Sinus tarsi syndrome

Last revised by Joshua Yap on 13 May 2023

Sinus tarsi syndrome is the clinical syndrome of pain and tenderness of the lateral side of the hindfoot, between the ankle and the heel. Imaging often demonstrates the ligaments and soft tissues in the sinus tarsi are injured.

Sinus tarsi syndrome has been described in dancers, volleyball and basketball players, overweight individuals, and patients with flatfoot and hyperpronation deformities. The incidence of sinus tarsi syndrome is unknown, but it has been associated with ankle sprains that may also result in talocrural joint instability. Most patients present in the 3rd to 4th decades of life.

  • localized pain in the sinus tarsi region: worsens when firm pressure is placed over the lateral opening of the tarsal sinus, and is most severe during walking or supination and adduction of the foot

  • feeling of instability aggravated by weight-bearing, especially on uneven surfaces

  • pain on palpation of the sinus tarsi with aggravation on foot inversion and eversion

  • cessation of pain on injection of a local anesthetic into the sinus tarsi is diagnostic for sinus tarsi syndrome

Sinus tarsi syndrome is caused by hemorrhage or/and inflammation of the synovial recesses of the sinus tarsi with or without tears of the associated ligaments.

Trauma is the most common cause following one single or a series of ankle sprains. Inflammatory arthritides such as rheumatoid arthritis, gout, or ankylosing arthritis are also associated.

  • canalis tarsi syndrome: considered a severe variant that can include medial hindfoot pain in addition to the typical lateral symptoms

Osteoarthritis of the subtalar joint and intraosseous cysts may be present in advanced cases.

Can show secondary bony changes at an earlier stage than radiography.

MRI is probably the best test to show changes in the soft tissues of the sinus tarsi including inflammation, scar tissue formation or ligamentous injuries. The T1-hyperintense fat in the sinus tarsi space is replaced by either fluid or scar tissue, and the ligaments may be disrupted. Ganglion cysts in the region of the sinus tarsi may compress the posterior tibial nerve.

Inflammatory changes on bone scan may be attributed to the sinus tarsi/subtalar region.

Conservative treatment is usually effective. It may include anti-inflammatory drugs, stable shoes, a period of immobilization, cryotherapy, ankle sleeve and orthoses. Treatment of ganglion cysts in the sinus tarsi typically consists of surgical excision. Recommendations for rehabilitation include balance and proprioceptive training, and muscle-strengthening exercises.

Long-term complications of sinus tarsi syndrome can be primarily described as an instability of the subtalar joint due to ligamentous injuries that result in synovitis and scar tissue formation in the sinus tarsi.

It was first described by Denis O'Connor in 1958.

For the clinical presentation of sinus tarsi syndrome, consider:

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