Extra-articular lateral hindfoot impingement syndrome
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.
- 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 and prognosis
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
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- 2. Donovan A, Rosenberg ZS. Extraarticular lateral hindfoot impingement with posterior tibial tendon tear: MRI correlation. (2009) AJR. American journal of roentgenology. 193 (3): 672-8. doi:10.2214/AJR.08.2215 - Pubmed
- 3. Malicky, Eric S. MD; Crary, Jay L. MD; Houghton, Michael J. MD; Agel, Julie MA; Hansen, Sigvard T. Jr. MD; Sangeorzan, Bruce J. MD Talocalcaneal and Subfibular Impingement in Symptomatic Flatfoot in Adults, The Journal of Bone & Joint Surgery: November 2002 - Volume 84 - Issue 11 - p 2005-2009
- 4. Jay M. Levin, James K. DeOrio. Surgical Technique for Management of Severe Calcaneofibular Impingement: Case Series:. (2020) Foot & Ankle Orthopaedics. doi:10.1177/2473011420953793
- 5. Syed Ehtasham Junaid, Anil Haldar, Raul Colta, Karan Malhotra, Kar Ho Brian Lee, Matthew Welck, Asif Saifuddin. The awareness of hindfoot malalignment on non-weight-bearing ankle MRI. (2021) Skeletal Radiology. 50 (7): 1317. doi:10.1007/s00256-020-03674-8