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Subtalar Arthritis

What Is Subtalar Arthritis?

Please see foot & ankle anatomy for more information about the subtalar joint.

Arthritis is disease (damage) of cartilage. Cartilage lines the surface of the bones where two or more bones form a joint. Cartilage allows smooth and frictionless movements. Disease of cartilage leads to roughened surfaces which causes friction and increased wear and tear in the joint. This in turn can cause inflammation, pain, and joint deformity.

Subtalar arthritis is when arthritis involves the subtalar joint.

MRI revealing extensive arthritis of the subtalar joint

MRI revealing extensive arthritis of the subtalar joint

What Can Cause It?

Any condition that damages the cartilage (joint surface) will cause subtalar arthritis to develop.

The common conditions that cause subtalar arthritis are:

What Are The Symptoms?

Typical symptoms of subtalar arthritis include:

  • Pain
    • Painful stiffness in the morning
    • Eases off with activity but later becomes constant
    • Worse in cold damp weather
    • Exacerbated by weight bearing, walking and standing
    • Limits activities (reduced walking distance, unable to do sports)
    • Limp
  • Swelling
  • Reduced movement in the joint (stiffness)
  • Change in foot shape (joint deformity)

What Investigations May Be Required?

Investigations help confirm the diagnosis, grade the severity of the condition and where applicable, aid in pre operative planning.


Plain radiograph (x-ray)

Weight bearing plain radiographs are a quick and effective way of confirming arthritis in a joint. In the early stages when there is inflammation with no damage to the joint they maybe normal. Most people however present when there is some structural damage.

The following are features of arthritis on a plain radiograph:

  • Decreased joint space
  • Subchondral sclerosis
  • Subchondral cysts
  • Osteophytes
  • Deformity (change in foot shape)
Radiographs of the foot showing a normal subtalar joint; and an arthritic subtalar joint (note complete loss of joint space posteriorly)

Radiograph of the foot demonstrating A – normal subtalar joint B – arthritic subtalar joint (note complete loss of joint space posteriorly)


MRI

MRI provides excellent high definition static images. It is useful in pre operative planning and to exclude any other pathology in the hindfoot. It is also useful in monitoring healing.

MRI is particularly useful in assessing:

  • Cartilage loss
  • Reactive bone changes
  • Effusion
  • Synovitis
  • Ligament damage
  • Tendon pathology (tenosynovitis, tendon tears)
  • Any other pathology

CT

CT images give excellent information on bone structure and is superior to plain radiography in that respect.

CT is particularly useful in the following cases:

  • 3D image reconstruction
  • Pre operative planning
  • Evaluating the joint in the presence of surgical hardware ie screws & plates
  • Assessing adjacent joints for presence of arthritis
  • Assessing bone healing (fusion)

Ultrasound

Ultrasound is a quick, painless and non invasive method of assessing soft tissue structures.

Ultrasound is particularly good at ascertaining:

  • Presence of inflammation in the lining of the joint (synovitis)
  • Evidence of fluid in the joint (effusion)
  • Evidence of adjacent soft tissue structure pathology such as tenosynovitis

Bone Scan

Bone scan is a non specific test. It utilises a radioactive dye, absorbed by the body and taken up by areas of high metabolic activity such as inflammation and infection. It will not tell you what the diagnosis is, but will usually tell you if an abnormality is present.

This test is done in special circumstances.

Picture of a bone scan showing increased uptake in the foot

Picture of a bone scan showing increased uptake in the foot

Can The Problem Get Worse?

The natural history of arthritis is very variable, some patients describe a rapid deterioration, while others take many years to get worse.

The changes associated with arthritis are irreversible, the joint will never return to its normal healthy state. That is not to say that all patients are symptomatic, some patients describe stiff joints with mild ache and are able to manage their symptoms with activity modification. However some patients describe significant pain and functional limitation.

You should see an Orthopaedic Foot & Ankle Surgeon if one or more of the following applies to you:

  • Pain affecting your quality of life
  • Pain affecting your ability to work
  • Your pain is getting worse
  • You have night pain
  • You have rest pain
  • You can no longer exercise or participate in sports to the level you desire
  • You have started to develop deformity in your foot or ankle
  • You have a swelling of unknown cause
  • You are unsure about the underlying diagnosis (cause of your symptoms)
  • Failure of conservative measures such as rest, time, anti-inflammatories and physiotherapy
  • Problems with footwear

As the arthritis becomes more severe and any deformity becomes fixed, adjacent joints will also become involved and become arthritic.


Grading a disease in medicine is used for the following reasons:

  • Assessing the severity of a condition
  • For accurate record keeping 
  • To help monitor disease progression
  • For ease of communication between colleagues for example
  • In some cases to give information on prognosis
  • In some cases to help guide treatment

There are a number of grading systems used for arthritis. We use the following grading system based on radiographic (x-ray) features at The London Foot & Ankle Clinic:

  1. Little or no joint space narrowing
  2. Minimal joint space narrowing with small marginal osteophytes
  3. Definite joint space narrowing and osteophytes
  4. Extreme joint space narrowing (no space between the bones on x-rays)

Non-Operative Treatment Options

Non-operative management for ankle arthritis aims at relieving pain and return to full activity including sports whenever possible. It is likely to be most effective in the early stages of the condition.

It should always be the first line of treatment. Options include:

Activity modification

A period of rest from sports and exercise that bring on symptoms. Avoiding high impact activities with lots of turning and twisting.


Footwear modification

Wearing above ankle boots that give more support to the ankle and subtalar joint. The use of a shoe with a heel cushion.


Insoles & orthotics

Ankle braces give more support and stability to the ankle and subtalar joint and could ease pain particularly when doing sports and exercise. Custom orthotics in the form of an AFO (ankle foot orthosis) coupled with insoles can be successful in easing symptoms.


Non steroidal anti-inflammatories

The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort in patients with subtalar arthritis by reducing inflammation in the joint.


Analgesics

The use of paracetamol and other painkillers to help reduce pain levels.


Physiotherapy

Physiotherapy works by strengthening muscles around not only the joint but the whole kinetic chain. Results are variable with arthritis and depend really on the severity of the disease. In a very stiff and damaged joint, physiotherapy may make your symptoms worse. Your surgeon will guide you.


Walking aids

The use of a walking stick or cane to reduce the forces going across the damaged joint.


Weight loss

Can relieve the pressure on painful damaged joints.


Dietary supplements

These are increasingly popular with people who have arthritis. The cartilage found in joints, normally contains glucosamine and chondroitin. It is thought that taking supplements of these natural ingredients may help to improve the health of damaged cartilage.

Research has provided mixed results but on the whole suggests that glucosamine sulphate is more likely to be helpful than glucosamine hydrochloride. If you are thinking of taking glucosamine, we suggest taking 1,500 mg per day of glucosamine sulphate. If you notice no improvement in your symptoms after 3 months then you should probably discontinue it. If you do find it improves your symptoms then you ned to continue taking the supplements. There is no extra benefit in taking glucosamine and chondroitin.

Remember that supplements also have side effects and it is advisable to discuss with your GP before starting any new treatment.


Other treatment options

There is no one treatment that has a reliably successful, quick and easy cure for arthritis. Therefore researchers and doctors are constantly looking for new and better ways of treating arthritis.

Many treatments have come into fashion and then gone away over the years once results had shown that the initial promise was premature and misplaced.

At The London Foot & Ankle Clinic we do not promote or discourage new treatment options for arthritis. We would however advise a cautious approach to relatively untested treatment modalities with little or no evidence to back their use. Patients undergo these treatments at their own risk.

Injections For Subtalar Arthritis

There are a number of treatments that involve an injection or series of injections for the treatment of subtalar arthritis.


Image guided steroid and local anaesthetic injection

This injection serves as both a therapeutic and diagnostic intervention. Steroids reduce inflammation and can ease painful symptoms. The local anaesthetic numbs an area of the body for roughly 12 to 48 hours.

The steroid is unpredictable in its success at easing painful symptoms but has very low risk of complications and therefore is an attractive therapeutic option prior to further more invasive surgical intervention. The local anaesthetic on the other hand is very predictable in its action. If there is an area of damage it will definitely ease symptoms for 12 to 48 hours. If symptoms do not ease during this period, one has to question whether the diagnosis is correct.

Steroids reduce inflammation and ease pain when injected directly into an arthritic joint. It is most likely to be effective in the early stages of arthritis.

We carry out almost all injections under a short general anaesthetic (1 minute) as injecting into a painful joint can be quite sore. While you are asleep and lying still a small needle is inserted into the joint and the position is confirmed using an x-ray in theatre. A small amount of dye is injected first to make sure the needle is in the correct spot and then a mixture of Depomedrone (steroid) and Bupivacaine (long lasting local anaesthetic) is injected. Undertaking the injection in this manner ensures a pain free experience for the patient and the best outcome clinically as there is no doubt about the placement of the injection.

The local anaesthetic will cause numbness in the area injected for approximately 12 to 48 hours. This action is predictable. What is not predictable is the duration of action of the steroid. It may work for one month, several months or even more than a year.

Injections are not repeated less than 6 monthly intervals.

Please read here for more information regarding injections and possible complications.

Intraoperative x-ray showing correct placement of needle in the subtalar joint (confirmed with radiopaque dye)

Intraoperative x-ray showing correct placement of needle in the subtalar joint (confirmed with radiopaque dye)


Image guided viscosupplementation

Normal joints have lubrication fluid called synovial fluid. A major constituent of synovial fluid is a substance called hyaluronic acid. This helps not only lubricate the joint but also act as a shock absorber easing the load across the joint.

It has been noted that people with arthritis tend to have lower concentrations of hyaluronic acid than normal.

Viscosupplementation involves injecting hyaluronic acid into arthritic joints. The procedure would be carried out as for a steroid injection under a short general anaesthetic and x-ray control.

Please read here for more information regarding injections and possible complications.

Operative Treatment Options

Surgical management is reserved for patients who have failed to respond to non operative treatment.

Patients should understand that the decision to undergo surgery should not be taken lightly.

Any intervention is considered in a step wise manner, with the least invasive procedure carried out first.


Subtalar arthroscopy +/- open debridement

This is suitable for only a small select group of patients with a small isolated area of damaged joint, loose body or inflamed tissue. Typically patients present with advanced disease and this is therefore not an option. It allows for not only direct visualisation of the joint surfaces (diagnostic) but also treatment as well, such as:

  • Removal of debris from the joint
  • Removal of loose bodies
  • Removal of inflamed tissue
  • Removal of unstable joint surfaces.

The operation is carried out via keyhole (arthroscopic) surgery or a small incision. It is performed under a short general anaesthetic as a daycase.


Subtalar fusion

This operation has excellent outcomes in terms of pain relief and return to activities of daily living.

It involves removing all remnants of the diseased joint (cartilage) and fusing the two main bones (calcaneum and talus) that form the subtalar joint together. With no more joint there will be no more movement and therefore no more pain. The aim is to sacrifice painful movement for pain relief.

The majority of patients when they first hear about this procedure are quite apprehensive. This is understandable, joints exist to allow movement. A fusion is the total opposite to this, and therefore most patients perceive it as unnatural. However contrary to what most people think, after a fusion you will be less likely to limp and be a lot more active. Please read this blog for more details.

The operation is usually carried out through a small incision on the side of the foot. In some patients the operation maybe performed through keyhole (arthroscopic) surgery. The operation is undertaken under a general anaesthetic and patients usually require an overnight stay in hospital.

The main longterm complication following a subtalar fusion is the development of adjacent arthritic joint disease, particularly talonavicular and calcaneocuboid joints.

The main short term complication is non union (the bones not fusing together). This is reported in numerous studies to be around 10%. In the event of this complication, the operation is repeated with bone graft to stimulate the healing and given time most patients eventually heal.

Currently subtalar fusion remains the treatment of choice for end stage subtalar arthritis. There is no subtalar joint replacement.

An x-ray of the foot showing a patient who developed subtalar arthritis after an ankle fusion and an x-ray showing as ubtalar fusion after surgey

A – Radiograph of the foot in a patient who developed subtalar arthritis after an ankle fusion B – treated successfully by a subtalar fusion

Potential Complications

It should be borne in mind that complications can result from a condition with or without surgery.


Potential complications of non-operative treatment include:

  • Worsening pain
  • Increased stiffness
  • Increasing deformity
  • Adjacent joint disease
  • Pain elsewhere, for example in the knee, hip or lower back (due to abnormal gait and compensatory mechanisms)

Complications can occur as with any type of surgery. Please see Complications for more detailed explanation of post surgical complications.

Potential general complications of any operative treatment include:

  • Risks and complications of anaesthesia
  • Bleeding
  • Infection (superficial and deep)
  • Blood clots
  • In the case of an MIS procedure it may be necessary to proceed to open surgery if during the operation it is felt that a better outcome will be achieved using an open technique
  • Failure to fully correct deformity (particularly if longstanding deformity)
  • Need for further surgery (revision or further treatment)
  • Persistent pain
  • Complex regional pain syndrome
  • Wound healing problems

Potential specific complications of subtalar arthroscopy +/- open debridement include:

  • Failure to alleviate symptoms and need for further surgery (fusion)
  • Sural nerve injury

Potential specific complications of supramalleolar osteotomy include:

  • Delayed union
  • Non union
  • Tendon or ligamanet injury

Potential specific complications of subtalar fusion include:


Note – these complications are not exhaustive and are meant as a guide

Post Operative Period & Recovery

Please read the information regarding what to expect post surgery on this website.

Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.


Immediate post operative period

All surgical procedures for subtalar arthritis will be carried out under a general anaesthetic.

Following subtalar arthroscopy +/- open debridement

You will have a small waterproof dressing applied to the front of the ankle to cover the arthroscopy portal sites/wound and a bandage applied. It is advised not to remove this bandage until reviewed by Mr Malik at the 2 week post operative check up. For 2 weeks following surgery it is recommended that you keep the area dry. You may wish to get a Limbo bag which will stop the wound getting wet.

Weight bearing status will really depend on how much has been done inside the joint. Most patients are touch weight bearing for 48 hours and then weight bear as tolerate after that with or without the use of crutches. A physiotherapist will guide you before your discharge from hospital. Please ensure someone is able to drive you home after the operation. It is important that you commence ankle range of motion exercises as soon as possible after the operation to prevent stiffness. Activities can be gradually increased as pain allows.

In addition following a subtalar fusion – 

You will have a backslab applied post operatively for two weeks. You will spend one night in hospital after your operation and receive intravenous antibiotics the next morning.

A backslab after foot and ankle surgery

A picture of a backslab

Please do not remove your backslab until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment.

You will be non weight bearing for approximately 6 to 8 weeks. The physiotherapist will guide you with the use of crutches after your operation and before your discharge from hospital.

For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time.

A picture demonstrating high elevation after foot and ankle surgery

A picture demonstrating high elevation

Naturally most people do not have a hospital bed at home. The same effect can be achieved by lying in a bed or lengthways on a sofa, with pillows behind your back and under your foot. You cannot have your leg elevated sitting in a chair. It is strongly advised that during the first two weeks you are house bound.

To minimise risk of infection keep the foot dry and cool. Avoid humid and hot environments. Keep the foot dry and when showering wear a Limbo bag.

To minimise the risk of blood clots please move your foot and ankle at regular intervals. Please ensure you are well hydrated. If you have a risk of blood clots please notify Mr Malik who may organise for you to have blood thinning injections as a precaution.


Two weeks post operatively

You will be reviewed at the clinic and your dressings removed. Your wound will be checked to see that it has healed and there are no signs of infection. Driving will be permitted for short trips if the left foot has been operated on and you drive an automatic. If the right foot has been operated on it will be at least 6 to 8 weeks before any driving is advisable.

Following a subtalar arthroscopy +/- open debridement

At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 3 to 4 months.  If completely healed you will be given advice regarding soft tissue massage and scar desensitisation. Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area. You may shower and get the area wet only if the wound has completely healed and is dry.

A referral to physiotherapy will be made at this stage. This is the earliest you may return to work.

In addition following a subtalar fusion – 

At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position whenever possible to minimise swelling. Your foot will be placed in another non weightbearing cast for a further 4 to 6 weeks. Short trips can be made outside, within limits of pain and swelling.


Six weeks post operatively

Following subtalar arthroscopy +/- open debridement

Significant improvement in swelling and pain. You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. You will require physiotherapy for approximately 3-6 months. This will help optimise the outcome of your operation.

In addition following a subtalar fusion – 

At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 4 to 6 months.

Depending on the x-ray findings you will either go into a walker boot and be allowed to weight bear through the operated foot, or you will have to remain non weight bearing in plaster.

If your x-rays are encouraging and your wounds completely healed you will be given advice regarding soft tissue massage and scar desensitisation. Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area. You may shower and get the area wet only if the wound has completely healed and is dry.


Three months post operatively

Following subtalar arthroscopy +/- open debridement

Final clinical examination. Discharge if satisfactory.

Following a subtalar fusion

Check radiographs should show signs of bone healing. You will be able to start wearing normal footwear (swelling permitted), although stiff soled shoes are advisable. You will require physiotherapy for approximately 3-6 months. This will help optimise the outcome of your operation.

FAQs

How long does the operation take?

This is probably the most common question asked of surgeons. Total operation time is different from the actual total surgical time. For example a flight involves not just the flying time, but the time checking in, going through security and boarding the plane for example.

The time given below is only a guide to the actual surgical time.

For a subtalar arthroscopy +/- open debridement

Up to 90 minutes.

For a subtalar fusion

Up to 90 minutes.


When can I drive?

For a subtalar arthroscopy +/- open debridement –

Most patients are able to drive after two weeks. Please see guidance below.

For a subtalar fusion – 

Not for at least 3 months post surgery.

Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen the post operative swelling.


When can I return to work?

For a subtalar arthroscopy +/- open debridement –

Most patients are able to return to work within 10 to 14 days.

For a subtalar fusion – 

This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 8 to 12 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.


What should the final outcome be?

Following a subtalar arthroscopy +/- open debridement –

Excellent pain relief and return to sports by 3 to 6 months. Failure of this outcome warrants further investigation and possible treatment.

For a subtalar fusion – 

Excellent pain relief and return to full activities of daily living.

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