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Sinus Tarsi Syndrome

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Sinus Tarsi Syndrome
George G. A. Pujalte
Rafael DaFonseca
Basics
Sinus tarsi syndrome is refractory pain, often chronic, over the anterolateral aspect of an ankle, often associated with previous ankle injury (1).
Description
  • Sinus tarsi is the lateral extension of the tarsal canal formed by the sulcus of the talus and calcaneus (2).
  • Within the sinus tarsi are the talocalcaneal interosseous ligament; cervical ligament; the subtalar joint capsule; synovium; and the medial, intermediate, and lateral roots of the inferior extensor retinaculum (2).
    • Talocalcaneal interosseous ligament is involved in movements of the subtalar joint (2). It functions to maintain apposition of the talus and calcaneus in all positions (2). Its rich innervation suggests that the sinus tarsi may be susceptible to neurogenic inflammation and may be a center of articular nociception (2).
Epidemiology
  • Patients with sinus tarsi syndrome are usually between their 3rd and 4th decades of life (3,4).
  • Often associated with dancers, volleyball players, basketball players, overweight individuals, and patients with foot deformities, usually flexible flat feet (5).
Risk Factors
Forefoot and calcaneal valgus, mechanical factors predisposing to supination ankle injuries, may lead to sinus tarsi syndrome after such injuries (6). In the majority of cases, the lateral ankle pain follows a history of an inversion ankle sprain (7).
Etiology
  • Soft tissue inversion injuries of the ankle most commonly involve the ligamentous structures of the lateral aspect of the ankle and sinus tarsi (8).
  • Posttraumatic fibrotic changes in the wall and surrounding tissue of veins, causing disturbance of venous outflow and increased intrasinusal pressure, may be a factor in the pathogenesis of sinus tarsi syndrome (7).
  • Sinus tarsi is not only a talocalcaneal joint space with interosseous ligaments, but also a source of nociceptive and proprioceptive information on the movements of the foot and ankle (2).
  • Sinus tarsi syndrome may result from disorders of nociception and proprioception of the foot (2).
Commonly Associated Conditions
  • 70% of cases are posttraumatic
  • 30% can be attributed to causes including systemic disease, structural abnormalities, and soft tissue masses, such as ganglions (3,9).
Diagnosis
4 clinical characteristics have been used to describe and diagnose the syndrome (3,4):
  • Pain at the lateral opening of the sinus tarsi, increasing with pressure, usually ceasing at rest
  • Perception of instability of the rear foot on uneven ground
  • Marked reduction of pain and discomfort following an injection of local anesthetic into the sinus tarsi
  • Clinical and stress radiographic examination showing no or minimal instability
History
  • Deep aching, throbbing, or sharp pain within the sinus tarsi may be associated with a sense of rear foot instability (3).
  • Pain over the lateral part of the ankle and hindfoot, over the sinus tarsi, is often the primary complaint (10).
  • A previous sprain or other injury is often the inciting event (3).
    • Initial injury may have responded to conservative therapies, but recurrent pain or pain settling into the sinus tarsi may be experienced with activities of daily living (3).
  • Can result in severe pain and instability of the ankle and the subtalar joints, particularly in athletes (8)
  • Pain and paresthesia may also be felt over the dorsolateral aspect of the foot (11). Intermittent pain often radiates into the leg, with resulting paresthesia over the distal aspect of the foot (11). Swelling may and may not be present (10).
  • Patients most often complain of “ankle” pain, when in reality, the pain is emanating from the subtalar area (3). When asked to identify the site of maximal tenderness, patients often point directly to the sinus tarsi region (3).
  • Pain may involve the anterior and lateral ankle, although this pain is less intense (3).
  • The perception of ankle symptoms may be secondary to previous trauma, referred pain, or an altered gait in an attempt to reduce pain (3).
Physical Exam
  • Diagnosis is often clinical; tenderness over the sinus tarsi often leads to the diagnosis of sinus tarsi syndrome (10).
  • Discomfort usually worsens with pressure over the lateral opening of the sinus tarsi, becoming more severe with the foot in varus position (7).
  • Symptoms are usually alleviated when the foot is immobilized in a valgus position (7).
  • Injury to the ligaments may result in laxity of the joints of the ankle complex, neuromuscular deficits are also likely to occur due to the injury to the nervous and musculotendinous tissue (12).
  • Neuromuscular deficits may be manifested as impaired balance, reduced joint position sense, slower firing of the peroneal muscles on inversion, slowed nerve conduction velocity, impaired cutaneous sensation, strength deficits, and decreased dorsiflexion range of motion (12).
  • Assessment of patients with lateral ankle sprain must address not only joint laxity and swelling, but should also include examination for neuromuscular deficits (2).
Diagnostic Tests & Interpretation
Imaging
  • Radiological examination usually will not reveal a bone lesion or any insufficiency of the ankle ligaments, and dynamically, there is usually no restriction of talocalcaneonavicular joint range of motion (7).
  • MRI, with or without arthrography, can lead to better definition of abnormalities in the sinus tarsi and tarsal canal (9).
Diagnostic Procedures/Surgery
  • Pain and functional instability in the region have been found to be reduced for a few hours after the injection of a local anesthetic into the opening of the sinus tarsi (6).
  • A reduction in electrical activity or complete electrical silence of both the peroneus brevis and longus muscles have been noted on electromyographic studies (2).
Differential Diagnosis
  • Peripheral mononeuropathies
  • Radiculopathy
  • Lateral ankle sprain
  • Anterolateral soft tissue impingement
  • Bifurcate ligament injury
  • Stress fractures of the cuboid, talus, or calcaneus (3,13)

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Treatment
  • Relative rest, avoidance of aggravating activities, and use of NSAIDs as needed for pain may give temporary relief (3).
  • Orthotics may be used to address forefoot valgus and calcaneal valgus, mechanical factors predisposing to supination ankle sprains (6).
  • Referral to physical therapy for ankle and leg strength and proprioception exercises is often quite appropriate (6).
  • Conservative treatment includes corticosteroid injections, immobilization in a cast, application of local anti-inflammatory gels or local irritants such as Capsaicin, and systemic drugs aimed at reducing neuralgic pain.
  • Physical therapy treatments may include mobilization, friction massage, and deep massage using US, soft laser, transcutaneous electrical stimulation, or any other method of deep massage. When there is ankle instability or a feeling of giving way, physical therapy should be tried 1st.
  • Corticosteroid injections mixed with local anesthetics have been shown to be effective (14).
  • Conservative treatment has been shown to be effective in up to 2/3 of patients (4). There seem to be no clear studies that delineate the length of time conservative measures should be tried, and the determination appears to be on a case-to-case basis for the most part, although, in our practice, a time frame of 4–6 wks is the most commonly used length of time for any conservative treatment chosen and applied to sinus tarsi syndrome.
Medication
  • A local anesthetic injection may be given as initial treatment for the pain of sinus tarsi syndrome; may also be diagnostic (6).
  • A mixed local anesthetic and corticosteroid injection may also be given as treatment for the pain of sinus tarsi syndrome, with 5–6 injections at weekly intervals usually sufficient (4,6).
Additional Treatment
Referral
Referral to orthopedic surgery may be appropriate after failure of conservative measures (6).
Surgery/Other Procedures
Surgical treatment of sinus tarsi syndrome may involve excision of the lateral half of the sinus tarsi contents, followed by below-knee casting for 3 wks and physical therapy (6).
Ongoing Care
Follow-Up Recommendations
Postoperatively, patients may be immobilized with a walking caliper for around 4 wks, then made to undergo physical therapy, usually for another 4–6 wks (4).
Prognosis
  • 2/3 of sinus tarsi syndrome cases respond to conservative treatment.
  • In the remaining 1/3 of cases, surgical intervention has been shown to cure or improve 90% of patients (4).
  • A 15-yr retrospective study on conservative treatment of sinus tarsi syndrome showed that most of these patients eventually required surgical intervention after nonoperative treatment failed to alleviate their symptoms, whereupon long-term follow-up revealed relief from pain after surgery (15).
Complications
  • Sinus tarsi syndrome responds well to therapeutic interventions, often mixed local anesthetic and corticosteroid injections (14).
  • Should surgery be required, there are usually few postoperative complications (1,16).
  • The most common reported complication from surgical intervention is a transient neurapraxia involving branches of the superficial peroneal nerve (17).
References
1. Lowy A, Schilero J, Kanat IO. Sinus tarsi syndrome: a postoperative analysis. J Foot Surg. 1985;24:108–112.
2. Akiyama K, Takakura Y, Tomita Y, et al. Neurohistology of the sinus tarsi and sinus tarsi syndrome. J Orthop Sci. 1999;4:299–303.
3. Schnirring-Judge M, Perlman M. Chronic ankle conditions: Sinus tarsi syndrome. In: Banks A, ed. Foot and ankle surgery, 3rd Ed, Vol 1; 35:1091–1092.
4. Taillard W, Meyer JM, Garcia J, et al. The sinus tarsi syndrome. Int Orthop. 1981;5:117–130.
5. Herrmann M, Pieper KS. [Sinus tarsi syndrome: What hurts?] Unfallchirurg. 2008.
6. Duddy RK, Duggan RJ, Visser HJ, et al. Diagnosis, treatment, and rehabilitation of injuries to the lower leg and foot. Clin Sports Med. 1989;8:861–876.
7. Schwarzenbach B, Dora C, Lang A, et al. Blood vessels of the sinus tarsi and the sinus tarsi syndrome. Clin Anat. 1997;10:173–182.
8. Mabit C, Boncoeur-Martel MP, Chaudruc JM, et al. Anatomic and MRI study of the subtalar ligamentous support. Surg Radiol Anat. 1997;19:111–117.
9. Dozier TJ, Figueroa RT, Kalmar J. Sinus tarsi syndrome. J La State Med Soc. 2001;153:458–461.
10. Mann R, Coughlin MJ. Athletic injuries to the soft tissues of the foot and ankle. In: Surgery of the foot and ankle, 6th ed. 1993;1165–1166.
11. Giorgini RJ, Bernard RL. Sinus tarsi syndrome in a patient with talipes equinovarus. J Am Podiatr Med Assoc. 1990;80:218–222.
12. Rab M, Ebmer J, Dellon AL. Innervation of the sinus tarsi and implications for treating anterolateral ankle pain. Ann Plast Surg. 2001;47:500–504.
13. Shear MS, Baitch SP, Shear DB. Sinus tarsi syndrome: the importance of biomechanically-based evaluation and treatment. Arch Phys Med Rehabil. 1993;74:777–781.
14. Zwipp H, Swoboda B, Holch M, et al. [Sinus tarsi and canalis tarsi syndromes. A post-traumatic entity] Unfallchirurg. 1991;94:608–613.
15. Kuwada GT. Long-term retrospective analysis of the treatment of sinus tarsi syndrome. J Foot Ankle Surg. 1994;33:28–29.
16. Oloff LM, Schulhofer SD, Bocko AP. Subtalar joint arthroscopy for sinus tarsi syndrome: a review of 29 cases. J Foot Ankle Surg. 2001;40:152–157.
17. Frey C, Feder KS, DiGiovanni C. Arthroscopic evaluation of the subtalar joint: does sinus tarsi syndrome exist? Foot Ankle Int. 1999;20:185–191.
Codes
ICD9
726.79 Other enthesopathy of ankle and tarsus


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