The subtalar joint is often forgotten when people present with ankle pain. However, it is often the site of breaks, sprains, and early arthritis, which causes pain in the ankle and foot. Overall, treatment is complex and may involve an ultrasound-guided subtalar joint injection. When and how should we do this injection?
What is the subtalar joint?
The subtalar joint is complex, consisting of the calcaneus (heel bone) below and the talus above. Strong ligaments hold the bones together. Above this is the ankle joint, which moves your ankle up and down—conversely, the subtalar joint moves the ankle outwards (eversion) and inwards (inversion). Functionally, the subtalar joint allows you to navigate uneven surfaces or terrains without losing balance. You couldn’t run, jump or dance properly without a subtalar joint.
Subtalar joint problems
As the subtalar joint is vital to proper movement, it is susceptible to damage from wear and tear, as well as trauma such as falls or sprains. Examples of damage to the subtalar joint include:
Osteoarthritis
The joint’s cartilage can wear away as we age, leading to inflammation and pain. Recent evidence also suggests that common lifestyle factors such as obesity, diabetes, and high cholesterol can make arthritis worse.
Inflammatory arthritis
Another type of arthritis that arises from the immune system can lead to inflammation and joint damage. Examples include rheumatoid arthritis and gout.
Pes planus
Pes planus, often referred to as a flat foot, occurs when the foot’s arch collapses, placing pressure on the subtalar joint and causing pain.
Tarsal coalition
A tarsal coalition occurs when the bones of the hindfoot fuse together, altering the way the bones move and causing abnormal forces on the subtalar joint. This condition is common in teenagers as they reach puberty. Typically, the bones of the hindfoot are entirely separate. However, in some cases, two or more bones are joined together, limiting movement and causing pain, which can lead to arthritis in the subtalar joint.
Calcaneal (heel) fracture
Sometimes, a break of the calcaneus after a fall or pain can involve the subtalar joint. If the bone heals in an abnormal position, it can lead to irregular forces on the subtalar joint, resulting in early arthritis and pain.
Subtalar joint pain: How to diagnose?
Generally, pain from the subtalar joint is deep and not well localised. Pain is often on the outside or inside of the ankle or heel. Usually, pain is felt when walking or running on uneven surfaces. Additionally, your doctor frequently finds subtalar joint stiffness and tenderness to touch.
Sometimes, subtalar joint pain can be confused with Achilles tendon pain. Generally, Achilles tendon pain is more focal at the site of the Achilles and does not spread as much. Also, pain increases as the tendon is loaded more, unlike subtalar joint pain, where this relationship does not hold.
Imaging techniques, such as X-rays, ultrasound, and MRI, help confirm a diagnosis. Often, a combination of imaging is needed to be sure. Sometimes, blood tests are necessary to rule out autoimmune or inflammatory arthritis as the cause. A subtalar joint injection can help diagnose subtalar joint pain.
It is essential to rule out other causes of heel or ankle pain, such as tibialis posterior tendonitis, calcaneal stress fracture, Achilles tendonitis, heel bursitis, sinus tarsi syndrome, and tarsal tunnel syndrome.
Subtalar joint injury treatment
Overall, we use simple treatments to alleviate pain and enhance function. These treatments include oral ibuprofen, ice, and orthotics. Physical therapy is also essential for improving calf and foot strength and balance. Foot intrinsic strengthening is also important.
Sometimes, a subtalar joint injection of cortisone can help. Occasionally, we perform hyaluronic acid or PRP injections in the subtalar joint.
In cases that fail all other treatments, surgery such as cutting the bone to reshape it (also known as osteotomy) or fusing the bones can be helpful. However, fusion of the subtalar bone will lead to loss of movement.
More on ultrasound-guided subtalar joint injection
Because the subtalar joint is complex, we recommend performing this injection with imaging guidance.
Previously, injections were done accurately with X-ray or ‘fluoroscopy.’ However, fluoroscopy injections have several drawbacks, including exposure to harmful radiation, the need for expensive equipment, and the inability to visualise other structures, such as nerves or vessels. Recently, doctors have been doing ultrasound-guided joint injections with excellent accuracy. There are several advantages to using ultrasound-guided subtalar joint injections, including the absence of radiation and the ability to perform the procedure in the office, rather than in a surgical unit, resulting in lower expenses.
Overall, we can direct the injection into the most painful spot in the subtalar joint, which can be medial, lateral, or behind. Generally, the lateral approach is easier and quicker to enter. However, all three methods for injecting the subtalar joint are accurate.
Other Frequently Asked Questions about Subtalar Joint Injection:
How long will a subtalar joint injection last?
Generally, a cortisone injection lasts 3 to 4 months. Other injections, such as PRP or hyaluronic acid, may last longer.
What is the evidence for subtalar joint injection?
We don’t have much evidence for subtlar joint injection. However, one study found that a cortisone injection for tarsal coalition (which causes subtalar joint pain) can delay surgery for up to 2 years. Another study that performed three hyaluronic acid injections for subtalar joint osteoarthritis found that pain and function were improved.
Final word from Sportdoctorlondon about ultrasound-guided subtalar joint injection
As with the other joints, the subtalar joint can cause ankle pain. Therefore, we should try simple treatments before more risky ones, such as a subtalar joint injection or surgery. Moreover, you should consult a doctor with experience in performing subtalar joint injections, preferably with ultrasound guidance.
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