FOOT & ANKLE INTERNATIONAL
Copyright  2012 by the American Orthopaedic Foot & Ankle Society
DOI: 10.3113/FAI.2012.0513
Neuroanatomical Basis for the Tarsal Tunnel Syndrome
ABSTRACT
Background: The results of surgical treatment for tarsal tunnel
syndrome have been suboptimal, especially in the absence of
space-occupying lesions. We attribute this to a poor under-
standing of the detailed anatomy of the ‘tarsal tunnel’ and
potential sites of nerve compression. Methods: This study
involved the dissection of 19 cadaveric feet. All findings and
measurements were documented with digital photography and
digital calipers. Results: This study demonstrated three well-
defined, tough fascial septae in the sole of the foot. In addition
to the flexor retinaculum and the abductor hallucis, two of these
septae represented potential sites of compression of the poste-
rior tibial nerve and its branches. The medial plantar nerve
may be entrapped under the medial septum. However, in 16 of
19 feet, the medial plantar nerve did not traverse beneath the
septum. The lateral plantar nerve traversed beneath the medial
septum in all specimens. The nerve to abductor digiti minimi
may be trapped under the medial and intermediate septum.
Conclusion: We detailed the anatomical relationship of the nerve
branches relative to the fibrous septae and found that the medial
plantar nerve did not traverse a septae in all specimens. Clinical
Relevance: We believe better understanding of the anatomical
relationships of the tarsal tunnel and a clear communication
system among anatomists, neuroradiologists and foot and ankle
surgeons will facilitate accurate preoperative localization of the
site of nerve compression possibly leading to better outcomes.
Level of Evidence: IV, Retrospective Case Control Study
Key Words: Tarsal; Tunnel; Nerve; Posterior; Tibial; Plantar
No benefits in any form have been received or will be received from a commercial
party related directly or indirectly to the subject of this article.
Corresponding Author:
Gurpal Singh, MD
University Orthopaedics, Hand and Microsurgery Cluster
National University Health System
1E, Kent Ridge Road
Singapore 119228
E-mail: gurpal singh@nuhs.edu.sg
For information on pricings and availability of reprints, email reprints@datatrace.com
or call 410-494-4994, x232.
513
Gurpal Singh, FRCSEd(Orth) and V. P. Kumar, FRCS
Singapore
INTRODUCTION
Tarsal tunnel syndrome describes a peripheral compres-
sion neuropathy of the posterior tibial nerve (PTN) and its
branches, the medial and lateral plantar nerves (MPN and
LPN respectively). The clinical symptoms are predominantly
sensory and can range from burning sensations, paresthesia,
disturbances in temperature perception to mild loss of sensa-
tion or tingling over the heel and sole of the foot.2,4 In
long-standing cases, there may be weakness of the intrinsic
muscles of the foot and toe contractures may develop.
Various etiologies have been described, including space-
occupying lesions, external compression by osseous promi-
nences, post-traumatic cases, edema, perineural fibrosis,
diabetes, and anomalies of muscle.3,15 A specific cause can
be identified in 60% to 80% of cases.2 The overall results
of surgical decompression with regards to symptom relief
and resolution have been poor especially where no defi-
nite etiology can be identified. In a study of 60 patients
(68 feet) by Gondring et al.,6 only 51% of the patients
had a marked improvement in quality of life after surgical
decompression. Ward and Porter16 reported only 42% satis-
factory outcome in patients with tarsal tunnel syndrome
post-surgery. It has been suggested that a more comprehen-
sive surgical decompression is necessary for more optimal
surgical outcomes.5,12
The traditional operation of tarsal tunnel release involves
division of the flexor retinaculum overlying the PTN behind
the medial malleolus9 and the fascia over the abductor
hallucis (AH).1 Wolf et al.18 and Mullick and Dellon12 more
recently highlighted the need to extend the decompression
into the foot by retracting the AH and releasing the fascia
overlying the MPN and LPN deep in the sole.
In this study we carried out a cadaveric dissection of 19
feet with the aim to demonstrate the detailed anatomical
relationships of the PTN, MPN, and LPN (as well as other
branches) and the three septae discussed above. This study
also attempted to investigate whether there are regional
differences in the course of the PTN, MPN and LPN along
the medial ankle and sole of the foot.
514 SINGH AND KUMAR
MATERIALS AND METHODS
Sixteen fresh-frozen adult human cadaver feet and three
formalin preserved feet were used in this study. The cadav-
eric feet were from six males and four females (in all but
one cadaver, both feet were dissected). The average age
was 63 ± 12 years. The average height of the cadavers
was 1.58 ± 0.19 meters. Preparation of each foot began
with removal of all skin and subcutaneous tissue from the
ankle to the metatarsophalangeal joints. Removal of the
plantar skin and subcutaneous fat exposed the main plantar
aponeurosis and its lateral band (Figure 1). The origins of
the plantar aponeurosis were separated from the calcaneus
and reflected distally. The medial, intermediate and lateral
septae11 of the foot were identified at this stage. These
septae separated the hind/midfoot into three distinct compart-
ments (Figure 2).The medial compartment contained the
abductor hallucis (AH) muscle. The intermediate compart-
ment contained the flexor digitorum brevis (FDB) superfi-
cially and the quadratus plantae (QP) deeply. The lateral
compartment contained the abductor digiti minimi (ADM).
Next, a longitudinal incision was made just posterior to the
medial malleolus and skin flaps were raised. The flexor reti-
naculum was then divided and the PTN and its accompa-
nying artery as well as the venae comitantes were identified
and traced proximally and distally. The vessels were sepa-
rated from the nerve at this stage. Careful dissection of the
PTN led to the identification of its calcaneal branch (CB)
as the latter passed from under the flexor retinaculum into
the subcutaneous tissue. The two terminal branches of the
PTN, the MPN and LPN were then followed into the foot
under the fascia at the origin of the AH and the AH muscle
itself. The overlying AH muscle was then elevated to expose
the nerves and they were followed distally. The MPN was
Fig. 1: Deep dissection of the medial aspect of the ankle and foot, showing
the posterior tibial nerve (PTN), its calcaneal branch (CB), and medial and
lateral plantar nerves (MPN and LPN). Their relationship to the abductor
hallucis (AH) muscle is shown. The nerve to the abductor digiti minimi
(ADM) is also shown.
Copyright  2012 by the American Orthopaedic Foot & Ankle Society
Foot & Ankle International/Vol. 33, No. 6/June 2012
Fig. 2: Deep dissection of the sole of the foot, demonstrating the medial,
intermediate and lateral septae. The intermediate septum is held with forceps.
The flexor digitorum brevis (FDB) muscle is reflected distally. MS, medial
septum; IS, intermediate septum; LS, lateral septum; ADM, abductor digiti
minimi.
then traced and its course studied in relation to the medial
septum (MS) of the foot. The LPN and its branch, the nerve
to the abductor digiti minimi (ADM), were identified and
their courses traced into the sole of the foot. The relation-
ship of these two branches to the medial intermediate and
lateral septae11 of the foot was studied. Measurements of
the points of penetration of the various branches through the
septae were measured from the posterior aspect of the calca-
neus. Three readings were taken for every measurement. The
average distance and standard deviations were recorded. The
course of the long flexor tendons (flexor digitorum longus
and flexor hallucis longus) was traced from behind the medial
malleolus into the sole of the foot. All findings were docu-
mented with digital photography.
RESULTS
All feet had distinct medial and lateral septae. The medial
septum was a dorsal extension from the medial margin of
the main plantar aponeurosis. It separated the AH from the
flexor digitorum brevis (FDB) and the quadratus plantae (QP)
which occupied the intermediate compartment of the hindfoot
(Figure 2). The lateral septum was the dorsal extension of
the lateral margin of the lateral band of the main plantar
aponeurosis. It bordered the ADM laterally. The intermediate
septum was well developed in nine specimens, indistinct in
five, and absent in five specimens (Table 1). The intermediate
septum was a dorsal extension of the lateral margin of the
main plantar aponeurosis and the medial margin of the lateral
band of the main plantar aponeurosis. If present, it separated
the FDB and the QP medially from the ADM laterally
(Figure 2).
Foot & Ankle International/Vol. 33, No. 6/June 2012 TARSAL TUNNEL SYNDROME - NEUROANATOMY 515

Table 1: Points of Compression of the Posterior Tibial Nerve and its Branches

Potential Points of Abductor Hallucis Medial Lateral

Compression Fascial Origin Septum Intermediate Septum Septum

Medial Plantar Nerve 19 3 0 0

Lateral Plantar Nerve 19 19 0 0
Nerve to Abductor 15 (not identified in 4 15 9 (Intermediate septum 0
Digiti Minimi specimens) not well developed
in remaining feet)
Calcaneal Branch 0 0 0 0

The flexor retinaculum is a common point of compression for the main trunk (posterior tibial nerve) as it divides into the medial and lateral plantar nerves.

In all the specimens, the PTN and its 2 main branches

passed under the flexor retinaculum behind the medial
malleolus (Figures 3 and 4). The CB arose from the PTN
under the flexor retinaculum and was clearly visualized in
15 of the specimens. It coursed into the subcutaneous tissue
over the medial aspect of the heel. The MPN branched from
the PTN under the distal end of the flexor retinaculum and
proceeded to pass under the fascial origin of the AH. It then
bypassed the medial aspect of the medial septum on its way
to its terminal branches in the forefoot in 16 of the specimens
(Figures 5 through 7). It passed through the medial septum
in the remaining three specimens before dividing into its
terminal branches. The point of penetration of the nerve
through the medial septum was 5.6 ± 1.6 cm from the
posterior aspect of the calcaneus (Table 2).
The LPN passed from under the flexor retinaculum, deep to
the fascial origin of the abductor AH muscle and the muscle
belly and passed through a perforation in the medial septum
in all our specimens to run between the FDB on its plantar
aspect and the QP dorsally (Figures 5 and 6). The point of Fig. 3: Deep dissection of the sole of the foot, showing the lateral septum
(LS), intermediate septum (IS) and medial septum (MS). The relationship
penetration through the septum was 4.1 ± 1.8 cm from the
of the lateral plantar nerve (LPN), medial plantar nerve (MPN) and nerve
to abductor digiti minimi (ADM) to the foot septae are demonstrated. In
this specimen, both the LPN and MPN are seen passing through the medial
septum. The nerve to ADM passes through the medial and intermediate
septae.

posterior border of the calcaneus (Table 2). It then proceeded

Fig. 4: Deep dissection of the medial ankle and sole of the foot, demon-
strating the medial plantar nerve (MPN), lateral plantar nerve (LPN) and
medial septum (MS). PT, posterior tibial nerve; CB, calcaneal branch.
Copyright  2012 by the American Orthopaedic Foot & Ankle Society
distally to divide into its terminal branches.
The branch to the ADM was clearly identified in 15 spec-
imens. It arose from the LPN just before the latter passed
under the AH. It accompanied the main nerve and pene-
trated the medial septum and proceeded laterally just distal to
the calcaneal tuberosity (Figures 5 and 6). This branch then
penetrated the intermediate septum (if present) to end in the
ADM. The points of penetration through the medial and inter-
mediate septae were 2.9 ± 1.1 cm and 3.3 ± 1.3 cm, respec-
tively, from the posterior aspect of the calcaneus (Table 2).
The course of the long flexor tendons was from under
the flexor retinaculum behind the medial malleolus and
dorsomedial to the MPN in the sole of the foot where they
516 SINGH AND KUMAR Foot & Ankle International/Vol. 33, No. 6/June 2012

Fig. 7: Coronal cross section of the hindfoot, showing the hindfoot septae
and the relationship of the nerves to them. AH, abductor hallucis; QP,
quadratus plantae; FDB, flexor digitorum brevis; ADM, abductor digiti
minimi.
Fig. 5: Illustration of the medial side of the ankle after dissection. The
posterior tibial nerve (PTN) is shown, branching under the flexor retinaculum
(FR) into the medial and lateral plantar nerves (MPN and LPN). The Table 2: Mean Distances of Points of Penetration of
calcaneal branch (CB) and nerve to abductor digiti minimi (ADM) are also
illustrated. AH, abductor hallucis.
Posterior Tibial Nerve Branches Through the Foot
Septae From the Posterior Border of the Calcaneus, A
Consistent Bony Landmark

Average distance
from posterior
border of
Anatomical Structure calcaneus/cm
Point where LPN passes 4.1 ± 1.8
through medial septum
Point where nerve to ADM 2.9 ± 1.1
passes through medial
septum
Point where nerve to ADM 3.3 ± 1.3
passes through intermediate
septum
Point where MPN passes 5.6 ± 1.6
through medial septum
(in specimens which MPN
passes through medial
septum)

LPN, Lateral plantar nerve; ADM, Abductor digiti minimi; MPN,

Fig. 6: Illustration of the sole of the foot after dissection. The medial plantar Medial plantar nerve.
nerve (MPN) is shown, skirting the medial septum (MS). The lateral plantar
nerve (LPN) is shown, passing through the MS and running alongside the
intermediate septum (IS). The nerve to the Abductor Digiti Minimi (ADM)
DISCUSSION
is seen passing through the MS and IS. LS, lateral septum.

Few studies have looked at the anatomy of the tarsal tunnel

ran medial to the medial septum. In the forefoot the flexor and the passage of the PTN and its branches in detail.5,7,18
digitorum longus divided into the four lesser toe tendons. Standard anatomy texts10,17 are also unclear regarding the
Copyright  2012 by the American Orthopaedic Foot & Ankle Society
Foot & Ankle International/Vol. 33, No. 6/June 2012
relationship of the PTN and its branches relative to the
fascial layers and septae in the foot. The senior author
has published an earlier study, defining three well-defined
tough fascial septae in the sole of the foot:11 the medial
septum (dorsal extension of the medial border of the main
plantar aponeurosis, also referred to as the deep fascia of the
abductor hallucis in some studies), the intermediate septum
(the dorsal extension of the lateral border of the main plantar
aponeurosis) and the lateral septum (the dorsal extension
of the lateral border of the lateral band of the plantar
aponeurosis). The septae are important as the MPN and LPN
run in close relationship to these septae and also on occasion
pass through them. These septae represent sites of potential
nerve entrapment and compression, particularly so in the hind
segment of the sole of the foot. This study demonstrated the
anatomical relationships of these septae in relation to the
course of the posterior tibial nerve and its branches in the
sole of the foot.
In our dissection it was clear that the main PTN could be
entrapped behind the medial malleolus under the tough flexor
retinaculum. Its calcaneal branch (CB) also arose from under
the retinaculum and could thus be compressed here. This
branch near its origin divided into its terminal branches and
passed into the subcutaneous tissue over the medial aspect
of the heel. Jerosch et al.8 found that the calcaneal branch
arose from the LPN in 25% of their cases and arose distal
to the flexor retinaculum in 16% of their patients. Abnormal
masses and vascular anomalies under the retinaculum would
aggravate the compression of these nerves.2,15
The MPN and LPN also came off the main branch under
the distal end of the retinaculum and may be compromised
there. These nerves also passed under the fascia of origin
of the AH, another potential site of compression. The further
progression of the MPN along the medial aspect of the medial
septum may leave it unaffected by any further compression.
Where this nerve passed under the medial septum as seen in
some of our specimens, might be another site of compression.
The LPN and its branch to the ADM both pass under the
medial septum and the latter nerve also may pass under the
intermediate septum should it be present which are potential
sites of compression.
Compression of the PTN and its CB as well as the MPN
and LPN could occur under the flexor retinaculum, especially
if a space occupying lesion was present. Further compression
of the MPN and LPN may occur under the hindfoot septae
mentioned above.
It is envisaged that results of this study will be helpful
in facilitating communication among anatomists, neuroradi-
ologists and foot and ankle surgeons by having clear and
concise terminology regarding the points of compression
–flexor retinaculum, abductor hallucis, medial septum, inter-
mediate septum and lateral septum. To date, there has been
much confusion regarding this nomenclature.
The results of surgical treatment of tarsal tunnel syndrome
have been less than optimal5,12,16 in several studies especially
Copyright  2012 by the American Orthopaedic Foot & Ankle Society
TARSAL TUNNEL SYNDROME - NEUROANATOMY 517
in patients who do not have a space-occupying lesion along
the course of the PTN, MPN and LPN. Other conditions
such as peripheral neuropathy and neurogenic claudication
must be excluded prior to arriving at a diagnosis of tarsal
tunnel syndrome. Mullick and Dellon12 emphasized the need
to extend the decompression well past the flexor retinaculum
into the ‘four medial ankle tunnels’ in the sole of the
foot. They mentioned a fascia that came into view after
the AH was retracted, through which the medial and lateral
plantar nerves passed, and which needed to be released for
complete decompression of the nerves. They reported 93%
good and excellent results in their study. Reference to this
tough fascial barrier mentioned above, which we describe as
the ‘medial septum’, had also been made by others5,18 but
the nomenclature used has been somewhat variable. From
the results of our study, the medial septum is probably the
most important site of compression other than the flexor
retinaculum that needs to be addressed during surgery. The
intermediate septum, if present, would theoretically only
compromise the nerve to the ADM. This may not have much
clinical significance, bearing in mind that the nerve to the
ADM is a predominantly motor nerve and symptoms related
to tarsal tunnel syndrome tend to be predominantly sensory
in nature. The medial septum deserves particular attention
during surgery, especially if no obvious space-occupying
lesion is identified under the flexor retinaculum.
CONCLUSION
A conservative nonoperative approach for tarsal tunnel
syndrome has been advocated in view of poor results
of surgical decompression13,16. A better understanding of
the detailed anatomy of the PTN and its branches will
hopefully improve results of surgical release. We intend
to follow up this cadaveric study with a clinical study
in collaboration with the neurology and neuroradiology
departments in our institution. This study serves as an
educational tool for initiating future studies and we suggest
that the anatomical basis, terminology, and classification of
tarsal tunnel syndrome be communicated more specifically
with this information.
ACKNOWLEDGMENTS
The authors thank Associate Professor K. Rajendran
(FRCS), of the Department of Anatomy, National University
of Singapore, for his help and advice with the anatomical
dissections, and Ms Bay Song Lin of the Department of
Anatomy, National University of Singapore for her technical
support and help with the illustrations.
REFERENCES
1. Albrektson, B; Rydholm, A; Rydholm U: The tarsal tunnel syndrome
in children. J Bone Joint Surg. 64B:215 – 7, 1982.
518 SINGH AND KUMAR
2. Bailie, DS; Kelikian, AS: Tarsal tunnel syndrome: diagnosis, surgical
technique, and functional outcome. Foot Ankle Int. 19(2):65 – 72, 1998.
3. Belding, RH: Neurilemmoma of the lateral plantar nerve producing
tarsal tunnel syndrome:a case report. Foot Ankle. 14:289 – 91, 1993.
4. Bracilovic, A; Nihal, A; Houston, VL; et al.: Effect of foot and
ankle position on tarsal tunnel compartment volume. Foot Ankle Int.
27:431 – 7, 2006.
5. Franson, J; Baravarian, B: Tarsal Tunnel Syndrome: A compression
neuropathy involving four distinct tunnels Clin. Podiatr. Med. Surg.
23:597 – 609, 2006. http://dx.doi.org/10.1016/j.cpm.2006.04.005
6. Gondring, WH; Shields, B; Wenger, S: An outcomes analysis
of surgical treatment of tarsal tunnel syndrome Foot Ankle Int.
24(7):545 – 50, 2003.
7. Heimkes, B; Posel, P; Stotz, S; Wolf, K: The proximal and distal
tunnel syndromes An anatomical study. Int Orthopaedics. 11:193 – 6,
1987. http://dx.doi.org/10.1007/BF00271447
8. Jerosch, J; Schunck, J; Khoja, A: Results of surgical treatment
of tarsal tunnel syndrome Foot and Ankle Surgery. 12:205 – 8, 2006.
http://dx.doi.org/10.1016/j.fas.2006.05.001
9. Lam, SJS: A tarsal tunnel syndrome. Lancet; 29;2(7270):1354 – 5,
1962.
10. Last, RJ: Anatomy Regional and Applied. Edinburgh: Edited by
Churchill Livingstone, 1973.
Copyright  2012 by the American Orthopaedic Foot & Ankle Society
Foot & Ankle International/Vol. 33, No. 6/June 2012
11. Ling, ZX; Kumar, VP: The myofascial compartments of the foot-A
Cadaver Study. J Bone Joint Surg. 90B:1114 – 8, 2008.
12. Mullick, T; Dellon, L: Results of decompression of four medial ankle
tunnels in the treatment of tarsal tunnels syndrome. J Reconst Microsurg.
24:119 – 126, 2008. http://dx.doi.org/10.1055/s-2008-1076089
13. Pfeiffer, WH; Cracchiolo, III: A Clinical results after tarsal tunnel
decompression. J Bone Joint Surg. 76:1222 – 30, 1994.
14. Patel, AT; Gaines, K; Malamut, R; et al.: Usefulness of
electrodiagnostic techniques in the evaluation of suspected tarsal tunnel
syndrome: an evidence-based review. Muscle Nerve. 32:236 – 40, 2005.
http://dx.doi.org/10.1002/mus.20393
15. Sammarco GJ, Chang L: Outcome of surgical treatment of tarsal
tunnel syndrome. Foot Ankle Int. 24:125 – 31, 2003.
16. Ward, PJ; Porter, ML: Tarsal tunnel syndrome: a study of the clinical
and neurophysiological results of decompression. J R Coll Surg Edinb.
43:35 – 6, 1998.
17. Williams, PL; Warwick, R: Gray’s Anatomy Edinburgh: Edited by
Churchill Livingstone, 1980.
18. Wolf, K; Posel, P; Heimkes, B; et al.: Tarsal tunnel syndrome. Nerve
Compression syndrome in the foot. Unfallchirurg. 94:291 – 4, 1991.