Sinus tarsi syndrome is an inflammatory reaction found within the sinus
tarsi. The sinus tarsi is the lateral entry point to the subtalar joint. The
subtalar joint consists of the talus on the top and the calcaneus (heel bone) on
the bottom. 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 repetitive traumatic load applied to the
subtalar joint resulting in forced inversion of the joint. Examples of
repetitive inversion activities that would injure the subtalar joint 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 strain on the sinus tarsi.
eversion of the subtalar joint can also contribute to the onset of sinus tarsi
syndrome. Ballet is a good example of an activity that results in forced
eversion of the subtalar joint. Each of the four positions of ballet result in one or both of the
feet being placed in a position where the subtalar joint is in forced eversion
placing 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 during 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 subtalar joint arthritis. MRI's can be useful in cases of sinus
tarsi syndrome and can identify inflamed tissue within the sinus tarsi.
Treatment of Sinus Tarsi Syndrome
Treatment of sinus tarsi syndrome begins with identification of the activity
that may be contributing to subtalar joint injury. Rest and bracing of the
subtalar joint, using an
ankle brace is helpful.
Orthotics do help to limit the range of motion of the subtalar joint.
It's important to recognize that most cases of sinus tarsi syndrome are due
to mechanical load applied to the subtalar joint. Therefore, the most
important aspect of caring for sinus tarsi syndrome is identifying and
eliminating pathological loads applied to the subtalar joint. Inflammation
within the sinus tarsi can be controlled with injectable cortisone. 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 sinus tarsi.
Surgical treatment of sinus tarsitis focuses on the removal of the soft
tissue contents of the sinus tarsi. The soft tissue plug found in the
sinus tarsi is called Hoke's tonsil. Removal of Hoke's tonsil acts to
denervate the sinus tarsi. Denervation of the sinus tarsi does not correct
the mechanical problems of the subtalar joint, but denervation removes the local
sensory feedback from the sinus tarsi. Therefore, removal of Hoke's
tonsile is simply used to eliminate the pain associate with sinus tarsi
Cervical ligament - the primary ligament found in the sinus tarsi. Also
known as the ligament of Farabeu.
Canalis tarsi - the deeper portion of the sinus tarsi extending deep within
the subtalar joint.
Sulcus calcanei - the lower portion of the canalis tarsi that consists of the
calcaneus (heel bone).
Sulcus tali - the upper portion of the canalis tarsi, comprised of the talus.
Sinus tarsi - opening to the tarsal bones.
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.
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
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 anesthetic in the sinus tarsi.
Impingement within the ankle
Intermediate dorsal cutaneous nerve entrapment
Peroneal tendon rupture
Subtalar joint arthritis
Tarsal tunnel syndrome
Products Recommended for Sinus Tarsi Syndrome:
This article was written by Jeffrey A. Oster, DPM and last revised on
2/8/13. Additional references include;
1. Akiyama K, Takakura Y, Tomita Y, Sugimoto K, Tanaka Y, Tamai S.
Neuro-histology of the sinus tarsi and sinus tarsi syndrome. J Orthop Sci.
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
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.
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
9. Shear MS, Baitch SP, Shear DB. (1993). Sinus tarsi syndrome: the importance
of biomechanically based evaluation and treatment. Arch Phys Med Rehabil. 74,
10. O'Connor D. Sinus tarsi syndrome. A clinical entity. J Bone Joint Surg
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