Lateral Ankle Lateral Ankle PainPain

Dr Riaan BarnardDr Riaan BarnardMBChB, BSc HonsMBChB, BSc HonsM Sport Med (3’rd year)M Sport Med (3’rd year)

Case HistoryCase History• Mr V presented 3 weeks ago with chronic L Mr V presented 3 weeks ago with chronic L

sided lateral ankle painsided lateral ankle pain• Pain history of about 8/12Pain history of about 8/12• Would wake up with severe ankle pain in the Would wake up with severe ankle pain in the

morning – improve during daymorning – improve during day• Works for Telkom, has to climb ladders against Works for Telkom, has to climb ladders against

telephone poles daily, out in rural areas daily, telephone poles daily, out in rural areas daily, walking a lot on uneven ground, sometimes walking a lot on uneven ground, sometimes mountain areasmountain areas

• Sometimes pain radiating rear foot area, feeling Sometimes pain radiating rear foot area, feeling of instability when walking uneven surfacesof instability when walking uneven surfaces

• Previous history of MVA – Grade II ATF injury Previous history of MVA – Grade II ATF injury with severe inversion mechanism. This was with severe inversion mechanism. This was fully rehabilitated, Matador Lace-up brace usedfully rehabilitated, Matador Lace-up brace used

• No other medical history of noteNo other medical history of note

Clinical ExaminationClinical Examination• Pain +/- 2cm maximally anterior to L lateral Pain +/- 2cm maximally anterior to L lateral

maleolus; dull and poorly localisedmaleolus; dull and poorly localised• No swelling, redness, no pain at N-pointNo swelling, redness, no pain at N-point• No mechanical instability of hind – mid foot No mechanical instability of hind – mid foot • Pain and mild stiffness with passive inversionPain and mild stiffness with passive inversion• On pressure to the sinus tarsi, dull aching On pressure to the sinus tarsi, dull aching

pain deep in ankle followedpain deep in ankle followed

Diff DiagnosesDiff Diagnoses

1.1. Sinus Tarsi and Canalis Tarsi SyndromeSinus Tarsi and Canalis Tarsi Syndrome

2.2. Antero-lateral Impingement SyndromeAntero-lateral Impingement Syndrome

3.3. Chronic GoutChronic Gout

4.4. Stress Fracture TalusStress Fracture Talus

Special InvestigationsSpecial Investigations• Sonar in rooms - ? Fibroses and ATF thickeningSonar in rooms - ? Fibroses and ATF thickening• X-rays – no bony pathologyX-rays – no bony pathology• Uric acid levels, ESR & CRP all normalUric acid levels, ESR & CRP all normal

• 1 ml of 1% Lignocaine injected sonar-1 ml of 1% Lignocaine injected sonar-guided into sinus tarsi. Waited for 10 guided into sinus tarsi. Waited for 10 minutes, Mr V asked to walk some minutes, Mr V asked to walk some distance and ankle re-examined. On distance and ankle re-examined. On return examination, 100% resolution of return examination, 100% resolution of pain.pain.

Bio-Psycho-SocialBio-Psycho-Social

DisabilityDisability

SickSickLeaveLeave

Sinus Tarsi Sinus Tarsi SyndromeSyndrome

Treatment Plan & ProgressionTreatment Plan & Progression• Sonar guided infiltration of Sinus Tarsi and Sonar guided infiltration of Sinus Tarsi and

Canalis Tarsi with 2cc Celestone Soluspan, Canalis Tarsi with 2cc Celestone Soluspan, mixed with 1cc Naropinmixed with 1cc Naropin

• Referral to Physiotherapist forReferral to Physiotherapist for

1.1. Mobilisation subtalar jointMobilisation subtalar joint

2.2. Proprioception exercisesProprioception exercises

3.3. Strengthening lateral ankle musclesStrengthening lateral ankle muscles

Mr V has not returned yet for follow up after the Mr V has not returned yet for follow up after the above interventions.above interventions.

DiscussionDiscussion

AnatomyAnatomy• Small osseous canal with opening antero-Small osseous canal with opening antero-

inferior of lateral maleolus; ascending cranially inferior of lateral maleolus; ascending cranially by 10by 10°, directed dorsally by 45° to point °, directed dorsally by 45° to point posteromedial direction to open posterior of posteromedial direction to open posterior of medial maleolusmedial maleolus

• Interosseous ligament lies inside Canalis Tarsi, Interosseous ligament lies inside Canalis Tarsi, dividing it in anterior portion – part of the TCN dividing it in anterior portion – part of the TCN joint – and posterior portion – as part of the joint – and posterior portion – as part of the subtalar joint.subtalar joint.

• Sinus Tarsi at its opening has a fat pad covering Sinus Tarsi at its opening has a fat pad covering it, rich in blood vessels, fat and connective it, rich in blood vessels, fat and connective tissue, with the canal lined out by synovial tissue, with the canal lined out by synovial membranemembrane

• Cruciform arrangement of strong Talo-Cruciform arrangement of strong Talo-Calcaneal Interosseous Ligament (TCIL), Calcaneal Interosseous Ligament (TCIL), expanding from lateral to medial between expanding from lateral to medial between calcaneus and talus, anchoring the two bones calcaneus and talus, anchoring the two bones strongly togetherstrongly together

• TCIL extends exactly in the axis of movement TCIL extends exactly in the axis of movement of the subtalar joint, which is important with of the subtalar joint, which is important with regard to hindfoot stability and mobility in regard to hindfoot stability and mobility in relation to inversion and eversion movementsrelation to inversion and eversion movements

ATFATF

CFLCFL

Lat TCLLat TCL

Ant TFLAnt TFL

PeronealPeronealTendonsTendons

Post FacetPost FacetCalcaneusCalcaneus FibulaFibula

3 Layers3 LayersExt BrevisExt BrevisRetinaculumRetinaculum

Causes Sinus Tarsi SyndromeCauses Sinus Tarsi Syndrome1.1. 70% of all patients had single / repeated 70% of all patients had single / repeated

inversion injury of ankleinversion injury of ankle

2.2. Repeated, forced eversion to ankle during Repeated, forced eversion to ankle during high jump take offhigh jump take off

3.3. Chronic overuse injury due to poor Chronic overuse injury due to poor biomechanics, especially excessive biomechanics, especially excessive subtalar pronationsubtalar pronation

4.4. Gout, inflammatory arthropathies and Gout, inflammatory arthropathies and osteoarthritisosteoarthritis

Clinical ManifestationsClinical Manifestations

O’Connor & Brown in 1957 described the first of 2 O’Connor & Brown in 1957 described the first of 2 syndromes, the STS being the first. The Canalis Tarsi syndromes, the STS being the first. The Canalis Tarsi Syndrome was later described as single entity, or Syndrome was later described as single entity, or occurring in conjunction with STSoccurring in conjunction with STS

• Poorly localised pain, most often centered 1,5-2cm Poorly localised pain, most often centered 1,5-2cm anterior to lateral maleolus in STSanterior to lateral maleolus in STS

• Minor localized swelling and occasionally pain over ATFMinor localized swelling and occasionally pain over ATF• Pain most severe in morning, diminishes with exercise, Pain most severe in morning, diminishes with exercise,

increases with running on curve in direction of painful increases with running on curve in direction of painful ankleankle

• Feeling of instability hind foot, difficulty in walking on Feeling of instability hind foot, difficulty in walking on uneven surfacesuneven surfaces

• Stiff subtalar joint, painful forced passive eversion and Stiff subtalar joint, painful forced passive eversion and forced passive inversionforced passive inversion

• Canalis Tarsi Syndrome pain radiates from sinus tarsi Canalis Tarsi Syndrome pain radiates from sinus tarsi opening across ankle to medial aspect of hind footopening across ankle to medial aspect of hind foot

DiagnosesDiagnoses

• X-rays:X-rays: to exclude any bony pathology / to exclude any bony pathology / arthropathyarthropathy

• Sonar:Sonar: acc to Shields et al (2003) abnormal acc to Shields et al (2003) abnormal hypoechogenicity within the sinus tarsi is hypoechogenicity within the sinus tarsi is compatible with STS. Identification of ATF compatible with STS. Identification of ATF ligament injury should prompt evaluation of the ligament injury should prompt evaluation of the sinus tarsi, as both occur with inversion injuriessinus tarsi, as both occur with inversion injuries

• MRI:MRI: can show increased signal and fluid in the can show increased signal and fluid in the sinus tarsiisinus tarsii

• Arthrogram:Arthrogram: acc to Zwipp et al (1996), shows acc to Zwipp et al (1996), shows sac-like bulge of the ventral synovial membrane sac-like bulge of the ventral synovial membrane of the subtalar joint. This line is normally finely of the subtalar joint. This line is normally finely denticulateddenticulated

““Diagnostic Treatment”Diagnostic Treatment”Zwipp et al (1996) suggested a single, sonar-Zwipp et al (1996) suggested a single, sonar-

guided 1cc 1% Lignocaine injection into the guided 1cc 1% Lignocaine injection into the sinus tarsi as sinus tarsi as first partfirst part of clinical investigation. of clinical investigation. If the pain disappears suddenly, and pain-free If the pain disappears suddenly, and pain-free functional hopping can be done afterwards, functional hopping can be done afterwards, conservative treatment is indicatedconservative treatment is indicated

• 3-4cc of 2% Lignocaine + 1cc corticosteroid 3-4cc of 2% Lignocaine + 1cc corticosteroid (Triamcinolone) can than be injected sonar-(Triamcinolone) can than be injected sonar-guided into the sinus tarsi via thin needleguided into the sinus tarsi via thin needle

• Injections are to be repeated weekly or Injections are to be repeated weekly or fortnightly for maximum 6 injectionsfortnightly for maximum 6 injections

• 80% permanent success rates were achieved80% permanent success rates were achieved• Conservative treatment should always be fully Conservative treatment should always be fully

exhausted before surgery should be exhausted before surgery should be consideredconsidered

Injection TechniqueInjection Technique• Needle at the level of the lateral maleolus tipNeedle at the level of the lateral maleolus tip• Half a transverse finger ventrally to the turning Half a transverse finger ventrally to the turning

margin of the lateral maleolusmargin of the lateral maleolus• Ascending cranially by 10Ascending cranially by 10°°• Directed dorsally by 45°Directed dorsally by 45°• Injections should be performed under sterile Injections should be performed under sterile

conditionsconditions• Patients must be informed about the possible Patients must be informed about the possible

risk of corticosteroid therapyrisk of corticosteroid therapy• With the combination of Canalis Tarsi With the combination of Canalis Tarsi

Syndrome symptoms, a much longer needle is Syndrome symptoms, a much longer needle is used, and with sonar-guiding infiltration deep used, and with sonar-guiding infiltration deep into the tarsal canal should be attemptedinto the tarsal canal should be attempted

Other Treatment ModalitiesOther Treatment Modalities• Relative rest, ICE, NSAIDs and Relative rest, ICE, NSAIDs and

electrotherapeutic modalitieselectrotherapeutic modalities• Subtalar joint mobilisation techniquesSubtalar joint mobilisation techniques• Biomechanical correction of excessive subtalar Biomechanical correction of excessive subtalar

pronationpronation• Rehab with proprioception and strength training Rehab with proprioception and strength training

techniques to peroneals and lateral ankle techniques to peroneals and lateral ankle stabilisersstabilisers

• Brown in 1960 described operative technique Brown in 1960 described operative technique which consists of dissection of the tarsal sinus which consists of dissection of the tarsal sinus by antero-lateral Ollier approach. Fat pad is first by antero-lateral Ollier approach. Fat pad is first resected, inflammatory changes in the TCIL resected, inflammatory changes in the TCIL removed by debridement, capsulectomy was removed by debridement, capsulectomy was then performed, followed by resection of then performed, followed by resection of synovia in area of posterior facetsynovia in area of posterior facet

• Modern approach now is through ArthroscopyModern approach now is through Arthroscopy

Learning Experience and Learning Experience and Take Home MessageTake Home Message

VictimVictim

vs.vs.

CulpritCulprit

ReferencesReferences

1.1. Brukner, P; Khan, K. Brukner, P; Khan, K. Clinical Sports Medicine.Clinical Sports Medicine. Third Third Edition, 2008. pg 640-641Edition, 2008. pg 640-641

2.2. Lee, KB et al. Subtalar Arthroscopy for Sinus Tarsi Lee, KB et al. Subtalar Arthroscopy for Sinus Tarsi Syndrome : Arthroscopic Findings and Clinical Outcomes Syndrome : Arthroscopic Findings and Clinical Outcomes of 33 Consecutive cases. The journal of Arthroscopic & of 33 Consecutive cases. The journal of Arthroscopic & Related Surgery, vol 24 (10) Oct 2008. pg 1130-1134Related Surgery, vol 24 (10) Oct 2008. pg 1130-1134

3.3. Oloff, LM et al. Subtalar Joint Arthroscopy for Sinus Tarsi Oloff, LM et al. Subtalar Joint Arthroscopy for Sinus Tarsi Syndrome: A Review of 29 Cases. Journal of Foot and Syndrome: A Review of 29 Cases. Journal of Foot and Ankle Surgery, Dec 2000. pg 152-157Ankle Surgery, Dec 2000. pg 152-157

4.4. Pisani, G et al. Sinus Tarsi Syndrome and Subtalar Joint Pisani, G et al. Sinus Tarsi Syndrome and Subtalar Joint Instability. Clinics in Podiatric Medicine and Surgery, vol Instability. Clinics in Podiatric Medicine and Surgery, vol 22 (1) Jan 2005. pg 63-7722 (1) Jan 2005. pg 63-77

5.5. Shields, G et al. Sonography of Sinus Tarsi Syndrome. Shields, G et al. Sonography of Sinus Tarsi Syndrome. Ultrasound in Medicine and Biology, vol 29 (5S), 2003Ultrasound in Medicine and Biology, vol 29 (5S), 2003

6.6. Zwipp, H et al. Sinus Tarsi and Canalis Tarsi Syndrome. A Zwipp, H et al. Sinus Tarsi and Canalis Tarsi Syndrome. A Post-Traumatic Entity. Journal of Foot and Ankle Surgery, Post-Traumatic Entity. Journal of Foot and Ankle Surgery, vol 2 1996. pg 181-188 vol 2 1996. pg 181-188