Sinus Tarsi Syndrome

[dibblego]

Exactly what is Sinus Tarsi Syndrome? I am quite well-versed in ankle anatomy (not by choice) and I was discussing the other day with my surgeon that, after having 4 operations to finally remove the source of excruciating pain, I believe I have lateral subtalar impingement -- a condition I've had all along since my initial injury (inversion sprain July 2007) which has been masked by overwhelming pain and so not attracting my immediate attention.

My surgeon suggests anterior subtalar impingement and I go along with it and he injects with cortisone. I report back no joy. I receive in the mail today a request slip for cortisone/anaesthetic injection into sinus tarsi. Then it dawns on me.

At the very centre of the broad area (anterior to lateral malleolus) I have been finding difficult to localise is the sinus tarsi. So I scramble and try to read up on Sinus Tarsi Syndrome which I'd come across before (I now own two foot/ankle orthopaedics text books since I was determined to find out my earlier conditions ultimately with success) only to find ambiguous or vague information. I also have passive inversion in the subtalar joint -- I've reported this "feeling" to GPs but they say I am making it up -- but I now have radiographs to prove it *sigh*.

Is it a nerve condition? Is it equivalent to subtalar tissue impingement? What might I expect my surgeon to find when he sticks his arthroscope in there in a few weeks?

I certainly don't feel like a nerve is trapped -- rather that a large chunk of tissue is trapped in this lateral subtalar region preventing range of motion. I can hear it "pop" if I move the joint around (without weight-bearing) in a particular manner. I get a small amount of free movement then a very definite block if I attempt dorsiflexion very early on (a physiotherapist has measured <0 degrees).

What exactly is Sinus Tarsi Syndrome? Even though I might not have it, I'm still genuinely curious. I'm determined to have a full understanding of what is going on in there prior to arthroscopic (hopefully the last!) surgery 27 July.

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[physiofixme]

The sinus tarsi is a canal running from an opening anterior and inferior to the lateral malleolus to a point just behind the medial malleolus. It forms part of the subtalar joint and contains some blood vessels, fat, subtalar ligaments.

Injury to it is either chronic overuse due to poor biomechanics (over pronation etc) or as the result of an acute ankle sprain.

Pain usually anterior to the lateral malleolus. It is often worse in the morning and may diminish with exercise. Can also have ankle and foot stiffness and occasionaly of weakness.

Treatment is usually rest, ice etc but in particular mobilisation of the subtalar joint. Corticosteriod injection can help but the biomechanics need to be addressed to prevent recurrance.

Any help??

Sounds like you've been doing your research. Have you considered a peroneal tendinopathy or a stress fracture of your talus??

[dibblego]

Thanks for the tips physiofixme.

I am quite certain that I have subtalar impingement anterior, behind and perhaps even posterior to the lateral malleolus. Probably in the sinus tarsi region too. I also have passive inversion and I am jammed in that slightly inverted position even when weight bearing. I don't believe that my subtalar joint moves at all.

This doesn't seem fully consistent with what you describe yet I have found one link which uses STS and lateral subtalar impingement interchangeably.

Is it possible that during an inversion sprain tissue has become trapped in the subtalar joint? Can this tissue impingement be described as Sinus Tarsi Syndrome?
Additional Comment I forgot:
On second read, that link seems to make a distinction. Therefore I have lateral subtalar impingement and not sinus tarsi syndrome. I believe I have localised it well enough for my surgeon. 30 days to go for my fifth and hopefully last time.

Any other tips are appreciated!

[dibblego]

Alas, I find another link which does use the term interchangeably!

I should point out that the reason I ask is because I want to know if literature on Sinus Tarsi Syndrome is applicable or not. I have lateral subtalar impingement. Is STS as described in the literate the same thing? How annoying -- not even my text books are clear on this.

[kennethckyuen]

Hi,

Just brainstorming. I am not sure if Sinus tarsi sydrome would impinge you but what I came across is an anterior glided talus over the malleolus. I did usually AP glide to the talus in supine, or MWM (please refer to Mulligan) or I even gave a distraction manipluation to the joint. Usually the impingement feeling would go away. Hope this could help a bit.
Additional Comment I forgot:
Hi,

Just brainstorming. I am not sure if Sinus tarsi sydrome would impinge you but what I sometimes came across is an anterior glided talus over the malleolus.

I usually AP glided to the talus in supine, or MWM (please refer to Mulligan) or a distraction manipluation to the joint. Usually the impingement feeling would go away. Hope this could help a bit.

[dibblego]

Thanks kennethckyuen. I shall consider your suggestion.

I have a steroid/anaesthetic injection today into the sinus tarsi. I've had no improvement. I am convinced that the impingement is further posterior along the subtalar joint -- perhaps even posterior to the lateral malleolus.

This is driving me crazy. I reviewed all my radiographic images and they all show a high signal in the area that I can feel through the skin which suddenly moves when producing the impingement (a "crack" sound). It is posterior to the lateral malleolus at the subtalar joint height level with my finger pushing inward toward the anterior. When dorsoflexing then everting, there is a very definite crunch sound and a sudden movement can be felt.

This is driving me crazy. *Twenty-three months* and I am so close to getting out of jail. I may just ask the surgeon to go in both anterior and posterior with his arthroscope -- anything to nail this problem -- whatever it is.

I can show the MR images if anyone is curious. Hints?

[physiofixme]

A local injection of anesthetic agent into the sinus tarsi is a great diagnostic tool. In sinus tarsi syndrome, this injection will relieve pain (albeit temporarily) Sometimes it's a process of elimination so if the injection didn't change your symptoms then in theory you can rule out sinus tarsi syndrome.

Also in answer to one of your queries: Sinus tarsi syndrome does often leave you with a stiff subtalar joint, however a stiff subtalar joint can be a symptom of other conditions as well.
Additional Comment I forgot:
Oh and by the way - the article that uses STS and lateral impingement interchangeably isn't correct. They are two different syndromes!! Oh the internet.........

[dibblego]

Yeah there has been no improvement at all. My symptoms don't align with sinus tarsi syndrome, more like lateral subtalar impingement. The joint is still popping and cracking every time I walk like it always has and my ROM is extremely limited.

I feel like it is more posterior along the subtalar joint than the sinus tarsi. I wish I could localise it and I hope my surgeon finds it. I may ask him to go in both anterior and posterior to the lateral malleolus -- find it at all costs as far as I am concerned.

[dibblego]

Holy Schmoly I am such an idiot! I have a subluxed peroneal tendon! Now I am scared.

[physiofixme]

Ouch!! Are you going to have the tendon surgically repaired??

[dibblego]

I guess I am -- not sure what technique is the best these days. My surgeon doesn't know yet -- he is on holidays. I've produced a video that shows the tendon dislocating. I plan to put it up on youtube in the next 24 hours.

What a mission!

[dibblego]

Thank you everyone for your helpful advice and support. I have finally proven to the world what my problem has been for the last 23 months after 4 operations with some amount of success but still having some sort of problem which nobody could not work out.

You may see it for yourself
YouTube - Peroneal Tendon Subluxation

What a mission. Thanks again. A serious operation awaits me. I know far too much about ankle anatomy and conditions. I am a computer scientist, not a medical expert!

*wipes brow of sweat* What a story for my grandchildren.

[longbow]

My husband had a cortisone injection for sinus tarsi syndrome on Tuesday 28th May, after a year of getting no treatment from GP. It has done absolutely nothing at all. He is very p****d off as pain is really bad.

[joelin02]

Can anyone who knows something about sinus tarsi syndrome give me some thoughts on my situation? So I'm 29 with a flat left foot. I sprained it six years ago and often sit with it tucked under my leg. A few months ago, I started feeling a dull pain near my sinus tarsi that would last a couple seconds when starting any activity. It lasted a month until I started wearing custom orthotics and the problem quickly went away.

I was pain free for a few months until last week. That is when I started feeling a minor, but irritating tingling near my sinus tarsi that would last a couple seconds when starting any activity. Sometimes I can flex my foot while sitting and the tingling will come back. I've tried RICE, ibuprofen and an ankle brace for about 7 days without much change in symptoms. Of course I'm still wearing the orthotics. Does anyone have experience with this issue? How problematic is the tingling? Should I be taking more aggressive measures? What are my options?

[davisjone]

Conservative treatment is usually effective for Sinus Tarsi. It may include anti-inflammatory drugs, stable shoes, a period of immobilization, cryotherapy, ankle sleeve and orthoses. Balanced and proprioceptive training, and muscle strengthening exercises are also recommended by dcotors. Inflammation within the sinus tarsi can be controlled with injectable cortisone, relief is achieved after 4-6 injections.

[longbow]

My husband had a general anaesthetic to have a cortisone injection. It didn't work. They won't do another. Good, as put in wrong place.

Acupuncture worked wonders!