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   Health > Ailments > Sinus Tarsi Syndrome
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Sinus Tarsi Syndrome

Just below the ankle is an obscure joint called the subtalar joint. The subtalar joint consists of the talus to the top and the calcaneus (heel bone) to the bottom. A small canal can be found in the subtalar joint called the sinus tarsi. When the nerves within the sinus tarsi become compressed, a painful condition results called sinus tarsi syndrome. Sinus tarsi syndrome is also referred to as sinus tarsitis.

Many patients with sinus tarsi syndrome describe a history of trauma to the subtalar joint. Trauma may be due to an ankle sprain or a fall. In addition to a traumatic onset, sinus tarsi syndrome may also be due to chronic inflammatory conditions of the subtalar joint.

Chronic inflammatory tissue can result from arthritis or cyst formation within the sinus tarsi or adjacent subtalar joint. First described in 1958 by O'Conner, sinus tarsi syndrome was initially thought to be due to post traumatic scarring. The onset of sinus tarsi syndrome usually occurs in the second or third decade of life.

Most doctors who work with the foot and ankle believe that sinus tarsi syndrome is due to traumatic load applied to the sinus tarsi and subtalar joint. Traumatic load applied to the sinus tarsi can be abrupt or chronic. Examples of activities that would eccentrically load the subtalar joint would include the trailing foot of a softball pitcher or bowler. Other examples include sitting with the feet tucked under the weight of your body.

Each of these activities results in forced inversion of the subtalar joint and sinus tarsi. Forced eversion of the subtalar joint can also contribute to the onset of sinus tarsi syndrome. Each of the four positions of ballet results in one or both of the feet being placed in a position where the subtalar joint is in forced eversion which places strain on the sinus tarsi. This strain on the sinus tarsi results in sinus tarsi syndrome.

The diagnosis of sinus tarsi syndrome is made by direct palpation of the sinus tarsi and range of motion of the subtalar joint. An injection of local anesthesia into the sinus tarsi is a common tool used to block the nerve sensation of the sinus tarsi. If pain relief is achieved following injection, the diagnosis of sinus tarsi syndrome is made.

X-rays do not provide information specific to sinus tarsi syndrome, but x-rays are necessary to rule out fractures of the talus or calcaneus. Also, x-rays can be used to evaluate the integrity of the subtalar joint and rule out arthritis. MRI's can be useful in cases of sinus tarsi syndrome and can identify inflamed tissue within the canalis tarsi. Anatomy

The sinus tarsi is a cone shaped area that lies between the talus to the top and calcaneus to the bottom. The sinus tarsi actually refers to the entry of the canalis tarsi, or deeper portion of the sinus. The canalis tarsi consists of the calcaneal portion called the sulcus calcanei. The dorsal or talar portion of the canalis tarsi is called the sulcus tali.

The canalis tarsi separates the two segments of the subtalar joint. The subtalar joint is actually three different joint facets that are separated by the canalis tarsi. The anterior and middle facets lie distal to the canalis tarsi. The posterior facet lies proximal to the canalis tarsi.

The subtalar joint is held together by both internal supporting structures and external structures that traverse the joint. The cervical ligament, also known as the ligamanet of Farabeu, lies within the sinus tarsi. Deeper to the cervical ligament is an interosseous ligament that connects the talus and calcaneus. Both the cervical ligament and interosseus ligaments help to stabilize the subtalar joint during pronation (flattening of the foot) and supination (increasing the arch of the foot).

The bifurcate ligament also originates in the sinus tarsi and extends across the top of the foot to the medial aspect of the foot. The bifurcate ligament is a two part, or Y shaped retinacular band that inhibits supination and prevents the extensor tendons on the top of the foot from 'bow stringing'. A fatty plug lies within the sinus tarsi. This fatty material is called Hoke's tonsile. Additional soft tissue found within the sinus tarsi includes the synovium of the subtalar joint.

Numerous small nerve endings are found in the canalis tarsi and are extensions of the posterior tibial nerve. Studies have shown that the nerve endings in the canalis tarsi are a source of nociceptive (pain) and proprioceptive (space orientation) neural sensation. Strain applied to the nerve endings of the sinus tarsi will stimulate a proprioceptive response and will initiate splinting of adjacent muscles and tendons in an attempt to limit excessive motion of the subtalar joint.

Arterial flow into the canalis tarsi comes from a combination of sources including the posterior tibial artery, anterior malleolar artery, peroneal artery and distal lateral tarsal artery. The artery in the tarsal canal is called the artery of the tarsal canal and supplies the majority of blood supply to the talus. Biomechanics

Compression of the tissues within the sinus tarsi occurs as the foot pronates (flattens). Testing has found that pronation significantly increases subtalar joint pressure and pressure within the sinus tarsi. It's very common to find patients who experience sinus tarsi syndrome also suffer from pathological flatfeet and conditions such as tarsal coalitions or posterior tibial tendon dysfunction.

Symptoms



The symptoms of sinus tarsi syndrome include the following;

Deep tarsal pain in the subtalar joint.
Tarsal pain that increases with time on the feet.
Pain that is relieved by rest.
Tarsal pain that increases with forced inversion.

The symptoms of sinus tarsi syndrome can often be relieved with an injection of local anaesthetic in the sinus tarsi. 63% of patients with sinus tarsi syndrome complain of pain following an ankle sprain.

Treatment of sinus tarsi syndrome



Treatment of sinus tarsi syndrome begins with rest and an injection of cortisone into the sinus tarsi. Rx orthotics do help to limit the range of motion of the subtalar joint. Ankle bracing can also be helpful.

If cortisone and bracing prove ineffective, ablation (destruction) of the nerve can be accomplished by chemical or thermal means. Chemical ablation is performed using serial injections of 4% alcohol. Relief with chemical ablation is achieved after 4-6 injections. Thermal ablation involves the use of a thermal ablation unit that freezes the nerve of the tarsal canal.

Surgical debridement of the sinus tarsi can also be used to denervate the sinus tarsi. Arthroscopic methods are available and have proven to be successful. Open evacuation of the contents of the sinus tarsi is also performed. In severe cases of sinus tarsitis where pain does not respond to surgical evacuation of the sinus, a fusion of the subtalar joint may be indicated.

References



1. Akiyama K, Takakura Y, Tomita Y, Sugimoto K, Tanaka Y, Tamai S. Neurohistology of the sinus tarsi and sinus tarsi syndrome. J Orthop Sci. 1999;4(4):299-303.

2. Schwarzenbach B, Dora C, Lang A, Kissling RO. Blood Vessels of the sinus tarsi and sinus tarsi syndrome. Clin Anat. 1997;10(3):178-82.

3. Oloff LM, Schulhofer SD, Bocko AP. Subtalar joint arthroscopy for sinus tarsi syndrome: a review of 29 cases. J Foot Ankle Surg. 2001 Mya-June;40(3):152-7.

4. Giorgini RJ, Bernard RL. (1990) Sinus tarsi syndrome in a patient with talipes equinovarus. JAPMA. 80(4), pp218-222.

5. Liberatore R, Lemont H (1987) Sinus tarsi syndrome or ligament injury? Letters to the editor. JAPMA. 77(11), pp623. Meyer JM, Lagier R (1977) Post traumatic sinus tarsi syndrome. Acta orthop scand. 48, pp121-128.

6. Bernstein RH, Bartolomei FJ, McCarthy DJ (1985) Sinus tarsi syndrome: Anatomical, clinical and surgical considerations. JAPMA. 75(9), pp475-479.

7. Borrelli AH, Arenson, DJ (1987) Sinus tarsi syndrome and its relationship to hallux abducto valgus. JAPMA. 77(9), pp495-499. 8. Frey C, DiGiovanni C, Feder KS. (1998) Arthroscopic evaluation of the subtalar joint: does sinus tarsi syndrome exist? AOFAS 1998 Annual Summer Meeting.

9. Shear MS, Baitch SP, Shear DB. (1993). Sinus tarsi syndrome: the importance of biomechanically based evaluation and treatment. Arch Phys Med Rehabil. 74, pp777-781.

10. O'Connor D. Sinus tarsi syndrome. A clinical entity. J Bone Joint Surg 1958;40(A):720-729.

About the author:
This article was written by Jeffrey A. Oster, DPM. Dr. Oster is a board certified podiatrist and medical director of www.Myfootshop.com, a consumer oriented reference for foot and ankle products and problems.
 
Dr.Jeffrey A. Oster, D.P.M.
 
 
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