How to Self-Treat Tarsal Tunnel Syndrome

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.
    Obesity.
  • Diabetes.
  • 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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18 Responses to How to Self-Treat Tarsal Tunnel Syndrome

  1. Barish February 16, 2020 at 4:35 am #

    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

    • Ben Shatto February 16, 2020 at 2:04 pm #

      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

      • Barish February 20, 2020 at 11:39 am #

        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.

        • Ben Shatto February 20, 2020 at 10:02 pm #

          Thank you Barish….I wish you a speedy recovery as well.

  2. Steve H February 17, 2020 at 10:27 am #

    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.

  3. Mary February 23, 2020 at 9:31 am #

    Hi Dr,
    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!

    • Ben Shatto February 23, 2020 at 10:25 pm #

      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

  4. Mirza February 24, 2020 at 6:32 am #

    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.

    Thanks

    • Ben Shatto February 24, 2020 at 10:13 pm #

      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

  5. Mirza February 25, 2020 at 6:51 am #

    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…

    Thanks again!

    • Ben Shatto February 25, 2020 at 10:11 pm #

      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!

  6. Britt Sine February 25, 2020 at 4:17 pm #

    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.

    • Ben Shatto February 25, 2020 at 10:09 pm #

      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!

  7. Tony March 7, 2020 at 5:43 am #

    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

    • Ben Shatto March 7, 2020 at 10:02 pm #

      Hi Tony,

      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!

  8. Amani July 9, 2020 at 10:50 am #

    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?

    • Ben Shatto July 9, 2020 at 9:38 pm #

      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

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