Sinus tarsi syndrome refers to pain on the outside of your ankle that worsens with weight bearing and on uneven surfaces. Sinus is the descriptive term for a cavity within bone, even though we mostly associate the word with nasal congestion and runny eyes during spring. Flattened foot arches, sports that require direction change, trail running or repetitive ankle sprains increase your risk of developing sinus tarsi inflammation. Physiotherapy can identify sinus tarsi syndrome and get to the cause of your symptoms. Sinus tarsi syndrome treatment includes physiotherapy rehabilitation.

Anatomy of your Sinus Tarsi

Your ankle joint functions like a corporate entity, with different departments responsible for different movements, but all working together to walk, hike, run, change direction, balance or land from a jump. The sinus tarsi is a tunnel between the calcaneus and talus bone.

These two bones form your hind foot. The talus bone is wedged between the dome of the tibia and fibula of your lower leg above, and calcaneus or heel bone from below. Two important joints are formed here, the tibiotalar & subtalar joints.

The ligaments of your lateral ankle include the anterior tibiofibular, anterior talofibular, calcaneofibular and lateral talocalcaneal ligaments. These can be injured when you roll over your ankle and cause a lack in static stability. Nestled between the talus and calcaneus is the interosseos and cervical talocalcaneal ligaments. These ligaments can also be injured when you roll over your ankle or if you have flat feet from repetitive eversion roll while you walk.

Also inside the sinus tarsi is connective tissue, nerve branches of the posterior tibial and cutaneous dorsolateral nerves, anastomoses of arteries and proprioceptive nerve endings that supply information of ankle position to your brain.

What does the sinus tarsi do?

The sinus tarsi serves as protection for the different structures that pass through it, allows space for the joint movement of walking and stabilise the ankle joint as a whole.

The tibiotalar joint flexes and points your foot, like a ballerina, and the subtalar joint absorbs forces and rotates a little as you walk. The natural position of the subtalar joint is to blame for broad, flat feet versus narrow, slender feet with high arches. Both editions have their own unique issues, from shoes that fit better to a higher risk for sinus tarsi syndrome.

Proprioceptive nerve endings within the sinus tarsi relays information of foot position to your brain on uneven terrain, high heels or when you balance on one leg. This in turn helps the body pick effective strategies to maintain balance.

How did I get sinus tarsi inflammation?

The ligaments inside the sinus tarsi stabilise the available movement, like putting up a play pen for your child to limit their crawling to where it is safe. The cervical ligament limits turning the foot in, and the interosseous ligament limits the foot turning out. This is important when walking or running and even more so if you lack dynamic stability because of muscle weakness.

A single traumatic inversion injury, repetitive ankle sprains or excessive eversion forces friction between the talus and calcaneus or even cause ruptures of these ligaments. This leads to instability and even more excess movement. The friction causes inflammation, ultimately leading to tenosynovitis. Pressure from the inflammation can impinge the nerve endings or vasculature structures.

The longer this goes on the higher the risk for developing scar or fibrotic tissue which can permanately impinge these sensitive structures.

Causes of sinus tarsi syndrome symptoms

Inversion ankle sprains causes up to 70% of sinus tarsi syndrome symptoms

Flat or fallen arches, pronation or pes planus (all describing the same thing) causes 10% of sinus tarsi inflammation

Biomechanical abnormalities, like hip abduction weakness and knee varus is to blame for the other 10% of sinus tarsi syndome

Symptoms of sinus tarsi syndrome

Mild

  • Dull ache on the outside of your ankle
  • Running or hiking aggrevates your symtpms
  • Worse with weight bearing
  • Tender over the outside of your ankle
  • No bruising
  • Certain positions cause pain, like turning your foot in
  • Stiffness of your ankle
  • Pain gets better with rest

Moderate

  • Unable to walk without pain
  • Ankle feels weak and unstable
  • Too painful to play physical games with your kids
  • Limited movement of your ankle
  • Poor balance on your affected side
  • Climbing stairs with difficulty

Serious

  • Pain when standing and walking
  • Symptoms get worse the further you walk
  • Unable to do weight-bearing exercise
  • Ankle feels unstable
  • Unable to stand on your affected leg because of pain
  • Cannot climb stairs with alternating strides

Tests that you can do to see if you have sinus tarsi syndrome

  • Sit on a chair or floor with your legs outstretched in front of you
  • First check your unaffected side by moving your ankle in and out, like you are waving your foot
  • Your lower leg and hip should stay still
  • Now compare with your affected leg
  • If you have pain with this movement on the outside of your ankle, you may have sinus tarsi inflammation
  • If you have markedly less movement with this movement you may have sinus tarsi syndrome

  • Check and compare the wear and tear on your favourite pair of shoes
  • Smoothed out edges on the inside of your shoes is indicative of pes planus or flattened arches
  • This increases the risk of subtalar pronation and developing sins tarsi syndrome

  • Stand comfortably with your feet slightly apart in front of a mirror
  • Check and compare the height of your foot arch
  • Flattened arches increase your risk of developing sinus tarsi syndrome
  • If your affected side’s arch is much flatter than the other side you may have sinus tarsi syndrome

  • Stand comfortably with your feet slightly apart
  • Shift all your weight to your unaffected side and lift your affected foot off the floor
  • See how long you can balance
  • Repeat on the other side
  • If you are unable to balance on your affected side due to pain you may have sinus tarsi syndrome
  • If your affected ankle feels unstable and you can only balance half the time you did on the unaffected side you may have sinus tarsi inflammation

How severe is my sinus tarsi inflammation?

Repetitive ankle sprains, even if you do not sustain ligament ruptures, swelling and bruising can result in sinus tarsi syndrome. Initially, you may be unable to train for a week, but the more scar tissue forms, the less active you will become. Pain and symptoms of instability and lack of control can become constant companions on your hikes, on your yoga mat or in your dance class. After exertion, your ankle feels stiff and can swell. The more scar tissue forms the less movement and more pain you will experience.

Longstanding synovitis can even disrupt the bone surface, ultimately increasing your risk of developing osteoarthritis.

Diagnosis of sinus tarsi syndrome

Physiotherapy diagnosis of sinus tarsi inflammation

Not all sinus tarsi syndromes can blame a big structural problem for their symptoms, like a stress fracture or osteophyte. The problem is functional, meaning that a lack of movement or control of movement is causing your symptoms. This will not be visible on an image, because most imaging is done non-weight bearing.  Our physiotherapists are experts in anatomy, we have experience in movement disorders and understand how something as far away as your hip may be contributing to your ankle symptoms. We offer you the option to get to the root cause of your problem and guide you to make responsible choices in training in the future.

X-rays

X-rays will show the integrity and alignment of the joints of your ankle. Fractures can be ruled out with X-rays and bony abnormalities of the talar dome and joint space will be visible.

Your physiotherapist can refer you to get x-rays taken if necessary.

Diagnostic ultrasound

Diagnostic ultrasound can be used to visualise the superficial ligaments of the lateral ankle to confirm sprains or ruptures. Ultrasound will not be able to show what is going on within the sinus tarsi with the interosseous and cervical ligaments and is therefor not used to confirm the diagnosis of sinus tarsi syndrome.

MRI

An MRI scan can show all of the structures of your ankle joint, including the space within the sinus tarsi. This is a costly image that needs to be ordered by a specialist.  If your physiotherapist suspects anything more than just a lateral ankle sprain, you will be referred to the right specialist.

Why is my sinus tarsi inflammation not going away?

If you become stuck in a cycle of pain, rest, return to movement and straight back into pain, you know how frustrating this can be. If you don’t have the correct diagnosis and address exactly what is contributing to your symptoms you risk irreversible damage to your ankle. Rest alone will not heal your problem, it can alleviate your symptoms as the inflammation settles, but the next time you try to run, hike or train you end up right back where you started. You need to address why this problem continues to come back, be it a lack of hip control, stiffness of your subtalar or other ankle joints or lack of proprioception and balance.

Rest won’t change how your ankle joints move, work on your unique problems, be it balance, weakness of your stabilisers or restriction in other joints.

What NOT to do

  • Continuous use of anti-inflammatory medication will only mask your symptoms and have nasty side effects in the long run

  • Walk, run, jog or hike through the pain

  • Do not ignore ankle pain that gets worse, it can be a sign of a bigger problem

  • Leave it untreated, if you are uncertain of the diagnosis, rather call us, be safe and avoid unnecessary time off training

  • Blame your symptoms on having “weak ankles”, that’s just code for not knowing what is going on

What you SHOULD do

  • Rest as needed from aggravating activities

  • Avoid activities that increase your symptoms, like standing for hours

  • Make a list of movement or activities that brings on your pain and rank them from most aggravating to least

  • Make an appointment to confirm the diagnosis and determine how severe your sinus tarsi syndrome is

  • Finish your treatment and rehabilitation programme for better long-term results

Making sinus tarsi inflammation worse

  • Single leg balance drills

  • Climbing stairs

  • Walking uphill

  • Running

  • Single leg deadlifts

  • Jumping, skipping and other plyometric drills

  • Wearing flat, unsupportive shoes, like a ballet pump

  • Balance drills on uneven surfaces

Problems we see when patients come to us with sinus tarsi syndrome symptoms

More times than we care to count sinus tarsi develops because of non-compliance to rehab protocols for injuries that happened long ago or misdiagnosis of sinus tarsi syndrome. You might have gone straight to the emergency room after your ankle injury and the doctor said all was well after your X-rays showed no fractures. But what of your ligaments, inflammation and gait pattern? Or maybe you were pressured to return to play for the sake of your team.

If you are reading this article you have probably already waited too long, get the right diagnosis now so that you can get the right treatment finally.

Medication and rest will only mask your symptoms until the next time you attempt a hike or run.

Braces or insoles require the right diagnosis and most probably life-long use, are you ready for that commitment?

Physiotherapy treatment also requires commitment, but the information, guidance and knowledge you gain from working with our team will last you a lifetime and get you back to what you love doing sustainably.

Physiotherapy sinus tarsi treatment

Our physiotherapists have years of experience in recognising symptom patterns and finding why you developed sinus tarsi syndrome in the first place. We know anatomy and understand how biomechanics influence local structures but also the repercussions certain movements can have on other structures further away. Our aim is to help you understand your problem and empower you to prevent this from happening again in the future.

We pride ourselves in our work and offer the best treatment for sinus tarsi syndrome symptoms by providing guidance and answers and implementing an effective and structured plan of action. Movement is medicine, we want you to feel confident in the dosage you take. We will also look at muscle strength, joint range of motion, flexibility, ligament stability and nerve control.

Phases of rehabilitation

Phase 1 of sinus tarsi treatment: symptom management (week 0 – 2)

After we have established why you have inflamed sinus tarsi we can use electrotherapy modalities to reduce your inflammation, like laser and ultrasound. Immobilisation with strapping can be used to limit any excessive movement or provide support for fallen arches.

To progress to the next phase of your treatment you should be able to strap yourself and know which shoes to pick to support your ankle.

Phase 2 of sinus tarsi treatment: stability & movement control (week 2 – 4)

We can introduce stability exercises now, this will be specific to your problem and may include hip and core work on top of your ankle exercises. We will progress from free active, open chain movements, to resisted exercises and finally weight bearing stability.

To progress to the next phase of your treatment you should be able to walk pain free on flat surfaces.

Phase 3 of sinus tarsi treatment: balance (week 4 – 6)

Now the exercises are more fun and less repetitive and boring. You can expect combining your stability drills with balance work. Unstable surfaces and one legged work will defenitely be in the mix.

To progress to the next phase of treatment you should be able to balance on one leg and take a short walk on an uneven surface, like gravel or sand without pain.

Phase 4 of sinus tarsi treatment: pliometrics (week 6 – 8)

Now we can add skipping, running and direction change to your program. Initially you may feel more confident with strapping on, but before you progress to the next phase of your treatment you should be able to skip for one minute, no strapping and no symptoms.

Phase 5 of sinus tarsi treatment: reintegration (week 8 – 12)

To makes sure you’re safe to turn to your normal training regime or sport, we’ll include some sport specific drills, like direction changes, shuttle runs and dribbles to your rehab program. You should feel confident that you can train with your team before progressing to the next phase of your rehabilitation and be able to do a solid 4 km jog, if required by your sport.

Phase 6 of sinus tarsi treatment: return to training & final clearance (week 12 onwards)

By now you should be able to jog,  jump and balance. We will repeat clinical tests to compress, load and evaluate your control of movement to sign off on your recovery, knowing you’re safe to participate.

We look forward to congratulate you on your next achievement!

Healing time for sinus tarsi syndrome

Sinus tarsi inflammation rarely happens as a once of problem. Repetitive injuries and non-optimal ankle biomechanics lead to changes within the sinus tarsi causing your symptoms. Your recovery time will be between 4 – 6 months and greatly depend on your compliance with treatment. Nothing worth while is ever a quick fix.

You will need physiotherapy treatment once a week for the first month of your treatment. Once your symptoms are under control, your treatment sessions can be spread further apart to allow for the changes in strength and endurance we expect to see from your rehabilitation program. How fast you recover will greatly be up to you. A full recovery and return to sport will take longer and should not be confused with the healing period.

Other forms of sinus tarsi treatment

  • Your doctor (GP) will probably prescribe anti-inflammatories and analgesic medication to relieve your symptoms. Remember that these medications are not treating the cause of your pain, only your symptoms.
  • A local cortisone injection can be done directly into the sinus tarsi, this will give you symptom relief for a short period of time. Now is a great time to progress through your rehab when your pain is not severe.
  • Orthotic insoles can be considered to alter your ankle biomechanics. This is normally a lifelong commitment and you will need to wear your insoles forever if you decide to go this route.

Is surgery an option for sinus tarsi syndrome?

Surgery can be an option if non-surgical treatment was ineffective. Your surgeon will discuss the risks and benefits of an open vs arthroscopic procedure with you to excise all synovial and scar tissue contributing to compression within the joint space. Because ankle movement relies on the interplay between different joints it is important to remember that this is just an option to remove tissue. Your true work starts on day one after surgery to regain range of motion and strength and stability for the ankle joint once again.

Arthrodesis is the fusion of the subtalar joint to restrict all movement and limit pain.

What else could it be?

This is a very common injury among people from all walks of life. It happens when the ankle is plantarflexed and inverted and is forced beyond the ligament’s capacity to protect. Lateral ankle sprains can range from bothersome to severe impact and limitations on day-to-day life. To prevent sinus tarsi syndrome from developing from repeated lateral ankle sprains it is best to have your injury evaluated by a medical professional.

  • Syndesmosis injury

A high ankle sprain that injures the syndesmosis needs urgent medical attention and most probably surgical intervention to restore ankle stability. This happens in the “opposite direction” of the more common ankle sprain described above, where the foot is everted and dorsiflexed beyond the ligament’s capacity.

Fractures to the calcaneus or talus bones are rare and result from high energy injuries, like car accidents on jumping and landing from a height. You would not be able to walk and have gross deformities and severe pain.

Inflammation of the peroneal tendons around the outside of the ankle causes pain at rest that improves with exertion. Pain is located behind the lateral malleolus and worse on resisted ankle eversion, passive ankle inversion and palpation over the muscle bellies on the lateral lower leg.

Osteoarthritis can develop over time and will cause decreased range of motion, morning stiffness and joint crepitus. This is a feeling similar to having sand in your joints that cause sounds as you move your ankle.

  • Tarsal tunnel syndrome

This is compression of the posterior tibial nerve found on the inside of the ankle. Pain with weight bearing and dorsiflexion that is sharp, shooting or like pins and needles is present. Weakness and atrophy of the small muscles in the foot happens with prolonged nerve compression.

Also known as

  • Inflamed sinus tarsi
  • Sinus tarsi inflammation
  • Ankle instability
  • Problem ankle
  • Talocalcaneal sulcus syndrome