Clin Podiatr Med Surg

21 (2004) 449 – 460

Subtalar joint instability: current

clinical concepts
Adam Budny, DPM
St. Vincent’s Charity Hospital, 2351 East 122nd Street, Cleveland, OH 44125, USA

Human anatomy has been investigated for centuries and the subtalar joint is no
exception. Rubin and Whitten [1] first theorized the specific clinical entity of STJ
instability, though they were unable to demonstrate any cases in their patient
population. It was not until almost 20 years later that their theory was proven.
Although the classification of subtalar joint instability was formally described by
Brantigan et al [2] in 1977, Chrisman and Snook [3] took note of it in 1969 when
they identified three of seven patients with symptoms of STJ instability who were
being treated for lateral ankle instability.
In subsequent years many anatomic studies have strived to define which
ligaments are most responsible for supporting the osseous structures that com-
pose the talocalcaneal joint. Most investigators recognize the importance of the
calcaneofibular ligament (CFL) and the interosseous-talocalcaneal (ITC) liga-
ments. In addition to this, a myriad of surgical reconstructions have been sug-
gested, all aimed at restoring stability while decreasing the loss of function
associated with sacrificing the peroneus brevis tendon by way of tenodesis.

Anatomy
The STJ complex consists of a number of bony articulations and several
ligamentous structures. In the middle third of the superior surface of the cal-
caneus is the posterior facet, which articulates with a corresponding facet on the
inferior aspect of the talus, making up the largest contact area between these two
bones. This saddle-shaped joint is separated from the middle and anterior facets
by the canalis tarsi, directed from proximal medial to distal lateral ending in the
sinus tarsi laterally. The middle and anterior facets can be distinct or blend into
one articular surface, supported by the sustentaculum tali and anterior process of
the calcaneus respectively. The anterior aspect of the subtalar complex is also

E-mail address: ambudny@dmu.edu

0891-8422/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.cpm.2004.03.003
450 A. Budny / Clin Podiatr Med Surg 21 (2004) 449–460

known as the talocalcaneonavicular joint, or ‘‘acetabulum pedis,’’ and formed by

the articulation of the talar head with the navicular [4].
These osseous structures are supported by a great number of ligaments (Fig. 1).
Located laterally, the CFL is nearly perpendicular to the posterior facet of the
subtalar joint and is responsible for congruence of the articular surfaces [5]. This
ligament becomes taught with inversion of the rearfoot and the ankle in a neutral
to dorsiflexed position. Inserting slightly anterior and inferior to this is the lateral
talocalcaneal ligament.
The ITC ligament has been under scrutiny in regard to its influence on subtalar
joint stability. Anatomically it is a frondiform-shaped ligament, with its limbs
directed inferiorly and its stem attaching superiorly to the talus. It has been de-
scribed as a major stabilizer of the STJ, resisting eversion as well as maintaining
apposition of the talus on the calcaneus [6,7]. The ITC ligament is located at the
pivot point of the STJ [6,8]. The cervical ligament is located along the antero-
lateral portion of the STJ, originating from the sinus tarsi and attaching to the
tuberculum cervicis. Together, the ITC and cervical ligaments separate the an-
terior and posterior aspects of the subtalar joint.
The inferior extensor retinaculum also contributes to the stability of the
subtalar joint. Having three distinct roots (lateral, intermediate, and medial), this
sling ligament maintains the extensor tendons. The lateral root has been described
as a more superficial component and contributes to stability in neutral and
dorsiflexed positions of the ankle [9].

Fig. 1. Ligamentous anatomy of the lateral ankle. Important structures include (clockwise from right)
anterior inferior tibiofibular ligament; anterior talofibular ligament; interosseous talocalcaneal liga-
ment; lateral talocalcaneal ligament; calcaneofibular ligament; posterior talofibular ligament; and
posterior inferior tibiofibular ligaments. Not shown are the bands of the inferior extensor retinaculum,
cervical, and bifurcate ligaments.
 A. Budny / Clin Podiatr Med Surg 21 (2004) 449–460 451

Although there is agreement in regard to anatomical positioning of the

aforementioned structures, debate continuously emerges in regard to the biome-
chanical influence of each on subtalar joint stability. Future research should be
aimed at clearly defining the role of these structures while functioning dynami-
cally, as most studies have focused on one ligament at a time (see references
[5,7,8,10]).

Biomechanics
The biomechanics of normal subtalar joint motion must be recognized before
any pathologic variation can be appreciated. Not only does the STJ react to
demands placed on it by the foot accommodating to uneven surfaces, the more
proximal appendicular skeleton also influences STJ motion. The accommodation
of the STJ to the forces allows the foot to transition from a flexible structure
on uneven surfaces to a rigid lever during the propulsive period of gait. Clinically,
25 to 30 degrees of inversion and 5 to 10 degrees of eversion are observed during
examination, representing an average range of motion for the STJ [4].
Originally defined by Manter and confirmed by Root, the STJ has been
described as having motion that is hingelike in nature with an axis perpendicular
to the plane of motion [11]. This axis is directed from distal-medial-dorsal
to proximal-lateral-plantar deviating 42 degrees from the transverse plane and
16 degrees from the sagittal plane. The STJ is designed to compensate for motion
in relation to the three cardinal planes of the body allowing for the triplanar
motions of pronation-dorsiflexion abduction and eversion, and supination-plan-
tarflexion adduction and inversion.
Sarrafian [4] agrees with the previous research and the motion about the
subtalar joint axis; however, he adds the important components of ‘‘slide, roll,
and spin.’’ These movements take place during passage of the articular surfaces
over one another and are the result of the male and female ovoid surfaces present
on the calcaneus and talus, respectively (Fig. 2) [4]. When a female ovoid moves
over a male ovoid, the roll is in the same direction as the slide and maximizes
surface contact between the articulation.
Lundberg [12] challenged the established hinge axis orientation of the talo-
calcaneal joint. By using Roentgen stereophotogrammetric analysis, he estab-
lished that the STJ functions in a polyaxial hinge manner. Although a basic hinge
function was observed, there was a significant amount of parallel translation
between axes according to varying positions of the foot. Mean deviation from the
sagittal plane of the foot ranged from 23 to 37 degrees while the leg was in
internal or external rotation respectively. Mean inclination from the transverse
plane varied from 29 degrees in pronation to 39 degrees in external rotation.
These observations contribute significantly to the normal range of motion seen
at the STJ. Individuals that have an axis with higher inclination from the
transverse plane will demonstrate an increase in adduction and abduction through
range of motion examination. In contrast, as the axis approaches a more hori-
452 A. Budny / Clin Podiatr Med Surg 21 (2004) 449–460

Fig. 2. Talus moving in relation to the calcaneous. Talus is the ‘‘female’’ ovoid, whereas the posterior
facet of the calcaneus provides the ‘‘male’’ ovoid surface. (A) Normal position. (B) Slide produces
posterior translation. (C) Roll produces rotation about a center point in the frontal plane. (D) Spin
causes rotation about a center point in the transverse plane.

zontal position there will be an increase in the frontal plane motions of inversion
and eversion. The same principles apply to deviation of the axis from the sagittal
plane. A greater (with more deviation) or lesser (with less deviation) amount of
dorsiflexion-plantarflexion will be allowed as the axis angulates from the sagittal
plane [11].

Mechanism of injury
Several mechanisms have been described as a cause of the subtalar joint
sprain, with the most prevalent mechanism including an inversion of the rearfoot.
When a pathologic rearfoot varus is present, the degree of sagittal plane posi-
tioning will influence the order of disruption of the lateral ligaments. For exam-
ple, if the foot is dorsiflexed while the rearfoot inverts, stress will immediately be
put on the CFL; whereas in a plantarflexion-inversion injury the ATFL will be
compromised earlier followed by the ITC [13]. It has been suggested that a
‘‘whiplash’’ injury may also be responsible for ITC ligament rupture. The
whiplash injury can occur during an abrupt stop, where the calcaneus is planted
and the talus continues anteriorly because of inertia carried by the body [8]. Such
injuries are common in cutting, jumping sports such as basketball and volleyball.
 A. Budny / Clin Podiatr Med Surg 21 (2004) 449–460 453

Table 1
Graphic representation of Meyer classification, including mechanism of injury, objective exam results,
and sample numbers found of each type
Stress exams Arthrogram
Mechanism Anterior Inversion Lateral Sinus Ligaments
Type of injury drawer stress capsule tarsi damaged Number
I Forced inversion + + + ATFL, PTFL, 15
CFL
II Forced inversion + ATFL, ITCL 9
III Hindfoot + + + CFL, cervical, 6
supinationa ITCL
IV Hindfoot + + + + ATFL, CFL, 2
supinationb cervical, ITCL
Abbreviations: ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament; PTFL, posterior
talofibular ligament; ITCL, interosseous talocalcaneal.
a
Ankle dorsiflexed.
b
Ankle in neutral flexion.

Lateral ankle sprains (LAS) are usually the result of hypersupination of the
foot while weight bearing, as such it follows that chronic ankle and STJ
instability can occur concomitantly. Hertel et al [14] evaluated these clinically
similar instabilities by examining 20 patients (12 LAS and eight controls). They
found that 75% of their patients with talocrural instability also had STJ instability.
Meyer et al [13] developed a classification scheme, whereby certain injuries
were placed into a group based on arthrographic and radiographic findings. A
positive anterior drawer was defined talar slippage greater than 8 mm; positive
inversion stress test was defined as tilt greater than 15 degrees. Arthrograms
were positive when leakage of dye was noted radiographically (Table 1). The
mechanism of injury was also classified into one of two types. The first mecha-
nism was a forced inversion stress, resulting in type I and II injuries. The second
mechanism involves hindfoot supination with the ankle dorsiflexed (type III) or
in neutral flexion (type IV) [13]. In their study of 40 patients, 32 had abnormal
arthrograms. Fifteen patients were categorized as type I, nine as type II, six as
type III, and two as type IV.

Diagnostic exams
Clinically, patients will present with a history of an acute or chronic ankle
sprain, which has resulted in difficulty ambulating. Instability of the subtalar joint
causes a feeling of ‘‘giving way’’ or ‘‘turning in’’ for the patients. This instability
can lead to limitations in daily activities and sporting activity and will cause
difficulty walking on uneven surfaces [15 – 17]. Other symptoms may be vague,
such as pain over the sinus tarsi or pain with inversion at the ankle joint. Lateral
ankle instability is not limited to the ligamentous and osseous structures intimately
associated with the ankle or subtalar joints, a differential diagnosis must include
peroneal muscle weakness, equinus, and proprioceptive dysfunction [18].
454 A. Budny / Clin Podiatr Med Surg 21 (2004) 449–460

After clinical examination is complete, the presence or absence of instability

should be demonstrated radiographically; however, this is an area of continued
debate. Because of the anatomic relationships between the talus and calcaneus,
certain stress views have been promoted by numerous authors to allow visual-
ization of the STJ [19 –24]. These include stress inversion and anterior drawer
tests, both of which demonstrate positive findings with loss of congruity between
the articular surfaces. Brodén [19] originally described two radiographic views
for evaluation of the STJ after calcaneal fracture by comparing the articular
surfaces of the talus and calcaneus (Fig. 3). Instability is believed to be present
when a lack of parallelism is demonstrated between the posterior articular
surfaces [5]. This theory has been challenged on numerous occasions [16 – 24].
Most authors suggest that the inaccuracies observed in these stress views stem
from the osseous structures that comprise the STJ. Incongruity between the ar-
ticular surfaces observed radiographically can result from the following: (1) view-
ing a three-dimensional structure on a two-dimensional image; (2) translation and
rotation of the facets upon one another; (3) the natural curved geometry of the
articular surfaces; or (4) inconsistency in stress applied to the hindfoot during
radiographic exam.
Sijbrandij et al [23] specifically tested the stress Broden’s view against CT
scans in patients with unilateral STJ instability. Their results showed increased
values of subtalar tilt in symptomatic limbs (range 6 to 18 degrees) with the
Broden’s view, yet significant amounts of tilt in asymptomatic limbs were
observed as well (4 to 12 degrees). More importantly they saw no tilt on the
CT scans except in the most posterolateral aspect of the joint, and again there was
overlap between injured and uninjured limbs. They describe the increased tilt
noted during stress views to be a result of intrinsic rotation and translation of the
articular facets. As a result they concluded that the Broden view is of limited value
in examining the STJ, and CT may be of more use when evaluating instability.
Harper also examined the Broden view to better define and correlate clinical
symptoms with radiographic findings [20]. Fourteen symptomatic lower extremi-
ties were compared with the contralateral asymptomatic side using a stress

Fig. 3. Radiographic demonstration of a normal Broden’s view radiograph. Note congruency of the
posterior articular surfaces of the STJ. An abnormal film would show increased gapping in the lateral
aspect of the joint.
 A. Budny / Clin Podiatr Med Surg 21 (2004) 449–460 455

Broden view. Eighteen asymptomatic extremities in 11 healthy individuals (no

history of injury) were also included. The symptomatic side had divergence of the
articular surfaces ranging from 7 to 22 degrees (average 12 degrees), whereas the
asymptomatic sides ranged from 6 to 15 degrees (average 11 degrees). Exami-
nation of the supplementary patients revealed divergence during stress radiog-
raphy to average 9 degrees with a range of 0 to 20 degrees. It was concluded that
instability does not appear to correlate with lateral widening of the joint during
Broden’s inversion stress views.
Pearce et al [21] developed a noninvasive method of measuring STJ motion
directly with CT scan. In their series of 20 subtalar joints, representing 10 healthy
individuals, they found that clinical evaluation of subtalar ROM was overesti-
mated threefold when compared with CT measurements. This large degree of
inaccuracy was determined to be a result of soft tissue influence, talocrural motion,
and examiner error. Therefore, they recommend that clinical evaluation of subtalar
joint ROM should no longer be used and, if measured, recorded as quartiles.
Definitive diagnosis is therefore an elusive task despite continued research.
Methods of documentation continue to challenge the physician, as quantitative
results do not necessarily correlate with clinical presentation. Loss of parallelism
during stress views and asymmetric opening of the joint space can be present in
the symptomatic as well as the asymptomatic limb. In addition, quantification of
STJ angulation using CT scans may be promising; however, a review of the
current studies shows that a consensus on normal values has not yet been
reached. The presenting symptomatology and a history of inversion ankle injury
are significant predictors for STJ instability and must be taken into account when
evaluating surgical candidates.

Treatment options
The treatment of injury to the STJ is as varied as the methods of evaluation
and there are numerous surgical procedures available for repair of the structural
instability (Table 2) [17,24 –29]. Initially, conservative measures must be taken
for treatment of this condition, including immobilization in conjunction with
NSAIDs and physical therapy [29]. Bracing and orthotics may be required for
long-term management if surgery is contraindicated or symptoms remain mild.
Relief of instability may be a more predictable outcome than resolution of pain
and can be addressed by a number of surgical approaches [20].
Many studies have been conducted in regard to isolated lateral ankle in-
stability; however, less attention has been paid to the STJ and thus limited long-
term results are available. Thermann et al [17] conducted a retrospective study of
223 patients, 42 of whom underwent a Chrisman-Snook ligament reconstruction
for isolated or combined subtalar instability (Fig. 4). Of the 34 procedures re-
viewed, 31 had good to excellent results with a mean decrease in subtalar tilt of
8 degrees. It was concluded that the Chrisman-Snook is the procedure of choice
for isolated subtalar instability.
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Table 2
Various surgical procedures are described according to author, ligaments reconstructed and tendon
utilized in reconstruction
Author Ligaments reconstructed Tendon utilized
Elmslie ATFL, CFL Fascia lata
Chrisman-Snook ATFL, CFL Half-peroneus brevis
Larsen ATFL, CFL Whole peroneus brevis
Schon ATFL, CFL, cervical Plantaris or half-peroneus brevis
Mann ATFL, CFL, cervical Half-peroneus brevis
Kato ITCL Split achilles
Pisani ITCL Half-peroneus brevis
Abbreviations: ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament; PTFL, posterior
talofibular ligament; ITCL, interosseous talocalcaneal.

Pisani [8] contends that the ITC ligament is responsible for STJ instability
(Fig. 5). This laxity can be associated with direct trauma (whiplash mechanism)
or the loss of proprioceptive control of the joint. His treatment focused on re-
construction of the ITC, with intensive physical therapy. In a retrospective review
of 38 patients, he found satisfactory results in 91%; however, six required re-
visional arthrodesis as a result of continued pain or instability. He concludes that
reconstruction of the ITC is a viable treatment option, although success depends
on minimal preexisting DJD and recovery of proprioception.
The Larsen ligamentous reconstruction uses the whole peroneus brevis tendon
and recreates the ATFL and CFL (Fig. 6) [26]. It was designed in an attempt to
stabilize the STJ and ankle joints by routing the tendon anteroposterior through
the fibula and then inferiorly to the calcaneus. Although not an anatomic
reconstruction, it is a viable technique and the authors described successful re-

Fig. 4. Chrisman-Snook anterior talofibular (ATF) and calcaneofibular ligament (CFL) reconstruction.
 A. Budny / Clin Podiatr Med Surg 21 (2004) 449–460 457

Fig. 5. Pisani interosseous-talocalcaneal (ITC) ligament reconstruction.

turn to sporting activity for all of their patients (n = 79) who complained of pain
and instability for 2 years.
Triligamentous reconstruction has also been proposed as a form of surgical
treatment [26,28]. Each of these procedures employs various routes through the
calcaneus, fibula, and talus to provide close anatomic restoration of the ATFL,
CFL, ITC, or cervical ligaments (Fig. 7). Schon described two procedures, using
either the plantaris tendon or the peroneus brevis if the former was inadequate or
absent, whereas Mann used a split peroneus brevis for this reconstruction [26,28].

Fig. 6. Larsen anterior talofibular (ATF) and calcaneofibular ligament (CFL) reconstruction.
458 A. Budny / Clin Podiatr Med Surg 21 (2004) 449–460

Fig. 7. Schon triligamentous reconstruction.

Revisional or primary arthrodesis are viable options, but should be reserved for
patients recalcitrant to other modalities of treatment. Successful care of these pa-
tients revolves around a high index of suspicion and evaluation of subjective and
objective findings. Good results have been seen with various procedures, and care-
ful planning will ensure positive clinical outcomes when applied appropriately.

Summary
Subtalar joint instability is becoming increasingly recognized in the medical
literature, and the physician must be able to differentiate it from ankle instability
to make appropriate clinical decisions. There are several diagnostic techniques
available for evaluation of the subtalar joint, each with its own advantages and
disadvantages. Clinical evaluation is simple and can be done in an office setting,
but proves inaccurate and nonreproducible. Radiographic analyses, especially
the CT scan, provide adequate visualization when used correctly, yet is time-
consuming and exposes the patient to radiation. Equally as daunting as finding an
adequate diagnostic tool is the search for an effective modality of treatment;
however, there are several procedures indicated for specific ligamentous injuries.
Continued interest in this topic will lead to enhancement of diagnostic tech-
niques and treatment modalities. The supporting articles based on small sample
groups need to be expanded to substantiate their claims. A more consistent
method of evaluation will lead to a precise approach to treatment on a case-by-
case basis, thereby producing better outcomes. Quantifying diagnosis will allow
for a series of treatment algorithms to be developed, each designed for a specific
injury, thus reducing wasted effort on improper management.
 A. Budny / Clin Podiatr Med Surg 21 (2004) 449–460 459

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