial Tendon Dysfunction (PTTD) because of the location and type of pain. In order to correctly diagnose TTS, other possible conditions should be ruled out first. You may have TTS if you are experiencing the symptoms listed above and they worsen with direct pressure or firm tapping over the tarsal tunnel. The only definitive way to diagnose TTS is to have a nerve conduction study performed by your physician.
Common Risk Factors for Tarsal Tunnel Syndrome (TTS) include:
- Direct trauma or injury (such as being kicked in soccer).
- Overuse of the foot and/or overtraining of the tendon that causes inflammation, swelling, and pain.
- Prolonged standing, walking, exercising or sudden increase in activity or exercise volume.
- Training overload. Performing too high of training intensities and volumes.
- Abnormal foot and ankle mechanics.
- Flat feet, which cause overpronation while running.
- Poorly fitting or worn out shoes.
- Weak ankle muscles (particularly, the posterior tibialis or the foot intrinsic muscles that help to support the arch of the foot).
- Weakness in the hip, pelvic, and/or core muscles causing faulty gait mechanics.
- A change in running surfaces or environments. This is most evident when transitioning from a softer running surface, such as dirt, to a concrete running track or running downhill.
- Running on cambered surfaces, such as the edge of a road, where overpronation can cause excessive and repeated stretch on the nerve. Alternately, a high arch can cause more compression particularly on the downhill side of the foot. Thus, compressing the tarsal tunnel and possibly leading to inflammation and symptoms.
- Excessive dorsiflexion (toes moving towards the shinbone) during running. Those who tend to excessively heel strike can develop TTS. If the terrain (such as hill running) forces excessive dorsiflexion, then the combination of landing on the heel while the ankle dorsiflexes can increase the tarsal tunnel compartment pressure. This can cause impingement of the artery, vein, and nerve and can lead to pain or neurologic symptoms.
Initial Treatment for Tarsal Tunnel Syndrome (TTS):
This condition typically begins as an overuse syndrome with an active inflammatory cycle occurring. The initial course of treatment includes PRICE, which stands for Protect, Rest, Ice, Compression, and Elevation.
- Protect. In more severe cases (especially those involving physical damage to the nerve), it’s necessary to protect the damaged area. This may be done through use of a walking boot or in some cases, a cast may be necessary to restrict movement completely which allows the nerve, joint, and surrounding tissues a chance to heal.
- Rest. In this case, rest would indicate tapering down from your regular exercise activity and discontinuing running (for the short term).
- Ice. Apply ice to the painful area. The rule for icing is to apply ice no more than twenty minutes per hour. Do not place the ice directly against the skin, especially if you are using a gel pack style. A bag of frozen peas can be ideal. Individuals with poor circulation or impaired sensation should take particular care when icing.
- Compression helps to prevent and decrease swelling. Swelling can cause increased pain and slow the healing response, so limit it as much as possible. A compression stocking can help to limit the amount of swelling and promote blood flow back out of the lower leg. This insures better nutrient exchange, waste removal, and limits the swelling. I particularly recommend wearing a pair during your rehabilitation phase and when tapering back into full activity. Although there are many different styles of compression stockings available, always be sure to choose a pair that is at least knee high.
- Elevation. Depending on your pain level and the amount of swelling present, this step may be more or less beneficial.
Depending on the severity you may also want to speak to your physician about utilizing anti-inflammatory medications such as NSAIDs (non-steroidal anti-inflammatory drugs). This class of medication can be used as a pain reliever as well as to reduce inflammation. Medications in this class include drugs such as over-the-counter Aleve and Ibuprofen or higher strength medications such as Meloxicam.
How to Self-Treat Tarsal Tunnel Syndrome (TTS):
Please refer to Tarsal Tunnel Syndrome Exercises for demonstrations of the following strategies that I recommend when self-treating TTS.
Self-mobilize the tissue. Be sure to mobilize the tissue in and around the upper leg, calf and shinbone (tibia). Take care not to be too aggressive when mobilizing right over the tarsal tunnel or you may make the pain worse. Instead, initially focus on any other mobility and myofascial restrictions in the lower legs. Utilize a foam roller to address any lower leg tightness or restrictions. I tend to use the foam roller for the larger parts of the leg including the thigh, back of the leg, calves, and buttock muscles.
Mobility bands, such as the Rogue Fitness VooDoo X Bands or EDGE Mobility Bands, are a novel way to self-mobilize the tissue of the calf, foot, and ankle. The use of mobility bands affects blood flow to the area and speeds up healing. Mobility bands also help reset some of the receptor cells in the muscle tissue that cause excessive muscle tightness. Application of the band starts at mid foot, and then wraps directly over the ankle. You will then pump your ankle back and forth for as much motion as possible in each direction. Typically, the mobility band is in place for 30-60 seconds. If you experience numbness or tingling or worsening of symptoms, please discontinue the treatment. (If you suffer from any form of blood clotting disorder or are on blood thinning medications, I would advise against utilizing mobility bands for any type of deep compression.)
Strengthen your foot and ankle complex. Weakness in the foot and ankle muscles is a major risk factor in developing TTS. I recommend initiating a complete ankle and foot strengthening protocol.
Improve your balance. Poor balance is often associated with muscle weakness in the foot and ankle as well as the knee and hip musculature. Weakness and balance deficits can lead to poor foot mechanics, which can lead to excessive strain on the foot/ankle complex. Practice balancing on one foot.
Gently stretch and “floss” the tibial nerve. You will need a belt or a towel to stretch the tibial nerve. Wrap the belt around the ball of your foot. Apply a forceful pull on the belt so that your foot and toes move toward your nose while tilting your foot slightly outward. While keeping this downward tension, slowly straighten your knee (as demonstrated). Repeat for 20-30 repetitions, and repeat twice a day.
Make sure you have normal range of motion in your ankle. In order to have proper foot mechanics, your ankle should have normal mobility. Your ankle should have range of motion in all directions. Also, be sure to stretch your calves so that they don’t restrict your ankle’s dorsiflexion. I typically advise at least two repetitions of holding for 60 seconds per calf stretch. Stretch both the gastrocnemius and soleus calf muscles (as demonstrated).
Address any sources of mechanical irritation and/or compression. Due to the location of the tarsal tunnel, it can be easily affected by poorly fitting shoes and/or socks. Avoid wearing socks or shoes that cause any type of rubbing or compression directly over the tarsal tunnel.
If you change running surfaces, progress slowly. If you typically run on softer surfaces, such as dirt or a running track, progress carefully and slowly to running on a harder surface (like concrete). If you run on roads, try to vary which side so that the natural camber of the road is not causing excessive strain on one foot versus the other. Overall, softer running surfaces are better for your body. If your job requires that you stand on a hard surface, adding a foam pad or rubber mat can decrease the strain on your foot and arch.
Avoid training overload. Don’t progress your training volume and/or intensity levels too quickly. TTS is most commonly diagnosed as an overuse injury. Proper training is very important to avoid overloading your body. Improper progression of training volume and/or intensity can easily lead an overuse injury like PTTD, Achilles tendinitis or other lower extremity injuries.
Add an orthotic. Additional foot control is often needed to normalize gait mechanics. Many running stores sell an over-the-counter orthotic such as Superfeet Blue Premium Insoles. The blue tends to fit most feet, but a variety of options are available for customization. In my experience, these insoles can last 1,000 to 1,500 miles easily.
If you continue to experience pain related to your foot or footwear, then you may need to consult with a physical therapist and/or podiatrist that specializes in feet and orthotics. A custom orthotic may be necessary to correctly support your foot and insure proper foot mechanics. Seek assistance from a professional such as a podiatrist or physical therapist who has experience with treating other runners.
Laser therapy. Laser therapy uses light to accelerate the body’s natural healing processes. It produces a photochemical, photothermal, and photomechanical effect. The photochemical effect is said to increase local energy production, activate enzymes, and decrease pain perception. The photothermal effect is said to increase circulation which will improve oxygen and nutrient delivery for healing. The photomechanical effect is said to increase lymphatic mobility and improve circulation as well.
Other treatments. When conservative measures fail, additional medical management may be necessary. This includes steroid injections to reduce the pain and inflammation in the area. This usually works best when you are actively working on rehabilitation to insure that the cause of TTS has been addressed. Surgery may also be needed. Tarsal tunnel surgery can be a complicated surgery. You will likely need an MRI to see what is causing the TTS. Sometimes, there are varicose veins or a cyst that are impinging on the nerve. If there is a cyst and removal is required, then the surgery should have a success rate of about 90%. If there isn’t a defined cause of the TTS (such as a cyst), then the chance of a successful surgery decreases. Surgery is best performed when there is a clear impingement in the tunnel which can be surgically fixed. Surgery is typically performed by a Doctor of Podiatry or an orthopaedic surgeon.
Ask for help. If you’re still experiencing pain after implementing these self-treatment strategies, then it may be time to seek additional help. Other medical conditions can mimic or be associated with TTS, including foot neuropathy and radiculopathy from the lumbar spine. Your medical physician or physical therapist can help to determine if your pain is associated with other conditions or other biomechanical related issues. Your physician could also prescribe a stronger anti-inflammatory medication if necessary. The American Physical Therapy Association offers a wonderful resource to help find a physical therapist in your area. In most states, you can seek physical therapy advice without a medical physician’s referral (although it may be a good idea to seek your physician’s opinion as well).
RETURN TO RUNNING
As you return to running and your normal training activities, insure the following:
- Your involved leg is as mobile and flexible as the other.
- Your involved foot and ankle is as mobile and flexible as the other.
- Your involved foot and ankle complex is as strong as the other leg.
- Your ability to balance is equal in both legs.
- You can jog, run, sprint, and jump without pain.
If you are not progressing after 3-4 weeks of implementing these treatment options, speak to your medical professional. Do not take this condition lightly. Be sure to properly address it so you don’t lose too much time with your training. As you taper back into your running program, follow these guidelines:
- Although you will need to progress and train on uneven ground and hills, initially start with level terrain only.
- Initially limit your running distance. I recommend starting with a distance approximately 50-75% of your pre-injury distance.
- Initially start with a slower pace. Don’t immediately progress back into very intense running activities, such as interval or hill training, until you have worked back up to your previous running distances and paces without pain.
Tarsal Tunnel Syndrome (TTS) most commonly starts out as an overuse injury, but it can be caused by a direct trauma or injury. If the condition is left untreated, the end result can be permanent nerve damage. When this condition is caught early, it can be self-treated. For additional information on common running injuries and how to self-treat, please visit www.thePhysicalTherapyAdvisor.com.
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Dear Dr. Shatto, thank you so much for this detailed explanation. Actually, I’d commented before below your text on posterior tibial tendonitis as I was almost 100% sure that it was what I was suffering from due to excessive training overload. However, although I’ve given it enough time and rest (I’ve given up running completely and changed into swimming trainings) I still have a sort of oddness inside of my ankle. It’s not exactly a pain but rather a burning sensation (especially at night on the bed) and an itchy feeling. There’s no swelling or sharp pain. Following your suggestion I’ve recently begun with running exercises by practicing jogging and walking exercises (like one minute jogging followed by one minute running up to 20 minutes), and it’s completely pain free, but I still have this spread sense of oddness on my ankle, right above medial malleolus and no sharp pain on any certain point. These all make me think that I was wrong in self diagnosing my initial injury which was actually tarsal tunnel syndrome or I might’ve simultaneously developed this latter. I know it’s not easy for you to give any recommendation without realizing a physical examination, but taking into account my description, what would you suggest? Do you think I should consider to see a sports medicine doctor or physical terapist and meanwhile give up again any running exercises? I also feel this odd feeling after swimming sessions, do you think it may aggregate tarsal tunnel symptoms? It’s nothing weight bearing but rather mechanical activity. I do appreciate your kind attention in advance, and once again I thank you so much for this comprehensive text. All the best from Turkey
Hi Barish, I think you maybe correct those symptoms could definitely be tarsal tunnel syndrome. It is also possible the symptoms are originating from your lumbar spine. At this point having someone deferentially diagnose the symptoms is probably the right course of action. If it is tarsal tunnel then someone needs to determine what is doing on mechanically that is leading to your symptoms. There is always a mechanical cause it just can be difficult to figure out. But yes given the symptoms and the ongoing nature meaning it hasn’t gone away completely I would at least get an examination and a self treatment plan. Hope that helps. Ben
Dear Dr. Shatto, thank you so much for your prompt reply, it’s absolutely fabulous and praiseworthy that you respond to every single case and question with absolute care and attention. I’ve been practising some easy tibial nerve flossing exercises for couple of days and I feel relatively better. If the symptoms persist, however, I’ll definitely go to see a physician as you recommend. Once again thank you so much and wishing you all the best.
Thank you Barish….I wish you a speedy recovery as well.
ik heb sinds 2019 last van stekende pijn binnenkant enkel th vd tarsale tunnel en een doof gevoel in de grote teen. heb injecties in de enkel gehad echo en tinel test bij de orthopeed wezen geen tarsale tunnel syndroom aan. ook aangepaste zooltjes.
ook een aantal dry needling ver bij de fysio gehad o.a. in triggerpoints kuit en scheenbeenspier.
klachten verdwenen totaal in 2020. ik was erg blij.
nu komt het weer terug. lijkt wel ook te maken te hebben met wisselen van schoenen omdat het weer voorjaar wordt. ik zit ook op een koor waar ik lang moet staan. dit lag ook een tijd stil toen ik geen klachten had. toeval?
ik ben echt ten einde raad. kunt u mij adviesgeven? ik heb 2 tens apparaten van dr Ho. 1 om met te voeten op te zitten (circulation Promoter) en 1 met pads
waar kan ik de pads het beste plakken?
en doe ook flos en stabilisatie oefeningen
Hi Ben, I am positive I have TTS, this started sometime back with out me realizing, where I switched to a different type of running shoes that was actually compressing the medial side of my ankle. I have been able to manage this and some weeks are better than others , the pain I get is very actuate and sharp within my inner heal. What I have noticed however is getting more pain now in the ball of my foot underneath my outer two toes. Could this be from landing differently on my foot to compensate for the pain? Thanks for the great info.
Hi Steve, yes you could definitely be developing something else due to the altered gait mechanics. The two most likely culprits are metatarsalgia or a morton’s neuroma. You may need to deal with this issue as well as continue to deal with the TTS. A nerve compression injury can take many months to heal and needs to be rested and the sources of the compression completely eliminated. Here are two links to help you. https://www.marathontrainingacademy.com/how-to-self-treat-metatarsalgia and https://www.thephysicaltherapyadvisor.com/2017/06/07/do-i-have-mortons-neuroma-in-my-foot/
All the best!
Recently diagnosed TTS. Duration of 2 weeks. I’m not doing any exercise except core and upper body and walking as little as possible. I’ve gotten Orthotics as I overpronate, been icing. How long should I expect the tingling and burning? I want to be realistic. If these symptoms persist (both feet), should I get air casts? I’m not getting a ton of guidance from podiatrist. Thank you!
Hi Mary, there are a lot of variables that determine length of symptoms. In my experience symptoms can start to improve in as little as week while others have lingered for months. It depends on your personal health status, how long you have had the symptoms and how well you have been able to deal with and eliminate the root cause of the problem. If the symptoms don’t show significant progress within 2-4 weeks I would think more aggressive measures maybe needed, though I have not had any clients have success with using air splints as a treatment measure. Hope that helps. Ben
Hi Dr Shatto, Recently diagnosed TTS, I have been continuing with my football (soccer) activities and I have noticed that once I first start to twist and turn I get a few moments of sharp pain but then the pain disappears as if there is no problem. Then the next day I have the same experience… It just seems odd that it the pain lasts for a short period of time once I start running for the first couple minutes of the game and then there is no pain for the rest of the game. Any ideas?
With my TTS I have had swelling under the inside of my akle/top of the arch for some weeks now. I have tried resting, icing and strapping it up but there does not seem to be any progression, hence why I have continued to play.
Hi Mirza, I can only guess as to the cause of your symptoms having no opportunity to evaluate you. But I would suspect there is an issue with the mobility of the foot/ankle complex that has led to the TTS. I suggest that you do several minutes of ankle warm ups prior to playing and see if that eliminates the sharp pain. I would also compare the strength, balance and mobility of your unaffected ankle/foot to the one giving you pain. Try to normalize your painful side to the non-painful side. This will likely take several weeks of diligent work. Hope that helps. All the best! Ben
Hi Dr Shatto
Thank you for your prompt response! I will take that information on board and see if we can make a difference.
However, I wanted to ask whether it is bad idea for me to continue playing? As I said the problem goes after a few minutes but I do not want to cause any permanent damage…
HI Mirza, I do not have a specific answer for you in a case like this. You need to use your best judgement. If you can play without pain and do not have any pain after or other signs of injury such as swelling, point tenderness, weakness or ongoing pain then it is likely not doing harm. But only you will have a good since of it. So use your best judgement. All the best!
Hi Dr. Shatto,
I had Achilles’ tendon surgery in July, and now 7 months post op developed tarsal tunnel. Limping and constant pins needles burning numbness. Did an MRI and EMG, tested positive with tinels test.
MRI showed liquid pockets at sinus tarsi, inflammation, no cysts or bone spurs, Electric nerve tests showed slowed reaction to nerve but not completely. I’m concerned if waiting too long for surgery that I will have permanent nerve dammage. But my case is difficult to diagnose if need surgery or just more time and nerve flossing, avoid walking etc. Any advice? As my Achilles surgeon gave up as tarsal tunnel not his specialty. Thanks for any advice, Britt 58 years female.
Hi Britt, This does sound like a difficult case. I would need more information to offer any solid opinion. I usually look at the whole coarse of symptoms to help determine if a surgical rout should be taken. Likely the TSS is due to the abnormal movements from the reconstruction surgery. I would consider surgery if I have tried other conservative measures and if the pain/symptoms were worsening or not showing any progress over time. Meaning 6-8 weeks of diligent rehab and conservative measures like anti-inflammatories. For a case like yours I would definitely seek a second opinion prior to any surgery. I hope that helps!
Hi Dr Shatto! I’m 29 years old I’m obese but I’m starting to train to people wrestle at this time I do wrestle and at this time I’m training barefoot I also stand at work from 8 to 5 and I go thru shoes like there going out of style and I’ve never had pain till now just in my left foot do you have any advice right now I’m experiencing numbness in my heel and burning feeling while standing on it I get use to the pain but right when I get out of bed I cant put any weight on it I weigh 406 pounds and I would like to continue training for pro wrestling
A couple of things you may try. Since you stand so much you may try a mild over the counter compression sock and see if that helps you. You also need to “warm up” the foot/ankle prior to standing on it in the morning. I will be posting a video on this in a few weeks on my YouTube channel. But in a nut shell you need to move the foot/ankle back and forth and maybe do some self massage and stretching prior to standing on it to prep that foot for weight bearing. You should continue to try and avoid pain and any numbness and tingling as much as you can. Hope that helps!
Hi, i’m 14 years old and i have crooked foots. And yesterday i experienced EXTREME pain in my two ankles. ( Before that i played at the park and ran a lot). It felt like my ankles were compressed really hard. It was sooo painful that i could only cry in pain, and the Tylenol did nothing either. I did research and i could have Tarsal Tunnel Syndrom. But i don’t know if its really that or not. Anyway, can you help, …anyone?
Hi Amani, I’m sorry your feet were hurting so bad. Unfortunately I can’t offer a diagnosis without evaluated your feet. But it is possible that you have a foot condition. Here are a couple good rules of thumb to hopefully help you. 1. If its hurting that bad try icing your feet maybe 10-15 each foot, just don’t put the ice directly on the skin. 2. If there are areas of your feet or lower or even upper leg that feel tight and restricted work on stretching and having good mobility. 3. If you have areas of your feet, lower or upper leg that are weaker than other areas work on strengthening those areas. 4. Don’t stress about your feet, keep active and having fun, just moderate your activity as needed. Hope that helps! All the best! Ben
Sorry Ben, I forgot to indicate that the pain is in the head of second metatarsal, and I feel this pain not only while stepping down stairs and walk but also when I touch the bone with my hand.
I am curious to know if you know of anyone getting this after, and or due to a full hip replacement? I have been told I have PTTD and possibly Tarsal Tunnel Syndrome, which has put me in a big walking boot now.
Not knowing all of this and having to move because of the hip surgery, I have about 5-6 weeks of walking on it thinking it was all due to the hip surgery. I am now worried that I have caused much more damage not taking care of it right away. What would your thoughts be on that? Will I heal okay, avoid any other type or surgery as I am now fully aware and keeping weight off of it.
I have never in my life had any problems with my feet and I use to run as well, this is all so confusing how this happened to me, right after my hip surgery.
Any suggestions, advice or comments would be greatly appreciated.
The timing of the development of Tarsal Tunnel like syndrome is very suspect. It very well could be due to changes in walking patterns after your hip replacement. And if that is the cause then working on normalizing your walking pattern and treating the tarsal tunnell should take care of the symptoms. However, it is possible something else is occuring including some kind of nerve related issue stemming from the surgery. You may need to follow up with your physician and possibly a nerve conduction study to confirm which nerves are involved. I have had clients with foot drop and other foot related nerve conditions due to nerve damage that occurred due to the hip replacement. I suggest additional medical follow up. Wishing you all the best. Ben
I’ve had flat feet all my life and I’ve tried many different ways to deal with daily jogging. A few months ago I started running in shoes with very narrow built-in arch supports. There was a tightness on the inside of my left ankle which was absent on the right, but I shrugged it off since they were otherwise very comfortable. Then about a week ago I started feeling a dull ache in my ankle and a sharp pain in my big toe when extending my left leg and foot simultaneously (like while stretching or scrambling into a pair of pants when you’re late for work).
I tossed the shoes, and I’m going to have my doc check things out for sure, but I think I caught a potential TTS situation in its infancy. Many thanks!
Tom…..good call making the adjustments early. Much better to identify those warning signs and make a change vs letting it develop into something more. All the best!
Hello. I am curious what running/walking shoes or even shoe types (stability, high cushinioned, no drop, etc.) will help with tarsal tunnel? I have suffered several years with tarsal tunnel (L) now – finally diagnosed last year by nerve conduction study. I also suffer from bilateral plantar fasciitis so footwear is so difficult to pinpoint. Your guidance and any advise would be appreciated. Several podiatrists and two neurologists have oven up on me already.
Hi JoAnn….great questions, but hard to answer without evaluating your feet. On average I would suggest a supportive shoe with an arch support, so more stability is typically better. I would also suggest you address any hip issues. Hip weakness is often associated with these conditions. I would be actively treating the tarsal tunnel, plantar fasciitis and as part of the treatment address the hip, I would be surprised if there where not some associated weakness and motor control issues. All the best!
Hi Ben, after tripping on a stair, I noticed my left big toe was bruised. That healed, but then I started to notice numbness in my third and fourth left toes. I tried to swim instead of to walk on it as much but the numbness didn’t go away. After about a year I noticed that I wasn’t able to spread those toes apart as much as I could on my right foot. I started to have tingling/ electric shock feelings & discomfort on the bottom of the feet in addition to the constant toe numbness. My toes except for the pinky toe seem to curl more than those of the right foot. I went to physical therapy and was in extreme pain during foot massage. Gradually with that and vibratory massage in my own my tolerance for massage has gotten much better. A nerve conduction study resulted in diagnoses of mild tarsal tunnel syndrome and of mild tendinitis. Regarding the ankle I feel the outside of it (just above the bone lump and approximately in line with the fourth left toe is where I have a knot/ pain/ an aggravated nerve during vibratory massage (not the inside of the ankle as I understand is characteristic of tarsal tunnel syndrome. In fact the area around the bone lump on the inside (medial) portion of the ankle feels completely normal. Do you in fact think I have tarsal tunnel syndrome based on what I mention or some other condition?
Hi David…..you are asking some great questions. Difficult for me to know without my own full assessment….But I would agree with you that there is likely something else at play here or at least in combination with the tarsal tunnel. Having multiple conditions at once is not all that uncommon. My first thoughts gravitate towards a lumbar condition that is causing the discomfort or an issue with fibular mobility that is causing the pain and symptoms. I would suggest seeing someone that is a sports medicine specialist and possibly is NAIOMT trained in PT. There needs to be a very thorough comprehensive mechanical examination starting from the lumbar spine down. There are answers to your questions you will just have to continue to be very proactive in your searching and finding someone to journey with you. I really hope that helps. Ben
Hello Dr, Ben,
I started to have feet pain in my first pregnancy last trimester in 2016. The pain lasted a year and got better after I lost Pamela weight. The pain came back in my second pregnancy last trimester in 2018. This time the pain was worst then before. After I deliver the baby the pain went away however it came back after three month in December 2018 and I’m still struggling with the server feet pain. The pain gets so server that I can’t stand walk lift etc. it causes too much inflammation in my whole body and affects everything. Earlier this year I was diagnosed with tarsal tunnel syndromes. I got cortisol injection twice, first time I saw huge improvement, second time I didn’t notice much chnage. The pain is extremely painful now , nothing is helping and the doc suggested tarsal tunnel release surgery. Do u recommend taht for me? What r the chances surgery can go wrong and affects my feet’s ? I need help please help me I’m in too much pain since past few years 😭😭😭😭😭😭 this issue has started to affect my knees now as well. I’m also having kneee pain now is this a sign of danger?
I’m so sorry to hear you have been in so much pain. With small children it must be very difficult to get around and keep up with them. It sounds like you have had some medical treatment for this. Tarsal tunnel surgery can be successful I believe the average rate of success is something around 75%. All surgery has the potential for complication including the risk of it just not working. If you feel you have exhausted all other options then it maybe worth the risk. I’m not sure I can offer more advice then that. It sounds like you are in a difficult position and so there may not be a right or wrong answer just a choice and path to travel down. I wish you the best of luck. Hang in there you can recover from this 🙂
Hi Dr. Ben,
I’m an avid runner, training for a marathon in 3 weeks. About a week ago during a run, I felt some initial tightness in the middle of my arch, I have high arches and supports, but that occasionally happens. I pushed through and started to feel an intense heat sensation in the medial ankle tendon area. It wasn’t painful (in my opinion, I have an extremely high pain tolerance), but I have been experiencing this heat sensation almost nonstop since the initial onset. The medial ankle tendon is noticeably swollen, I’ve been taking anti-inflammatories. I’m still actively training, would a support like a wrap or brace help alleviate this sensation?
HI Betsey….It sounds like you are on the verge of injury. Its possible you have the start of plantar fasciitis or posterior tibialis syndrome. I would be aggressively treating this with ice, stretching, mobility work ect… Though you have high arches you may also benefit from an orthotic to help support the arch. One area of caution is……it is rarely a good idea to do something new such an orthotic or new shoes before a race. So tread carefully with any big changes pre-race. You will have to decide if you can triage and push through for the race. So for now work on recovery! Hope that helps.
Dear Ben shatto
I just happened to see your blog.
I had my TKA with spinal anesthesia. After I can home I had home health care PT ..after few days being home I noticed I could not curl my toes and my foot felt heavy. I let my Ortho know about my condition to which they responded it will go away.
After two weeks in pain I decided to see a foot doctor. He evaluated and said my tibial nerve was tender to touch so he gave me a cortisone shot Rx gabapentin and diclofenac gel to put over my foot and ankle and ice.
Five days passes by my pain was severe so I had an EmG test that confirmed tibial nerve damage.
I am petrified a healthy 64 year old female active have knee surgery dealing with Tibial nerve damage.
Three weeks have passed now I am seeing a foot surgeon who deals with this type of neuropathy refers by my foot doctor.
Mean while what can I do to help support my healing.
Any perspective or advice will help.
Hi RB….I’m so sorry to hear about this. I realize I don’t have the complete medical history here. But based off the above information I would be very cautious to go into a surgery at this point. Maybe there is a clinical indication but likely the nerve damage happened in relation to the TKA given the timing. Possibly a compression or traction related injury. Unless there is still an issue causing excessive compression or traction I’m not sure why the surgical referral. Again I’m sure there is more to the story. In regards to healing. Nerves heal very very slowly. They will average a regrowth rate of 1 inch per month. Give or take. This means a complete recovery could be a year out. Symptoms typically improve as time goes on. There isn’t too much you can do to help it grow faster. But there are a lot of things you can do to make it grow more slowly. Focus on healthy nutrition. If your diabetic control your blood glucose levels, avoid smoking, stay as active as you can. Sometime acupuncture can be helpful. Focus on being as healthy as you can. Though it won’t help your nerve regenerate faster it will prevent it from regenerating at a slower pace. Hope that helps. It is a long recovery typically so hang in there.
Last April (2020) I went over on my right ankle when running and had some minor pain for the next three weeks. I then went on a long walk and the pain came back much more severely. Almost a year later, I have intermittent pain – it’s a tingly/irritated feeling – which comes and goes. I have good days and bad days.
I’ve never had any real problems with physio exercises or ROM, and walking is fine. On bad days, standing tends to aggravate it. However my main issue is not being able to wear shoes – all trainers (as they fit around where the tenderness is on the inside of the ankle) cause the pain to flare up after 30 mins or so. The only shoe I can wear with no irritation is walking boots (which isn’t very practical for working in an office!)
I’ve recently been diagnosed with Tarsal Tunnel Syndrome by the foot and ankle surgeon which I think makes sense. The consultant prescribed gabapentin and is referring me for an EMG. I was wondering if you had any advice on what I could do as I’m very hesitant to go for surgery. I’m also not sure about taking gabapentin.
Do you think this can be solved conservatively? I have tried rest, NSAIDs, ice, physio etc. I’m going to start nerve gliding exercises.
I am a 24-year-old female, low BMI, otherwise very fit and well.
Hi Scarlett, I think the EMG is a good option to insure a proper diagnosis. Then the question is why are you getting tarsal tunnel if that is in fact what you have. Was there a nerve injury that occurred after the fall? In which case the Gabapentin maybe helpful. Is there something compressing the area or scar tissue affecting the nerve. I think the key is to dig deeper into the why so you can address the actual mechanical cause of the symptoms. So yes I think conservative treatment is definitely an option, but first figure out the why and what is causing the nerve to be irritated that will guide your next treatment options. Hope that helps!
Hi Ben, thank you for your reply!
I’ve had an ultrasound which shows grade 2 hypertrophy of the posterior tibial tendon sheath, so I guess that it’s that extra tissue that may be compressing the nerve? If that is the case, what conservative treatment would you recommend or is surgery to remove that tissue the only option?
To respond to your question – when I first did the injury there was no issue with the nerve or pain when wearing shoes for the first 3-4 months, so I’m guessing this must have developed later on…
Thank you 🙂
Hi Scarlett, wow….now that is interesting. You are likely correct that this developed basically as scar tissue after the initial injury. I think you need to do the EMG to see how much the nerve is being impacted. Depending on severity it could be constricting the nerve to the point it could die completely. Based on EMG results you maybe able to do conservative treatment or surgery maybe indicated. Nerve glides and tendon glides specific for the posterior tibial tendon would definitely be indicated as long as they do not increase your nerve symptoms.
Thanks so much for your responses Ben – I’ll let you know how I get on with the EMG!
I am a fitness instructor and I love to run. 2 weeks ago I was teaching a class where we do a lot of lunges and during class my foot had a tingling sensation, I just figured I overworked my foot for the day. I taught two classes the next day and that night I woke up with a horrible burning on the outer side of my foot and it ran up to my calf. Now 2 weeks later the burning is gone but I have loss sensation under my middle toes on the sole of my feet. I am also sensitive under my inner ankle and if I press hard it sends a tingling and sharp pain to the bottom of my foot. I’ve been to my physical therapist and he heated, iced, scraped my calf and foot and taped it to see if it helped so he could make me orthotics. He also told me no jumping exercises for several weeks until I saw improvement. I am also taking Tylenol and ibuprofen to lessen the pain. Do you have any other suggestions for me.
Hi Annie….I think in a case like this it is important to know the cause of the symptoms. Is this a peripheral nerve entrapment or from the spine? Is it a neuroma? There are several possibilities and the treatments will vary. Did the PT give an actual diagnosis for the nerve symptoms? As long as you are getting nerve type symptoms you need to find out what is compressing or injuring the nerve and work towards fixing that first. Hope that helps. Ben
Hi Ben, I have been having symptoms which seem likely to be TTS for three months now. Due to a knee injury I wasn’t walking much when it first started, so I still don’t fully understand why I got this. The only thing I can imagine is that the tibial nerve was under tension too much, because I had to sit with my injured knee in straight position. In my case, the condition is quite limiting because the foot gets painful very quick, so I have to use a chair to do dishes for example and my walking radius is more or less my home. So far despite only very limited walking, there has been only very little improvement. I’m doing the foot strengthening exercises and nerve gliding daily as far as it doesn’t aggravate the symptoms. I also want to start swimming once the pools open again. I have seen a orthopede a month ago and was now referred to a neurologist for further investigation (they also think it’s TTS). To me it seems, the doctors do not see this problem very often and my physiotherapist didn’t know what it is, so I’m a bit worried about being properly treated for sth that could potentiall become chronic. As you mentioned above, recovery can take a long time, can you give me an approximate timeline based on your experience? At this point, I have pain when I walk more than a handful of steps and when I stand in the same spot for more than 20 seconds. I have tingling feelings in the feet mainly towards the evening and when I put the foot into eversion + dorsiflexion. Thanks 🙂
Hi Sabrina….I’m sorry you are suffering with this. Its difficult to give a time table for recovery given the many possible variables. I know you feel that the positioning of the knee during your knee recovery could be the cause. I don’t know how you hurt your knee but it maybe there was injury elsewhere in the leg at the same time as the knee injury. Your physio needs to look at the lower extremities as a whole and separately. Look for differences between the two legs and work towards symmetry and normal movement patterns and normal symmetrical strength. If the nerve was injured due to a traction injury or some other type of injury then the time table for nerve healing is 1 inch per month approximately. This means take the length of the tibia in inches and figure it will be approximately that long to recovery. This of course is an estimate and is only valid assuming a true peripheral nerve injury. The neurologist will be able to determine the type of injury to the nerve with a nerve conduction study. Hope this helps! Best of luck!
Hi Ben, thank you for replying. In the end, the neurologist measured slowed conduction velocity in the nerve going to the two small toes bilaterally. I didn’t specify before but I have it on both sides, initially it was only the left but a few days later also the right foot. We did a Cortisone injection on the left foot, which helped a bit but didn’t fully resolve the pain when walking. So now the neurologist thinks that it’s not TTS, but just a nerve injury which needs time to heal. I also asked if it doesn’t improve in two months (it’s 4.5 months now), if nerve release surgery is indicated and she said no. I’m a bit confused by all of this, because from what I read TTS doesn’t always respond to Cortisone and if appropriate treatment is used too late, the nerve damage may be permanent. So now I’m not sure if I should get a second opinion or just wait and see what happens, mainly I’m afraid that too much time will pass and the damage is permanent.
Hi Sabrina….these are interesting findings. The area you describe could easily be a peripheral nerve injury possibly TTS or something affecting the Sural nerve. But it could also be from the spine approximately S1. Also interesting that it is on both sides. Has anyone screened the lumbar spine for the possible cause? A PT should be able to do this for you. But in a nut shell what you are trying to do is find out in any lumbar movements and they may need to be repeated or sustained make your foot/toe symptoms better or worse. I would look for someone in your area that has been McKenzie certified. They would help screen the spine for sure. Hope that helps! Ben
Hi Ben, I haven’t written here in a while. Thank you for answering my questions so far. I still have the same issues so pain in tarsal tunnel area and am only able to walk very limited distances. I also cannot stand on my toes without being in a lot of pain. If I do the foot exercise where you crunch the towel, it also flares up. The neurologist checked my spine, so we don’t think it’s coming from there directly. Yesterday, I saw a pain specialist, he felt that maybe despite the positive nerve conduction study, the nerve is not injured (anymore) because I’m not having any shooting pain or tingling in the area anymore. In your experience, does TTS always present with typical neurological pain symptoms or can it also just be more dull pain? Do you think it’s possible that maybe there is something wrong with the Posterial Tibial Tendon as well? I don’t have pain when I press the ankle outwards (like the doctor does for testing for PTTD), but when I do ankle resistance exercises with only low amount of repeititions and resistance, I get a flareup. What do you think?
Hi there, I’m sorry you have continued to have pain. Yes you can still have tarsal tunnel symptoms without the typical neurological pain. Especially since it has been so chronic for you. But yes you are right. PTT symptoms can be varied and nuanced. And if you are getting similar symptoms as the volume increases when activating the PTT it does suggest a possible issue there. You would need imaging like an MRI to confirm. But at this point it seems reasonable to look for possible other issues that are contributing to your issues since the complaints have continued.
I have been diagnosed with Rafael tunnel syndrome we have currently done everything but surgery our last hope is physical therapy. I’m scared to do PT because if I bend my foot towards my shin or move my heel so that my toes are pointing away from me I get this super sharp pain and a tight knit in my calf. Is the something that can happen with tarsal tunnel? My podiatrist is at a loss.
Sorry had a few spelling errors tarsal tunnel. And a tight knot in my calf is what I meant.
Sandra…..Yes, pain like that is possible especially with a nerve entrapment or even with fascial pain. PT should not cause any further damage to the area but there maybe some initial discomfort. I would suggest it is still worth trying before taking a large step like surgery. Give it a try and just be upfront with the PT about the severe pain and your fear of it worsening. Hope that helps! All the best! Ben
Hello. I have been diagnosed with Tarsal Tunnel by 3 different doctors. The pain has continued now for almost 3 months. I am a teacher and am on my feet often. I have tried numerous conservative treatments and the pain has gotten better, but I am still unable to place my heel to the floor and walk normally. My MRI showed that I have an extra tendon in my ankle that is compressing my nerve. I am going to see an orthopedic surgeon next week. Do you think my only way to walk normally again is to have the surgery? I am very reluctant about surgery, but am frustrated that all other methods haven’t yielding positive results enough for me to walk normally again and it’s been 3 months.
Hi Rachel…Yes….I do think it is possible. The “extra” Tendon has likely always been there and so it has only been recently (3 months) that it has potentially been an issue. What changed for you 3 months ago? Try to get to the root of that problem. What muscle imbalances may have changed 3+ months ago that caused this area to inflame and become symptomatic. Focus of the deeper how and why when progressing towards treatment not just the symptoms and there is a good chance it can be dealt with without surgery. Hang in there! Ben
I had aggressive physical therapy on my calves and ankles starting in May. About 2 weeks in, I developed neuropathic symptoms in my feet and especially big toe. The symptoms subsequently spread to my ankles and calves. The symptoms became so painful that I had to take medical leave from my job as a professor. Recently, I also developed some swelling in the arches of my feet. Yesterday, I noticed mild swelling in the area of the tarsal tunnel on one foot. I also found a painful area near the tibial nerve in the ankle of the second foot. I have no ankle reflexes. Do you think I could have Tarsal Tunnel Syndrome in both feet? I have a history of Ledderhose disease and the excess scar tissue might also be causing nerve entrapment in my feet. I had an MRI and there is no evidence of lumbar nerve compression.
Hi Wendy….these symptoms are concerning. It sounds like you have ongoing nerve entrapment likely of peripheral nerves or even a form of compartment syndrome. The first think I would do is have an EMG study of your lower leg and find out which nerve are affected and where. Then you can guide treatment more effectively. I wouldn’t delay too long as long term compression like this can have permanent consequences. I would not do any aggressive therapy until you have a more accurate diagnosis. Hope this helps and best of luck! Ben
Thanks Ben! Today my chiro did cold laser therapy. Said he wanted to do several treatments since I seem to have tried everything else. The main thing I changed was doing an virtual workout program in the evenings at home without sneakers on. I am not sure what I was thinking, but I do think that could have contributed to it, I didn’t change to that 3 months ago, but did it all through COVID lockdown, so many many months honestly. 3 months ago we took a trip to the beach, and I walked around all week barefoot on the sand/dunes, I am pretty sure that was my final moment…..
Ahhhh….Well that makes since. Soooooo…..if you didn’t have an issue with the extra tendon till all of that happened then I think its reasonable to assume you can get back to normal without surgery. Just my opinion 🙂 No harm in trying the cold laser, as long as you can afford the fees. Best of luck!!
I am a flat-footed, bunion-toting, but otherwise healthy 27-year old woman. I was recently diagnosed with TTS. Prior to the day of continuous flareups, I did a high impact workout indoors without shoes… the next day I was in excruciating pain. The following day, I went to see a podiatrist who diagnosed me with TTS. I decided to go with laser treatments. It has been nearly a week and I feel much better. However, I still experience a flare up or two throughout the day. However, this morning I had constant flares of pain for nearly two hours. It has not been that bad since I have been receiving treatment. Is this potentially normal for the healing process? If so, on average, what is the healing timeframe for this type of injury?
Hi Mo…Great question. You are likely right in the middle of the inflammatory/healing cycle. The first phase is apprx 2 weeks then you go into the second phase that can by 4-6 weeks depending on the severity. So with only 1 week in…just keep doing what you are doing. Best of luck! Ben
I have symptoms consistent with TTS in both feet that developed over the last six months as I have slowly added running to my exercise routine. I really appreciate this article and your replies to everyone’s questions. I have two questions for you. You mention the inflammatory/healing cycle, including multiple phases — can you describe that in more detail or link me to a description? My other question is about differential diagnosis of TTS versus lumbar spine dysfunction. I have an appointment with a sports medicine doctor this week — can I expect the doctor to be able to differentiate between TTS and L5 dysfunction by manual exam? How would you do that differential?
Hi Monika…Here is some info on phases of healing. Dr. Google has plenty on the topic 😉
Phases of Healing
The different phases of healing include: inflammation, proliferation, maturation, and remodeling.
The different phases or stages are not mutually exclusive and overlap considerably. Depending on treatment methods and activities, you can influence the outcomes either positively or negatively.
Acute – Protection Phase
The acute stage of rehabilitation, also initially known as the protection phase for the first several days post injury, is correlated with the bleeding and inflammation phase of healing. The healing process begins right away by bleeding. In order to prevent any further damage, the body’s response is to limit all movement by swelling and spasming (splinting) muscles.
This initial inflammatory response is a critical component to healing the damaged area.
The usual time frame for acute initial symptoms to occur is two to four days post injury. This can vary depending on how you treat your injury. The acute phase of rehabilitation often takes much longer.
Sub-Acute – Repair Phase
The sub-acute phase of rehabilitation typically correlates with the proliferation phase. During this phase, the body is progressing with the healing of the injury. A soft tissue injury is termed as sub-acute when the initial acute phase transitions into the repair of the injured tissues. This phase of tissue healing as well as rehabilitation starts three to six days post injury when your body starts to make new or heal the injured tissues. This phase commonly lasts up to six weeks.
During this phase, your body is eliminating waste materials that may be present from the initial injury. It’s also starting the healing process by bringing in nutrients and a mixture of extracellular matrix and collagen to make new tissue. The development of a new network of blood vessels, if needed, will replace the damaged ones (a process called angiogenesis).
From a rehabilitation standpoint, this is the most critical phase in order to insure a speedy recovery. The aim is to reduce the need to protect your injury as the new scar tissue begins to mature and strengthen. It’s also an important time to provide your body with all of the necessary resources to heal quickly and completely. The rehabilitation goal is to help your body produce the strongest scar tissue possible while limiting loss of function when taking steps to prevent future re-injury.
Late Stage – Remodeling Phase
The late stage or remodeling phase is often correlated with the end of the sub-acute phase of rehabilitation and the return to sport phase of rehabilitation. During the remodeling phase, your body continues to heal and remodel the damaged tissue. Healing is a continuum. This phase starts between six and eight weeks post injury and will last three months or more.
At this stage, your healing tissue is reasonably mature but as you stretch, stress, and strengthen around the new scar tissue you may find that it’s not strong enough to cope with your increasing physical demand. This is why a properly coached and graded rehabilitation plan is critical. Although it may appear that the injury has finished healing when maturation phase begins, it’s important to keep up with the treatment plan.
Monika…as far as TSS vs L5…yes a thorough physical examination should give a high degree of certainty if its TSS vs L5. However, to be 100% certain you can do a nerve conduction study this will for sure tell you what is impacting the nerve. Peripheral nerve injury or spinal nerve root.
Hope that helps!
Hi Ben. I had two tkr in 2016 and 11 months later 2017.2 weeks after my second one I developed numbness in the balls of my feet and first 3 toes both feet. After EMG was diagnosed with tts. I have VERY flat over pronated feet. After PT NEW ORTHRO’s not helping I had minimally invasive tarsal decompression in my worse foot being the left. No improvement. More PT. No improvement. Had a second surgery 1 yr later no improvements. More pt. Nothing helped. A new podiatrist stating previous s surgeries did not help because 1.can never be done minimally invasive and 2. Surgeon did not go down far enough into the branch to release full compression. I believe symptoms are caused from my gait after my tkr’s and as soon as surgery completes just my walking compresses the nerve again. My symptoms are minimal very early in the morning but by midday are bad. Burning, tingling, and numbness all at same time. I press on foot just below navicular bone and symptoms get worse. Do you have any recommendations as to what type of dr., if any, can help? My heels are starting to get shooting pains periodically so plantar fasciitis probably the issue. Do you have any suggestions for me. Terrible discomfort. Thank you
This sounds like a terrible scenario for you. I am sorry. I do believe you are on the right track with it being a walking issue after the total knee replacements. The Total knees likely changed your normal mechanics causing a chain reaction effect into the feet. At this point there are likely multiple structures affected. This issue is now chronic with a lot of altered mechanics. My advice is find a PT that can start from square one with you. Someone that will take a slow and steady approach. Not crazy new fads or techniques but someone that will do a thorough analysis and then progressively help you through this process. Since so much attention has been played to the feet you may consider an approach where you address the hips downward. I can’t give any specific treatment recommendations given your situation but work from the hips downward focus on the hip external rotators then the knees and improving your gait. Then the feet. Likely addressing TSS, plantar fasciitis as well as someone to examine the navicular and make sure the mobility and alignment is correct there too. I sure hope this is helpful for you. Don’t give in. The body can do miraculous things. All the best!!! Ben
I am a 29 yr old male who has developed all the symptoms of Tarsal Tunnel in both feet after an aggressive walking program to get fit.
I had flexor tendinitis and posterior tibial tendonitis confirmed by a PT that I have solved, but 3 months after onset of injury my nerve pain is still quite bad. I get tingling in my feet all the time. Hot and cold sensations. Shooting pains in the bottom of the feet and on the side.
Tested negative on an EMG/NCS and an MRI of the worst side (left) showed an unremarkable Tarsal Tunnel space.
I have a positive tinel on the right with no tenderness over the tunnel, and a negative tinel on the left, but with tenderness over the tunnel. Inversion/eversion test positive on both sides.
I had a steroid injection 2 weeks into symptoms which helped, and another one just done nerve sensations intensified again.
In your opinion, do you think my best bet is to just keep strengthening my foot and ankle and hope it clears up in the next few months, or should I push for surgery sooner to avoid permanent nerve damage?
Any advice would be appreciated.
HI JW…..that is a tough call. You may need to also consider other medications for nerve pain such as gabapentin temporarily. I would say that foot strengthening is a must but you must also focus up the chain especially in the hip. Hip position and strength has a large effect on foot position during weightbearing. As far as surgery vs no surgery…I really can’t advise on this. Sometimes surgery is necessary but I am always one for more conservative management as much as possible. If the EMG’s are both negative then I’m not sure of the clinical push for immediate surgery. Something to discuss with your MD for sure. Best of luck and keep us posted how you progress.
I ruptured the medial slip of my plantar fascia over two years ago. I followed the advice of my doctor and after wearing a boot for three weeks went to physical therapy. It seemed to be healing well until about a year and a half ago. Then I started getting very sharp stabbing pain in my medial arch, as well as numbness and pain in the medial ankle. I’ve tried the exercises you recommend for TTS, and haven’t found much relief. About a month ago, I realized that the pain and numbness (which now is also in the metatarsal area) was exacerbated by shoes that cinch tight around the ankle, which I should have realized earlier as I have a positive Tinel’s sign. I recently went to a Dr. about an unrelated problem in my lumbar spine. MRI revealed stenosis. This Dr. thinks my nerve pain in my foot is related to the lumbar nerve impingement, not TTS. In your experience, can spinal radiculopathy cause TTS symptoms, including Tinel’s sign?
Hi. Thanks for the great questions. These kinds of injuries can always be tricky. Especially when so much time has gone by. It also reinforces the importance of getting an accurate diagnosis. The short answer to your question is yes spinal stenosis can mimic tarsal tunnel syndrome. But it’s also possible that you have both conditions. The conditions need to be treated differently and so I would recommend additional medical follow up to determine which condition you may or may not have. Typically a nerve conduction study could be performed to determine if the nerve is being trapped at a more peripheral level such as the tarsal tunnel or spinal level from stenosis. I would suggest starting there first to guide the appropriate treatment once the accurate diagnosis is made. I hope that helps! Keep us posted on how you’re doing.
Thank you so much for this useful forum and for taking the time to reply to us! I was hoping I could get your opinion on this. 3 weeks ago, I experienced a sudden pain in my left foot. It literally came on like a light switch (kind of felt like a cramp/charlie horse) about 1 inch below my inner ankle. The painful area is very slightly under the foot, but it’s more so along the side. I went to a podiatrist, and she said it could be plantar fascitiis (micro-tears), but I’m not sure if I agree with this diagnosis because of the weird sensations i’m having which make me think it’s more nerve related. The painful spot is tender to touch, and I’ve also been experiencing dull ache in that area. I’ve had a lot of muscle twitching on & off in the exact spot where it hurts, sometimes a throbbing pain. My left foot & toes generally just feel slightly number compared to my right (not an intense numbness, but it feels weaker overall). I do feel some (very little) relief after walking a bit, which makes me question if it is in fact plantar fascitis but the other symptoms I have make me feel like it’s a nerve injury. Especially the fact that I’ve never had pain there before, and one day it just came on so suddenly within a second! I’ve been massaging it, icing/heat, and doing gua sha on the painful area as well which I find gives me some relief but nothing cures it. After researching online, I feel like it could be TTS because the pain does radiate a bit to my ankle. Any thoughts or recommendations on what I should be doing? What type of imaging testing or other testing should I get done? Do you recommend seeing a podiatrist again or maybe a physiotherapist? I feel lost and not sure what to do. I appreciate your help!
Hi there. I’m glad this forum is so helpful. That has definitely been my hope. Based off your description of the pain and how it started, I am more likely to think you may have posterior tibialis syndrome. I would probably see a physio first especially if you want a more active treatment course. Here is a link to an article I have written on the topic (https://www.marathontrainingacademy.com/posterior-tibialis-pain). Also here is a link to our Resilient Runner Program (https://marathontrainingacademy.clickfunnels.com/injury1) that has a whole section on this injury. Best of luck! Ben
Thank you so much :)!
You were right! I went to a physiotherapist who said it was posterior tibialis tendonitis and not plantar fasciitis. She also pointed out my flexor hallucis longus pain as I feel dull aches in my big toe and in my calf. My arch is also collapsed more on my left foot (the problematic side) as well compared to my right. I’m going to get custom orthotics made soon, I’ve invested in better shoes, and I am following daily strengthening/stretching exercises. I was wondering if you had any other suggestions for recovery? Over the past few weeks, the pain has slightly improved but I am definitely still not 100%. I would like to get back into going for walks and working out again (I will avoid high-impact for a while) but I’m scared to aggravate it and make the pain worse. I’m only 24 years old and want to take an active treatment course. I think the physio’s diagnosis is correct, but I didn’t do any sort of imaging testing – not sure if that could be useful as well. I have an upcoming MRI appointment for a separate issue in my lower back, and was thinking of also asking to do some sort of imaging testing on my left foot (mri/ultrasound). Could this help at all? Thank you in advance. I appreciate any advice.
Well, this is good news. A more accurate diagnosis will help with treatment. An MRI is likely best to see the extent of the injury. If the arch has already partially fallen, then there is likely some damage. If therapy is helping, then you could stay the course. But if there is the possibility or need for additional medical interventions, then having the MRI will be very helpful in guiding next steps for treatment. Usually you will need the MRI ordered ahead of time so they can plan out the schedule. It’s not something they can just add on. So I would call the imaging center and ask about that. Hope that helps. Keep us posted on how things are progressing.
Hello. I am a 48 yr old female weighing 142 pounds who is the construction field. I am constantly on my feet even if I’m in the office (standing desk). I run in the morning (only a couple miles) every day. I have never had problems with my feet until last July. I was unloading 60lb bags of concrete for a patio. Soft ground. This is just another day of work, no big deal. However, the next day, both of the tops of my feet were bruised and a small bump in the middle of the bruises. I believe I unknowingly broke the metacarpals on each foot. No real pain though. A couple days later I have foot pain. Tingling, burning, pins & needles but only on soft ground. I am fine on pavement. The pain was debilitating and my days were cut down to 3 hours. It’s been months now and I work only in the office (still at a standing desk) and I have quit running. My pain level is fine in the daytime but in the evenings it is back. It does change my gait and I limp from one foot to the next. I am taking ibuprofen, stretching, massage and ice packs. There is no swelling. I don’t know how to manage this since it is both feet. Suggestions??
Hi there….I’m sorry you are going through this. It sounds terrible. Since this occurred on the job, was worker’s comp involved at all? (If you’re in the US.) There are a lot of variables as to what could have happened and what continues to happen. I think you need to be evaluated by a medical professional first to see what exactly is causing the issue. You may need an x-ray or even a bone scan to determine if there is a non-healing fracture. Both are relatively inexpensive. Probably a podiatrist would be the best first step as they can order the appropriate imaging. Once you have a more concrete reason for the symptoms, a thorough rehabilitation program can be established. Hang in there. You can definitely recover from this and get back to running! Keep us posted on how things are progressing. Wishing you all the best!
I fractured my tibial near my knee June 21 this year. Been treated, but about 3 months ago my foot started hurting. I claimed it was from limping due to my fracture but no one would agree. Never saw a doctor, just NP. She released me back to work. I asked about the foot and was told it could not be caused by the fracture. Could not work caused excessive pain. Looked up and found Tarsal tunnel syndrome and how it can be caused in 97% of people from a tibial fracture causing pressure and swelling. No one will give an answer. Can you explain best way to treat this. I also have deep thrombosis and flat feet which I read adds to this problem. Could use advice so I can get back to work. Email is email@example.com
o sorry to hear you have been going through all of this. I am not sure if you did any formal physical rehabilitation after this injury or not? But you have potentially multiple issues that will need addressed. Likely, you have ongoing hip and quadriceps weakness post injury which will have a direct impact on the foot. The deep vein thrombosis could also be a factor depending on location. Then given the flat feet and possible change in gait mechanics that could also be affecting the foot/ankle complex. In a situation like this, I cannot give specific advice as there are too many variables that need to be evaluated. You need to see a physiotherapist that can evaluate you from the hip down and develop a thorough and comprehensive treatment plan. This will be your best option for a speedy recovery. Your other option is to purchase the Resilient Runner program and follow the advice for the tarsal tunnel and for a meniscus repair as that will be similar in rehab at this stage post tibial fracture. I hope that helps! Best of luck!
Hello Dr. Ben, I am a runner but I have never had any problems with my ankles and tarsal tunnel syndrome until I took up snowboarding. After my last trip, my foot went numb and feels cold underneath my big toe. I saw a foot surgeon, but he did not identify it as tarsal tunnel. I however, noticed that the abrasion I had over my tarsal tunnel, from my boot, provoked an odd sensation in the affected area when palpated. I then came to realize that this discovery was a positive Tinel’s test. This happened to me last year, but it abated rather quickly. Is there anything you would recommend? And is it safe to listen to that surgeon, who said it’s really nothing to worry about. Btw, he ordered his PA to inject cortisone into the MCP joint, because I had also had hallux rigidus in that area, which had resolved. I have another trip planned this week, but I definitely do not want to risk any serious nerve damage by riding on this. Thanks in advance.
Thanks for the question. Clearly from your description, you had a boot and/or sock problem. The symptoms you had are not normal and should not be taken lightly. You need to adjust the fit of the boot so this does not happen or get new boots. So yes, I disagree with the surgeon regarding not worrying about this issue. If you continue to traumatize this area, it may cause permanent or at the very least, a long term issue that does not need to happen. So I would definitely make changes to the footwear to prevent this issue. Best of luck!
Dear Dr. Ben,, Your article is absolutely perfect which reflects the patient feelings who ever suffering with TTS , even me . My Self suffering with Heel Pain (pin point) on both legs from last six months with burning sensation on Shinebone/calfbone. I have visited twice the different Ortho specialist. First time Dr advised me to use the D-vit(50,000IU/week) as it was 20.1 ng/ml along with Celebrex 200mg. After 8 weeks of D-Vit and 2 weeks of NSAID nothing much changed. Then I have changed to another Dr last week and he did X-ray of Heel bone and said minor heel spur on left leg and suggested me again D-Vit (25000IU/ 3days once) and Etoricoxib 120mg , However pain not reduced till date. Normally, I use the safety shoe 2hrs a day and other time casual shoe for 6 hrs. Since the pain started i`m using the silicon heel pads to reduce the pain.
Until reading your article i was not aware of TTS and your article explains the exact symptoms that i`m feeling. Please advise me.
I’m sorry you are dealing with this condition. I would suggest following the recommendations in the article. And since your description of symptoms also mention the heel and shin, you may find assistance in the shin splints article and/or plantar fasciitis article. If you want even more thorough information and treatment recommendations, you could check out the Resilient Runner Program:
All the Best!
I’m training for a 100 mile trail running race with a lot of climbing and descending. The nature of the training is most likely the trigger of the pain (uneven surfaces, going uphill/downhillI and obviously been running a lot ) I have been running 40-60 miles per week on it for the last two months and while the pain is a sharp electrical shock that occurs right behind the big toe metatarsal bone – it only occurs randomly and not too frequently maybe 2 or 3 times a run. (If it does react it’s normally on a downhill portion). It doesn’t seem to have gotten any worse or better during the time. I’m not sure if it’s TTS or PTT but based on the sharp tingling pain it’s TTS? Also is it dangerous to continue if it doesn’t get any worse? I’m going to plan on doing ankle/arch exercises for extra support, see if inserts help, and get compression socks. Any other advice would be greatly recommended!
I cannot say for sure if it is “safe” to continue. Typically if it’s stable and not changing/worsening, then it is okay with a high degree of monitoring. I would also suggest not changing or adding a bunch of things at once. Add one thing at a time, and then give it a week and see if there was any change. If you change a bunch of things at once, you will not be able to determine what is affecting the change. So always better to change one variable at a time.
Hope that helps!
Also kind of cool I got my feet scanned at Fleet Feet in the link above. I think some of the problem is I have been wearing size 10s which are too small for my feet and could possibly be the source of why it is aggravated on the downhill.
Looking at the scan I can’t tell if my right foot is beginning to pronate or if it is just swollen. Do you have any suggestions? How can I build my right arch to be stronger?
Very interesting. Thanks for sharing. Building the muscles that support the arch is important and I have information on that in the Resilient Runner Program as well as in my articles on plantar fasciitis. But there are often structural components that affect this and the strength of the hip (especially the external rotators of the hip) are an integral part in managing how the foot interacts with the ground.
Also you have to remember that the longer you are running, the more your foot will swell and so this compounds the issue of a too small shoe. I would start with a larger shoe with some motion control and see how you fair as you proceed with the rehabilitation exercises. Best of Luck!
Here is the link to the Resilient Runner program:
Hello and good evening Sir,
This may sound silly but I was sitting at my office computer and turned fast while wearing low cut shoes and right below my ankle slammed into the metal leg holding the swivel rollers. It was very painful and hurt for a few minutes then sudsided. The next day my foot from the ankle down became numb and has been in and out of the tingling warmth sensation. Could this incident bring about TTS?
33yr old male
Sorry to hear about that. Yes…Direct trauma can cause this to occur. Typically as the area heals and the swelling reduces, the symptoms will go away.
Thank you so much for taking the time out of your day to respond. I will keep an eye on the area. Thanks again!
Hi Dr. Shatto,
Over three years ago, I was tackled in soccer as I was about to kick the ball, and his studs made contact with my navicular bone. Even after weekly physio sessions since the beginning, I am still in physical discomfort every day. This summer, I was even put in a walking boot for 8 weeks (so the bone should be healed), but I am still in pain. My injured foot has a high arch, whereas my non-injured foot is relatively flatter. I’ve been wearing insoles since my injury, but I’d like to get rid of them because I don’t want to be reliant on orthotics. Right now, I’m working on naturally increasing my foot strength. What do you think I should do next? After three years, it appears that nothing will help me, despite the fact that I have tried everything.
*Additional information* My x-rays and MRI both showed that my foot was fine. I saw a dozen doctors and surgeons, and they all said the same thing: the foot is fine and there is nothing to be concerned about. But I’m still in pain; could this be a neurological injury?
I’m sorry to hear about this. Yes, it could be a neurologic injury, but typically there will be pain in other areas, not specifically over a bone and nowhere else. You may try placing a small “button” (like 1 mm to 1.5 mm thick) under the bone. It should not be too high, but high enough to feel it. See if providing extra support just to that location helps some. I have used this trick many times, BUT only if you have normal sensation in your feet. And start for only small amounts of time and build up to it. Also though it’s a “button” type shape, I used typically a small piece of gauze and tape it in place. I sure hope this make sense. I don’t have a YouTube video on this yet, but sounds like I should. You could try Googling “Navicular Button” or “Navicular Support” All the best!
Dear Dr Shatto
I was diagnosed with tts about 2 years ago by a physiotherapist.
My symptoms are not painful, my left foot feels wet, from halfway down the calf and I have a slight ache in the ankle. I’ve also developed flat feet over the years.
I used to do running for a few years regularly but no longer do, I do bootcamp style training through the summer months and have a semi regular yoga practice. I also like to do park runs in the summer but my local park run is on a hard surface.
My physio said my yoga would help and gave me a few exercises to do but I was lead to believe that there was nothing more that could be done and that it would steadily get worse until I’d need an operation.
After reading your article, it seems that there’s much more that could be done to help it, I will look into getting some orthotics but can you give me any more advice please?
Tarsal tunnel, like many lower leg injuries, are multifactorial. So you can’t just treat the injury site, but have to look from the spine down. Address any asymmetries or muscle imbalances. Particularly, look at hip external rotation strength. Since it is a chronic issue, it will take time to resolve, but it can. You just have to give the body the opportunity to improve by eliminating the factors causing the issues. Best of luck!
Hello Dr. Shatto,
My primary care physician suggested I might have TTS when I described an odd numb sensation on my very lower calf just above the ankle. I was having some foot tingling at the time, but do not anymore. I just have this spot on my lower calf that feels odd. It showed up after a run on pavement after not running for quite some time. At first I noticed it in the shower as it felt sensitive to the heat. That sensitivity is gone now but the spot just feels odd and tight. I notice it more when I wear shorts. If I have on tight spandex exercise pants I don’t feel it.
What do you recommend? Do you think the tibial flossing might help? I haven’t run since but I do walk multiple miles each day for exercise. I notice it less when I rest from exercising a day or two, but I’d like to keep up my routine and eventually add back in some more aerobic stuff.
Yes, I think flossing is a good option. It definitely won’t hurt you. You may also try a different kind of shoe. Your local running store can help find the right fit. Also, if compression is helpful you may look up kinesiotaping options on YouTube for Tarsal tunnel. You are likely to find benefit with that as well. All the best!
First, thank you for posting this info. It seems like most everything I read indicates that most people do not recover from this with conservative treatment. And that surgery is iffy when it comes to outcomes. My question is, have you ever worked with a person who actually had this go away via the use of conservative treatment modalities?
Hi Ben – This is the most helpful thing I’ve found regarding TTS on the internet – thank you! I’m not sure if you’re still responding to this threat, but just in case…
I’ve been dealing with what I THOUGHT was plantar fasciitis for nearly a year in my left foot. After a round of PT, it seems it’s more likely PPT – an X-ray also revealed a bone spur in my heel. I’m an active person, a Pilates Instructor, and a runner. I’m fairly certain increasing my running mileage is what initially caused this pain to start. PT exercises didn’t really help me but I’m very hopeful to avoid potential surgeries. Do you know of any successes of treating TTS with myofascial work? Or any other therapies I should consider?
Is it best to stop running completely while this heals?
Thanks so much
whoops, not “PPT” but “TTS” — long day 😉
Hi Ben, some months ago l did a toe flex raise and felt a pull near my third right toe. I stopped doing the exercise but the next day when l went for a walk l started to feel a sharp intermittent pain on the mid bridge of my foot which continues ever since. Then about a week ago l started to develop pain in my arch and big toe now it feels a band of muscle from heel to the ball of the foot has gone tight especially where the big toe is aswell as the arch seems tight too. I saw a physio on Tuesday but really he did not say what it was so l declined exercise without a diagnosis. He did say to rotate the foot and flex daily which l have been doing daily. I do have flat feet and he has referred me to orthotics any ideas what it might be.?