Surgical and Radiologic Anatomy

, Volume 41, Issue 12, pp 1433–1439 | Cite as

Incidence of symptomatic os trigonum among nonathletic patients with ankle sprain

  • Heba M. KalbounehEmail author
  • Omar Alajoulin
  • Mohammad Alsalem
  • Yasmeen Mansour
  • Jamil Shawaqfeh
  • Tala Altarawneh
  • Dua Alhusni
  • Mohammed H. Al-Muhtaseb
Original Article



Os trigonum syndrome is a rare condition, often affecting athletes. A paucity of data exists on the incidence of os trigonum syndrome in nonathletic population. The study aimed to determine the incidence and clinical characteristics of os trigonum syndrome in nonathletic patients with sprained ankles.


The sample consisted of 798 adolescent and adult patients that attended the emergency department or Foot and Ankle Clinic with acute ankle sprain. Lateral and/or oblique lateral radiographs of the feet were screened for the presence of os trigonum in relation to age and gender. A cohort of 163 patients with os trigonum was followed up prospectively over a 48-month period to correlate the presence of the os trigonum with patient symptomatology.


Os trigonum was found in 20.4% (163/798) of sprained ankles. Patients aged 18–35 exhibited most os trigonum [42.3% (69/163)], with higher incidence in females. 5.5% (9/163) of the os trigonum patients developed an os trigonum syndrome after a standard treatment of an ankle sprain [3.8% (3/78) of males and 7.1% (6/85) of females]. Females aged between 18 and 35 years had higher incidence of os trigonum syndrome compared to males of a similar age.


Os trigonum syndrome should be suspected in nonathletic patients with an ankle sprain unresponsive to standard treatment. About 1.1% of acute ankle sprain patients develop an os trigonum syndrome. This finding can help identify the source of a patient’s symptoms, leading to an accurate diagnosis, appropriate treatment and reducing the potential chronic symptoms.


Os trigonum Ankle sprain Nonathlete Posterior impingement Anatomy 


Author contributions

KH: manuscript writing. AO: data collection and management. AM: manuscript writing and analysis design. MY: literature review and data collection. SJ: data collection. AT: data analysis. AD: data analysis. AMH: project development.

Compliance with ethical standards

Conflict of interest

The authors declare that the research was conducted without any commercial or financial relationships that could be seen as a potential conflict of interest.


  1. 1.
    Bureau NJ, Cardinal E, Hobden R, Aubin B (2000) Posterior ankle impingement syndrome: MR imaging findings in seven patients. Radiology 215:497–503. CrossRefPubMedGoogle Scholar
  2. 2.
    Burman M, Lapidus P (1931) The functional disturbances caused by the inconstant bones and sesamoids of the foot. Arch Surg 22:936–975CrossRefGoogle Scholar
  3. 3.
    D’Hooghe P, Alkhelaifi K, Almusa E, Tabben M, Wilson MG, Kaux JF (2018) Chronic lateral ankle instability increases the likelihood for surgery in athletes with os trigonum syndrome. Knee Surg Sports Traumatol Arthrosc. CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Eastwood D (2002) Foot injuries in children, pediatric trauma. In: Bulstrode C, Buckwalter J, Carr A et al (eds) Oxford textbook of orthopedics and trauma, vol 3. Oxford University Press, New York, pp 2743–2750Google Scholar
  5. 5.
    Escobedo EM, MacDonald TL, Hunter JC (2006) Acute fracture of the os trigonum. Emerg Radiol 13:139–141. CrossRefPubMedGoogle Scholar
  6. 6.
    Fallat L, Grimm DJ, Saracco JA (1998) Sprained ankle syndrome: prevalence and analysis of 639 acute injuries. J Foot Ankle Surg 37:280–285CrossRefGoogle Scholar
  7. 7.
    Hamilton WG (1982) Stenosing tenosynovitis of the flexor hallucis longus tendon and posterior impingement upon the os trigonum in ballet dancers. Foot Ankle 3:74–80. CrossRefPubMedGoogle Scholar
  8. 8.
    Havens RT, Kaloogian H, Thul JR, Hoffman S (1986) A correlation between os trigonum syndrome and tarsal tunnel syndrome. J Am Podiatr Med Assoc 76:450–454. CrossRefPubMedGoogle Scholar
  9. 9.
    Huang J, Servaes S, Zhuang H (2014) Os trigonum syndrome on bone SPECT/CT. Clin Nucl Med 39:752–754. CrossRefPubMedGoogle Scholar
  10. 10.
    Johnson RP, Collier BD, Carrera GF (1984) The os trigonum syndrome: use of bone scan in the diagnosis. J Trauma 24:761–764CrossRefGoogle Scholar
  11. 11.
    Mann RW, Owsley DW (1990) Os trigonum. Variation of a common accessory ossicle of the talus. J Am Podiatr Med Assoc 80:536–539. CrossRefPubMedGoogle Scholar
  12. 12.
    Mc DA (1955) The os trigonum. J Bone Joint Surg Br 37-B:257-265Google Scholar
  13. 13.
    McMurray T (1950) Footballer’s ankle. J Bone Jt Surg Br 32:68–69CrossRefGoogle Scholar
  14. 14.
    Mellado JM, Ramos A, Salvado E, Camins A, Danus M, Sauri A (2003) Accessory ossicles and sesamoid bones of the ankle and foot: imaging findings, clinical significance and differential diagnosis. Eur Radiol 13(Suppl 6):L164–L177. CrossRefGoogle Scholar
  15. 15.
    Mouhsine E, Crevoisier X, Leyvraz PF, Akiki A, Dutoit M, Garofalo R (2004) Post-traumatic overload or acute syndrome of the os trigonum: a possible cause of posterior ankle impingement. Knee Surg Sports Traumatol Arthrosc 12:250–253. CrossRefPubMedGoogle Scholar
  16. 16.
    Nault ML, Kocher MS, Micheli LJ (2014) Os trigonum syndrome. J Am Acad Orthop Surg 22:545–553. CrossRefPubMedGoogle Scholar
  17. 17.
    Niek van Dijk C (2006) Anterior and posterior ankle impingement. Foot Ankle Clin 11:663–683. CrossRefPubMedGoogle Scholar
  18. 18.
    Nwawka OK, Hayashi D, Diaz LE, Goud AR, Arndt WF 3rd, Roemer FW, Malguria N, Guermazi A (2013) Sesamoids and accessory ossicles of the foot: anatomical variability and related pathology. Insights Imaging 4:581–593. CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Oloff LM, Schulhofer SD (1998) Flexor hallucis longus dysfunction. J Foot Ankle Surg 37:101–109CrossRefGoogle Scholar
  20. 20.
    Rathur S, Clifford PD, Chapman CB (2009) Posterior ankle impingement: os trigonum syndrome. Am J Orthop (Belle Mead NJ) 38:252–253Google Scholar
  21. 21.
    Ribbans WJ, Ribbans HA, Cruickshank JA, Wood EV (2015) The management of posterior ankle impingement syndrome in sport: a review. Foot Ankle Surg 21:1–10. CrossRefPubMedGoogle Scholar
  22. 22.
    Roche AJ, Calder JD, Lloyd Williams R (2013) Posterior ankle impingement in dancers and athletes. Foot Ankle Clin 18:301–318. CrossRefPubMedGoogle Scholar
  23. 23.
    Rungprai C, Tennant JN, Phisitkul P (2015) Disorders of the Flexor Hallucis Longus and Os Trigonum. Clin Sports Med 34:741–759. CrossRefPubMedGoogle Scholar
  24. 24.
    Russell JA, Kruse DW, Koutedakis Y, McEwan IM, Wyon MA (2010) Pathoanatomy of posterior ankle impingement in ballet dancers. Clin Anat 23:613–621. CrossRefPubMedGoogle Scholar
  25. 25.
    Schnirring-Judge M, Perlman M (2001) Chronic ankle conditions. In: Banks A, Downey M, Martin D, Miller S (eds) McGlamry’s comprehensive textbook of foot and ankle surgery, vol 1, 3rd edn. Lippincott Williams & Wilkins, Philadelphia, pp 1091–1141Google Scholar
  26. 26.
    Smyth NA, Zwiers R, Wiegerinck JI, Hannon CP, Murawski CD, van Dijk CN, Kennedy JG (2014) Posterior hindfoot arthroscopy: a review. Am J Sports Med 42:225–234. CrossRefPubMedGoogle Scholar
  27. 27.
    Song AJ, Del Giudice M, Lazarus ML, Lomasney LM, Demos TC, Dux K (2013) Radiologic case study. Os trigonum syndrome. Orthopedics 36(5):63–68. CrossRefGoogle Scholar
  28. 28.
    Sopov V, Liberson A, Groshar D (2000) Bone scintigraphic findings of os trigonum: a prospective study of 100 soldiers on active duty. Foot Ankle Int 21:822–824. CrossRefPubMedGoogle Scholar
  29. 29.
    Struijs PA, Kerkhoffs GM (2010) Ankle sprain. BMJ Clin Evid 2010:1115PubMedPubMedCentralGoogle Scholar
  30. 30.
    Watson CA, Dobas DC (1976) The os trigonum: a discussion and case report. Arch Podiatr Med Surg 3:17Google Scholar
  31. 31.
    Wolff MH, Sty JR (1985) Painful ankle. Os trigonum vs fracture. Clin Nucl Med 10:197. CrossRefPubMedGoogle Scholar
  32. 32.
    Yan YY, Mehta KV, Tan TJ (2016) Fracture of the os trigonum: a report of two cases and review of the literature. Foot Ankle Surg 22:e21–e24. CrossRefPubMedGoogle Scholar
  33. 33.
    Zwiers R, Baltes TPA, Opdam KTM, Wiegerinck JI, van Dijk CN (2018) Prevalence of os trigonum on CT imaging. Foot Ankle Int 39:338–342. CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Anatomy and Histology, Faculty of MedicineUniversity of JordanAmmanJordan
  2. 2.Ankle and Foot Section, Orthopedic and Trauma DepartmentJordanian Royal Medical ServicesAmmanJordan
  3. 3.Radiology DepartmentJordanian Royal Medical ServicesAmmanJordan

Personalised recommendations