The tibial nerve divides into medial and lateral plantar nerves within the tarsal tunnel at the level of the sustentaculum tali, just distal to the medial malleolus. The medial calcaneal branch may arise before or after this division.
The tibial nerve plantar division level determines the clinical pattern in tarsal tunnel syndrome. Zone III compression at the division point produces combined medial and lateral plantar symptoms. The abductor hallucis muscle separates the two divisions as they enter the foot, and the medial and lateral plantar nerves diverge into their respective plantar compartments.
Tibial nerve compression at the medial-lateral plantar division producing combined plantar numbness in all toes with heel pain from medial calcaneal branch involvement, the most severe pattern of tarsal tunnel syndrome.
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