Extra-articular lateral hindfoot impingement syndrome

Dr Henry Knipe and Dr Yuranga Weerakkody et al.

Extra-articular lateral hindfoot impingement syndrome is a non-traumatic cause of ankle impingement. This can include talocalcaneal, calcaneofibular (subfibiular) or combined talocalcaneal-subfibular impingements.

It presents as the sequela of a pathological tibialis posterior dysfunction, which can cause pes planus (flatfoot) and hindfoot valgus deformity. Healed intra-articular calcaneal fractures, neuropathic arthropathy and inflammatory arthritides may also play a causative role.

Impingement results from abnormal contact laterally as the valgus deformity results in sinus tarsi narrowing, which it does normally during eversion (although to a lesser degree in normal individuals) 3. Alternatively, there may be subluxation of the subtalar joint resulting in impingement between the calcaneum and the fibula 4

In cases of sinus tarsi narrowing, calcaneofibular impingement is unlikely to occur without sinus tarsi impingement. Thus, it is thought that impingement occurs laterally first through the sinus tarsi and then progresses to the calcaneofibular interval 3

In cases of trauma and calcaneal fractures that have malunited there may be lateral calcaneal wall blow-out with widening of the heel 4

Hindfoot valgus (often defined as a tibiocalcaneal angle >11º) with one or both of the following 5:

  • talocalcaneal impingement: high STIR signal at opposing non-articular talar and calcaneal surfaces +/- sclerosis/cysts with high signal in the lateral sinus tarsi
  • calcaneofibular impingement: high STIR signal at opposing non-articular fibular and calcaneal surfaces +/- sclerosis/cysts with high signal in the calcaneofibular interval (i.e. subfibular soft tissues)

Treatment may be non-operative or operative. Operative treatment is reserved for patients that fail non-operative treatment. The aim of operative treatment is to correct the hindfoot valgus and includes 4:

  • medialising calcaneal osteotomy
  • subtalar arthrodesis
  • combination of the two 
  • additionally, removal of any subfibular or superolateral calcaneal bone causing impingement 

Article information

rID: 62238
Tag: cases
Synonyms or Alternate Spellings:
  • Extra-articular calcaneofibular impingement (EA-CFI)
  • Extra-articular talocalcaneal impingement (EA-TCI)
  • Extraarticular lateral hindfoot impingement syndrome
  • ELHIS
  • Extra-articular lateral hindfoot impingement syndrome (ELHIS)

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Cases and figures

  • Case 1
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  • Case 2
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