NB This page is from the 2005 Hyperbook.
Last evidence check November 2004.
The main problems encountered in the tarsal joints are arthritis and post-traumatic pain and instability.
The subtalar and talonavicular joints are frequently affected by rheumatoid arthritis, leading to a flatfoot deformity as the static restraints are overcome by the forces of gait (Keenan 1990). Lesser tarsal joints may also be affected by RA and this may contribute to flatfoot in some patients.
Post-traumatic OA may affect any of the tarsal joints:
Primary OA, often as part of generalised OA, is rarely commented on in textbooks, but is seen reasonably frequently in practice, especially in the TMT joints. Osteoarthritis may also occur in association with tarsal coalitions.
Subtalar joint pain is felt mainly in the lateral hindfoot on activity. If there is a valgus hindfoot or synovitis, there may be impingement pain felt mainly on lateral hindfoot deviation. Some patients complain of instability or locking, which may be described as being in the ankle.
Talonavicular pain is felt on the medial, dorsal or occasionally lateral midfoot. Patients often describe it as being in the ankle, and it is important to clarify exactly where “ankle” symptoms are felt. Dorsal osteophytes may present as painful lumps or be misinterpreted as ganglia.
Calcaneocuboid pain is felt on the lateral side of the hindfoot. It may be difficult to distinguish from peroneal tendon pain. Some patients complain of clicking or instability.
Tarsometatarsal pain is usually felt on the dorsum or (1 st TMT joint) medial aspect of the midfoot. Sometimes pain is referred into the forefoot and may even present as apparent metatarsalgia. Large osteophytes causing pressure on the shoes, either dorsally or on the plantar aspect of the 1 st TMT joint may be the main complaint.
All patients should be asked about:
Examination may show features of a generalised arthropathy, or, less commonly, neurological disease. There may be a generalised deformity of the foot, most commonly flatfoot, in which case the Achilles tendon may be tight and ankle dorsiflexion limited. The function of the long tendons, particularly the tibialis posterior, should be assessed by standard tests.
Examination of individual tarsal joints will generally show reduced movement in the presence of arthritis. Reproduction of symptoms by manipulation of the joints helps to localise the source of pain. Pressure areas related to osteophytes should be noted. Any forefoot abnormalities should also be noted.
An apparent underlying inflammatory arthropathy or neurological disorder should be investigated by standard means.
The tarsal joints should be imaged by standing AP, lateral and oblique radiographs. In the presence of hindfoot malalignment a standing hindfoot alignment radiograph will help tell whether the deformity is at the ankle or subtalar level, or both. Talocalcaneal coalitions are often apparent on a lateral view, but an axial calcaneal view or CT will give additional information. Calcaneonavicular coalitions are usually apparent on an oblique view of the midfoot.
CT can help assess complex deformities. Either CT or MR can be used to evaluate coalitions.
Arthritic pain can usually be controlled with analgesics and/or NSAIDs; there is little evidence that NSAIDs have additional efficacy. Shoes should be chosen with support and accommodation in mind. Mobile deformities may have less pressure problems with corrective orthoses, while stiff deformities may be more comfortable with off-the-shelf or moulded supportive orthoses. Physiotherapy is often useful to optimise range of motion, muscle strength and proprioception, especially in the presence of complaints of instability.
Steroid injections into the tarsal joints can, anecdotally, be useful to control symptoms, although there are no published results.
There are no formal studies of the effectiveness of non-surgical treatment of hindfoot arthritis.
Surgery for painful hindfoot joints consists mainly of fusion. Arthroscopic debridement can be useful in the subtalar joint for early OA, especially if there are synovitis or osteochondral flaps.
Selective fusions provide satisfactory relief of individual joint symptoms in the majority of patients; triple fusion is not usually required. Selective injections of local anaesthetic and/or steroid can be helpful in choosing which joints to fuse, although there is no evidence on the validity of this approach.
Modern surgical techniques emphasise minimal resection consistent with exposing fresh bone, internal fixation with compression screws or staples and bone grafting as necessary. Sufficient bone graft can usually be harvested from the calcaneum and/or tibia, unless structural graft is necessary, for instance in distraction arthrodesis of the subtalar joint after calcaneal fracture.
Successful fusion is obtained in 85-90% in most studies, with non-union rates of 5-10%. Non-union is slightly higher in the talonavicular joint, probably because of difficulty in debridement and fixation. Degenerative changes develop in about 10% of adjacent joints, though often asymptomatic.
Instability of the subtalar joint usually occurs in association with ankle ligament injuries. Some series of ankle instability report subtalar problems in 10% of cases, others rarely identify it. This may, to some extent, reflect how carefully the subtalar joint is evaluated.
Patients usually complain of giving way or pain “in the ankle”, occasionally of clicking or locking. Occasionally excess laxity of the subtalar joint can be detected clinically with a medial displacement or anteromedial stress test. There is often associated ankle instability or peroneal tendon problems.
Standard ankle anterior draw or talar tilt stress radiographs may demonstrate abnormal movement at the subtalar joint. Oblique stress radiographs may also be useful. MR can show subtalar ligament lesions and joint surface abnormalities.
As with ankle instability, most patients respond to a rehabilitation programme to improve muscle strength, flexibility and proprioception. Persistent symptoms may be treated by stabilisation:
Arthroscopic debridement of the subtalar joint can be useful for synovitis and joint surface injuries, and this may have a more significant role to play in the future.
If end-stage arthritis develops a fusion may be necessary
This is an uncommon post-traumatic problem which presents with lateral hindfoot pain and clicking. It may be difficulat to distinguish from peroneal tendonopathy. Manual stress testing or stress radiography may reproduce pain or show abnormal movement.
Local physiotherapy and a rehabilitation programme are usually helpful. Steroid injection into the joint can help pain.
Stabilisation techniques with tendon graft have been described, with fusion as a last resort.
Bossing, usually over the TMT or talonavicular joints, is quite common and usually presents as a swelling that rubs on the shoes. There may be an overlying adventitious bursa which can be confused with a ganglion. Some TMT bosses irritate the deep peroneal nerve. If no arthritic changes are shown by clinical or radiological assessment, these bosses are probably quite benign, although there are no outcome studies.
Many tarsal bosses show little on radiographs, implying that a good deal of the swelling is soft tissue.
Some patients need only reassurance or advice on choosing shoes with enough room to accommodate the boss. Surgical removal is usually successful, although some patients find the scar still rubs on their shoes. We have not had any new deep peroneal nerve lesions, and about 10% recurrence, usually within 2 years.