Os Trigonum Syndrome Research Articles

Os Trigonum Syndrome

Os trigonum syndrome is the result of an overuse injury of the posterior ankle caused by repetitive plantar flexion stress. It is predominantly seen in ballet dancers and soccer players and is primarily a clinical diagnosis of exacerbated posterior ankle pain while dancing on pointe or demi-pointe or while doing push-off maneuvers. Symptoms may improve with rest or activity modification. Imaging studies, including a lateral radiographic view of the ankle in maximal plantar flexion, will typically reveal the os trigonum between the posterior tibial lip and calcaneus. If an os trigonum is absent on radiography, an MRI may reveal scar tissue behind the posterior talus, a condition associated with similar symptoms. Os trigonum syndrome is often associated with pathology of the flexor hallucis longus tendon. Treatment begins with nonsurgical measures. In addition to physical therapy, symptomatic athletes may need surgical excision of os trigonum secondary to unavoidable plantar flexion associated with their sport. This surgery can be performed using open or arthroscopic approaches.

Os Trigonum Syndrome on Bone SPECT/CT

A 16-year-old female athlete presented with increased pain in the distal left lower extremity. A possible stress fracture or shin splint of the left tibia was first considered. A 3-phase bone scintigraphy showed a very small focus of increased activity in the posterior left foot. A diagnosis of os trigonum syndrome was made after SPECT/CT images pinpointed the activity at the left os trigonum.

Secondary synovial osteochondromatosis of the ankle in a child

We describe a case of a large intra-articular ossifying mass of the ankle joint in a 12-year-old boy who sustained a severe ankle twisting injury at 6years of age. The mass is presumed to be the result of secondary synovial osteochondromatosis originated from a fractured osteochondral fragment of the medial tubercle of the posterior process of the talus. The mass could be differentiated from os trigonum syndrome, Trevor disease and primary synovial osteochondromatosis based on its location, size and radiologic and histological features.

Posterior ankle and subtalar arthroscopy: indications, technique, and results.

Over the decades, arthroscopy has grown in popularity for the treatment of many foot and ankle pathologies. While anterior ankle arthroscopy is a widely accepted technique, posterior ankle/subtalar arthroscopy is still a relatively new procedure. The goal of this review is to outline the indications, surgical techniques, and results of posterior ankle/subtalar arthroscopy. The main indications include: 1) osteochondral lesions (of subtalar and posterior ankle joint); 2) posterior soft tissue or bony impingement; 3) os trigonum syndrome; 4) posterior loose bodies; 5) flexor hallucis longus (FHL) tenosynovitis; 6) posterior synovitis; 7) subtalar (or ankle) joint arthritis; 8) posterior tibial, talar, or calcaneal fractures (for arthroscopic reduction and internal fixation). Although posterior ankle/subtalar arthroscopy has shown to be safe and effective in the treatment of many of the above mentioned conditions, thorough knowledge of the anatomy, correct indications, and a precise surgical technique are essential to produce good outcomes.

Os trigonum syndrome: A retrospective and comparative study

Amac: Bu calismanin amaci, magnetik rezonans goruntuleme (MRI) ile ostrigonum sendromu hastalarinin MRI ozel-liklerinin degerlendirmesidir. Gerec ve yontem: Retrospektif olarak 76 ayak bilegi MRI goruntusu alinarak degerlendirildi. Hasta supin pozisyonda iken once notral sonra fleksiyonda MRI cekim yapildi. Bulgular: Toplam 76 ayak bilegi MRI goruntusunden 16 (%21)\'sinda os trigonum sendromu ile uyumlu goruntu vardi. Os trigonum sendromu olan hastalarin yas ortalamasi 34.60±13.21 yil idi. Os trigonum sendromu olan olan hastalari-nin 4\' u kadin, 12\' isi erkekti. 16 os trigonum sendromundan 12\'isinde lezyon sagda idi. Os trigonum sendromlu olgu-larinin MRI ozellikleri detayli olarak degerlendirildiginde; 12 hastada ostrigonum ve talus arasindaki sinkondroz ek-lemde dejeneratif degisiklikler, 7 hastada fleksor hallusis longus tenosinoviti, 11 hastada ayak bilegi posteriorunda cil-talti dokuda odem ile uyumlu hiperintensite izlendi. Sonuc: MR goruntuleme os trigonum sendromu tanisinda belirleyici olarak kabul edilebilir.

Síndrome do impacto posterior do tornozelo: um diagnóstico que deve ser lembrado pelo reumatologista. Relato de dois casos

The ankle is a common site of painful symptoms in athletes and nonathletes. Posterior ankle pain can be the end result of several pathologies, and a diagnostic challenge for rheumatologists. The posterior ankle impingement syndrome, also known as os trigonum syndrome and posterior tibiotalar compression syndrome, is a clinical disorder characterized by acute or chronic posterior ankle pain triggered by forced plantar flexion, which causes chronic repetitive microtrauma. Pathology of the os trigonum-talar process is the most common cause of this syndrome, but there are other causes, such as tenosynovitis of the flexor hallucis longus, ankle osteochondritis, subtalar joint disease, and fracture. Diagnosis is based on clinical history and physical examination, and complemented by findings on plain radiography (RX), ultrasound (US), scintigraphy, computed tomography (CT), and magnetic resonance imaging (MRI). It is worth noting that RX has low cost and good sensitivity, US can provide guidance to therapeutic infiltrations, and MRI allows the assessment of surrounding soft tissues.

Hindfoot Endoscopic Findings of Posterior Ankle Impingement Syndrome in Ballet Dancers (SS-56)

Introduction Posterior ankle pain is a common but serious problem in ballet dancers. Certain kinds of pathological conditions have been reported, such as os trigonum (OT) syndrome, fracture of the Stieda process, flexor hallucis longus (FHL) tendinosis and/or tenosynovitis, soft tissue impingement, and so on. They are considered as a pathological unit of posterior ankle impingement syndrome (PAIS). The purpose of this study is to elucidate the pathologies of PAIS and to clarify how to approach and treat these conditions. Methods Between September 2007 and August 2010, 35 feet of 32 patients, including only one foot of a male patient, underwent hindfoot endoscopic surgery due to PAIS. Average age was 19.6 years (range, 12-40) at the time of surgery. The pathological conditions were retrospectively analyzed mainly with operative findings, also referring with X-ray, MRI, and histological findings. Surgical technique presented by van Dijk was applied to all feet. Results Synchondrosis injury (SCI) was detected in 14 feet, synovitis associated with one or more movable os trigonum (mOT) in 12, a fracture (or microfracture) in os trigonum or posterior process of the talus in four, DJD beneath the OT in two. Injury to the FHL tendon matrix was observed in 23 feet, distal insertion of FHL muscle fibers in 12, and anomalous muscle (FDAL) in two. Intermalleolar ligament (IML), which is also called a tibial slip, a part of transverse tibiofibular ligament, or a pseudomeniscoid were found in 21 feet (60%), ranging from 1 to 5 mm in width. Among them, five were adherent to the FHL tendon sheath, and three had behavior linked with the FHL motion, which seemed to undergo posterior ankle impingement. Osteochondral lesion of the medial talar trochlea were observed in two feet, nodular fibrosis in posterior talocalcaneal ligament and marked synovitis in ankle and posterior subtalar joint in one, respectively. A great majority of feet were affected with two or more pathologic conditions, except four feet. 22 feet (62.9%) had combined bony impingement (SCI, mOT, fracture) with FHL tendon injury. Conclusion Bony impingement was the major pathological process, related in more than 90 percent of the patients; special attention, however, should be paid to some other conditions that concomitantly existed. The hindfoot arthroscopic approach has great diagnostic potentials to posterior aspect of ankle and posterior subtalar joint. And also enables to treat bony impingement, IML lesions, and tenolysis of the FHL and/or FDAL tendon. But when repair of the severely injured FHL tendonor extirpation of ganglions on the tendon sheath is necessary, the other approach should be considered.

A 17-Year-Old Ballet Dancer with Medial Ankle Pain

A 17-Year-Old Ballet Dancer with Medial Ankle Pain

Therapeutic impact of [18F]fluoride positron-emission tomography/computed tomography on patients with unclear foot pain

To evaluate the therapeutic impact of [(18)F]fluoride positron-emission tomography/computed tomography ([(18)F]fluoride PET/CT) imaging on patients with unclear foot pain. Twenty-eight patients were prospectively included in this study. Therapeutic management was defined by two experienced dedicated foot surgeons before and after [(18)F]fluoride PET/CT imaging. Twenty-six patients underwent cross-sectional imaging [CT, magnetic resonance (MR)] prior to PET/CT. A retrospective analysis of the magnetic resonance imaging (MRI) diagnoses was performed when a therapy change occurred after PET/CT imaging. In 13/28 (46%) patients therapeutic management was changed due to PET/CT results. Management changes occurred in patients with the following diagnoses: os trigonum syndrome; sinus tarsi syndrome; os tibiale externum syndrome; osteoarthritis of several joints; non-consolidated fragments; calcaneo-navicular coalition; plantar fasciitis; insertional tendinopathy; suggestion of periostitis; neoarticulations between metatarsal bones. Os trigonum, os tibiale externum, subtalar osteoarthritis and plantar fasciitis were only seen to be active on PET/CT images but not on MR images. [(18)F]fluoride PET/CT has a substantial therapeutic impact on management in patients with unclear foot pain.

Posterior Ankle Impingement: Clarification and Confirmation of the Pathoanatomy

The diagnosis of posterior hindfoot pain may prove to be elusive as there are many potential causes of hindfoot pain, including both soft tissue and osseous abnormalities. This is a case presentation of os trigonum syndrome, with the diagnosis suggested by magnetic resonance imaging (MRI), confirmed by ultrasound, and treated with os trigonum resection. Specific findings of os trigonum syndrome can be seen on MRI, including bone marrow edema pattern and high signal intensity in the synchondrosis as well as in the surrounding soft tissues. Diagnostic injections performed with imaging guidance can help confirm the diagnosis in equivocal cases. Diagnostic and interventional imaging procedures can help confirm the diagnosis of os trigonum syndrome in a patient presenting with hindfoot pain.

Subtalar Arthroscopic Procedures for the Treatment of Subtalar Pathologic Conditions: 115 Consecutive Cases

Arthroscopic procedures of subtalar pathology has shown promising results in previous studies, but the number of patients was relatively small. This article describes our experience and evaluated the clinical outcomes of 115 patients treated with subtalar arthroscopy for a range of subtalar pathologies. One hundred fifteen patients were followed up for >1 year after undergoing a subtalar arthroscopic procedure. Mean patient age was 40 years, and mean follow-up period was 42 months. Preoperative diagnosis included sinus tarsi syndrome in 31 patients, degenerative arthritis in 30, calcaneal fracture in 15, arthrofibrosis in 10, os trigonum syndrome in 8, talar fracture in 5, talocalcaneal coalition in 7, and calcaneal tumor in 1. The clinically modified American Orthopaedic Foot and Ankle Society (AOFAS) and AOFAS ankle-hindfoot scales and patient satisfaction were evaluated. Thirty-one patients had subtalar synovitis and underwent synovectomy; 9 had mild degenerative disease and underwent debridement and chondroplasty; 6 had chondromalacia and underwent intra-articular shaving; 11 had a loose body removed; 10 underwent arthroscopic resection for arthrofibrosis; 8 had symptomatic os trigonum and underwent arthroscopic excision; 6 underwent excision and multiple drilling for an osteochondral lesion of the talus; and 26 had severe degenerative joint disease and underwent arthroscopic subtalar arthrodesis. The mean modified AOFAS ankle-hindfoot scale in the subtalar fusion group was increased from 33 points preoperatively to 84 points postoperatively (P< .005), and the mean AOFAS ankle-hindfoot scale in the other-than-fusion group increased from 69 points preoperatively to 89 points postoperatively (P<.005). Ninety-seven percent of patients were satisfied with the procedure, and there were no serious complications.

Posterior Impingement in a Pediatric Population

Fracture of the os trigonum is exceptionally rare, and it is even rarer in the pediatric age group. Symptomatically and radiographically, it may be confused with what is known as the os trigonum syndrome (constellation of symptoms produced by fracture of the lateral tubercle of the posterior talar process). The authors report a case of a fracture of the os trigonum, as well as its clinical features and management.

Os trigonum syndrome in ancient Anatolian settlements

An os trigonum is a small, round bone situated just behind the ankle joint. Clinical research shows that the os trigonum is present in about 5-15 % of normal feet. It occurs when one part of the bone does not fuse with the rest of the talus during growth. The present study is made on the skeletons, which were found in the Karagündiiz, Dilkaya and Van Kalesi-Eski Van Sehri settlements, Van province, Anatolia, dated in the Middle Ages. In this study 228 skeletons were examined, 120 males and 108 females. 376 tall were studied: 227 from Karagiindtiz, 93 from Dilkaya, and 56 from Van Kalesi-Eski Van Sehri. The percentage of the os trigonum syndrome was recorded as 6.6 %.

Osteo-arthritis of the os trigonum–calcaneal joint

Os trigonum is an incidental radiographic finding at the posterior aspect of the talus in around 10% of the population. A small proportion are symptomatic as part of Posterior Ankle Impingement (os trigonum syndrome), in which several structural and inflammatory changes may be demonstrated on MRI. We report a case of an os trigonum–calcaneal joint associated with dysplastic talus in a patient without primary posterior ankle impingement syndrome. She presented with clinical and radiographical evidence of osteoarthritis within this joint, which responded well to surgical excision via a postero-medial approach.

MR imaging of the ankle and foot—A review of the normal imaging appearance with an illustration of common disorders

Summary This article aims to provide a brief overview of magnetic resonance imaging (MRI) of the ankle for the clinician. A basic review of MRI protocols for the region is followed by discussion of the most common imaging sequences. The appearance of normal ankle anatomy is reviewed with emphasis on structures prone to injury; congenital and developmental abnormalities and normal variants. These are correlated to annotated images. Imaging of ankle and foot pathology and trauma is then discussed with emphasis on the identification of ankle pathology for the manual physician. Illustrative examples are given with discussion of specific common conditions including avascular necrosis, accessory navicular, Haglund's syndrome, Morton's neuroma, osteochondral defects, osteomyelitis, os trigonum syndrome, peroneus quartus, plantar fasciitis and tendinitis/tendinosis.

Arthroscopic resection of symptomatic “os trigonum”: Report of 2 cases

Zusammenfassung Ein symptomatisches Os trigonum ist eine nicht seltene Ursache fur Beschwerden im posterioren Sprunggelenksbereich. Dies trifft vor allem Sportler und Tanzer. Das Os trigonum ist ein sekundares Ossifikationszentrum des Talus lateral des Sulcus fur den Flexor hallucis longus. Es findet sich mit einer Inzidenz von 1,7% bis 7%. Klinische Beschwerden konnen sich aufgrund von entzundlichen Veranderungen oder nach einem Unfall manifestieren. Arthroskopische Therapieformen ersetzen auch hier offene OP-Verfahren und konnen so iatrogene Begleitschaden reduzieren. Das Ziel der vorliegenden Arbeit ist es die Operationstechnik der biportalen arthroskopischen Resektion eines symptomatischen Os trigonum darzustellen und gleichzeitig die klinischen Ergebnisse bei zwei Patienten zu prasentieren.

Syndrome de l'os trigone

The os trigonum syndrome is a rare entity with scant evidence in literature regarding diagnosis and treatment. The current literature concerning the clinical presentation, diagnostic techniques and treatment options are reviewed.

Isolated ossicle causing posteromedial ankle impingement—a new diagnosis?

Posterior impingement syndromes of the ankle have been well described in the literature. It is most commonly associated with a prominent or fractured posterior talar process, an os trigonum or fibrotic scar tissue [Foot Ankle Int 15 (1994) 2; J Bone Joint Surg Am 78 (1996) 1491; Foot Ankle 11 (1991) 404]. There have been few reports of isolated posteromedial impingement lesions and those reported discuss findings of mechanical impingement resulting from disorganised scar tissue or ligament damage [Arthroscopy 9 (1993) 709; Am J Sports Med 29 (2001) 550]. We present two cases of posteromedial impingement of the ankle resulting from an isolated accessory bony lesion, causing symptoms distinct from fibrotic scar tissue impingement or the os trigonum syndrome.

Outcome of resection of a symptomatic os trigonum.

While an os trigonum at the posterolateral aspect of the talus is usually asymptomatic, this inconsistently present accessory bone has been associated with persistent posterior ankle pain, which has been described as the os trigonum syndrome. We present the clinical results of excision of the os trigonum through a posterolateral approach and report several factors affecting the clinical outcome. During a five-year period from 1994 through 1999, forty-one patients had a failure of nonoperative treatment of os trigonum syndrome and underwent excision of a symptomatic os trigonum. In all cases, the os trigonum syndrome was diagnosed on the basis of the history, physical examination, and radiographs. Postoperatively, the patients were evaluated according to the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. A questionnaire was used to evaluate the effect of several factors on the clinical outcome. The average duration of follow-up was forty-four months. The postoperative AOFAS score averaged 87.6 points. The thirty-three patients who had had symptoms for two years or less prior to the surgery had an average postoperative score of 90 points compared with 78 points for the eight patients who had had preoperative symptoms for more than two years (p = 0.011). Eight patients had sural nerve sensory loss, which was temporary in four and permanent in four. A superficial wound infection developed in one patient, and reflex sympathetic dystrophy developed in another. An os trigonum that is persistently symptomatic after a minimum three-month trial of nonoperative treatment can be excised through a posterolateral approach with highly satisfactory results. The main complication of this procedure is sural nerve injury.

Endoscopic treatment of hindfoot pathology

The arthroscope has served the orthopaedic surgeon as a diagnostic and operative tool since 1931. Several reports on its use in the treatment of extra-articular injuries have been published over the past few years. The surgical approach to the posterior ankle region is associated with some complications stemming from the poor blood supply to this region that can lead to wound complications and the formation of painful scars that later cause irritation when shoes are worn. We describe our experience in treating 3 hindfoot pathologic conditions, chronic Achilles tendonitis, os trigonum syndrome, and Haglund’s deformity, by using an endoscope as an alternative to open surgical techniques. All the patients underwent a 2-portal endoscopic procedure, they suffered no complications, and they resumed their daily and sports activities after 2 to 3 months. Our results with the endoscopic treatment of hindfoot and Achilles tendon injuries indicate it to be a good alternative to the surgical approach, and to have the added advantage of reducing postoperative morbidity.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 2 (February), 2003: pp E13–E13