Sinus Tarsi Syndrome: Anatomy, Diagnosis, Injection, and Surgical Treatment

Sinus tarsi syndrome — a clinical syndrome of anterolateral ankle pain localized to the sinus tarsi (the tunnel between the calcaneus and talus containing the interosseous talocalcaneal ligament, cervical ligament, and fat pad) — most commonly develops following ankle inversion sprain with ligamentous injury within the sinus tarsi, and can also occur as a manifestation of subtalar arthritis, posterior tibial tendon dysfunction, or inflammatory arthropathy. The condition is frequently underdiagnosed because standard ankle X-rays are normal and the sinus tarsi is rarely systematically palpated in patients with ‘persistent lateral ankle pain after ankle sprain.’

Anatomy and Clinical Features

Sinus tarsi anatomy: the space between the posterior and middle facets of the subtalar joint, bounded by the floor of the talocalcaneal sulcus and the calcaneal sulcus; contains the interosseous talocalcaneal ligament (ITCL — the primary stabilizer of the subtalar joint), the cervical ligament, and a synovial-lined fat pad; rich sensory innervation from branches of the peroneal and posterior tibial nerves. Pathology after ankle sprain: inversion injury tears the ITCL and cervical ligament; synovitis and fibrosis develop within the sinus tarsi; the residual instability and inflammatory tissue produce the characteristic symptoms. Clinical presentation: point tenderness directly over the sinus tarsi (anterolateral to the lateral malleolus, at the junction of the calcaneus and talar neck); symptoms worse on uneven ground and with pronation; sensation of ‘giving way’ from subtalar instability; hindfoot stiffness. MRI findings: obliteration of the normal fat signal within the sinus tarsi (replaced by low T2 signal fibrous tissue); ITCL and cervical ligament signal abnormality; synovitis; adjacent subtalar joint chondral changes. Diagnostic injection: fluoroscopic or ultrasound-guided injection of 1–2mL of local anesthetic into the sinus tarsi — complete pain relief confirms diagnosis; concurrent corticosteroid produces 60–70% prolonged response.

Treatment

Conservative: ultrasound-guided corticosteroid injection into the sinus tarsi (60–70% 6-month response); custom orthotic with sinus tarsi/subtalar support and lateral heel post to limit inversion; ankle bracing for subtalar instability component; physical therapy for subtalar proprioception rehabilitation. Surgical: sinus tarsi arthroscopic debridement — two-portal sinus tarsi approach; synovectomy and removal of fibrotic scar tissue from the sinus tarsi; excellent visualization of the ITCL and cervical ligament; concurrent subtalar chondral lesion treatment if present; 80–85% success rate when conservative care fails; outpatient procedure with rapid recovery. Open sinus tarsi debridement: for severe scarring or subtalar fusion when arthritis is confirmed as primary pathology. Dr. Biernacki at Balance Foot & Ankle diagnoses sinus tarsi syndrome with ultrasound-guided injection and performs arthroscopic debridement at our Bloomfield Township and Howell offices. Call (810) 206-1402.

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Frequently Asked Questions

When should I see a podiatrist?

See a podiatrist for any foot or ankle pain that persists more than 2 weeks, doesn’t improve with rest, limits your daily activities, or is accompanied by swelling, numbness, or skin changes. People with diabetes or circulation problems should see a podiatrist regularly even without symptoms.

What does a podiatrist treat?

Podiatrists diagnose and treat all conditions of the foot, ankle, and lower leg including plantar fasciitis, bunions, hammertoes, toenail problems, heel pain, nerve pain, diabetic foot care, sports injuries, fractures, and foot deformities — both surgically and non-surgically.

What can I expect at my first podiatry visit?

Your first visit includes a full medical history, physical examination of your feet and gait, and in-office diagnostic imaging if needed (X-rays, ultrasound). We’ll discuss your diagnosis and create a plan tailored to your foot type. Most visits take 30–45 minutes.

Need Treatment at Balance Foot & Ankle?

Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin see patients at our Howell and Bloomfield Township offices.

Book Online or call (810) 206-1402

Most Common Mistake We See

The most common mistake we see is: Waiting too long before seeking care. Fix: any foot pain lasting more than 4 weeks, or any sudden severe symptom, deserves a professional evaluation rather than more rest.

Warning Signs That Need Same-Day Care

In-Office Treatment at Balance Foot & Ankle

If home treatment isn’t providing relief for your foot and ankle conditions, our podiatry team at Balance Foot & Ankle can help with same-day evaluations and advanced in-office care.