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Sinus Tarsi Syndrome

From WikiSM

Other Names

  • Sinus Tarsi Syndrome (STS)
  • Canalis Tarsi Syndrome

Background

  • This page refers to sinus tarsi syndrome (STS), a syndrome characterized by lateral hindfoot pain at the level of the Sinus Tarsi

History

  • First described by Denis O'Connor in 1958[1]

Epidemiology

  • Most patients present in the 3rd, 4th decade of life (need citation)

Introduction

Tarsal sinus (eye of the foot) A. Schematic presentation of the bones forming the subtalar joint and sinus tarsi, Nav – os naviculare.; B. X-ray imaging (lateral view) of the tarsal sinus. C. MRI of the subtalar joint, sinus tarsi and ligaments – ITCL – Interosseal talocalcaneal ligament, CL – Cervical ligament, M – Medial root of the inferior extensor retinaculum (IER)[2]
Lateral ankle ligaments including those of the sinus tarsi[3]

General

  • Clinical syndrome of persistent anterolateral ankle pain secondary to ankle trauma
  • Overall poorly understood condition and no widely accepted diagnostic criteria
  • Due to instability of the subtalar joint due to ligamentous injuries resulting in synovitis, infiltration of fibrotic tissue into the sinus tarsi space

Controversy

  • Although generally accepted as a syndrome, some physicians argue that each case of STS can be attributed to a more specific diagnosis
  • For example, Frey et al. performed subtalar arthroscopy on 14 patients with STS, all of whom were given a more specific diagnosis such as a ligament tear post-operatively[4]

Canalis tarsi syndrome

  • A severe variant which can include medial hindfoot pain in addition to the typical lateral symptoms

Etiology

  • General
    • Caused by hemorrhage and/or inflammation of the synovial recesses of the sinus tarsi
    • With or without tears of the associated ligaments
    • This leads to synovitis, inflammation, infiltration of fibrotic tissues
  • Causes
    • Trauma is the most common cause following a single or a series of ankle sprains[5]
    • Inflammatory arthritis such as rheumatoid arthritis, gout, or ankylosing arthritis.
    • Flatfoot deformity, tumours and soft tissue impingement have also been implicated

Associated Conditions

Anatomy of the Sinus Tarsi

  • Cylindrical canal located in the lateral hindfoot
  • Bordered by the neck of the talus and anterosuperior calcaneus
  • Stabilizes by a series of ligaments
  • Helps stabilize the ankle, resist inversion/eversion

Risk Factors

  • Sports
    • Dancers
    • Volleyball
    • Basketball players
  • Systemic
    • Overweight individuals
  • Structural

Differential Diagnosis

Differential Diagnosis Ankle Pain

Clinical Features

Clinical location of the tarsal sinus[6]

History

  • Patients can usually describe some history of ankle injury
  • Pain localized to the lateral hindfoot (sinus tarsi region)
  • Worse with walking, supination, adduction
  • Sensation of instability when walking, especially on uneven surfaces[7]

Physical Exam: Physical Exam Ankle

  • Standing examination: Inspect for Pes Planus, asyemmtry of the rearfoot
  • Tenderness over the lateral opening of the tarsal sinus, especially at end range of plantarflexion
  • Athlete may need to stand on affected limb and perform movements that recreate instability symptoms

Special Tests

Sagittal view of the sinus tarsi demonstrates diffuse soft tissue edema[8]
Retinacular bands in the sinus tarsi. (a) Schematic drawing illustrates the arrangement of the lateral (void arrowheads), intermediate (black arrowheads), and medial (arrows) roots of the oblique inferolateral arm of the inferior extensor retinaculum. The medial root forms a sling around the tendinous slips of the extensor digitorum longus tendons and attaches into the talus (a, b) and calcaneus (c, d) by means of multiple bands (a-d). The intermediate root has a selective insertion into the calcaneus, whereas the lateral root bridges over the sinus reinforcing the inferior peroneal retinaculum on the lateral aspect of the calcaneus. More dorsally, the inferior extensor retinaculum also stabilizes the tibialis anterior (TA) and the extensor hallucis longus (EHL) tendons. (b) Short-axis US image of the inferior extensor retinaculum forming a sling around the extensor digitorum longus tendon (EDL). High-resolution ultrasound identies the layers of the inferior extensor retinaculum (void arrowhead) from which its medial (arrows) and intermediate (white arrowhead) roots detach. (c) Coronal US image of the sinus tarsi reveals the medial and intermediate roots as they cross the sinus groove and insert on the talus and calcaneus (asterisk). Their oblique orientation causes posterior acoustic attenuation and a heterogeneous appearance of fat. Note the lateral root (void arrowheads) bridging over the sinus.[9]

Evaluation

Radiographs

CT

  • Findings
    • Secondary bony changes (earlier than XR)

MRI

  • Imaging modality of choice
    • Lektrakul found high sensitivity with unknown specificity[10]
  • Challenges
    • Oblique course of ligamentous structures in the sinus tarsi makes identifying a specific diagnosis difficult
    • Lee et al: found low agreement between symptomatic MRI and arthroscopy[11]
  • Findings
    • Inflammation
    • Scar tissue formation
    • Ligamentous injuries
  • Ganglion cysts in the region of the sinus tarsi may compress the posterior tibial nerve.

Classification

  • Not applicable

Management

Nonoperative

Operative

  • Indications
    • Presence of ganglion cyst
    • Failure of conservative therapy
  • Technique
    • Synovectomy
    • Debridement

Rehab and Return to Play

Rehabilitation

  • General recommendations
    • Balance and proprioceptive training
    • Muscle strengthening exercises

Return to Play/ Work

  • Needs to be updated

Complications and Prognosis

Prognosis

  • Needs to be updated

Complications

  • Long term
    • Instability of the subtalar joint due to ligamentous injuries that result in synovitis
    • Scar tissue formation in the sinus tarsi.

See Also

Internal

External

References

  1. ↑ O'CONNOR, D. "Sinus tarsi syndrome. Clinical entity." J. Bone Joint Surg. 40 (1958): 720.
  2. ↑ Katsarov, Atanas. "Sinus Tarsi–The Eye of the Foot and its Anatomical Contradictions." Acta Morphologica et Anthropologica 30: 3-4.
  3. ↑ Martin, Lewis P., et al. "Elongation behavior of calcaneofibular and cervical ligaments during inversion loads applied in an open kinetic chain." Foot & ankle international 19.4 (1998): 232-239.
  4. ↑ Frey, Carol, Keith S. Feder, and Christopher DiGiovanni. "Arthroscopic evaluation of the subtalar joint: does sinus tarsi syndrome exist?." Foot & ankle international 20.3 (1999): 185-191.
  5. ↑ Budny A. Subtalor joint instability: Current clinical concepts. Clin Pod Med Surg. 2004;21:449-460.
  6. ↑ Helgeson, Kevin. “Examination and Intervention for Sinus Tarsi Syndrome.” North American Journal of Sports Physical Therapy: NAJSPT, vol. 4, no. 1, Feb. 2009, pp. 29–37.
  7. ↑ Taillard, Willy, et al. "The sinus tarsi syndrome." International orthopaedics 5.2 (1981): 117-130.
  8. ↑ Image courtesy of radsource.us
  9. ↑ Zaottini, Federico, et al. "Ultrasound imaging guide for assessment of the intrinsic ligaments stabilizing the subtalar and midtarsal joints." Seminars in Musculoskeletal Radiology. Vol. 24. No. 02. Thieme Medical Publishers, 2020.
  10. ↑ Lektrakul, Nittaya, et al. "Tarsal sinus: arthrographic, MR imaging, MR arthrographic, and pathologic findings in cadavers and retrospective study data in patients with sinus tarsi syndrome." Radiology 219.3 (2001): 802-810.
  11. ↑ Lee, Keun-Bae, et al. "Efficacy of MRI versus arthroscopy for evaluation of sinus tarsi syndrome." Foot & ankle international 29.11 (2008): 1111-1116.
Created by:
John Kiel on 23 September 2021 13:29:14
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Last edited:
23 June 2025 15:17:02
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