Quick answer: Os Trigonum Syndrome is a clinical condition that responds to evidence-based treatment when caught early. Symptoms include pain, swelling, and altered function. Diagnosis requires clinical exam, often imaging. Treatment ladder: conservative care first (4-6 weeks), then targeted interventions if needed. Call (810) 206-1402.
Board-Certified Podiatric Foot & Ankle Surgeon · Last reviewed: May 5, 2026
Medically reviewed by Dr. Tom Biernacki, DPM · Board-Certified Podiatric Surgeon · Last reviewed: April 2026 · Editorial Policy
The most important clinical decision with Os Trigonum Syndrome isn’t which treatment to start with — it’s identifying the correct subtype. That changes everything. Call (810) 206-1402.
Quick Answer
Medically reviewed by Dr. Tom Biernacki, DPM
Board-certified podiatric surgeon | Balance Foot & Ankle
Last reviewed: May 2026
Os Trigonum Syndrome 2026: Posterior Ankle Pain DPM relates to foot pain — typically caused by overuse, footwear, or biomechanics. Most patients improve in 6-12 weeks with conservative care. Same-week appointments in Howell + Bloomfield Hills: (810) 206-1402.
✅ Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatrist · Last updated April 6, 2026
Os Trigonum Syndrome: Causes, Symptoms, and Treatment
What Is Os Trigonum Syndrome?
Os trigonum syndrome is a painful condition of the back of the ankle caused by compression or irritation of the os trigonum — a small accessory bone located behind the talus (ankle bone). Approximately 7 to 14 percent of the population has an os trigonum, but most people never know it is there. Problems arise when the bone is repeatedly compressed between the talus and the heel bone during plantarflexion (pointing the foot downward), a motion common in ballet, soccer, gymnastics, and downhill running.
What Causes the Pain?
The os trigonum is either a separate bone that failed to fuse during skeletal development or a fracture of the posterior process of the talus. During extreme plantarflexion — such as a ballet dancer rising onto pointe or a soccer player kicking the ball — the os trigonum is pinched between the talus and the calcaneus. Repeated compression causes inflammation of the surrounding soft tissues, including the flexor hallucis longus tendon sheath, which runs directly adjacent to the os trigonum.
Os trigonum syndrome can also be triggered by a single traumatic event, such as a forced plantarflexion injury from missing a step or landing awkwardly from a jump.
Symptoms
The primary symptom is deep, aching pain at the back of the ankle that is worse with plantarflexion activities — pointing the toes, going up on tiptoe, or kicking. Swelling and tenderness are present directly behind and below the ankle on the outer side. The pain typically worsens with activity and improves with rest. In some cases, a clicking or catching sensation is felt at the back of the ankle.
Who Gets It?
Os trigonum syndrome is most prevalent in ballet dancers, gymnasts, soccer players, and downhill runners — athletes who repeatedly plantarflex their ankles under load. It can also affect everyday patients after a forced ankle injury or with a congenital os trigonum that becomes symptomatic with age or activity increase.
Diagnosis
Diagnosis begins with a clinical examination. A positive “nutcracker test” — pain provoked by passively plantarflexing the ankle against resistance — strongly suggests os trigonum syndrome. X-rays confirm the presence of the accessory bone. MRI is used to assess soft tissue inflammation, flexor hallucis longus tendon involvement, and bone edema.
Non-Surgical Treatment
Rest and activity modification: Avoiding the provocative plantarflexion movements for four to eight weeks. Dancers may need to take a break from pointe work.
Ice and NSAIDs: Reduce acute inflammation.
Immobilization: A walking boot may be prescribed for four to six weeks in more severe cases.
Corticosteroid injection: An ultrasound-guided injection into the os trigonum region can provide significant pain relief and allow return to activity. This is often the most effective conservative treatment.
Physical therapy: Once pain is controlled, rehabilitation focuses on restoring range of motion, strength, and activity-specific movement patterns.
Surgical Treatment
When conservative care fails after three to six months, surgical excision of the os trigonum is effective. The procedure can be performed arthroscopically through small incisions, with a relatively fast recovery of four to eight weeks for most patients. Outcomes are excellent, with most athletes returning to full sport participation.
Balance Foot & Ankle and Os Trigonum Syndrome
Our podiatrists have experience treating posterior ankle impingement conditions including os trigonum syndrome in athletes and active patients throughout Michigan. If you have persistent back-of-ankle pain with pointed-toe movements, schedule an evaluation at one of our locations.
Os Trigonum Syndrome Treatment in Michigan: Conservative Care and Surgical Excision
Michigan dancers, gymnasts, soccer players, and other athletes requiring maximal plantarflexion who develop posterior ankle pain should be evaluated for os trigonum syndrome — impingement of the accessory os trigonum bone (present in approximately 10% of the population) between the talus and calcaneus with forced plantarflexion. At Balance Foot & Ankle, os trigonum evaluation includes lateral ankle X-ray to identify the ossicle, and MRI or ultrasound when differentiation from FHL tendinopathy, posterior impingement without ossicle, or subtalar pathology is needed. Conservative treatment — activity modification, corticosteroid injection into the posterior ankle with fluoroscopic or ultrasound guidance, and physical therapy addressing posterior capsular flexibility — resolves a significant proportion of cases without surgery. For athletes who fail conservative care, arthroscopic os trigonum excision is an effective procedure with rapid return to sport in most cases. Michigan athletes with posterior ankle pain limiting their sport should call Balance Foot & Ankle at (810) 206-1402 for evaluation at our Howell or Bloomfield Hills office.
Related Treatment Guides
Michigan patients experiencing foot or ankle problems can schedule an appointment at Balance Foot & Ankle — with locations in Howell (4330 E Grand River) and Bloomfield Hills (43494 Woodward Ave #208). Call (810) 206-1402 for same-week availability.
Related Patient Guides
- Ankle Pain: Causes by Location & Treatment
- Achilles Tendinitis: Symptoms & Treatment
- Stress Fracture in the Foot: Symptoms & Recovery
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4330 E Grand River Ave
Howell, MI 48843
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Bloomfield Hills Office
43494 Woodward Ave, #208
Bloomfield Hills, MI 48302
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Os Trigonum Syndrome Treatment in Michigan
Same-day appointments in Howell & Bloomfield Hills, MI. Board-certified podiatrists, 4.9★ rating.
Or call: (810) 206-1402
Pros & Cons of Conservative Care for foot care
Advantages
- ✓ Conservative care first
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Considerations
- ✗ Self-treatment can mask issues
- ✗ See a podiatrist if pain >2 weeks
Dr. Tom’s Recommended Products for foot care
Affiliate disclosure: As an Amazon Associate, Balance Foot & Ankle earns from qualifying purchases. We only recommend products we use with patients.
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Ready to Get Back on Your Feet?
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About Your Care Team at Balance Foot & Ankle
Dr. Tom Biernacki, DPM · Board-Certified Foot & Ankle Surgeon. Specializes in conservative-first care, minimally invasive bunion surgery, and complex reconstruction.
Dr. Carl Jay, DPM · Accepting new patients. Specializes in sports medicine, athletic injuries, and routine podiatric care.
Dr. Daria Gutkin, DPM, AACFAS · Accepting new patients. Specializes in surgical reconstruction and pediatric podiatry.
Locations: 4330 E Grand River Ave, Howell, MI 48843 · 43494 Woodward Ave Suite 208, Bloomfield Hills, MI 48302
Hours: Mon–Fri 8:00 AM – 5:00 PM · (810) 206-1402
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Visit Balance Foot & Ankle — Same-Day Appointments Available
Our podiatry team serves patients throughout Michigan including Howell, Brighton, and Bloomfield Hills. If you’re dealing with heel pain, ingrown toenails, or a foot injury, we have same-day appointment availability.
Same-day appointments available. (810) 206-1402
Related Conditions
Frequently Asked Questions
When should I see a podiatrist?
See a podiatrist if: foot or ankle pain has lasted more than 2–4 weeks without improvement, you’re changing your gait to avoid pain, you have an open wound or sore that isn’t healing, you notice nail discoloration or thickening, you have diabetes and any foot concern, or pain is severe enough to wake you at night. Most foot conditions are easier and cheaper to treat early — what starts as a minor issue can become a surgical problem with months of delay.
What is the difference between a podiatrist and an orthopedic surgeon?
Podiatrists (DPM — Doctor of Podiatric Medicine) specialize exclusively in the foot, ankle, and lower leg. Orthopedic surgeons (MD/DO) have broader musculoskeletal training but variable foot/ankle subspecialization. For foot and ankle-specific problems, a podiatrist often has more focused training and experience. For injuries involving the leg above the ankle, complex pediatric cases, or multi-level reconstruction, orthopedic consultation may be appropriate. We frequently co-manage patients with orthopedic colleagues.
How do I know if my foot pain is serious?
Signs that warrant same-day or next-day evaluation: severe pain that appeared suddenly without clear cause, swelling, redness, and warmth that appeared suddenly (possible gout, infection, or Charcot fracture), an open wound that looks infected (redness spreading, pus, warmth), inability to bear weight, or any foot problem in a diabetic patient. Pain that’s been present for weeks and is stable is important but not an emergency — schedule within 1–2 weeks.
Can foot problems cause back and knee pain?
Yes — this is a kinetic chain effect. Abnormal foot mechanics (overpronation, supination, leg length discrepancy) cause compensatory changes in knee, hip, and lumbar alignment. Roughly 30% of patients presenting to our clinic with knee pain have a treatable foot-level biomechanical cause. Correcting foot mechanics with orthotics or appropriate footwear often provides significant knee and back relief. If you have chronic knee or back pain and haven’t had your foot mechanics evaluated, it’s worth a consult.
Are orthotics worth it?
For the right conditions, yes — custom orthotics are among the most cost-effective interventions in podiatry. They’re most effective for: plantar fasciitis, flat feet with secondary knee/back pain, leg length discrepancy, metatarsalgia, posterior tibial tendon dysfunction, and diabetic foot pressure management. Quality OTC orthotics ($35–60) resolve symptoms for 60% of patients with mild-to-moderate conditions. Custom orthotics are appropriate when OTC options have failed or when the biomechanical problem is complex. We cast custom orthotics in-office.
How do I choose the right running shoes?
Start with your foot type (flat, neutral, high arch) and running pattern (overpronator, neutral, supinator). Flat feet and overpronators do best in stability or motion-control shoes. Neutral feet do well in neutral-cushioned shoes. High arches need maximum cushioning with flexible soles. Always buy running shoes at the end of the day (foot swelling peaks then), get properly fitted by a specialist, and replace every 300–500 miles. If you’ve been injured repeatedly, a gait analysis can identify the mechanical flaw driving your injury pattern.
What is the difference between a sprain and a fracture?
A sprain is a ligament injury (the tissue connecting bones); a fracture is a break in the bone itself. Both can occur with the same trauma (ankle roll, fall). The old test — ‘if you can walk, it’s not broken’ — is wrong; many fractures are initially weight-bearable. Key differences: a fracture typically produces localized bone tenderness along the bone itself, while a sprain is tender over the ligament. X-ray is the standard to differentiate. High-grade sprains without proper treatment can be as disabling as fractures.
How do I prevent foot and ankle injuries?
The four most impactful prevention strategies: (1) Supportive, appropriately fitted footwear for your foot type and activity. (2) Gradual activity progression — the 10% rule (never increase weekly mileage or intensity by more than 10%). (3) Regular calf and ankle mobility work. (4) Strengthening the posterior tibial tendon, peroneals, and intrinsic foot muscles. Most overuse injuries are preventable; most acute injuries are not — but ankle sprain recurrence (60–70% without rehab) is prevented by balance and proprioception training.
What is os trigonum syndrome?
Os trigonum syndrome is a condition caused by an extra bone (os trigonum) at the back of the ankle that becomes pinched between the heel and shin bones during downward pointing of the foot. It causes posterior ankle pain, particularly during activities requiring repetitive plantarflexion such as ballet, soccer, and swimming.
How is os trigonum syndrome diagnosed?
Diagnosis is made through clinical examination revealing posterior ankle tenderness with a positive nutcracker test — pain reproduced by forced plantarflexion. X-rays confirm the presence of the os trigonum, and MRI or ultrasound can show fluid, edema, or inflammation around it.
How is os trigonum syndrome treated?
Conservative care includes rest, ice, anti-inflammatory medications, a walking boot, and physical therapy. Corticosteroid or platelet-rich plasma injections can reduce inflammation. Surgical excision of the os trigonum is highly effective for athletes who fail non-operative treatment, with most returning to full activity within 4–6 months.
Dr. Tom Biernacki, DPM is a board-certified foot & ankle surgeon (ABFAS & ABPM) at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has made him one of the most-followed foot & ankle educators on YouTube.