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Sinus tarsi ? ultrasound

Discussion in 'General Issues and Discussion Forum' started by bunion, May 1, 2008.

  1. bunion

    bunion Member

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    79 y/o w/fLateral ankle/foot pain radiates proximal posteriorly from sinus tarsi area to lower back. Distal radiation to plantar medial heel and medial foot. Pain on pressure to fibular malleolus and sinus tarsi. Xrays negative for fracture some arthritis present. patient given lower back nerve block by pcp and on minidose pack prednisone with no relief. Mri pending. I gave patient plain lidocaine nerve block sinus tarsi area and all symptoms resolved after a few minutes. Sinus tarsi syndrome ? Nerve entrapment? What is the anatomical connection / nerve course for dorsal lateral to plantar medial radiation - peroneal to posterior tibial? Seems to be fairly consistent pattern of anesthesia post injection. Any suggestion for diagnostic ultrasound reference images of sinus tarsi area? Thanks
    Last edited: May 1, 2008
  2. Mart

    Mart Well-Known Member

    Hi Bunion

    I have tried doing high res diagnostic ultrasound exams of the sinus tarsi to look for evidence of inflamatory process. Typically power doppler can be useful and I use it to look for synovitis, acute plantar fascia and tendon injury, it will differentiate regions of acute inflamation nicely because of increased density of motion from RBCs and gives additional information to B mode grey scale.

    Inherant pitfalls in interpretation include misinterpreting presence of normal vasculature. There are an abundance of vessels in the sinus tarsi area and I have attatached an nice image of a prepared specimin to illustrate this. So far I have not had any confidence in imaging this area with US but am still working on it.

    I have not been able to find anything in the literature pertaining to using US for imaging the borders of the sinus, there is plenty written on ATFL which is easy to get good views of, and to a lesser extent structures associated with lateral anterior ankle impingement syndrome.

    There are some papers on MR examination of lateral ankle structures which include sinus which likewise is somewhat problematic with reliable visualisation.

    Like you I use physical exam, biomechanical characteristics and then diagnostic injection to workup problem.

    some references below which you might find of interest, please let us know how thing work out.



    The St. James Foot Clinic
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    Blood vessels of the sinus tarsi and the sinus tarsi syndrome.
    Schwarzenbach B, Dora C, Lang A, Kissling RO.
    Orthopaedic University Hospital Balgrist, Section of Physical Medicine and Rheumatology, Zürich, Switzerland.
    This study describes the arterial and venous blood vessels in the sinus tarsi of a series of nine anatomical specimens and in a traumatically amputated leg, studied by arteriography. The sinus tarsi artery was formed in all cases from anastomoses between various arteries of the lateral region of the foot. These usually included the anterior lateral malleolar, and proximal lateral tarsal arteries; in 70% there was a branch from the distal lateral tarsal artery, and in 30% a branch from the peroneal artery. In all cases, there were anastomoses within the sinus tarsi between the sinus tarsi artery and the canalis tarsi artery, derived from the posterior tibial artery. Whatever its origins, the sinus tarsi artery was the principal supplier of intrasinusal structures and of the talus. There was a large venous plexus in the sinus tarsi, which drained particularly the venous outflow from the talus and the anterior part of the capsule of the posterior talocalcaneal joint to the lateral and medial venous systems of the foot. Posttraumatic fibrotic changes in the wall and surrounding tissue of the veins, causing disturbance of venous outflow and increased intrasinusal pressure, are proposed by the authors as one possible factor in the pathogenesis of the sinus tarsi syndrome.

    [Sinus tarsi syndrome : What hurts?]
    [Article in German]
    Herrmann M, Pieper KS.
    Abteilung Anatomie und zelluläre Neurobiologie, Universität Ulm, Albert-Einstein-Allee 11 , 89069, Ulm, Deutschland.
    Sinus tarsi syndrome, described by O'Connor in 1958 and Brown in 1960, is a clinical finding often seen after an accident, consisting of a painful reaction to pressure on the sinus tarsi. This syndrome has also been described in dancers, volleyball and basketball players, overweight individuals, and patients with foot deformities (flatfoot). We looked for mechanical and functional macroscopic structures in the canalis and sinus tarsi that can be associated with sinus tarsi syndrome in order to deduce therapeutic consequences.We found a complex fibrous layer in the sinus and canalis tarsi that forms slips around the synovial sheats of the extensor tendons under the inferior extensor retinaculum. Both limbs run deep to the base of the sinus and canalis tarsi. The lateral band inserts into the sinus tarsi at the calcaneus, while the medial band inserts at the canalis tarsi at the talus and calcaneus. Instead of the term "interosseous ligaments," we recommend referring to the "fundiform ligament" with one lateral and one medial band.Regarding function, one can assume that the medial band of these fundiform ligaments controls the talus at eversion and inversion together with the well-vasculated and well-innervated interarticular fat pads in the sinus and canalis tarsi. While contracting the long extensor muscles of the toes, the ligament forms a control mechanism for the longitudinal arch of the foot in the moving phase.A question is how variations in vascularization or disorders in innervation will alter the turgor of the pads of fat tissue. That is, such alterations would influence the distribution of synovia in the neighboring joints as well as the tension of the involved ligaments.

    1: Acta Anat (Basel). 1978;102(2):184-94. Links
    [Form and attachment of the human sinus tarsi and canalis tarsi ligaments]
    [Article in German]
    Schmidt HM.
    In addition to loose connective tissue, fat and blood vessels, the sinus and canalis tarsi also contain the capsules for the intertarsal joints as well as several varyingly stable tracts of fibers which present themselves in varying planes and directions but are nevertheless in a discernible arrangement to one another. This arrangement of fibers was studied on the feet of 40 adults whereby five distinct and clearly definable bundles could be regularly dissected. Starting from the lateral side and going medialis of the retinaculum mm. extensorum inferius, also a lig. talocalcaneum obliquum and a lig. canalis tarsi. Microscopically, fibrocartilage is evidenced in the ligaments and retinacula near their points of attachment to the bone. The ligaments lying lateral to the axis of movements for the talocalcaneal joint restrain the inversion while the medially lying lig. canalis tarsi prevents the eversion
    1: J Orthop Sci. 1999;4(4):299-303. Links
    Neurohistology of the sinus tarsi and sinus tarsi syndrome.
    Akiyama K, Takakura Y, Tomita Y, Sugimoto K, Tanaka Y, Tamai S.
    Department of Orthopaedic Surgery, Nara Medical University, Kashihara, Nara 634-0813, Japan.
    The purpose of this study was to clarify the neural anatomy of the sinus tarsi. The nerve endings of the synovium in the sinus tarsi were examined. The synovial membrane in the sinus tarsi was excised in 20 patients with sinus tarsi syndrome (20 feet) and in 2 feet from subjects without symptoms (controls). In 15 of the 20 patients and the two controls, the excised synovial membrane was studied histologically with staining by a modified Gairns gold chloride method. Numerous neural elements were observed in the sinus tarsi in all examined synovium. There were abundant free nerve endings and three types of mechanoreceptors: Pacinian corpuscles, Golgi corpuscles, and Ruffini corpuscles. Macroscopic observation and histological examination, using hematoxylin and eosin, in the other 5 patients revealed chronic synovitis in the sinus tarsi. Our findings suggest that the sinus tarsi is not only a talocalcaneal joint space but a source of nociceptive and proprioceptive information on the movement of the foot and ankle. Sinus tarsi syndrome may result from disorders of nociception and proprioception in the foot.

    Attached Files:

  3. bunion

    bunion Member

    thanks for the information
  4. Mr/Mrs. Bunion:

    Your patient probably has sinus tarsi syndrome. Since you have given no biomechanical data I assume you are not thinking mechanically. Invariably these patients have feet which stand and walk in the maximally pronated subtalar joint (STJ) position. As the STJ pronation moment from ground reaction force increases in magnitude, the compression force between the anterior edge of the lateral process of the talus and the floor of the sinus tarsi of the calcaneus likewise increases in magnitude. Any vascular, ligamentous or neural structures that get compressed within the sinus tarsi between the talus and calcaneus as the sinus tarsi loses its volume with maximal STJ pronation will have increased risk of injury and pain.

    I believe that I was the first to ever describe the correlation between a medially deviated STJ axis and the interosseous compression forces within the sinus tarsi to the diagnosis of sinus tarsi syndrome within the medical literature (Kirby KA: Rotational equilibrium across the subtalar joint axis. JAPMA, 79: 1-14, 1989). And yes, a medially deviated STJ axis is a real, not "imaginary", entity. Treatment with medial heel skive foot orthoses, shoes with increased heel height differential and serial cortisone injections within the sinus tarsi helps the vast majority of these patients. My paper on rotational equilibrium and my discussion on sinus tarsi syndrome is included in the paper attached below.

    Hope this helps.

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