Anterior tarsal tunnel syndrome, also called deep peroneal nerve entrapment, s an uncommon form of nerve entrapment at the top of the foot. It’s caused by compression of the deep peroneal nerve, leading to pain and altered sensation over the top of the foot. So what is anterior tarsal tunnel syndrome, and how do we treat it? 

deep peroneal nerve supplying skin between the 1st and 2nd toes

What is anterior tarsal tunnel syndrome? 

Anterior tarsal tunnel syndrome is entrapment of the deep peroneal nerve as it passes under a band of tissue on the front of the ankle called the inferior extensor retinaculum. The deep peroneal nerve supplies a small muscle on the top of the foot and sensation to the web space between the first and second toes.

It’s the front-of-foot counterpart to the more familiar tarsal tunnel syndrome. The important distinction:

  • Anterior tarsal tunnel syndrome — the deep peroneal nerve, on the top of the foot
  • Posterior (classic) tarsal tunnel syndrome — the tibial nerve, on the inner sole

What causes deep peroneal nerve entrapment?

The nerve is usually compressed under the extensor retinaculum, from:

  • Tight footwear, laces, ski boots, or military boots pressing on the top of the foot
  • Repetitive micro-trauma, or an ankle sprain putting the nerve on stretch
  • A ganglion cyst or a bony spur (from the talus, navicular, or metatarsals)
  • An extra bone (os intermetatarseum) or an enlarged small muscle on the top of the foot

Symptoms of anterior tarsal tunnel syndrome

Typical features include:

  • Aching or burning pain over the top of the foot
  • Numbness or tingling in the web space between the first and second toes (the deep peroneal nerve’s sensory area)
  • Symptoms worse with tight shoes, and sometimes at night
  • In longer-standing cases, wasting of the small muscle on the top of the foot (extensor digitorum brevis)

Because the symptoms can be vague, anterior tarsal tunnel syndrome is often under-recognised.

How is deep peroneal nerve compression diagnosed?

Diagnosis combines the clinical picture with tests:

  • Ultrasound — images the deep peroneal nerve and any compressing cyst or spur, and guides an injection
  • MRI — shows the nerve, a mass, or muscle wasting, and excludes other causes
  • Nerve conduction studies and EMG — can show delayed conduction and changes in the small foot muscle, helping confirm it 
  • X-ray — where a bony spur or extra bone is suspected

How is anterior tarsal tunnel syndrome treated?

Most cases settle with conservative treatment aimed at relieving the pressure:

  • Footwear changes — looser lacing, better-fitting shoes, and padding to take pressure off the top of the foot (often the single most useful step)
  • Activity modification — reducing aggravating activities while symptoms settle
  • Treating a specific cause — for example draining a ganglion, or removing a bony spur
  • Surgery — decompression of the nerve, reserved for persistent cases or a clear structural cause

Frequently asked questions about deep peroneal nerve compression 

What’s the difference between anterior and posterior tarsal tunnel syndrome?

They involve different nerves in different places. Anterior tarsal tunnel syndrome affects the deep peroneal nerve on the top of the foot, causing pain there and numbness in the first web space. Posterior (classic) tarsal tunnel syndrome affects the tibial nerve on the inner sole, causing burning symptoms in the sole and heel. The location of the symptoms is the main clue.

Can my shoes cause anterior tarsal tunnel syndrome?

Yes — this is one of the commonest causes. Tight shoes, tight laces, ski boots, or military boots press directly on the nerve on the top of the foot. Loosening the lacing, changing footwear, and padding the area are often the most effective first steps.

Can it be treated without surgery?

Usually, yes. Relieving the pressure on the nerve — mainly through footwear changes — along with activity modification and, where needed, an ultrasound-guided injection, settles most cases. Surgery is reserved for persistent symptoms or a clear structural cause such as a ganglion or bony spur.

Why is there numbness between my first and second toes?

Because that web space is precisely the area of skin supplied by the deep peroneal nerve, tingling is a sign of anterior tarsal tunnel syndrome and helps distinguish it from other causes of foot pain.

Final word from Sport Doctor London about anterior tarsal tunnel syndrome

Anterior tarsal tunnel syndrome is an under-recognised cause of top-of-foot pain, caused by entrapment of the deep peroneal nerve. The tell-tale sign is numbness in the web space between the first and second toes. Because tight footwear is a common cause, changes in footwear are often the key, and most cases settle without surgery.

If you have persistent pain or numbness over the top of your foot, Dr Masci can assess you in London, including ultrasound in clinic. Contact the team here or call +44 (0) 203 488 0350.

Other related foot and nerve conditions: