Subtalar Joint Instability

  • Vincenzo Candela
  • Umile Giuseppe LongoEmail author
  • Giuseppe Salvatore
  • Alessandra Berton
  • Nicola Maffulli
  • Vincenzo Denaro


Subtalar joint instability is a chronic functional talocalcaneal instability characterized by a combination of anterior movement, medialization, and varus tilt of the calcaneus. It may result from chronic tear or insufficiency of interosseous talocalcaneal ligament (ITCL), cervical ligament (CL), and calcaneo-fibular ligament (CFL) or as a consequence of acute subtalar dislocation. Clinical symptoms include a feeling of uncertainty during walk on uneven ground, swelling, painful stiffness of the subtalar joint, and diffuse pain in the hindfoot and onto the sinus tarsi. Weight-bearing X-rays including Broden views, CT scan, MR imaging, and arthrography are helpful for the correct diagnosis. Treatment consists of physical therapy directed at the soft tissue envelope and dynamic stabilizers and, if conservative treatment is unsuccessful, operative treatment with anatomical or nonanatomical reconstructions.


  1. 1.
    Sarrafian SK. Biomechanics of the subtalar joint complex. Clin Orthop Relat Res. 1993;(290):17–26.Google Scholar
  2. 2.
    Rockar PA Jr. The subtalar joint: anatomy and joint motion. J Orthop Sports Phys Ther. 1995;21(6):361–72.CrossRefGoogle Scholar
  3. 3.
    Goto A, Moritomo H, Itohara T, Watanabe T, Sugamoto K. Three-dimensional in vivo kinematics of the subtalar joint during dorsi-plantarflexion and inversion-eversion. Foot Ankle Int. 2009;30(5):432–8.PubMedGoogle Scholar
  4. 4.
    van Dijk CN, Longo UG, Loppini M, Florio P, Maltese L, Ciuffreda M, et al. Conservative and surgical management of acute isolated syndesmotic injuries: ESSKA-AFAS consensus and guidelines. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):1217–27.CrossRefGoogle Scholar
  5. 5.
    Lubberts B, Vopat BG, Wolf JC, Longo UG, DiGiovanni CW, Guss D. Arthroscopically measured syndesmotic stability after screw vs. suture button fixation in a cadaveric model. Injury. 2017;48(11):2433–7.CrossRefGoogle Scholar
  6. 6.
    Jotoku T, Kinoshita M, Okuda R, Abe M. Anatomy of ligamentous structures in the tarsal sinus and canal. Foot Ankle Int. 2006;27(7):533–8.CrossRefGoogle Scholar
  7. 7.
    Pisani G. Chronic laxity of the subtalar joint. Orthopedics. 1996;19(5):431–7.PubMedGoogle Scholar
  8. 8.
    Heilman AE, Braly WG, Bishop JO, Noble PC, Tullos HS. An anatomic study of subtalar instability. Foot Ankle. 1990;10(4):224–8.CrossRefGoogle Scholar
  9. 9.
    Weindel S, Schmidt R, Rammelt S, Claes L, v Campe A, Rein S. Subtalar instability: a biomechanical cadaver study. Arch Orthop Trauma Surg. 2010;130(3):313–9.CrossRefGoogle Scholar
  10. 10.
    Karlsson J, Eriksson BI, Renstrom PA. Subtalar ankle instability. A review. Sports Med. 1997;24(5):337–46.CrossRefGoogle Scholar
  11. 11.
    Mullen JE, O’Malley MJ. Sprains--residual instability of subtalar, Lisfranc joints, and turf toe. Clin Sports Med. 2004;23(1):97–121.CrossRefGoogle Scholar
  12. 12.
    Aynardi M, Pedowitz DI, Raikin SM. Subtalar instability. Foot Ankle Clin. 2015;20(2):243–52.CrossRefGoogle Scholar
  13. 13.
    Longo UG, Ciuffreda M, Locher J, Maffulli N, Denaro V. Apophyseal injuries in children’s and youth sports. Br Med Bull. 2016;120(1):139–59.CrossRefGoogle Scholar
  14. 14.
    Choisne J, Ringleb SI, Samaan MA, Bawab SY, Naik D, Anderson CD. Influence of kinematic analysis methods on detecting ankle and subtalar joint instability. J Biomech. 2012;45(1):46–52.CrossRefGoogle Scholar
  15. 15.
    Bonnel F, Toullec E, Mabit C, Tourne Y, Sofcot. Chronic ankle instability: biomechanics and pathomechanics of ligaments injury and associated lesions. Orthop Traumatol Surg Res. 2010;96(4):424–32.CrossRefGoogle Scholar
  16. 16.
    Giannoulis D, Papadopoulos DV, Lykissas MG, Koulouvaris P, Gkiatas I, Mavrodontidis A. Subtalar dislocation without associated fractures: Case report and review of literature. World J Orthop. 2015;6(3):374–9.CrossRefGoogle Scholar
  17. 17.
    Zimmer TJ, Johnson KA. Subtalar dislocations. Clin Orthop Relat Res. 1989;238:190–4.CrossRefGoogle Scholar
  18. 18.
    Barg A, Tochigi Y, Amendola A, Phisitkul P, Hintermann B, Saltzman CL. Subtalar instability: diagnosis and treatment. Foot Ankle Int. 2012;33(2):151–60.CrossRefGoogle Scholar
  19. 19.
    Keefe DT, Haddad SL. Subtalar instability. Etiology, diagnosis, and management. Foot Ankle Clin. 2002;7(3):577–609.CrossRefGoogle Scholar
  20. 20.
    Broden B. Roentgen examination of the subtaloid joint in fractures of the calcaneus. Acta Radiol. 1949;31(1):85–91.CrossRefGoogle Scholar
  21. 21.
    Sijbrandij ES, van Gils AP, van Hellemondt FJ, Louwerens JW, de Lange EE. Assessing the subtalar joint: the Broden view revisited. Foot Ankle Int. 2001;22(4):329–34.CrossRefGoogle Scholar
  22. 22.
    van Hellemondt FJ, Louwerens JW, Sijbrandij ES, van Gils AP. Stress radiography and stress examination of the talocrural and subtalar joint on helical computed tomography. Foot Ankle Int. 1997;18(8):482–8.CrossRefGoogle Scholar
  23. 23.
    Sugimoto K, Takakura Y, Samoto N, Nakayama S, Tanaka Y. Subtalar arthrography in recurrent instability of the ankle. Clin Orthop Relat Res. 2002;394:169–76.CrossRefGoogle Scholar
  24. 24.
    Thermann H, Zwipp H, Tscherne H. Treatment algorithm of chronic ankle and subtalar instability. Foot Ankle Int. 1997;18(3):163–9.CrossRefGoogle Scholar
  25. 25.
    Hollis JM, Blasier RD, Flahiff CM, Hofmann OE. Biomechanical comparison of reconstruction techniques in simulated lateral ankle ligament injury. Am J Sports Med. 1995;23(6):678–82.CrossRefGoogle Scholar
  26. 26.
    Karlsson J, Eriksson BI, Renstrom P. Subtalar instability of the foot. A review and results after surgical treatment. Scand J Med Sci Sports. 1998;8(4):191–7.CrossRefGoogle Scholar
  27. 27.
    Gould N, Seligson D, Gassman J. Early and late repair of lateral ligament of the ankle. Foot Ankle. 1980;1(2):84–9.CrossRefGoogle Scholar
  28. 28.
    Hsu AR, Ardoin GT, Davis WH, Anderson RB. Intermediate and long-term outcomes of the modified Brostrom-Evans procedure for lateral ankle ligament reconstruction. Foot Ankle Spec. 2016;9(2):131–9.CrossRefGoogle Scholar
  29. 29.
    Evans DL. Recurrent instability of the ankle; a method of surgical treatment. Proc R Soc Med. 1953;46(5):343–4.PubMedPubMedCentralGoogle Scholar
  30. 30.
    Nicholas JA. Ankle injuries in athletes. Orthop Clin North Am. 1974;5(1):153–75.PubMedGoogle Scholar
  31. 31.
    Zwipp H, Rammelt S, Grass R. Ligamentous injuries about the ankle and subtalar joints. Clin Podiatr Med Surg. 2002;19(2):195–229.CrossRefGoogle Scholar
  32. 32.
    Kato T. The diagnosis and treatment of instability of the subtalar joint. J Bone Joint Surg. 1995;77(3):400–6.CrossRefGoogle Scholar
  33. 33.
    Pisani G, Pisani PC, Parino E. Sinus tarsi syndrome and subtalar joint instability. Clin Podiatr Med Surg. 2005;22(1):63–77.. viiCrossRefGoogle Scholar
  34. 34.
    Liu C, Jiao C, Hu Y, Guo QW, Wand C, Ao Y. Interosseous talocalcaneal ligament reconstruction with hamstring autograft under subtalar arthroscopy: case report. Foot Ankle Int. 2011;32(11):1089–94.CrossRefGoogle Scholar
  35. 35.
    Knupp M, Stufkens SA, Bolliger L, Barg A, Hintermann B. Classification and treatment of supramalleolar deformities. Foot Ankle Int. 2011;32(11):1023–31.CrossRefGoogle Scholar
  36. 36.
    Molloy AP, Ajis A, Kazi H. The modified Broström-Gould procedure—early results using a newly described surgical technique. Foot Ankle Surg. 2014;20(3):224–8.CrossRefGoogle Scholar
  37. 37.
    Hentges MJ, Lee MS. Chronic ankle and subtalar joint instability in the athlete. Clin Podiatr Med Surg. 2011;28(1):87–104.CrossRefGoogle Scholar

Copyright information

© ISAKOS 2019

Authors and Affiliations

  • Vincenzo Candela
    • 1
  • Umile Giuseppe Longo
    • 1
    Email author
  • Giuseppe Salvatore
    • 1
  • Alessandra Berton
    • 1
  • Nicola Maffulli
    • 2
    • 3
  • Vincenzo Denaro
    • 1
  1. 1.Department of Orthopaedic and Trauma SurgeryCampus Bio-Medico UniversityRomeItaly
  2. 2.Faculty of Medicine and Surgery, Department of Musculoskeletal DisordersUniversity of SalernoSalernoItaly
  3. 3.Centre for Sports and Exercise MedicineBarts and The London School of Medicine and Dentistry, Mile End HospitalLondonEngland

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