Introduction

Tarsal tunnel syndrome (TTS), also known as "tibial nerve dysfunction" or "posterior tibial nerve neuralgia" is considered to be an uncommon condition. It involves damage or compression of the tarsal tunnel structures, especially the posterior tibial nerve, which is found in your ankle.^1,2

The symptoms might worsen during or following physical exercise, at night, and normally improve with rest. The symptoms may be confined to the ankle, the undersides of the foot or somewhere more ambiguous. If TTS is chronic, then the symptoms may be constant and prolonged. The usual symptoms include:^1,2

• Burning sensations
• Sharp shooting pain
• Numbness
• Tingling or “pins and needles” feelings (paresthesia)
• Weakness in your foot muscles

TTS can be due to either internal or external factors. These include poorly fitted shoes, pedal oedema, arch drop/flat feet, high arches, injuries, irregular growths like varicose veins, masses like lipomas near the tibial nerve, and conditions that affect the whole body, like diabetes. 

However, during pregnancy, TTS is another outcome that can occur due to the hormonal and physical changes that take place. Some pregnant persons commonly experience varicosities/varicose veins, which can lead to compression of the tibial nerve. Persons assigned females at birth (AFAB) who have had more than one child are more predisposed to TTS than those who have only had one child.^1,2,3 If you want to know more about how pregnancy can worsen the symptoms of tarsal tunnel syndrome, you’re in the right place. 

Causes and risk factors in pregnancy

Hormonal changes

• Increased relaxin and progesterone, leading to ligament laxity and nerve compression

Relaxin is a hormone generated by the ovaries and placenta and is crucial for the reproductive systems of persons assigned femaleat birth (AFAB). When produced during the menstrual cycle, this hormone relaxes the uterus and prepares the uterine lining for implantation, while during pregnancy, relaxin relaxes the ligaments and muscles, resulting in more flexibility, as well as prevents uterine contractions. It also helps to prepare the cervix for labour and delivery.⁴

The levels of relaxin are constantly high during pregnancy and peak around the first trimester or within 14 weeks of pregnancy. The increased quantity of relaxin can cause laxity (loose ligaments) mainly in the pelvis-pubic area, but also in the shoulder, hips, spine, feet and ankles. This can then lead to nerve compression and pain.^4,5,6

• Fluid retention causes swelling and increased pressure in the tarsal tunnel

Oedema or fluid build-up within the tarsal tunnel structures can cause swelling of the tibial nerve and increased pressure on it.⁷

Physical changes

• Weight gain is increasing strain on the feet and nerves

When a person assigned female at birth (AFAB) becomes pregnant, there is an expected weight gain, but this varies extremely. Some individuals can gain between 10 kg to 12.5 kg; gaining most weight after 20 weeks of pregnancy.⁸ This extra weight leads to increased strain on the feet and subsequently the nerves. 

• Changes in walking pattern and foot posture due to altered centre of gravity

Throughout pregnancy, the posture and gait are altered, and the centre of gravity changes and moves forward. This increases lumbar lordosis, the head and trunk are further drawn back, which impacts normal movement. The plantar arches of the feet are also known to drop and flatten during pregnancy.⁹

Exacerbation of symptoms during pregnancy

The symptoms of TTS worsen throughout pregnancy due to the increased weight gain, walking and prolonged standing. TTS is more prevalent during the third trimester, with increased swelling in the ankles and feet.³

Diagnosis challenges in pregnant patients

Overlapping symptoms with other pregnancy-related conditions 

The symptoms of TTS are quite vague and similar to other nerve-related conditions that can occur during pregnancy.  

• Plantar fasciitis – a disorder that involves inflammation of the band of tissue that runs along the undersole of the foot, called the plantar fascia. The pain is usually described as stabbing and based around the heel of the foot¹⁰
• Sciatica – this is when the sciatic nerve, which runs from the lower back to the foot becomes irritated, inflamed or compressed, leading to symptoms like pain, paresthesia, numbness, and muscle weakness¹¹

Clinical assessment

Due to the challenges with diagnosis, a thorough clinical examination should be conducted for accurate diagnosis and subsequently appropriate management. Tests can also be conducted, and these include: 

• Tinel’s sign – This test assesses the signs of nerve irritation or nerve damage at a specific site. The sign is considered as a tingling or “pins and needles” feeling when the healthcare provider taps the skin over a nerve 
• Electromyogram (EMG) – This is an electrodiagnostic test that evaluates the health and function of the skeletal muscles and the nerves. This test is often done alongside a nerve conduction study (NCS)¹³ 
• Magnetic resonance imaging (MRI) – This non-invasive imaging technique that generates clear images of the organs, bones and soft structures inside you¹⁴ 

Management and treatment approaches

Conservative treatment

Rest, elevation, and cold therapy to reduce swelling

It is recommended that the patient get plenty of rest to promote healing and prevent further injury. Elevating the affected foot above the heart can reduce inflammation. Using ice packs for around 20 minutes a couple of times a day can reduce swelling and pain.^1,2

Supportive footwear and orthotics to alleviate pressure

Orthotic shoes, braces, casts or splints, as well as accessories like a medial heel wedge, can help to correct biomechanical abnormalities by keeping the foot in place and reducing tension on the nerve.^1,2

Physical therapy and exercises

Stretching and strengthening exercises to relieve nerve compression

Exercises and stretches like nerve gliding may be recommended to alleviate symptoms, improve strength and range of motion. Soft tissue physical therapy options are ultrasound, iontophoresis, phonophoresis, and electrical stimulation.^1,2

Medical interventions

Medications

Non-opioid analgesics like acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), as well as topical lidocaine and NSAIDs, can help with pain and inflammation. Neuropathic pain drugs like gabapentin, pregabalin, and tricyclic antidepressants may also be prescribed.^1,2

Corticosteroid injections 

Steroid injections can be recommended to reduce pain and inflammation. Injections directly into the tarsal tunnel may reduce oedema.^1,2

Surgery 

Surgery is only suggested if the non-surgical treatments are unsuccessful in alleviating symptoms or if a definitive cause of entrapment is recognised. Patients with symptoms caused by a space-occupying lesion commonly respond well to surgical intervention. Operations can widen the tarsal tunnel or release the tibial nerve. For example, flexor retinaculum resection. The success of surgery varies from 44% to 96%, and persons with a positive Tinel sign usually respond better to surgical decompression than those who do not. Individuals with an early diagnosis, of younger age, with a short history of symptoms, a distinct cause, and no history of ankle pathology also respond well to surgery.^1,2

FAQs

What is tarsal tunnel syndrome in pregnancy?

Tarsal tunnel syndrome (TTS) in pregnancy occurs when the posterior tibial nerve is compressed within the tarsal tunnel. This compression leads to symptoms such as burning pain, tingling, numbness, and weakness in the foot and toes. Pregnancy-related factors like fluid retention (oedema), weight gain, hormonal changes, and ligament laxity contribute to increased pressure in the tarsal tunnel, making pregnant individuals more susceptible to TTS.

What aggravates tarsal tunnel syndrome?

Several factors can worsen TTS by increasing pressure on the posterior tibial nerve:

• Prolonged standing or walking—increases strain on the foot and worsens nerve compression
• Weight gain—extra body weight during pregnancy adds stress to the feet
• Swelling (oedema) – common in pregnancy, excess fluid retention compresses the nerve
• Flat feet (overpronation) – changes in foot structure due to the relaxin hormone lead to nerve irritation
• Tight footwear—can press against the tarsal tunnel and worsen symptoms
• Poor circulation—common in later pregnancy, reducing nerve function and worsening symptoms

What impact do the hormones of pregnancy have on the joints?

Pregnancy hormones, particularly relaxin and progesterone, cause ligament laxity, joint instability, and increased swelling, which can contribute to musculoskeletal discomfort and nerve compression. These hormonal changes make pregnant individuals more susceptible to conditions like TTS, lower back pain, and hip instability due to excessive joint movement and swelling.

What are the symptoms of carpal tunnel syndrome in pregnancy?

Carpal tunnel syndrome (CTS) is common in pregnancy due to fluid retention and swelling, which compresses the median nerve in the wrist. Symptoms include:

• Numbness and tingling—mostly in the thumb, index, middle, and half of the ring finger
• Pain and burning sensations—radiating from the wrist to the fingers, sometimes extending to the forearm
• Weak grip strength—difficulty holding objects due to muscle weakness
• Worsening symptoms at night—swelling increases when lying down, leading to more pronounced numbness and pain

Summary

Tarsal tunnel syndrome (TTS) in pregnancy is a condition caused by compression of the posterior tibial nerve within the tarsal tunnel, leading to pain, tingling, numbness, and muscle weakness in the foot. Pregnancy-related hormonal and physical changes, including increased levels of relaxin and progesterone, contribute to ligament laxity and fluid retention, which exacerbate nerve compression. Additional risk factors such as weight gain, altered gait, and varicose veins further increase susceptibility to TTS, particularly in the third trimester when swelling is most pronounced.

Diagnosis is often challenging due to overlapping symptoms with conditions like plantar fasciitis and sciatica. Clinical assessments, including Tinel’s sign, electromyography (EMG), and MRI, help distinguish TTS from other pregnancy-related nerve disorders. Treatment focuses on conservative measures, such as rest, elevation, cold therapy, supportive footwear, and physical therapy. In more severe cases, medications, corticosteroid injections, or surgery may be considered.

TTS symptoms generally improve postpartum as hormone levels and fluid retention normalise, but long-term foot health strategies are essential for recovery. Awareness and early intervention can help manage symptoms effectively, ensuring better comfort and mobility during pregnancy.