The treatment of tarsal tunnel syndrome focuses on relieving pressure around the posterior tibial nerve while addressing the underlying cause of the compression. Unlike plantar fasciosis, where treatment targets a degenerative ligament, tarsal tunnel syndrome is a nerve compression disorder. Successful management therefore depends on reducing irritation of the nerve rather than simply treating pain.
The first step is identifying why the nerve has become compressed. In some patients, the cause is excessive pronation or flat feet, while others may have a ganglion cyst, scar tissue following an ankle injury, tendon inflammation or swelling within the tarsal tunnel. Treatment is most successful when it addresses the underlying cause rather than simply reducing symptoms.
Activity modification is often recommended during the early stages of treatment. Activities that repeatedly aggravate the nerve, such as prolonged standing, long walks or high-impact exercise, may need to be temporarily reduced while the irritation settles. This does not mean complete rest, but rather modifying activity so that symptoms gradually improve instead of progressively worsening.
Footwear can have a significant influence on symptoms. Tight-fitting shoes or footwear that places pressure around the inside of the ankle may increase nerve compression. Many patients benefit from well-fitting shoes that provide appropriate support, adequate toe-box width and good overall stability. Footwear recommendations should always be individualised according to the patient's foot structure and biomechanics.
Orthotic therapy may be helpful for selected patients, particularly when excessive pronation contributes to increased tension around the posterior tibial nerve. By improving foot alignment and reducing abnormal mechanical stress, orthoses may decrease irritation of the nerve during walking. However, orthotics are not appropriate for every patient and should be prescribed only after a comprehensive biomechanical assessment.
Physiotherapy and rehabilitation also play an important role. Treatment may include exercises to improve ankle mobility, strengthen the muscles supporting the foot and lower limb and optimise walking mechanics. In some cases, carefully supervised nerve gliding exercises may help improve mobility of the posterior tibial nerve, although these should be introduced cautiously because overly aggressive stretching may temporarily increase symptoms.
When inflammation around the nerve contributes to compression, carefully selected patients may benefit from an ultrasound-guided injection. Performing the injection under ultrasound guidance allows the medication to be accurately placed around the nerve while avoiding nearby blood vessels and tendons. Depending on the clinical situation, the injection may be used to reduce inflammation, confirm the diagnosis or both. The decision to perform an injection should always follow a thorough clinical assessment rather than being used as a routine treatment.
If an identifiable space-occupying lesion such as a ganglion cyst is compressing the nerve, treatment may be directed specifically at that abnormality. In some situations, aspiration, injection or surgical removal may be considered depending on the nature of the lesion and the patient's symptoms.
Patients with diabetes require particular attention. If diabetic peripheral neuropathy is present, treatment focuses primarily on optimising blood glucose control and managing the underlying neuropathy. However, diabetes does not prevent someone from also developing tarsal tunnel syndrome, and focal nerve compression should still be assessed and treated when appropriate.
Most patients improve with appropriate conservative treatment. Symptoms often settle gradually over weeks or months as pressure on the nerve decreases. Early treatment generally produces better outcomes than waiting until longstanding nerve compression has caused persistent neurological symptoms.
Surgery is reserved for patients whose symptoms remain significant despite well-conducted non-surgical treatment or when a specific structural lesion is compressing the nerve. The operation aims to decompress the posterior tibial nerve by releasing the flexor retinaculum and removing any structures contributing to the compression. Surgical treatment is discussed in more detail in a later section of this chapter.
The key to successful treatment is recognising that tarsal tunnel syndrome is rarely just a painful nerve. It is usually the result of an underlying mechanical or structural problem that has increased pressure within the tarsal tunnel. Identifying and correcting that cause provides the greatest opportunity for long-term improvement.