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Palpating the posterior facet of the calcaneus

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Simon Spooner, Dec 30, 2009.

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    Someone was talking to me recently about palpating the posterior facet of the calcaneus as a way of determining subtalar joint neutral. My initial thoughts on this are: how do you palpate the posterior articular facet of the calcaneus? Anyone got any experience of this?
  2. LuckyLisfranc

    LuckyLisfranc Well-Known Member


    Palpating the posterior (and middle) facets of the subtalar joint is one of the most simple, yet most poorly appreciated aspects of surface anatomy I have encountered in my experience of teaching students and educating podiatrists. I was not taught this properly until I spent time with experienced podiatric surgeons. It is a mighty example of how the tip of a finger is the most important diagnostic tool in your toolkit, and often more useful than radiographic imaging.

    The posterior facet is easily appreciated by taking into account the anatomical landmarks that are most easily identifiable.

    Firstly; palpate the tip of the lateral malleolus. Then invert and event the STJ repeatedly whilst dragging your finger firmly from superior to inferior SLOWLY until you get get to the lateral wall of the calcaneus. Move back up superiorly again SLOWLY and you will be in the lateral talar/ankle joint gutter. Keep dragging your finger between these two points until you can sense the point where the joint line is, all the while continuing to invert and evert the STJ.

    Pain along this region is commonly linked to degenerative or traumatic injury involving the STJ.

    Moving anteriorly along the joint line will get you to the sinus tarsi; an easy place to put in a diagnostic injection to confirm joint pathology.

    The middle facet is appreciated in a similar fashion - moving between the medial malleolus and the sustentaculum tali (which forms the outer medial floor of the middle facet).

    Its handy to practice this with an anatomical foot model next to you.

    Practice will improve accuracy to the point where you can 'nail' the joint line within a few moments. Going from 'know areas' to 'known areas' in this approach can allow you to palpate any joint within the foot.

    Hope this helps.

  3. Interesting question Simon. Thanks for bringing it up :drinks.

    I suspect there is some confusion regarding the bit of the Calc in question.

    With Grays Anatomy (36th ed) on my lap the closest to a posterior Facet is what it describes as the "posterior facet for the talus." its on the top of the calc.

    Be Quite tricky to palpate that without dissecting the joint which I suspect most patients would not agree to as part of a clinical exam!:butcher::pigs:

    I rather suspect that what he (or she, could be she ;)) means is the posterior surface (not the posterior facet at ALL! That would just be stupid!)

    As to the accuracy of bisecting the posterior surface of the calc, I suspect that would be pretty tricky to do with any meaningful degree of accuracy or repeatability (even more so than the soft tissue bisection). My copy of Grays does not have a posterior view of the calc but my McMinn does. It shows two things.

    1. That better than half the posterior surface is covered by the Tendo Achillies Which would be a mare to palpate through)

    2. That if you COULD palpate it you would find it is about 10 degrees inverted relative to the a line drawn perpendicular to the medial / lateral processes of the tuberosity (the plantar weight bearing bits).

    This raises an interesting question for those who follow the paradigm of trying to "balance" forefoot / rearfoot varus / valgus (or invertus / evertus if you prefer). What line should they be attempting to use as the perpendicular? It matters quite a bit because if one were to assume that the bisection should be vertical then we must assume that the weight bearing tuberosities are not designed to bear equal weight! To balance the Calc in Mcminn so that the posterior surface is vertical would, presuming a symetrical load and even distribution of soft tissue, would require a 10 degree lateral wedge (or there abouts).

    One would also need to adjust one's thinking in terms of the forefoot...

    Interesting question for those still searching for neutral. I'd be interested to know what the original Root literature described and what the contempary Root theorists think (you out there Jeff?).

  4. Sorry for the Double post. LL's came through while I was doing mine.

    Thanks to LL for a really helpful practical post! I will certainly give it a try using that method.:drinks

    Still not sure how that will help in terms of finding neutral though. And I maintain that the only way to actually PALPATE the facet (rather than the margins of the joint) would be to chop the leg off just below the talus. ;).

  5. Did they explain when it´s in neutral and when is is not what you should feel ? Also if it´s Varus or Valgus how do you know how much and then the big question did they explain how this changes your prescription variables ? Also when you make the device and the patient come back in how do you determine the "foots in Neutral" when the patients wearing the device ?

    Anyway Happy New Year all.
  6. I don't know of any way to palpate the posterior facet of the subtalar joint (STJ) in order to determine STJ neutral position. As LL described, yes, small portions of the edges of the posterior STJ this joint can be palpated with careful practice, but this tells you little about STJ neutral.

    By the way, one thing that LL wrote that I totally agree with is that manual examination of the foot and lower extremity is poorly taught in schools and/or is not taught very much in podiatric seminars. I have noted that there is an over-reliance on tests and imaging studies to diagnose in the podiatric surgical residents who I currently help train and in the podiatrists that I have lectured to and given demonstrations to in various countries. Learning to use your hands in an effective manner for diagnosis is the key to being the best podiatrist for your patients.
  7. TedJed

    TedJed Active Member

    The palpation method described by LL is one that really requires a lot of practice and experience. Developing one's palpatory senses in one's finger tips is, IMHO, an invaluable skill and resource.

    Practising with a skeletal model nearby is an excellent suggestion.

    Here's a technique I undertook to develop my sense of 'touch';
    Pluck a hair from your scalp and get someone to place it on an open copy of the Yellow Pages. (Blind technique.) They then cover it. Your job is to 'find' the hair by touch. The placement of the hair changes and the no. of pages keeps increasing until you can no longer find the hair.

    A chiro buddy and I used to compete with this game (it was cheaper than losing on the golf course!) when I first started practising manual therapies. Ca$h can be such a powerful motivator!;)

    If you can get to over 14 pages, your sense of touch is doing well!:D

  8. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Heartened to hear that the technique I described is not too dissimilar to other clinicians.

    One thing I forgot to add - after practice and palpation of many posterior facets it becomes easier to appreciate periarticular osteophyte formation. This is very similar, though much more subtle than running your finger over the dorsal articular margin of a degenerative 1st MTP joint/hallux limitus.

    A definitive 'ridge' of osteophytic growth can be felt along this facet in the presence of degenerative or post-traumatic OA. This correlates well with the degree of subchondral sclerosis and joint space narrowing on plain radiographs. This is particularly obvious whenever you come across a intraarticular calcaneal # a few years down the track and the joint is rapidly degenerating.

    As well, in the presence of the (relatively rare) posterior facet coalition - pain along this facet is reasonably diagnostic whilst awaiting radiographic confirmation.

  9. Thanks Lucky. I appreciate that we can feel along the joint margins, but is this really palpating the posterior facet ? As Robert suggested, given the orientation of the posterior facet and the positioning of the talus can this really be achieved without disarticulation of the talus?
  10. Griff

    Griff Moderator

    Attached for you squire


    Attached Files:

  11. Thanks Ian, as I suspected we can't glean much from this paper as they only used lateral views. We really need a posterior to anterior view in max supination, "neutral" and max pronation. This way we could see how much of the posterior facet is exposed in these three positions and how palpable it might be.
  12. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Clearly you cannot palpate within the facet via surface palpation. Only surgical dissection will aloow this to occur.

    However, you can run you finger along the articular margins of the posterior and middle facets very easily. Synovitis, oedema and marginal osteophytes are easily detected and prognostic for intra-articular disease. This is no different to a knee joint examination.

    The only lower limb joints that I know of that you can feel the actual chondral surface through external examination are the MTP joints and the talar dome (ankle joint).

  13. TedJed

    TedJed Active Member

    This is an accurate observation LL. One can indirectly gauge the quality of motion of articular surfaces to assist in the clinical diagnosis process; e.g. sinus tarsi & ankle mortice - with the calcaneus distracted from the ankle, one can gently rock the talus posteriorly and anteriorly.

    1. A healthy joint will offer firm resistance with no discernible motion of the talus.
    2. A subluxed talus will grit & grind like a train slipping off its tracks. Pain dorsally (ankle mortice) or plantarly (STJ) will give the practitioner feedback of which articular surface is compromised.
    3. The degree & quality of crepitus enables the practitioner to assess whether the pathology is peri- or intra-articular.

    This method can be applied to most joints; distract the joint's distal articulations while gliding the bone in question.
    E.g for the (R) cuboid, distract the 4th & 5th rays with LH while gliding the cuboid sup/inferiorly with your (R) thumb & index finger.

    Straightforward to do for navic and cuneiforms. You can't feel the articular surfaces, but you can feel irregularities referring to your palpating fingers/thumbs.

    Less mess than dissection or surgery!:butcher:

  14. Once again I agree. How does this help us determine the neutral position for the STJ?
  15. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    I have no idea...:wacko:

  16. Quite!

    I think we can be pretty certain that the individual in question does not know the difference between the posterior facet and the posterior surface. With luck this will be pointed out to him.
  17. drsarbes

    drsarbes Well-Known Member

    Good Thread -----
    in my own experience I can palpate the lateral border of the posterior facet. I've tried a couple of times to scope the posterior facet and this surface anatomy is fairly easy to appreciate.

    It might be a leap to associate this surface anatomy with the actual joint.

    That's my 2 cents.


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