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Ankle pain can be debilitating making a simple step almost impossible, and a common source of ankle pain is the Subtalar joints.  What are the Subtalar Joints?  Why does my Subtalar Joint Hurt?  What Movement Occurs at the Subtalar joint?  What are the treatment options for Subtalar Joint Pain?  Let’s dig in.

What Are the Subtalar Joints?

The foot has 33 joints one of which is the subtalar joint.  The joint is also known as the talocalcaneal joint and is where the ankle bone (talus) meets the heel bone (calcaneus) to form a joint.  It is located near the heel and is immediately beneath the inside and outside ankle bones (malleoli).  The subtalar joint allows for the ankle to be turned inward (inversion) and outward  (eversion) (1).   Ligaments are thick bands of connective tissue that connect one bone to another and provide important stability.  The subtalar joint has 5 major ligaments with the interosseous talocalcaneal ligament being the most important (2).  Ankle sprains can injure the ankle ligaments leading to instability.

Why Does my Subtalar Joint Hurt?

The ankle joint complex bears a force of approximately five times body weight during stance in normal walking, and up to thirteen times body weight during activities such as running (3)   Accordingly it is susceptible to injury.   Common cause  causes of subtalar joint injury include:

Sprains:  Stretching or tearing of the supporting ligaments

Trauma:  Motor vehicle accidents, falling from a height directly onto the heel, sports injuries, fractures, dislocations, and fusion of the tibiotalar joint.

Systemic Conditions:  Lupus, Lyme’s disease, Rheumatoid arthritis

Trauma including ligament injuries is the most common cause of subtalar joint arthritis (4)   The incidence of subtalar joint arthritis is approximately 3.4% of the population over 50 (5).   Pain is the most common complaint which is aggravated by standing, walking especially on uneven surfaces.  Many times there is also a loss of range of motion.

Understanding the importance of ankle sprains is critical since ankle sprains stretch or tear the supporting ankle ligaments which in turn can result in instability.  Ankle instability creates excessive movement in the joint which can cause damage to ligaments, tendons, and cartilage leading to arthritis. To learn more about the importance of instability and how it creates arthritis please click on the video below.

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What Movement Occurs at the Subtalar Joint?

The subtalar joint allows the foot to turn inward (inversion) and outward (eversion).  The ligaments provide critical stability for the joint.  Remember that really bad ankle sprain while hiking or playing basketball last year?  If left untreated it can lead to arthritis, subtalar joint pain, and loss of motion.

Treatment Options for Subtalar Joint Pain

There are multiple traditional treatment options for subtalar joint pain listed below.  Which treatment is best for you is dependent upon the level of pain and severity of arthritis.

Conservative Treatment

Activity modification, weight reduction, ankle bracing, orthotics, and physical therapy

Medications

Oral anti-inflammatory agents, oral steroids, injected steroids.  NSAIDs are thought to increase viral spread whereas steroids compromise our immune system and our ability to fight off infections.  Both should be avoided. Safe anti-inflammatory agents include fish oil and curcumin.

Surgery

There are different types of surgeries depending upon the severity of the injury which includes trimming the diseased area, ankle fusion, and ankle replacement.  Fusion surgery is associated with the risk of adjacent segment disease (ASD) and the need for additional ankle surgeries (6).  Failure of the bones to heal, a condition called nonunion, can also occur requiring additional surgery (7).

Are There Other Options?  Yes

Regenerative Options for Subtalar Joint Pain

At the Centeno-Schultz Clinic, we have successfully treated subtalar joint pain and other ankle injuries with bone marrow concentrate and PRP injections.  Stem cells can fill in areas of cartilage loss (8).  Ligament and tendon injuries are treated with a precise ultrasound-guided injection of PRP or bone marrow concentrate.  These injections can strengthen damaged ligaments restoring stability to the joint.   At the Centeno-Schultz Clinic, we are experts in the treatment of ankle injuries.  Board-certified, fellowship-trained physicians are available for in-office or telemedicine consultations.  We see patients both from Colorado and all around the world.

Meet  TJ

TJ is a 39-year old patient who previously lived and worked in Nepal.  She was an avid world traveler and hiker until severe ankle arthritis put her on the sidelines.  Her pain was severe at 7-9/10 and limited her ability to walk.  The patient was told she needed an ankle fusion which she declined.  Instead, she opted for a culture-expanded stem cell procedure using her own stem cells at the Regenexx Cayman Clinic.  The procedure is called Regnexx C and allows patients to grow their bone marrow-derived stem cells to a much higher number in a highly specialized lab.  The expanded cells are then used in patients with severe arthritis in one or more of their joints and damaged ligaments and tendons.  The Centeno-Schultz Clinic has the ability to see and treat patients both in Denver and Grand Cayman.  The procedure is technically challenging and can not be performed by your PCP or orthopedic surgeon. To watch an advanced ultrasound-guided injection please click on the video below.

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In Conclusion

The subtalar joint is an important joint in the ankle that is susceptible to injury.  Trauma including untreated ankle sprains is the most common cause of subtalar joint pain and arthritis.  Pain is typically localized near the heel and aggravated by walking. Treatment options include conservative care, medications, and surgery.  Surgical complications include adjacent segment disease and failed bone healing.   A new novel technique using bone marrow concentrate and PRP can treat subtalar pain and dysfunction without the risk of compromising immune function or acceleration of viral spread.  It is a nonsurgical treatment option without the risks, complications and extensive rehab associated with fusion or ankle replacement. If your subtalar joint pain is keeping you on the sidelines schedule an evaluation at the Centeno-Schultz Clinic before the injuries and damage progress. Think of TJ, back out there doing what she loves!

 


1.Krähenbühl N, Horn-Lang T, Hintermann B, Knupp M. The subtalar joint: a complex mechanism. EFORT Open Rev. 2017; 2 (7): 309– 316

2. Rockar PA. The subtalar joint: anatomy and joint motion. J Orthop Sports Phys Ther. 1995;21(6):361-72.

3. Burdett RG. Forces predicted at the ankle during running. Med Sci Sports Exerc. 1982;14(4):308-16.

4. Rammelt, S., Bartoníček, J. & Park, K. H. Traumatic Injury to the Subtalar Joint. Foot Ankle Clin. 23, 353–374, https://doi.org/10.1016/j.fcl.2018.04.004 (2018).

5. Murray, C. et al. Population prevalence and distribution of ankle pain and symptomatic radiographic ankle osteoarthritis in community dwelling older adults: A systematic review and cross-sectional study. PLoS One 13, 1–21, https://doi.org/10.1371/journal.pone.0193662

6.Sokolowski M, Krähenbühl N, Wang C, et al. Secondary Subtalar Joint Osteoarthritis Following Total Ankle Replacement. Foot Ankle Int. 2019;40(10):1122-8.

7. Joveniaux P, Harisboure A, Ohl X, Dehoux E. Long-term results of in situ subtalar arthrodesis. Int Orthop. 2010;34(8):1199-205.

8.Wakitani S, Imoto K, Yamamoto T, Saito M, Murata N, Yoneda M. Human autologous culture expanded bone marrow mesenchymal cell transplantation for repair of cartilage defects in osteoarthritic knees. Osteoarthr Cartil. 2002;10(3):199-206.