Medial Subtalar Dislocation
Subtalar dislocation is caused by damage to 2 distinct types of skeletal muscles: the talonavicular and talocalcaneal joints.
Subtalar dislocations are a rare ankle injury accounting for approximately 1%-2% of all joint dislocations. These injuries occur as a result of high-energy trauma including car crashes and sports injuries. The strong joints around the ankle are the tightly connected muscles joining the talus and calcaneus explains the rarity of this injury.
According to Malaigne and Burger, there are four types of subtalar dislocations: medial lateral anterior and posterior. This classification depends on the orientation of the foot relative to the talus at the time of the injury. Medial subtalar dislocation predominates About 80% of dislocations are called acquired clubfoot, which occurs when the foot is in plantar flexion and the lateral collateral ligament is stressed when forceful pronation is exerted on the forefoot. Less commonly, lateral dislocation or acquired flat feet (15%-35%) posterior dislocations (from 0.8% to 2.5%) and anterior dislocations (1%). 
It is usually associated with fractures of the ankle, talus, calcaneus, or fifth metatarsal , and isolated subtalar dislocations are rarely seen . Subtalar dislocations can cause severe deformation of the foot shape.
Clinically Relevant Anatomy
The subtalar joint is the synovial joint between the talus and calcaneus. The facets of the talus and calcaneus are alternately concave and convex. They are surrounded by strong ligaments that make this joint relatively stable. 
Subtalar joint movement is complex because the axis of rotation is at an angle. Open-chain subtalar joint motion combines dorsiflexion/abduction/valgus and plantarflexion/adduction/varus. In a closed chain, these movements are called pronation and supination. 
The most important ligament in the subtalar joint is the intertalareal ligament. There are four other weaker connections between the talus and the calcaneus, and they are: the anterior talacane ligament, the posterior talacane ligament, the lateral talacane ligament, and the medial talacane ligament. Calaceal ligament .
Subtalar dislocations are more common in high-energy trauma, such as a fall from a height (20%) or a road traffic accident (48%) .
Subtalar joint dislocations mostly occur in plantar flexion, and most of them are closed injuries . If the foot lands in inversion or eversion, this will result in a medial (80%) or lateral (17%) subtalar dislocation, respectively. before (1%) and after (2.5%) dislocations have also been examined and described, but they are extremely rare .
- Bony or soft tissue dysplasia.
- Impaired ankle function.
- Hypoplastic ankle ligaments or calcaneal facets.
- Hypoplasia of the malleoli.
- Posttraumatic ligamentous insufficiency due to recurrent ankle sprains.
- Atrophy of the peroneal muscle predisposes to this particular injury pattern.
Related Articles Subtalar Joint Arthritis – PhysiopediaAnatomy Subtalar Joint The subtalar joint, also known as the talar heel joint, forms the articulation between the two tarsal bones (talus and calcaneus). The talus and calcaneus each have three facets. Posterior talus and calcaneus The articulation is the largest component of the subtalar joint.  Malalignment of the subtalar joint can lead to primary osteoarthritis of the ankle in the long run. See more function and biomechanics of the subtalar joint here [edit | edit source] The subtalar joint is Essential: Foot and ankle function and gait.  Rotation transfer from leg and ankle to foot.  Shock absorption in the early stance phase  Subtalar joint motions are varus-valgus  and supination-pronation (three-dimensional motion) . Pronation combines dorsiflexion abduction and valgus, and supination combines plantarflexion adduction and varus . Major ligaments of the subtalar joint [edit | editorial source] Anterior talar ligament Posterior talar ligament Lateral talar ligament Medial talar ligament Ligamentous non-weightbearing subtalar joint motion [edit | edit source] In the non-weight-bearing position, motion is described as that of the distal segment, ie, the calcaneus. The calcaneus moves over the relatively stationary talus and lower leg. Supination is a combination of Adduction inversion and plantar flexion. Pronation is a combination of abduction-valgus and dorsiflexion. The most easily observed calcaneal-coupled movements are varus and valgus. Calcaneal movement in varus when in varus, valgus in valgus Movement of the calcaneus. Weight-bearing movement[edit | edit source] Movement is the same as in the non-weight-bearing position, but the parts that move are described differently. Movement of the proximal segment to the distal segment is described. EtiologyEdit source] Subtalar dislocation Dislocation of the subtalar joint . Subtalar joint instability. Joint misalignment. Rheumatoid Arthritis. Fracture of the calcaneus/talus. Upper ankle deformity.  Primary Osteoarthritis Infection: Septic Arthritis Deposition Disease: Gout Pseudogout Tarsus Alliance  Clinical Symptoms of Osteoarthritis [edit | edit source] Coarse crepitus. Bone enlargement. Joint line tenderness. Reduced joint range of motion.  Treating [edit | edit source] Conditions such as arthritis can affect ankle range of motion  so doing subtalar ROM is important Exercises (inversion-valgus and supination-pronation). Physical therapy management [edit | edit source] Maitland mobilization of the subtalar joint [edit | edit source] Subtalar joint traction Subtalar joint medial glide and lateral glide Passive and active ROM exercises [edit | edit source] Active and Passive supination and pronation exercises as well as inversions and eversions.  Subtalar Joint – PhysiopediaIntroduction Subtalar Joint The subtalar (ST) joint is the joint in the foot between the two tarsal bones (talus and calcaneus). The joint is structurally classified as synovial joint and functions as a planar synovial joint. The ST joint allows rotation of the foot, clinically known as inversion and valgus . Pronation and supination allow : The foot and ankle can turn/change direction to maintain balance when walking on uneven terrain. acts as a shock absorber Structures [edit | edit source] Subtalar Ligament Advanced View The ST joint is a polyarticular joint with three articular surfaces that provide surfaces for joint glide.  The ST joint can be divided into two parts: The anterior subtalar part: the head of the Medial facet of the calcaneus . This allows anterior sliding (anterior articulation) of the posterior subtalar portion: the concave surface of the talus sits posterior to the convex surface of the calcaneus . This allows for backward sliding (posterior articulation) of the talus seen from below There are several The ligaments surrounding the subtalar joint provide stability. They can be divided into intrinsic ligaments (cervical and interosseous calcaneal ligaments) and extrinsic ligaments (calcaneofibular-triangular ligaments) . See more here: Foot and Ankle Structure and Functional Movement[edit | Edit source] The movements that occur at the subtalar joint are sliding and rotating. The combination of these movements is known clinically as inversion and valgus; these are considered the primary movements of the subtalar joint . The mechanics of the foot are not isolated. this is Accompanied by movements of the talocanoscaphoid and calcaneocuboid joints . Supination of the subtalar joint is primarily produced by the tibialis anterior and posterior muscles with assistance from the extensor hallucis longus and flexor hallucis longus and flexor digitorum longus. Pronation is Produced primarily by the peroneus brevis and tertiary muscles with assistance from the extrinsic muscles that extend the toes (extensor digitorum longus and hallucis longus). Function [EDIT | EDIT SOURCE] Ankle and foot in neutral and over-pronated ST joint is key to many Functional activities such as walking and running. The mechanism by which the subtalar joint propels you is complex . The primary movements of this ST joint include supination, which rolls the foot toward the midline of the body, and internal rotation, which moves the foot away from the midline. Both sports require a combination of different movements. Pronation requires a combination of dorsiflexion abduction and eversion. Supination needs to be combined with plantarflexion adduction and varus The video explains the anatomy and motion of the subtalar joint: Physiotherapy relevance [edit | editorial source] Medial ST dislocation The subtalar joint is critical to mobility and is therefore as prone to degeneration as every weight-bearing joint trauma and joint-specific disorders such as instability . Any damage to the subtalar joint and surrounding joints The soft tissues that support it can cause painful deformities in the foot (often permanently) and affect gait and mobility. Diseases that affect this joint include: Subtalar osteoarthritis Juvenile rheumatoid arthritis that is directly related to the joint: The subtalar joint is usually the first joint affected Osteoarthritis Calcaneal Fracture (the subtalar joint is usually destroyed causing the joint to become arthritic). Rheumatoid Arthritis: Mainly attacks joint tissue, usually ankle and foot ST joint instability. Subtalar dislocations occur by breaking down 2 separate bones Disorders where the subtalar joint is affected indirectly or due to other defects or injuries of the foot or ankle: Pes cavus/Pes planus Chronic ankle instability Tarsal coalition Tarsal sinus syndrome Foot and Ankle Structure and Function – Physiological Anatomy The foot and ankle form a complex system consisting of 28 bones, 33 joints, 112 ligaments, controlled by 13 extrinsic and 21 intrinsic muscles. The foot is divided into hindfoot, midfoot and forefoot. It acts as a rigid structure for Bearing weight, it also acts as a flexible structure to adapt to uneven terrain. The foot and ankle serve a variety of important functions, including: Supporting body weight. Provide balance. damping. Transfer ground reaction forces. compensation proximal dislocation. Replacement of hand function for upper limb amputee/paralyzed patients.    Structure [edit | edit source] The ankle or tibiotalar joint forms the junction of the lower leg and foot. The bony components of the ankle include the distal tibia fibula and talus. The anatomy below the ankle includes the foot, which includes: Hindfoot: The hindfoot of the foot consists of two of the seven tarsal bones, the talus and the calcaneus. The joint of the talus and calcaneus is called the subtalar joint There are three facets each on the talus and calcaneus. Midfoot: The midfoot is composed of five of the seven tarsal bones: the navicular cuboid, medial cuneiform, and lateral cuneiform. The junction between the hindfoot and midfoot is called the Chopart joint and includes the Heels the dice joint. Forefoot: The forefoot is the front of the foot. It includes the metatarsal phalanges (toes) and the sesamoids. Each finger has one metatarsal and three phalanges, except for the big toe which only has two phalanges. joints of the midfoot and The forefoot forms the Lisfranc joint.  Ankle (TC) joint [edit | edit source] The TC joint is formed between the distal tibia and fibula and the talus, commonly known as the ankle joint. The distal and lower part of the tibia – called the plafond – connects to the The fibula is connected distally to the talar dome by forming a strong mortise through the tibiofibular ligament. It is a hinge joint that allows dorsiflexion and plantarflexion movements in the sagittal plane. Subtalar (ST) joint [edit | edit source] Subtalar joint It is also known as talar joint Joint, formed between the talus and calcaneus. The talus and calcaneus each have three facets. The posterior subtalar joint forms the largest component of the subtalar joint. The subtalar joint allows inversion and eversion of the ankle and hindfoot.  Tarsal (MT) joint |Editorial source] Also known as the transverse tarsal joint or Chopart joint. Viewed from above is an S-shaped joint. It consists of two joints – the talonovicular joint and the heel-cuboid joint. Tanarvicular (TN) joint – formed between the head of the anterior talar and the superior concavity scaphoid. It does not have its own joint capsule, but shares a joint capsule with the two anterior talar-heel joints. Calcanoid Cuboid (CC) Joint – Formed between the anterior facet of the calcaneus and the posterior cuboid. Both articular surfaces are convex and concave, The joints are convex longitudinally and concave laterally. There is little movement at this joint. The tarsal metatarsal (TMT) joint complex [edit | edit source] Also known as the Lisfranc joint. This complex separates the midfoot from the forefoot. The distal tarsal row consists of three cuneiform bones And the cuboid is attached to the base of each metatarsal to form the TMT complex. It is an S-shaped joint divided into 3 distinct columns : Medial – Consists of the first metatarsal and the medial cuneiform. Medial – Consists of the medial and lateral cuneiforms of the 2nd and 3rd metatarsals respectively. Lateral – Consists of the 4th and 5th metatarsals and the cuboid. Metatarsophalangeal (MTP) Joints and Interphalangeal (IP) Joints [edit | edit source] The MTP joints form between the metatarsal heads and the corresponding bases of the proximal phalanges. fingers The joints of the toes are formed between the phalanges of the toes. Each toe has proximal and distal IP joints, except the big toe which has only one IP joint. Joint Type Joint Motion Plane Kinematic TC Joint Hinge Sagittal Plane Dorsiflexion and Plantarflexion ST Joint Primarily Condylar Lateral Some sagittal varus and valgus Dorsiflexion and plantarflexion MT joint TN joint – ball and socket CC joint – modified saddle Mostly transverse Some sagittal varus and valgus Flexion and extension TMT joint Planar MTP joint Extension Abduction & Adduction IP joint Hinge Sagittal Flexion & Extension  Kinematics [edit | edit source]  Ankle joint [edit | edit source] The tip of the medial malleolus lies in front of and above the lateral malleolus, which makes its axis oblique to sagittal and frontal planes airplane. The axis of rotation is approximately 13°-18° transverse to the frontal plane and 8°-10° to the transverse plane.  Motion in other planes, such as the horizontal and frontal planes, is required to achieve full motion in plantarflexion and dorsiflexion.  The normal available range of dorsiflexion reported in the literature varies between 0°-16.5°  and 0°-25°  and varies with loading. The normal range of plantar flexion has been reported to be approximately 0°-50°. Axis of subtalar joint edit source code] The subtalar joint is located approximately 42° superior in the sagittal plane and approximately 16° to 23° medial in the transverse plane.  The literature describes a wide range of subtalar movements ranging from 5° to 65°.  The mean ROM was 5° in pronation and 20° in supination. Inversion and eversion ROM were determined to be 30° and 18°, respectively.  The total inversion movement is approximately 2:1, and the ratio of inversion to valgus movement is 3:2.  Tarsal joint [edit | editorial source] The mid-tarsal joint rotates in two axes due to its anatomy complicated. The longitudinal axis (“A” below) is approximately 15° above the horizontal plane and approximately 10° inboard of the longitudinal plane. The oblique axis (“B” in the figure below) is located approximately 52° above the horizontal and approximately 57° from the midline. this The longitudinal axis is close to the axis of the subtalar joint, and the oblique axis is close to the axis of the calf joint. MT joint lock [edit | edit source] An important function of the foot is to propel weight during the stance phase . This feature is locked by the MT connector and unlock. During heel strike, the foot needs to be flexible to adapt to the surface, and the MT joint unlocks to provide this flexibility. Later in the gait cycle, the foot needs to act as a rigid lever to push the weight of the body forward, which is achieved through the MT joint locking. During pronation/valgus of the foot, the axes of the TN and CC joints are parallel to each other, making it easier for them to move independently and unlock the MT joint. During supination/inversion, the axes cross each other and lock the MT joint, making it difficult to move. blackwood et al al concluded that forefoot motion increases when the calcaneus is everted. This is consistent with the MT joint locking mechanism.  Lisfranc Joint Complex [edit | edit source] Sagittal degrees of motion for each TMT joint are shown below  TMT joints degrees of motion 1st 1.6o 2nd 0.6o 3rd 3.5o 4th 9.6o 5th 10.2o MTP and IP Joints [edit | edit source] The MTP joint is biaxial, moving in the sagittal and transverse planes. MTP joints have large sagittal plane motion and very little transverse plane motion. Hyperextension at the MTP joint is approximately 90°, and Flexion is about 30° to 50°. IP joints are hinged joints that restrict movement in one direction. Kinematics [edit | edit source] Kinematics refers to the movement of the articular surfaces. Talus calf joint – The talus rolls within the mortise during dorsiflexion and plantarflexion. During dorsiflexion, the talus rolls forward and slides backward. In plantarflexion, the talus rolls backward and slides forward. Subtalar joint – Secondary to the anatomy of the subtalar joint, the coupled motion of dorsiflexion abduction and eversion produces pronation The coupled motion of plantar flexion adduction and varus produces supination. It proposes two articulation points – the anterior talar heel joint and the posterior talar heel joint.  During the reversal of the open kinetic chain, the calcaneus rolls into the reversal state, and it Swipe/swipe sideways. During eversion, the calcaneus rolls into eversion and slides/slides medially. Middle tarsal joint – For the talonavicular joint, the concave navicular bone moves over the convex talus, so rolling and gliding move in the same direction. follow dice The joint is a saddle joint, so the orientation changes depending on the movement. During flexion and extension the cuboid is concave and the calcaneus is convex; thus, rolling and sliding occur in the same direction as the talonavicular joint. However, during abduction-adduction, the cuboid is convex, while The calcaneus is concave, so rolling and sliding occur in opposite directions. Lisfranc Joint – Secondary to the complex bony and ligamentous anatomy, the primary role is stability in the midfoot as it has little movement. It has three distinct arches and the main The stabilizing structure of the TMT joint is the Y-shaped ligament, called the Lisfranc ligament. MTP and IP Joints – Glide and Roll move in the same direction as the MTP joints because the concave bases of the phalanges move over the convex heads of the metatarsals. This also applies to The IP joint slides and rolls in the same direction as the concave distal phalanx moves over the convex proximal phalanx. Joint closed stacking position Open stacking position Capsular Concave Convex Convex-convex regular Rolling and sliding 10o from calf joint Full dorsiflexion Intermediate plantarflexion and pronation and supination Limitations of plantarflexion, although clinically dorsiflexion. Restrictions are more common. Proximal – Mortise formed by the tibiofibular ligament and fibula Distal – Trochlear surface of the talar dome Opposite direction Subtalar joint Full inversion Inversion/plantarflexion Restriction of inversion in chronic arthritis. Limitations of eversion. Proximal-anterior, middle and posterior facet of talus Distal-calcaneus Anterior, middle and posterior talar articular surface Opposite direction Tanarovoid joint Full Supination Limit ROM Limits of dorsiflexion, plantarflexion, adduction and internal rotation. Proximal – Head of Talar Distal – Concave Surface of Talar Navicular Isotropic Calcaniocuboid Joint Full Supination Midpoint Between Extreme ROMs Limited Dorsiflexion Plantar flexion adduction and internal rotation. Distal – The cuboid is concave during flexion and extension. The calcaneus is concave during adduction-abduction. Proximal – The calcaneus is convex during flexion and extension. A cuboid is convex in adduction-abduction. Flexion and extension = same direction Adduction-Abduction = Opposite direction Lisfranc joint Full supination Between supination and pronation First MTP joint hyperextension Slight (10o) extension More loss of motion in extension than in flexion. Distal – base of phalanges Proximal – metatarsal heads Coordinate 2nd to 5th MTP Maximum joint flexion Slight (10o) extension Loss of flexion. Distal – base of phalanges Proximal – metatarsal heads Same direction Interphalangeal joints Full extension Slight flexion limited in all directions, more extension. Distal Phalanx Proximal Phalanx Synchronous gait and foot [edit | edit source] Gait consists of a repeated cycle of stance phases (foot-strike intermediate and terminal stances) with the feet on the ground and swing phases with the feet in the air. There is an additional phase when running: the flotation phase when the feet leave the ground ground. During walking, when the foot is supinated on strike, the Chopart joint is locked, making the foot stiff when the heel first hits the ground. The foot pronates and flattens during mid-stance when the foot is in full contact with the surface. The terminal stance is characterized by propulsion through the heel off the ground and toes. The Lisfranc joint allows slight dorsiflexion and plantarflexion. The force is then transferred to the midpost of the front foot during the toe-off phase of the pedaling and the forefoot is supinated. The jambs work in the final stages of push-off while providing Mainly sensory input. The base of the fifth metatarsal alone absorbs a tremendous amount of force and weight. The combination of the fixed midfoot slightly flexible Lisfranc joint and the flexible metatarsophalangeal joint creates a propulsion lever during gait . Effects on kinetic chain/gait[edit | edit Source] As discussed above for MT joint locking, the transition of the foot from pronation to supination is an important function, helping to adapt to uneven terrain and acting as a rigid lever during push-off. During pronation, the MT joint unlocks, providing flexibility and Help maintain balance. The MT Joint Lock provides stiffness to the foot and maximizes stability during supination. If the foot is kept pronated, this results in hypermobility of the midfoot and places greater demands on the neuromuscular structure of the foot to stabilize and maintain it upright posture. On the other hand, if the foot remains supinated, midfoot mobility is reduced, which impairs the foot’s ability to adapt to terrain and increases the demands on surrounding structures to maintain postural stability and balance. Cote et al.  concluded that postural stability Influenced by foot position in both static and dynamic conditions. A chain reaction is secondary to the positioning of the feet. In a closed-chain movement, the following kinetic chain reactions occur in an overpronated foot: Calcaneal eversion Talar adduction and plantar flexion Medial Talar Rotation Tibia and Fibula Internal Rotation Knee Valversion Femur Internal Rotation Pelvic Anterior Tilt In a closed-chain motion, the following kinetic chain reaction occurs in an over-pronated foot: Calcanus varus Talar abduction and dorsiflexion Lateral pelvis to rotate Lateral rotation of the talus Tibia and Fibula Varus at the knee Lateral rotation of the femur Retroverted pelvic arches [edit | edit source] The arches of the feet function as a support-absorbing base and serve as rigid levers during gait propulsion. medial longitudinal The arch lateral longitudinal arch and transverse arch are the 3 arches that coordinate the arch of the foot. Medial Longitudinal Arch (MLA)[edit | edit source] It is the longest and tallest of all arches. The bony components of the MLA include the calcaneus, talus, navicular, three cuneiform bones, and Anterior 3 metatarsals. The arch consists of two columns: the front and the back. The anterior column consists of the first 3 metatarsal heads and the posterior column consists of the calcaneal tubercle. The plantar aponeurosis forms a support beam connecting the two Pillar . The apex of the MLA is the superior articular surface of the talus. In addition to the plantar aponeurosis, the MLA is supported by the spring and deltoid ligaments. The tibialis anterior and posterior muscles play an important role in elevating the medial border of the arch And the flexor hallucis longus acts as the bowstring. Lateral Longitudinal Arch (LLA) [edit | editorial source] It is the lowest arch of the foot, consisting of the fourth and fifth metatarsals of the cuboid calcaneus as its skeletal components. Like the medial longitudinal arch (MLA), the posterior column consists of Calcaneal tubercle. The anterior column consists of the metatarsal heads of the 4th and 5th metatarsals. The long and short plantar ligaments of the plantar aponeurosis provide support for the LLA. The peroneus longus tendon plays an important role in maintaining the lateral border of the arch of the foot. Transverse arch [edit | edit source] It is sunken in non-weight bearing and extends medial to lateral over the midtarsal and tarsal metatarsal regions. The skeletal part of the arch of the foot consists of the metatarsal head cuboid and 3 cuneiform bones. The medial and lateral columns of the arch are composed of They are the medial longitudinal arch and the lateral longitudinal arch, respectively. The arch is maintained by the tibialis posterior and peroneus longus tendons, which cross the plantar surface from medial to lateral and lateral to medial, respectively. Windlass mechanism of the foot[edit | edit source] Planta of the foot The aponeurosis acts like a windlass mechanism. A hoist is usually a horizontal cylinder that rotates with a crank or belt on a chain or rope to pull a weight. A common use of a windlass is to pull a ship’s anchor called a windlass. This mechanism can be seen in foot. When the MTP joint is hyperextended, the plantar aponeurosis becomes tight as it wraps around the MTP joint. This action brings the metatarsals and tarsals together, transforming them into a rigid structure, and ultimately raising the longitudinal arch. This function is very important Provides a rigid lever for gait propulsion during launch. Functions of the foot edit source] Sufficient flexibility and stability are required for all functions of the foot. Mobility is necessary to absorb the body’s ground reaction forces.  Subtalar pronation has a shock-absorbing effect Impact during initial heel contact.  Pronation is also necessary to achieve rotation of the leg and absorb the effects of this rotation. Subtalar pronation plays a role in shock absorption through eccentric control of the supinator muscle.  On the other side, Chopart’s joint becomes Unlocks so the forefoot can stay loose and flexible.  In the middle, the foot needs flexibility to adapt to changes in the surface.  Foot stability is necessary to provide a stable base for the body. Feet need to be able to bear weight and act as a stable lever to push Body forward  This function requires pronation control of the subtalar joint.  Normal foot function enables the foot to transition from a mobile adapter to a rigid lever at the appropriate time. The foot needs to be flexible enough to access all The position of the gait cycle while maintaining fluidity and stability.   Physiological mobility is essential; if there is too much mobility, the foot has no ability to stabilize. When this condition is met, the joint can support standing in a stable maximum close-pack Location.  Many overload injuries can be observed in the feet, legs and lower back when the normal transition of the two functions is not normal.  Therefore, the three-phase grounding must fall within the normal time interval, otherwise there will be a certain compensation Mechanisms that lead to overuse syndrome will be used (eg: knee flexion with decreased dorsiflexion).   (Example: Chondromalacia tibial splints) During the transition from the intermediate phase to the advanced phase, the mechanism often fails. Facilitates transition from eversion to inversion The muscle stretches like a spring and stores potential energy by the tibialis posterior .  At the end of the mid-stance phase, the muscles change from working eccentrically to concentrically, and energy is released. The tibialis posterior then causes abduction and dorsiflexion caput tali with everted hindlimbs.  Meanwhile, the peroneus longus muscle at the end of mid-stance will pull the forefoot through plantarflexion of the first toe.  This is how the forefoot becomes stable.  When the front foot moves during the propulsion phase, the hoist The phenomenon begins. When the metatarsophalangeal joint begins to dorsiflex, the plantar fascia is under stress. The calcaneus becomes vertical and tears when turned inward. Like this, the hind legs are inverted in the relaxation of the front feet.  When some abnormal situation occurs Normal gait cycle of body function Some functional orthotics may be used.  This orthosis has the ability to correct the biomechanical function of the foot.  In contrast, insoles support only the arch of the foot. Reduced or limited lower extremity mobility Caused by joint limitations.  In these cases, some classical mobilization or mobilization according to manual therapy can be applied.  When the cause is muscle shortening, some stretching may be prescribed. Good (running) shoes were also pointed out.  Ankle and foot Mobilization – PhysiopediaIntroduction This page discusses the Maitland mobilization technique. Joint mobilization refers to manual therapeutic techniques used to regulate pain and treat joint dysfunction that limits range of motion (ROM) by specifically addressing changes joint mechanics. Altered joint mechanics may be due to painful and muscular protective joint effusion contracture or adhesions of the joint capsule or misalignment or subluxation of supporting ligaments or bony surfaces.  Leg and ankle joints[edit | edit source] Tibiofibular joint[edit |Edit source] Ventral slip of the proximal tibiofibular joint [edit | edit source] Indications [edit | edit source] Increased motion of the fibular head. Correct the position error of the subluxed head. Patient position [edit | edit source] Side lying and torso and hips are Slightly turn to prone. Bend the top leg forward so it rests on a table or pillow. Therapist’s position and hand position [edit | edit source] A therapist standing behind the patient places one hand under the tibia to stabilize it. put the other hand on The fingers behind the head of the fibula will wrap anteriorly. mobilize force edit source] Force is applied through the heel of the hand in an anterolateral direction. Anterior-posterior sliding of the distal tibiofibular joint [edit | edit source] Indications [edit | edit source] Increases mobility when ankle motion is limited.  Ankle [edit | edit source] Resting position [edit | edit source] 10 degrees plantar flexion calf traction [edit | edit source] Indications [edit | edit source] Assess initial treatment for general pain relief flexibility. Patient Position [edit | edit source] Therapist’s supine position and hand placement [edit | edit source] The therapist stands at the end of the couch and wraps the fingers of both hands around the instep and places the thumb on the plantar surface of the foot. joint must in rest position. Use the belt to secure the legs. Mobilization edit source] The foot is pulled on the long axis. It will last for a few seconds. Anterior (ventral) gliding [edit | edit source] Indications [edit | edit source] Ventral gliding indicates increased plantarflexion Patient position [edit | edit source] prone with feet on edge of table. Therapist position and hand position [edit | edit source] One hand on instep, level I distraction applied. The Webspace of the other hand is placed behind Talus and calcaneus. Mobilizing Forces Edit Source] Pushes the calcaneus forward so that the talus slides forward. Posterior (dorsal) glide [edit | edit source] Indications [edit | edit source] Increased dorsiflexion patient position [edit | edit source] supine Lying with heels on edge of sofa[edit source] The therapist is next to the patient with the legs secured by a belt or hand. The palm side of the other hand rests just above the talus distal ankle. Keep the foot in a stationary position and apply Class I traction in the downward direction. Mobilization editorial source] Sliding is performed on the talar bone in the posterior direction relative to the tibia. . Subtalar (Talocalcaneal) joint[edit | Editorial source] This joint is formed between the calcaneus and talus. The calcaneus is convex and connects with the concave talus. Resting position [edit | edit source] Distraction midway between varus and valgus [edit | edit source] Indications [edit | edit source] Pain control Improving general mobility in varus and valgus Patient position and therapist hand position [edit | edit source] Supine with legs supported on table and heels on edge. Limb external rotation, ankle dorsiflexion and stability The pressure of the thigh against the plantar surface of the patient’s foot. Grab the calcaneus and secure the talus to the table. Mobilizing ForcesEdit Source] The calcaneus pulls distally with respect to the long axis of the leg. Gliding inside or outside[edit | edit source] Indications [edit | edit source] Slide medially to increase eversion; slide laterally to increase inversion. Patient Position and Hand Position [edit | edit source] The patient is lying on their side or prone with their legs supported on a table or roll of towel. therapist alignment The shoulder and arm are parallel to the sole of the foot. Then fix the talus with the proximal hand and place the base of the distal hand on the inside of the side of the calcaneus, causing a lateral slide and the outside for a medial slide. mobilization force edit source] finger is Wraps over the plantar surface to apply Level I traction in a caudal direction and move the calcaneus medially or laterally.  Intertarsal and tarsal metatarsal plantar glide [edit | edit source] Instructions: [edit | edit source] Added accessory movement Plantarflexion required for supination Patient position and hand placement [edit | edit source] Supine with hips and knees flexed. Another position is sitting high with the feet propped on the therapist’s lap. Therapist’s position and hand position[edit | edit Source] The proximal bone is fixed with the index finger on the plantar surface of the bone. The therapist is positioned on the outside of the foot to move the foot on the inside. The proximal hand rests on the back of the foot, with the fingers on the inside. this The distal hand uses the thenar to wrap the plantar surface to provide mobilization. Mobilization Edit Source] The distal bone pushes from the dorsum of the foot to the sole of the foot. Intertarsal and dorsal tarsal gliding[edit | edit source] Indications[edit |Edit Source] Component to improve dorsal glide during pronation. Patient position [edit | edit source] prone, knee flexed 90 degrees. Where the therapist puts his hand[edit | edit source] If the lateral part (the lateral tarsal joint like a cuboid) is To mobilize, the therapist must stand on the inside with the fingers wrapped around the outside. The therapist places the second metacarpal joint on the bone to be moved. Mobilization edit source] Force is given from the sole of the foot in the dorsal direction surface.Sinus Tarsi Syndrome – PhysiopediaDefinition/Description The sinus tarsi is the canal or tunnel between the talus and calcaneus. Sinus tarsi syndrome is pain or injury in this area. Ankle/foot trauma (such as a sprained ankle) or overuse (such as repetitive standing or walking) is the main cause of the syndrome. This can also occur if the person has flat feet or hyperpronated feet, which can cause compression of the sinus tarsi. Some are characterized by pain and sensation on the anterolateral side of the ankle (front of the lateral malleolus) Unsteadiness or difficulty walking on unstable surfaces.  A recent discussion of sinus tarsi syndrome (STS) describes this entity as subtalar joint instability primarily due to ligamentous injury leading to synovitis and infiltration of fibrotic tissue into the sinus tarsi Space. Clinically Relevant Anatomy[Edit | Edit source] The sinus tarsi is a tunnel between the talus and calcaneus that contains structures that contribute to ankle stability and its proprioception, but may be present in the sinus tarsi damaged. joint between talus and talus The calcaneus is also called the subtalar joint. This joint consists of 3 facets: the anterior-medium facet and the posterior facet. Changes in these facet structures can affect the stability of the subtalar joint. The joint is also made up of external ligaments (calcaneofibular and deltoid ligaments) ligaments) and intrinsic ligaments (interosseous muscles, calcaneal ligaments (number 5 in Figure 1), cervical ligaments (number 6 in Figure 1)) and medial lateral and medial roots of the inferior extensor retinaculum.  This all provides additional stability joint. Rupture of the intrinsic ligament allows increased motion of the subtalar joint, which can lead to instability.  Legend RE Number Anterior ankle structure 1 Anterior tibiofibular ligament 2 Anterior talofibular ligament 3 Calcaneofibular ligament 4 Lateral Talucalcaneal ligament 5 Intertalalcaneal ligament 6 Talarocervical ligament Akiyama considers the sinus tarsi not only as a space between the talar and calcaneal joints but also as a source of nociceptive and proprioceptive information about foot and ankle movement, sinus tarsi The syndrome may be caused by nociception and proprioceptive disturbances in the feet.  Epidemiology/Etiology [Edit | Edit source] Sinus tarsi syndrome occurs mainly after traumatic lateral ankle sprains or multiple ankle sprains (mainly due to weakness of the anterior talofibular ligament) , which results in Interosseous muscles and cervical ligament injuries. The sinus tarsi ligament may be sprained or torn, and the sinus tarsi synovial recess may be inflamed and hemorrhaged. This happens 70% of the time.  This pathology is mainly synovitis and Infiltration of fibrotic tissue into the sinus tarsi space due to instability of the subtalar joint due to ligamentous injury.  Sinus tarsi syndrome can also occur as a compression injury, such as in people with flat or pronated feet. Compression of the talus and calcaneus together as a result of deformation. This can lead to bone-to-bone contact of the talus and calcaneus with sinus inflammation or arthritis.  Features/clinical presentation[edit | edit source] The syndrome is characterized by pain on the lateral side of the ankle. “this The pain is most severe with standing and walking on uneven ground or with supination and adduction of the foot. “ People with sinus tarsi syndrome can also experience a feeling of hindfoot instability (functional instability). When the syndrome is the result In the case of an ankle inversion sprain, the lateral collateral ligament of the ankle is also likely to be damaged, as the ligament in the sinus tarsi is the last ligament to tear in a traumatic ankle sprain.  Additionally, loss of stability in the ankle will allow for a greater range of motion to the subtalar joint. This excessive movement increases the forces on the synovium and sinus tarsi. Subtalar synovitis leads to chronic inflammation and fibrotic tissue infiltration of the sinus tarsi, resulting in ankle pain.  In addition to those The injury can also damage the ligaments in the tibiotalar and talar heel joints and increase the range of motion between the talonal and subtalar joints.  DIFFERENTIAL DIAGNOSIS EDITORIAL SOURCE] These common conditions may produce the same painful signature or symptoms:  Ankle sprain Calcaneal Fractures Talar fractures Peroneal tendonitis Subtalar joint arthritis Tarsal tunnel syndrome Pain localized to the sinus tarsi with ankle instability is a good indication that a patient has STS. STS is usually diagnosed by stopping Symptoms after injection of lidocaine into the sinus tarsi.  Diagnostic procedure [edit | editorial source] The diagnosis of sinus tarsi syndrome is usually made by excluding other pathologies of the foot. CT scans can rule out fractures, but are insufficient to diagnose STS. most commonly used The method is MRI. MRI findings may include fluid filling of the sinus tarsi space or scar tissue, structural changes in ligaments, or degeneration of the subtalar joint.  Magnetic resonance imaging (MRI) is the best way to visualize internal structures The sinus tarsi especially the interosseous and cervical ligaments. MRI findings may also include structural changes in the interosseous and cervical ligaments and degeneration of the subtalar joint.  Results from a cadaveric study showed that initial and reconstructed MR Arthrography along and perpendicular to the ligamentous axis may be helpful to further evaluate individual sinus tarsi structures.  The exam [edit | edit source] requires a complete ankle examination and comparison with the other ankle.  Acute ankle injuries will Usually presents as pain with swollen ecchymosis (discoloration from bruising) and tenderness on the anterolateral ankle. Because the synovitis and fibrotic tissue associated with STS takes time to develop, athletes with subtalar joint injuries may not initially There are symptoms that may be limited to the sinus tarsi.  The stability of the subtalar joint is assessed by medial and lateral subtalar joint glides by moving the calcaneus onto a stable talus in the transverse plane and using subtalar joint traction.  Standing position Patients may exhibit a flatfoot posture or an asymmetrical rearfoot angle to the leg.  On passive examination, ankle range of motion may be limited in pronation and supination, but sinus tarsi pain in the end ranges of plantarflexion and supination is a Typical sign of STS. If the interosseous and cervical ligaments are damaged, translational range of motion of the subtalar joint may be increased, but this is not always the case.  The therapist should check the calf and subtalar joints for signs of hypermobility, as injuries can affect These important joints of the lower body. Focal ankle discomfort in the sinus tarsi space and a sense of instability with subtalar joint pronation and supination motion will help identify STS.  The therapist should also evaluate for any muscle weakness Fibula and plantar flexors. This is done with resistance tests of the ankle: a pronation test and a flexion test.  There is a stability test that is thought to recreate subtalar joint instability. Athlete is tested in supine position with ankle at 10 degree angle Dorsiflex to maintain the calf joint in a stable position. The forefoot is first stabilized by the examiner’s hand while varus and internal rotation are applied to the calcaneus. Then apply a counter force on the ball of your forefoot. Examiner assesses excessive medial Displacement of the calcaneus and reproduction of athletes’ complaints of instability and symptoms.  Medical management [edit | editorial source] Treatment of sinus tarsi syndrome can be conservative or surgical. The first includes physical therapy (see Physical Therapy Management) Local injection of corticosteroids or drugs in the sinus tarsi  Surgical treatment is also very effective in most cases, but needs to be considered as a last resort if conservative treatment fails.  Subtalar arthroscopy is helpful in the diagnosis and treatment of STS. also Subtalar arthroscopy can directly observe the pathological findings of STS.  When conservative treatment fails, STS can be treated by open surgery and subtalar arthroscopy. Kuwada  reported the long-term results of an STS in which all patients who underwent open resection 100% pain relief with no complications was reported over a 15-year period. Lowy et al.  reported that 15 of 21 STS patients who underwent open surgery achieved complete pain relief and the remaining 6 achieved partial relief. In addition, Frey et al.  reported that Of the 21 patients with STS, 43% had a favorable outcome after subtalar arthroscopy and 43% had a favorable outcome; only 3 patients (14%) had a poor outcome. Therefore, according to these studies, open surgery and arthroscopic treatment produced similar satisfactory results. It is worth noting that arthroscopic treatment Address the symptoms of STS alone with open surgery involving resection of all synovial tissue in the lateral contents of the sinus tarsi. Subtalar arthroscopy has been reported to be associated with complications of neuritic sinus tract formation and superficial wound infection Although these respond to nonsurgical treatment.  Subtalar arthroscopy identified lesions in the subtalar joint in patients with STS and showed that treatment of these lesions improves function.  Given the preliminary clinical results and the state of the art One would expect resection of the triquetrum and arthrodesis of the subtalar joint to evolve into major procedures. Furthermore, with the determination of a definitive value for heat-induced capsular ligament contraction, the possibility of resolving subtalar instability may be imagine.  Physical Therapy Management [Edit | Edit source] Since STS usually occurs after an ankle sprain, the foot is braced or taped while the joints and ligaments recover. Therefore, the activities of the ankle joint, especially the subtalar and talar calf joints are Necessary for the treatment of STS. Joint mobilization exercises should be performed in all directions, especially in pronation and supination. It is also important that they be performed in a full range of motion if there is no painful stimulus.   “‘No randomized controlled trials  Treatment may include rubbing massage, electrotherapy (such as ultrasound), laser therapy, cryotherapy, and other types of deep massage in order to affect the tissue of the sinus tarsi. massaged with ice cubes The lateral ankle may help reduce inflammation and pain.  If activities can be performed without pain, they should be started as soon as possible. Since the peroneal muscles and Achilles tendon tend to be weak with sinus tarsi, it is critical to adjust procedural therapy to strengthen those muscles. Standing on your toes to flex your ankles is a great exercise, and doing an eccentric exercise on the edge of a stairway is an even better way to increase strength. Stability training is the final stage of rehabilitation. Patients must perform proprioceptive exercises such as lunges Improves ankle proprioception and stability.   An exercise program to improve subtalar joint stability and lower extremity function will be the hallmark of an STS treatment program. Joint stability is dependent on passive joint structures, dynamic muscle responses and neural control.  Treatment options for STS include proprioception training, balance training taping, and bracing muscle strengthening exercises. Some athletes suffer from synovitis and taking anti-inflammatory drugs can help reduce inflammation. on ice Affected areas can also help.  Clinical bottom line [edit | editorial source] Sinus tarsi syndrome is a foot pathology that occurs primarily after trauma to the ankle. This can also occur if the person has flat feet or (over)pronated feet, which can cause compression of the sinus tarsi. Some are characterized by pain and instability on the outside of the ankle. The diagnosis of sinus tarsi syndrome is usually made by excluding other pathologies of the foot. Magnetic resonance imaging (MRI) is the best way to visualize structures and the changes within them sinus tarsi. Subtalar joint stability was assessed by medial and lateral subtalar joint glides by moving the calcaneus onto a stable talus in the transverse plane and using subtalar joint traction. Ankle range of motion may be limited during passive examination Pronation and supination, but sinus tarsi pain in the extremities of plantarflexion and supination are classic hallmarks of STS. In addition, muscle strength must be assessed for weakness of the peroneal and plantar flexor muscles. Treatment of sinus tarsi syndrome conservative or efficient. Surgical treatment: This treatment is very effective in most cases, but needs to be considered as a last resort if conservative treatment fails. STS is then treated with open surgery and subtalar arthroscopy. Conservative treatment: STS often occurs behind the ankle joint sprain. Thus, the foot is braced or taped during joint and ligament recovery. Because of this event, ankle mobilization, especially the subtalar and talocrural joints, is required in the treatment of STS. Joint mobilization exercises should be conducted in all countries direction, but especially in pro-supination. Just as importantly, they should be performed with a full range of motion and be pain-free.
Mechanism of Injury
Medial subtalar dislocation – caused by forced inversion applied to the plantarflexed foot.
During this position, the talar neck will articulate and pivot about the thigh support, which will result in rupture of the lateral talonavicular capsule and ligaments, followed by the subtalar ligament . Talar kyphosis fractures are common Dislocated from inside.
Lateral subtalar dislocation – caused by forced eversion of the dorsiflexed foot during high energy trauma.
In this position the head of the talus rotates around the anterior axis of the calcaneus this will cause separation of the talonavicular and subtalar ligaments and joint capsules. Partial or complete rupture of the deltoid ligament may be presented with this injury due to high force disability.
Posterior subtalar dislocations – result from the foot being forced against the heel.
Anterior subtalar dislocations – result from anterior traction on the foot when the foot is in a fixed position. It is rare to see an obvious foot deformity with a posterior or anterior posterior ligament herniation.
Lower extremity fracture + lat malleolus fracture
Patients with subtalar dislocation present with increased pain and complete inability to bear weight on the affected foot.
Significant ankle deformity can be seen. The head of the talus is herniated, and the talonavicular and subtalar medial joints are very tender and painful on palpation.
A CT scan is usually performed to determine the type of injury . Associated foot and ankle injuries also occur in 88% of patients. The ankle, calcaneus, and navicular fractures are at highest risk. The cuboid cuneiform and metatarsals may also be injured. all parts of Foot that may be damaged by subtalar dislocation must be examined radiographically .
Subtalar dislocations require reduction with manual pressure and traction under general anesthesia. Talar shifts are performed with the knees bent to reduce tension on the soleus and gastrocnemius muscles.
Subtalar instability was subsequently assessed by using fluoroscopy.
Pure dislocations (dislocations without accompanying fractures) generally have a better prognosis . There is no consensus on how long or how long the ankle should be immobilized after a dislocation. Studies have shown that immobilization times range from 3 to 8 weeks, depending on concomitant injuries .
Physical Therapy Implications
Due to incidence, most studies of subtalar dislocations include patients with medial dislocations.
Several studies have shown that early mobilization after uncomplicated medial subtalar dislocation helps patients regain daily function within 2 months .
Physical therapy can be initiated while allowing early mobilization after completion of the exposure period approximately 2-3 weeks after reduction. The goal of physical therapy at this time is to reduce inflammation for increased range of motion and prevent muscle shortening.
According to this study at 3 weeks post-injury after active range of motion exercises for the ankle foot and muscle-strengthening exercises began. After the third week patients started with partial weight bearing exercises and progressed to full weight bearing by week five. The exercise gives it all weight-bearing was performed using a below-the-knee implant that acted on an ankle brace. This brace allowed plantar- and dorsiflexion but prevented inversion and eversion movements.
This study concluded that all patients regained normal ankle ROM (assessed by goniometer). The percentage of ankle ROM between the injured and healthy lower limbs was 92.5% which was considered very satisfactory by both physiotherapists and patients. AOFAS ankle-hindfoot scale (American Orthopedic Foot and Ankle Society) score is 90.75 points (range: 82-97). AOFAS ankle-hindfoot scale for pain function and consistency. After 3 years reductive no radiographic evidence of arthritis or avascular necrosis of the talus was found. Two patients complained of mild pain with the hind legs.
It should be noted that this study may not apply to all medial subtalar dislocations and surgical consultant policy may vary between consultants.
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