Key Takeaways
- Tarsal tunnel syndrome is compression of the tibial nerve beneath the flexor retinaculum at the inner ankle, producing burning heel and arch pain rather than the sharp first-step pain of plantar fasciitis.
- Tarsal tunnel pain typically worsens through the day, with activity, and at night, while plantar fasciitis pain peaks with the first steps out of bed and eases as you keep walking.
- A positive Tinel's sign — tapping behind the inner ankle bone reproduces shooting pain into the foot — is the most useful physical exam finding and the strongest predictor of surgical success.
- Nerve conduction studies support the diagnosis but do not make it: roughly half of asymptomatic adults over age 45 show abnormal distal tarsal tunnel electrodiagnostics.
- Surgical tarsal tunnel release relieves symptoms in 44% to 96% of patients, with the best outcomes in younger patients who have a clear structural cause and a short duration of symptoms.
A Bruised Heel, a New Cleat, and a Diagnosis Worth Double-Checking
On July 27, 2026, the Detroit Tigers placed outfielder Kerry Carpenter on the 10-day injured list with plantar fasciitis in his left foot. The Detroit News reported that Carpenter had been playing on a bruised heel for roughly two weeks before he left a game early, and that the bruise traced back to a molded spike on a new pair of cleats that sat directly under his heel. The manufacturer has since modified the design.
That diagnosis is almost certainly correct, and I have no involvement in his care. But the shape of that story — weeks of heel pain, a change in footwear, a bruise that would not settle — is exactly the scenario in which a second diagnosis hides behind the first. In my practice, the condition most often missed in stubborn heel pain is tarsal tunnel syndrome: compression of the tibial nerve as it passes behind the inner ankle.
Short answer: Tarsal tunnel syndrome is compression of the tibial nerve where it passes behind the bump on the inside of your ankle. It causes burning, tingling, or numbness in the heel and arch. Unlike plantar fasciitis, the pain often worsens at night and with activity, and it requires nerve-directed treatment rather than arch support alone.
The Science: A Nerve in a Tight Space
The tarsal tunnel is a fibro-osseous corridor on the inside of the ankle, roofed by a band of connective tissue called the flexor retinaculum. Running through it are the posterior tibial artery, vein, tendon, and — the structure that causes trouble — the tibial nerve. Inside or just past the tunnel, that nerve splits into the medial plantar nerve, the lateral plantar nerve, and the medial calcaneal branches.
One of those branches deserves its own name. The first branch of the lateral plantar nerve, known as Baxter's nerve, turns sharply and threads between two muscles before reaching the heel. Entrapment of Baxter's nerve is the most common neurological cause of chronic heel pain, and it is routinely mistaken for plantar fasciitis because it hurts in the same place. On MRI, fatty atrophy of the abductor digiti minimi muscle is an indirect sign that Baxter's nerve has been compressed for some time.
Anything that reduces space in a tunnel that has no room to spare can compress the nerve. In roughly two-thirds of cases we find an identifiable cause: a ganglion cyst, dilated veins, an accessory muscle, tenosynovitis of the adjacent tendons, scar tissue from an old ankle fracture, or a bone spur. A collapsing flatfoot also matters. When the heel drifts into valgus, the tibial nerve is stretched around the inside of the ankle, and traction alone can reproduce symptoms.
The symptom pattern is what separates it from plantar fasciitis. Plantar fasciitis is mechanical: sharp, localized heel pain with the first steps in the morning that eases within a few minutes of walking. Tarsal tunnel syndrome is neurologic: burning, electric, or pins-and-needles pain that spreads into the arch and toes, worsens as the day goes on, and frequently wakes patients at night. Patients describe it as a hot band or a sock they cannot take off.
On exam, the single most valuable test costs nothing. Tapping over the nerve behind the medial malleolus — the Tinel's sign — should reproduce shooting pain or tingling down into the foot. A positive Tinel's sign before surgery is the strongest published predictor that decompression will help. Electrodiagnostic testing is useful confirmation but cannot stand alone, because about half of asymptomatic adults over 45 have abnormal distal tarsal tunnel studies. This is a diagnosis made with your hands and confirmed with a machine, not the other way around.
The Solution at P.O.W.
We start by separating the two diagnoses rather than assuming one. That means a focused nerve exam, a Tinel's test, sensory mapping of the heel and arch, and an honest look at foot alignment while you stand. Weight-bearing CT scanning at our Monroeville office lets us see how your hindfoot actually loads under body weight, which is the only way to judge whether a valgus heel is putting the nerve on stretch. MRI and high-resolution ultrasound identify space-occupying lesions and muscle atrophy patterns.
Most patients improve without surgery. Non-operative care targets the nerve directly: activity and footwear modification, an orthosis or brace that corrects hindfoot valgus and takes the nerve off tension, and a structured rehabilitation program. At POW PT, Dr. Josh Lombardi, DPT, CSCS, uses tibial nerve glides, soft-tissue work along the flexor retinaculum, and progressive intrinsic foot and posterior tibialis strengthening to restore both nerve mobility and the arch support that protects it. A diagnostic injection around the nerve can confirm the source of pain when the picture is mixed.
When symptoms persist despite good conservative care — particularly with a clear structural cause and a positive Tinel's sign — surgical tarsal tunnel release is appropriate. The procedure divides the flexor retinaculum and frees the tight fascial bands around each branch, including Baxter's nerve when it is involved. Published success rates range from 44% to 96%. That spread is not random. The best results come from correct patient selection: younger patients, an identifiable cause, a positive Tinel's sign, a short symptom history, and no prior ankle pathology. When a flatfoot is driving the traction, correcting the alignment at the same time matters more than the release itself.
For patients whose heel pain really is plantar fasciitis, our approach is different and equally deliberate — which is precisely why getting the diagnosis right in the first visit changes everything that follows.
Frequently Asked Questions
How do I know if my heel pain is plantar fasciitis or a pinched nerve?
Timing and quality of the pain are the best clues. Plantar fasciitis causes sharp, localized heel pain with your first steps in the morning that improves after a few minutes of walking. Tarsal tunnel syndrome causes burning, tingling, or numbness that spreads into the arch and toes, gets worse as the day goes on, and often wakes you at night. Numbness of any kind points toward nerve involvement.
What does tarsal tunnel syndrome feel like?
Most patients describe burning or electric pain along the inside of the ankle that radiates into the heel, arch, and sometimes the toes. Some report tingling, a pins-and-needles sensation, or a feeling of wearing a tight sock. Symptoms typically worsen with prolonged standing, walking, or running and can be severe enough at night to disrupt sleep.
Does tarsal tunnel syndrome go away on its own?
Mild cases triggered by a temporary factor — a swollen ankle after a sprain, poorly fitting footwear, or a sudden training spike — can settle once that factor is removed. Symptoms caused by a structural problem such as a ganglion cyst, varicose veins, or a collapsing flatfoot rarely resolve without treatment. Persistent numbness lasting more than six weeks warrants an evaluation.
What test confirms tarsal tunnel syndrome?
There is no single confirmatory test. Diagnosis rests on the clinical exam, especially a positive Tinel's sign behind the inner ankle bone. Nerve conduction studies and EMG provide support, and MRI or ultrasound identifies compressing lesions. Because about half of asymptomatic adults over 45 have abnormal electrodiagnostic findings, results must always be matched to your symptoms and exam.
How long is recovery after tarsal tunnel release surgery?
Most patients are in a protective boot or splint for two to three weeks while the incision heals, then begin progressive weight-bearing and physical therapy. Burning pain often improves within weeks, but numbness can take several months to recover because nerves regenerate slowly. Return to running or field sports is typically planned around three to four months, guided by symptoms and strength testing.
Can flat feet cause tarsal tunnel syndrome?
Yes. When the arch collapses and the heel tilts outward into valgus, the tibial nerve is stretched around the inside of the ankle. That traction alone can produce tarsal tunnel symptoms without any cyst or mass. This is why correcting alignment with an orthosis, a brace, or in some cases a reconstructive procedure is often more effective than releasing the nerve by itself.
Schedule an Evaluation
Heel pain that hasn't responded to arch supports, stretching, and time deserves a real nerve exam — not another guess. Dr. Prisk and the team at Prisk Orthopaedics and Wellness evaluate stubborn heel and arch pain with weight-bearing CT, advanced imaging, and a hands-on diagnostic exam. Call (412) 525-7692 or schedule online at orthoandwellness.com.
About the Author
Victor R. Prisk, MD is a board-certified orthopaedic surgeon specializing in foot, ankle, and sports medicine, and the CEO and Medical Director of Prisk Orthopaedics and Wellness, P.C. A former NCAA gymnast and competitive bodybuilder, he brings an athlete's understanding of training and recovery to surgical and non-surgical care. He is the author of The Leucine Factor Diet and directs the performance and rehabilitation programs at P.O.W. and P.O.W.Fit.
