Tarsal tunnel syndrome is a complex and often under-diagnosed or misdiagnosed condition that affects the foot and ankle. It is a compression neuropathy of the posterior tibial nerve as it passes in the anatomic tarsal tunnel in the medial ankle under flexor retinaculum. This article reviews diagnosis, conservative treatment, and surgical outcomes, which have dramatically improved with more comprehensive release of the foot nerves in addition to the tibial nerve. Internal neurolysis facilitates a second level of nerve decompression in needed cases. Physical therapy protocols have made it possible for patients to return to ambulation with limited long-term down time.