Subtalar arthroscopic debridment for the treatment of sinus tarsi syndrome: case series

Arthroscopic Management of Sinus Tarsi Syndrome

Sinus tarsi syndrome (STS) is a clinical entity characterized by pain of the lateral hindfoot and a sense of instability especially on uneven surfaces due to chronic inflammation characterized by fibrotic tissue remnants and synovitis of the sinus tarsi, associated with both traumatic and nontraumatic causes. Arthroscopic debridement of the subtalar joint is an effective and safe alternative in the treatment of STS refractory to conservative treatment. The purpose of this Technical Note is to report the details of arthroscopic management of STS.

The Evolution of Sinus Tarsi Syndrome-What Is the Underlying Pathology?-A Critical Review

Background and Objectives: Sinus tarsi syndrome (STS) is defined as pain located at the lateral opening of the tarsal sinus. The exact etiology of sinus tarsi syndrome is not completely understood. Some do not believe it to be a true pathology. This review aims to clarify the definition of sinus tarsi syndrome to better understand the underlying pathologies. We further propose an algorithm to evaluate sinus tarsi pain and provide advice for consecutive treatment options. Design: This is a narrative review. By searching PubMed, the available current literature was reviewed. Articles were critically analyzed to determine the pathoanatomy, biomechanics, and etiology of sinus tarsi pain. Algorithms for clinical evaluation, diagnosis, and treatment were also recorded. Finally, the authors approach to evaluating and treating sinus tarsi pain was included in this review. Results: Reviewing the available literature, STS seems to be a catch-all phrase used to describe any pain in this anatomic region. Many causes of sinus tarsi pain were listed, including impingement, subtalar instability, and many other pathologies around the ankle. Conclusions: A thorough evaluation of patients presenting with pain in the sinus tarsi or instability of the hindfoot is essential to determining the underlying cause. When the cause of pain is still not clear after clinical exam and radiologic assessment, subtalar arthroscopy can be helpful as both a diagnostic and treatment tool. We propose that the term of STS should be avoided and that a more accurate diagnosis be used when possible. Once a diagnosis is made, appropriate treatment can be initiated.

Sinus tarsi and sinus tarsi syndrome: An imaging review

The sinus tarsi is a funnel-shaped region at the junction of mid-foot and hind-foot which contains fat, vessels, nerves and ligaments. The ligaments help stabilise the subtalar joint and maintain the longitudinal arch of the foot. The nerve endings contain proprioceptive fibres indicating a role for the sinus tarsi in movement of the foot. Sinus tarsi syndrome is a clinical entity characterised by lateral hind-foot pain with worsening on palpation and weight-bearing, and perceived instability. It is associated with both traumatic and non-traumatic causes. Magnetic resonance imaging is the imaging modality of choice for assessment of the sinus tarsi and sinus tarsi syndrome. In this review article, we review the anatomy and various aetiologies of sinus tarsi syndrome, along with the imaging appearances.

Lateral endoscopy of the sinus tarsi: Anatomy, technique and current indications

Numerous pathologies are reported in the lateral mid- and hind-foot. Access to the sinus tarsi is difficult, making lateral endoscopy the preferred approach. The present technical note describes the anatomy, technique and current indications for lateral endoscopy of the sinus tarsi.

A high rate of talocalcaneal interosseous ligament tears was found in chronic lateral ankle instability with sinus tarsi pain

PURPOSE

To evaluate the arthroscopic findings of subtalar joints, including interosseous talocalcaneal ligament (ITCL) tear, in patients with chronic lateral ankle instability (CLAI) and sinus tarsi pain.

METHODS

A total of 118 ankles (109 patients) having CLAI with sinus tarsi pain who had undergone subtalar arthroscopy and lateral ankle ligament surgery were evaluated. The medical records, radiologic images, and the arthroscopic images and videos were reviewed. ITCL tears were classified into 4 grades: grade 0 (no tear), grade 1 (mild), grade 2 (moderate), and grade 3 (severe). The efficacy of magnetic resonance imaging (MRI) in diagnosing ITCL tears was also evaluated by comparing preoperative official readings of MRI to arthroscopic findings. The pre- and postoperative functional scores were also assessed.

RESULTS

The overall tear rate of ITCL was 107/118 (90.7%). There were 29 ankles (23.6%) with grade 1, 42 ankles (35.6%) with grade 2, and 36 ankles (30.5%) with grade 3 tears. Isolated lateral ankle instability (LAI) was diagnosed in 43 ankles (36.4%), subtalar instability (STI) in 30 ankles (25.4%), and LAI with STI in 45 ankles (38.1%). There was a statistically significant relationship between the ITCL tear grade and the final diagnosis. ITCL tear was confirmed or suspected in 81 ankles (68.6%) on preoperative MRI. Pain Visual Analog Score and functional outcome scores including the American Orthopaedic Foot & Ankle Society and Karlsson-Peterson scores showed significant improvement after the surgery.

CONCLUSION

A high rate (90.7%) of ITCL tears was noted in CLAI patients with sinus tarsi pain. ITCL damage may play an important role in subtalar instability in patients with CLAI and sinus tarsi pain. Subtalar arthroscopic evaluation for ITCL tear is important for correct diagnosis for CLAI with sinus tarsi pain.

LEVEL OF EVIDENCE

IV.

Current concepts in sinus tarsi syndrome: A scoping review

INTRODUCTION

Sinus tarsi syndrome is a relatively unknown condition presenting with pain and a feeling of instability. We aim to summarise evidence on the aetiology, diagnosis and treatment of the condition, whilst answering the question of whether the term should be used.

METHODS

Scoping review following the methodological frameworks of Arksey and O'Malley, Levac and Peters. The review protocol is registered with the Open Science Framework: (https://osf.io/wj6ct/?view_only=59445d344ec34b6fab640d2fa7a83943).

RESULTS

In total, 605 studies were identified, 31 of which met selection criteria. Sinus tarsi syndrome is used to describe a range of distinct underlying pathologies. MRI and arthrography show non-specific abnormalities in patients and identifying underlying pathologies is challenging.

DISCUSSION

The distinct range of underlying pathologies makes identifying specific imaging abnormalities and optimal treatments difficult. Further research in determining optimal treatments for specific pathologies and investigating the efficacy of conservative treatment must be conducted, before we can justify a more specific diagnosis.

Six out of ten patients with sinus tarsi syndrome returned to pre-injury type of sport after subtalar arthroscopy

PURPOSE

The purpose of this study was to determine multiple return to sport rates, long-term clinical outcomes and safety for subtalar arthroscopy for sinus tarsi syndrome.

METHODS

Subtalar arthroscopies performed for sinus tarsi syndrome between 2013 and 2018 were analyzed. Twenty-two patients were assessed (median age: 28 (IQR 20-40), median follow-up 60 months (IQR 42-76). All patients were active in sports prior to the injury. The primary outcome was the return to pre-injury type of sport rate. Secondary outcomes were time and rate of return to any type of sports, return to performance and to improved performance. Clinical outcomes consisted of Numerous Rating Scale of pain, Foot and Ankle Outcome Score, 36-item Short Form Survey and complications and re-operations.

RESULTS

Fifty-five percent of the patients returned to their preoperative type of sport at a median time of 23 weeks post-operatively (IQR 9.0-49), 95% of the patients returned to any type and level sport at a median time of 12 weeks post-operatively (IQR 4.0-39), 18% returned to their preoperative performance level at a median time of 25 weeks post-operatively (IQR 8.0-46) and 5% returned to improved performance postoperatively at 28 weeks postoperatively (one patient). Median NRS in rest was 1.0 (IQR 0.0-4.0), 2.0 during walking (IQR 0.0-5.3) during walking, 3.0 during running (IQR 1.0-8.0) and 2.0 during stair-climbing (IQR 0.0-4.5). The summarized FAOS score was 62 (IQR 50-90). The median SF-36 PCSS and the MCSS were 46 (IQR 41-54) and 55 (IQR 49-58), respectively. No complications and one re-do subtalar arthroscopy were reported.

CONCLUSION

Six out of ten patients with sinus tarsi syndrome returned to their pre-injury type of sport after being treated with a subtalar arthroscopy. Subtalar arthroscopy yields effective outcomes at long-term follow-up concerning patient-reported outcome measures in athletic population, with favorable return to sport level, return to sport time, clinical outcomes and safety outcome measures.

LEVEL OF EVIDENCE

IV.

Anterior and Posterior Subtalar Arthroscopy Via Anterolateral and Dorsolateral Portals

Sinus tarsi syndrome is the clinical syndrome of lateral heel pain with local tenderness at the sinus tarsi and is frequently associated with a history of inversion sprain to the ankle. The lateral heel pain can be due to the capsule-ligamentous structures lateral to the axis of the anterior and posterior subtalar joints. Anterior and posterior subtalar arthroscopies are needed to detect and treat the disorders of both joints. In this Technical Note, we describe the details of a 2-portal arthroscopic approach to both anterior and posterior subtalar joints. This allows complete examination of all the possible sources of lateral heel pain in sinus tarsi syndrome.