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EMERGENCY:Burning across the whole sole that worsens after prolonged standing is NOT typical plantar fasciitis — it is more likely tarsal tunnel syndrome. —call040-46324365immediately — 24 hours, 7 days— 24/7

PERIPHERAL NERVE DISORDERS

Tarsal Tunnel Syndrome in Hyderabad: The Burning Sole of the Foot That Gets Worse After a Day on Your Feet — Nerve Compression Behind the Ankle, Diagnosed and Treated at KIMS

Expert plantar nerve NCS, MRI ankle with dedicated tarsal tunnel sequences, high-resolution PTN ultrasound, weight-bearing foot X-ray and gait analysis, custom orthotic arch supports for pes planus, activity modification, NSAIDs, ultrasound-guided perineural corticosteroid injection, and tarsal tunnel decompression with neurolysis at KIMS Neuroscience, Secunderabad, Hyderabad.

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TTS is entrapment of the posterior tibial nerve (PTN) within the tarsal tunnel — a fibro-osseous space behind and below the medial malleolus, bounded by the flexor retinaculum. The PTN divides into the medial plantar nerve (sole medial 3.5 toes), lateral plantar nerve (sole lateral 1.5 toes), and medial calcaneal nerve (heel pad). Compression produces burning, tingling, and numbness on the SOLE OF THE FOOT (not the dorsum), worsened by prolonged standing. The most common confusion: plantar fasciitis. The distinction: TTS = burning across the ENTIRE SOLE worsening with prolonged standing; plantar fasciitis = HEEL pain worst in the FIRST STEPS OF THE MORNING, improving with walking. Tinel's sign at the medial malleolus = most useful examination finding. Causes in India: pes planus (most common), post-traumatic (after calcaneal fracture), diabetes (double crush), space-occupying lesions (ganglion, lipoma). NCS of the medial and lateral plantar nerves is the diagnostic gold standard.

TTS vs plantar fasciitis — the critical distinction: Plantar fasciitis: HEEL pain, worst in FIRST STEPS OF THE MORNING, IMPROVES with walking, Tinel's at calcaneal tubercle. TTS: BURNING across the ENTIRE SOLE, worsens with PROLONGED STANDING, IMPROVES with REST, Tinel's behind the MEDIAL MALLEOLUS. Different nerve, different treatment.
Tinel's at the tarsal tunnel — the key finding: Firm percussion over the PTN just posterior and inferior to the medial malleolus reproduces burning and tingling radiating into the sole and toes. The most diagnostically useful physical examination finding for TTS.
Plantar nerve NCS — the specific test: At KIMS, NCS of the medial and lateral plantar nerve branches (sensory and motor) is the electrodiagnostic gold standard for TTS. Standard sural nerve NCS (used for diabetic neuropathy) does NOT assess the tarsal tunnel. Plantar nerve latencies (medial >3.7 ms, lateral >4.0 ms) confirm TTS.
Pes planus — India-specific cause: Flat feet (pes planus) increase stretch on the PTN as it courses around the medial ankle. Very common in India. Custom arch support orthotics (correcting pes planus) are the first conservative intervention at KIMS.
Post-traumatic TTS after calcaneal fracture: The calcaneus forms the LATERAL WALL of the tarsal tunnel. A displaced calcaneal fracture, haematoma, or subsequent fibrosis can directly compress the PTN. Any patient with burning foot after calcaneal fracture: TTS assessment at KIMS.
Structural causes: Ganglion cyst within the tunnel (MRI ankle) = best surgical outcome after excision · Lipoma · Varicosities · Anomalous muscle · Flexor hallucis longus tenosynovitis narrowing the tunnel
Conservative vs surgery: Custom orthotics for pes planus · Ultrasound-guided corticosteroid injection (60–70% relief, 3–6 months) · Tarsal tunnel decompression: ~80% significant improvement · Best outcomes with clear structural cause (ganglion) or short duration

Fact	Details
Definition	PTN entrapment under flexor retinaculum (laciniate ligament) posterior to the medial malleolus · Medial + lateral plantar + medial calcaneal nerve compression
TTS vs plantar fasciitis	TTS: burning entire sole, worsens prolonged standing, Tinel's at medial malleolus · PF: heel pain, worst first morning steps, improves walking, tender calcaneal tubercle
India causes	Pes planus (most common) · Post-traumatic (calcaneal fracture) · Ganglion cyst · Diabetes (double crush: lower entrapment threshold) · Hypothyroidism (fluid retention)
NCS	Medial plantar sensory latency >3.7 ms · Lateral plantar sensory latency >4.0 ms · Compare with sural nerve (which does NOT traverse the tarsal tunnel) · MRI ankle for structural cause
Tinel sign	Behind medial malleolus (NOT at heel) · Most diagnostically useful physical sign for TTS
Intrinsic foot muscle weakness	Abductor hallucis weakness + hammer-toe = significant axon loss · Indication for surgery over continued conservative management
Surgical outcome	~80% significant improvement · Best outcomes: structural cause (ganglion excision) or short duration · Post-traumatic neurolysis: more variable

About This Condition

Tarsal Tunnel Syndrome at a Glance

The essential facts that shape how tarsal tunnel syndrome is recognised at KIMS — the anatomy of the fibro-osseous tunnel behind the medial malleolus, what the posterior tibial nerve and its three terminal branches control, the India-specific causes (pes planus, post-traumatic, ganglion cyst, diabetes), and how TTS is distinguished from plantar fasciitis.

What it is

Tarsal tunnel syndrome (TTS) is entrapment of the posterior tibial nerve (PTN) and its terminal branches — the medial plantar nerve, lateral plantar nerve, and medial calcaneal nerve — within the tarsal tunnel. The tarsal tunnel is a fibro-osseous space behind and below the medial malleolus, bounded medially by the flexor retinaculum (laciniate ligament) and laterally by the medial surface of the calcaneus. The posterior tibial nerve, posterior tibial artery, and four tendons (tibialis posterior, flexor digitorum longus, flexor hallucis longus) all pass through this tunnel.

What the posterior tibial nerve controls

The PTN supplies: medial plantar nerve — sensory to the medial sole and plantar surface of the medial 3.5 toes; motor to the abductor hallucis, flexor hallucis brevis, flexor digitorum brevis, and medial two lumbricals. Lateral plantar nerve — sensory to the lateral sole and plantar surface of the lateral 1.5 toes; motor to the abductor digiti minimi, interossei, lateral two lumbricals, adductor hallucis, and flexor digiti minimi. Medial calcaneal nerve — sensory to the heel pad (medial heel). PTN compression affects these sensory territories and, in severe cases, produces intrinsic foot muscle weakness and toe clawing.

Common causes in India

Pes planus (flat feet): the most common underlying structural factor in India. Flat foot reduces the height of the medial arch, increasing the volume in the tarsal tunnel and stretching the PTN across the medial ankle. Post-traumatic: swelling and fibrosis after ankle fracture, sprain, or calcaneal fracture. Space-occupying lesions within the tarsal tunnel: ganglion cyst (most common), lipoma, varicosities of the posterior tibial vein, anomalous muscle. Generalised conditions: diabetes mellitus (which lowers the threshold for entrapment neuropathy); hypothyroidism (fluid retention); and rheumatoid arthritis (tenosynovitis narrowing the tunnel).

TTS vs plantar fasciitis — the most common confusion

Tarsal tunnel syndrome and plantar fasciitis both produce heel and foot pain and are frequently confused. Key distinction: plantar fasciitis produces pain at the heel (specifically the plantar heel, worst in the first steps of the morning, relieved by walking, and reproduced by palpation of the medial calcaneal tubercle). Tarsal tunnel syndrome produces burning, tingling, and numbness on the sole of the foot (the sensory pattern of the plantar nerves), a positive Tinel's sign behind the medial malleolus (not at the heel pad), and symptoms that worsen with prolonged standing and improve with rest.

Appointment

040-44885000

About This Condition

The Shop Worker Whose Feet Were on Fire

A 44-year-old supermarket floor worker in Hyderabad attends KIMS with a 16-month history of burning and tingling in the soles of both feet, worse on the right. The symptoms appear after approximately 2–3 hours of standing and walking at work, build progressively through the day, and are severe enough by the end of her shift that she removes her shoes immediately on arriving home and soaks her feet in cold water. The symptoms improve after sitting down for 30 minutes. At night, she has occasional tingling that wakes her, but the nocturnal symptoms are much less prominent than the positional ones. She has been told she has plantar fasciitis and has been on physiotherapy for 6 months with no improvement.

At KIMS, the examination: Tinel's sign positive at the right tarsal tunnel (behind and just below the medial malleolus) — percussion here reproduces burning tingling that radiates into the sole and toes. Foot inspection: bilateral flat feet (pes planus, grade II on the right). Sensory testing: reduced light touch on the plantar surfaces of the right foot, particularly the medial sole. Normal dorsal foot sensation (sural nerve territory — not affected by tarsal tunnel compression). Motor examination: mild weakness of the abductor hallucis (right toe abduction slightly reduced). No intrinsic wasting.

NCS at KIMS: medial plantar nerve sensory latency 4.8 ms (normal <3.7 ms); lateral plantar nerve sensory latency 5.1 ms (normal <4.0 ms). Motor latencies of the medial and lateral plantar nerves to the abductor hallucis and abductor digiti minimi: mildly prolonged. MRI right ankle: no ganglion or space-occupying lesion within the tarsal tunnel; mild tenosynovitis of the flexor hallucis longus tendon; the PTN appears mildly oedematous at the tarsal tunnel level. Ultrasound: right PTN CSA 11 mm² at the tarsal tunnel (mildly swollen).

Management at KIMS: custom orthotic arch supports (prescribed via orthotics service) to correct the pes planus and reduce the stretch on the PTN. Anti-inflammatory medication for 4 weeks. At 6-week review: 50% improvement — she can complete a 6-hour shift before symptoms become significant. At 3-month review: ongoing improvement but still unable to complete full 8-hour shifts without significant symptoms. Corticosteroid injection into the tarsal tunnel (not into the nerve) is performed at KIMS. Significant additional relief at 6 weeks post-injection. She continues with orthotics and completes full shifts. Surgical tarsal tunnel decompression discussed if symptoms recur or worsen.

Book a Consultation

Speak directly with The KIMS Neuroscience team and the KIMS tarsal tunnel specialist team — neurosurgery, foot and ankle surgery, clinical neurophysiology (NCS/EMG), neuroradiology, ultrasound-guided injections, orthotics and gait analysis, and physiotherapy coordinated under one roof. No referral required. Monday to Saturday.

040-44885000Emergency line: 040-46324365

Recognising Tarsal Tunnel Syndrome

Clinical Features

The four pillars of clinical recognition at KIMS — burning and tingling on the plantar surface, positional and activity-related worsening with prolonged standing, Tinel's sign behind the medial malleolus as the single most useful examination finding, and the intrinsic foot muscle weakness that flags advanced disease.

Burning and tingling on the plantar surface — the cardinal symptom

The sensory symptoms of TTS are felt on the sole of the foot and the plantar surfaces of the toes — in the territory of the medial and lateral plantar nerves. The quality is typically burning, electric, or tingling — neuropathic in character. The medial plantar nerve territory (medial sole, medial 3.5 toes) is more commonly affected than the lateral plantar territory. Heel tingling (from the medial calcaneal nerve) can coexist. The dorsum of the foot and the heel pad proper (if from the calcaneal branch given off before the tunnel) may be spared, helping to localise the compression.

Positional and activity-related worsening

TTS symptoms classically worsen with prolonged standing and walking (which increases venous engorgement and pressure within the tarsal tunnel) and improve with rest. This positional pattern distinguishes TTS from peripheral neuropathy (which is constant and symmetric). Shoes that are tight around the ankle may aggravate TTS by adding external pressure over the tarsal tunnel. Removal of footwear at the end of the day, elevation of the foot, and rest produce relief. Night symptoms, when present, occur from positional pressure on the medial ankle during sleep.

Tinel's sign at the tarsal tunnel — the key examination finding

Tinel's sign at the tarsal tunnel is elicited by firm percussion with a reflex hammer or finger over the posterior tibial nerve just posterior and inferior to the medial malleolus. A positive Tinel's reproduces burning or tingling radiating into the sole and toes (distal Tinel's) and may also radiate proximally up the calf (proximal Tinel's). A positive Tinel's at this site is the single most diagnostically useful physical examination finding for TTS.

Intrinsic foot muscle weakness — a sign of severity

The intrinsic foot muscles (abductor hallucis, flexor hallucis brevis, interossei) are supplied by the plantar nerves. In severe or longstanding TTS, weakness of these muscles produces reduced great toe abduction strength and, ultimately, hammer-toe deformity (from loss of intrinsic muscle balance). Intrinsic weakness is an indicator of significant motor axon loss and is an argument for surgical decompression rather than continued conservative management.

Diagnosis at KIMS

Tarsal tunnel syndrome is diagnosed at KIMS with a structured workflow that combines electrophysiology, cross-sectional imaging, dynamic ultrasound, and weight-bearing foot biomechanics :

Nerve conduction studies — plantar nerve latencies

NCS of the medial and lateral plantar nerves (sensory and motor branches) is the electrophysiological gold standard. Prolonged sensory latency across the tarsal tunnel, slowed motor distal latency to the abductor hallucis (medial plantar) and abductor digiti minimi (lateral plantar), and reduced amplitudes (indicating axon loss) confirm TTS. The comparison with the asymptomatic side and with sural nerve conduction (which does not traverse the tarsal tunnel) helps localise the compression.

MRI ankle — structural cause identification

MRI of the ankle with dedicated tarsal tunnel sequences identifies space-occupying lesions (ganglion cyst, lipoma, varicosities, anomalous muscle) within the tunnel that require specific surgical attention. MRI also assesses tendon pathology (particularly flexor hallucis longus tenosynovitis, which can narrow the tunnel and contribute to PTN compression), bony abnormalities, and post-traumatic scarring.

Ultrasound — dynamic nerve assessment

High-resolution ultrasound of the PTN at the tarsal tunnel measures the nerve CSA (>10–12 mm² is abnormal), identifies dynamic compression (compression worsening with ankle eversion or dorsiflexion), and guides corticosteroid injection to the perineural space under direct ultrasound visualisation.

Foot X-ray and gait analysis

Weight-bearing foot X-ray assesses the degree of pes planus (Meary's angle, calcaneal pitch) that contributes to dynamic PTN stretch. Gait analysis (at KIMS or orthotics clinic) guides custom orthotic prescription.

Treatment

Treatment at KIMS

The KIMS tarsal tunnel syndrome programme is built around four integrated management areas — custom orthotic arch support for pes planus, activity modification with NSAID support for tenosynovitic exacerbations, ultrasound-guided perineural corticosteroid injection, and tarsal tunnel decompression with neurolysis when conservative measures fail or a space-occupying lesion is identified.

Four Integrated Management Areas

Conservative Treatment

Custom Orthotics — Medial Arch Support: Addresses the underlying pes planus by correcting the foot posture and reducing the dynamic stretch on the PTN. Custom orthotics prescribed after podiatric or orthopaedic assessment. Off-the-shelf arch supports provide partial benefit while custom orthotics are being made.

Activity modification: Reduce prolonged standing; use anti-fatigue mats at the workplace; elevate the foot during rest; avoid constrictive ankle footwear.

NSAID anti-inflammatory medication: Short course for acute exacerbations associated with tenosynovitis.

Corticosteroid injection: Ultrasound-guided injection of methylprednisolone or triamcinolone into the perineural space at the tarsal tunnel. Provides significant symptom relief in approximately 60–70% of patients for 3–6 months. Useful as a diagnostic test (if injection produces complete temporary relief, this confirms TTS) and as a bridge to surgery or longer-term orthotics.

Tarsal Tunnel Decompression Surgery: Indicated for: TTS failing 3–6 months of conservative treatment; space-occupying lesion within the tunnel requiring excision; significant NCS amplitude reduction indicating axon loss; intrinsic foot muscle weakness. At KIMS, tarsal tunnel decompression is performed under general or regional anaesthesia (spinal or ankle block): the flexor retinaculum is divided along the full length of the tarsal tunnel; the medial and lateral plantar nerve branches are individually traced and any intraneural or perineural fibrosis released; space-occupying lesions are excised. Duration: 45–60 minutes. Return to light activity: 3–4 weeks. Outcomes: approximately 80% of patients achieve significant symptom improvement. Best outcomes in patients with a clear structural cause within the tunnel (ganglion) or a short symptom duration.

Related Conditions

Tarsal tunnel syndrome belongs to the family of peripheral nerve disorders evaluated and managed at KIMS Neuroscience. Explore related peripheral nerve conditions or return to the peripheral nerve disorders hub.

Carpal Tunnel Syndrome Meralgia Paresthetica

FAQs

Frequently Asked Questions

The distinction between plantar fasciitis and tarsal tunnel syndrome is important because the treatment is completely different. Plantar fasciitis: pain specifically at the plantar heel, worst in the first steps of the morning, provoked by pressure on the medial calcaneal tubercle, and typically improves with walking (as the fascia warms up). Tarsal tunnel syndrome: burning and tingling on the entire sole (not just the heel), worsening with prolonged standing, and a positive Tinel's sign behind the medial malleolus. If your symptoms are burning across the whole sole, are worst after hours of standing (not worst in the morning), and include tingling in the toes — TTS is the more likely diagnosis. At KIMS, NCS of the plantar nerves and Tinel's sign examination distinguish the two within a single consultation. Call 040-44885000.

This is one of the most common and clinically important distinctions in foot neurology. Diabetic peripheral neuropathy (DPN): produces symmetric burning and tingling in both feet in a "stocking distribution" (ankles and below, both sides equally); the severity does not change significantly with standing or rest; and NCS shows generalised slowing of all nerves in the legs. Tarsal tunnel syndrome: symptoms are asymmetric (one side more than the other or one side only); the symptoms are markedly position-related (worse with standing, better with rest); and NCS shows localised slowing of the plantar nerves across the tarsal tunnel, with relatively preserved sural nerve conduction. At KIMS, NCS of the plantar nerves compared with the sural nerve (which does not pass through the tarsal tunnel) helps distinguish local entrapment from generalised neuropathy. The two can coexist: diabetes lowers the threshold for entrapment, making TTS more common in diabetics. Call 040-44885000.

A ganglion cyst within the tarsal tunnel that is compressing the posterior tibial nerve and producing symptoms (burning, tingling in the sole, positive Tinel's, and NCS abnormality) is a structural cause of TTS that is best treated surgically. Unlike idiopathic TTS (where conservative treatment is tried first), a space-occupying lesion within the tunnel that can be excised directly is a more specific indication for surgical decompression and ganglion excision. The outcomes of surgery for TTS with a ganglion are better than for TTS without a structural cause — because the cause is definitively removed. Conservative treatment (injection, orthotics) is unlikely to resolve a mechanical compression from a cyst within a rigid fibro-osseous tunnel. At KIMS, tarsal tunnel decompression with ganglion excision is a definitive treatment in this situation. Call 040-44885000.

Yes — post-traumatic tarsal tunnel syndrome after calcaneal (heel bone) fracture is well-documented. The calcaneus forms the lateral wall of the tarsal tunnel; a fracture with displacement, haematoma, or subsequent fibrosis can directly compress or tether the posterior tibial nerve within the tunnel. The burning and tingling you describe beginning after the fracture, in a distribution consistent with PTN compression (sole of the foot, plantar toes), with a positive Tinel's behind the medial malleolus, is strongly suggestive of post-traumatic TTS. MRI ankle at KIMS assesses the degree of perineural fibrosis and whether a malunited fracture fragment is contributing to compression. When fibrosis is the primary cause, tarsal tunnel neurolysis (releasing the nerve from surrounding scar tissue) is the surgical treatment, though outcomes for post-traumatic TTS are more variable than for primary entrapment. Call 040-44885000.

The burning sole after a day on your feet. The tingling that starts at the ankle and spreads into the toes. The flat feet that have always been there but the burning that started 2 years ago.

Tarsal tunnel syndrome is confirmed with plantar nerve NCS at KIMS Neuroscience, Secunderabad, Hyderabad and treated with orthotics, injection, or surgical decompression. Call 040-44885000.

040-44885000

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