Subtalar Joint Injection

Subtalar Joint Injection is used in case of chronic capsulitis that is caused by Trauma after fracture or severe impaction injury, often years later. RA overuse in older obese patient.

Subtalar joint chronic capsulitis is characterized by Pain deep in medial and lateral sides of heel; CP: passive adduction of the calcaneus.

The subtalar joint is divided by an oblique septum into anterior and posterior portions. It is slightly easier to enter the joint just above the sustentaculum tali, which projects a thumb’s width directly below the medial malleolus.

See Also: Ankle Anatomy

Equipment Needed

• Syringe: 2 ml
• Needle: Blue, 23 gauge. 1.25 inches (30 mm)
• Kenalog 40: 30 mg
• Lidocaine: 1.25 ml, 2%
• Total volume: 2 ml

Subtalar Joint Injection Technique

1. Position the patient on their side with the foot supported to ensure that the medial aspect of the heel is facing upwards.
2. Identify the bump of the sustentaculum tali.
3. Insert the needle perpendicularly, immediately above and slightly posterior to the sustentaculum tali.
4. Deposit half of the solution at this location.
5. Withdraw the needle slightly and angle it obliquely anteriorly through the septum into the anterior compartment of the joint space.
6. Deposit the remaining solution in this location.

After Subtalar Joint Injection, avoid excessive weight-bearing activities until pain free. Orthotics and weight control are helpful in preventing recurrence.

Notes

The Subtalar Joint Injection is a difficult injection to perform because of the anatomical shape of the joint. If the needle does not enter the joint immediately, deposit a small amount of the mixed solution into the area. This will allow more comfortable further attempts to place the needle intraarticularly. It may be repeated at infrequent intervals if necessary.

Ultrasound guided subtalar joint injection is a valuable orthopedic technique with the following benefits:

• Enhanced Accuracy: Ultrasound guidance allows for precise needle placement within the subtalar joint, minimizing the risk of inadvertent tissue damage and maximizing the effectiveness of the injection.
• Real-Time Visualization: The dynamic real-time imaging provided by ultrasound enables to visualize the needle path, ensuring its proper positioning and avoiding critical structures.
• Improved Patient Comfort: By accurately delivering medication to the intended site, patients often experience reduced pain and improved joint function.
• Minimized Side Effects: Ultrasound guidance enables the use of smaller needle sizes, reducing the likelihood of complications such as bleeding, infection, or nerve injury.

With appropriate training and practice, the subtalar joint can be reliably and safely targeted with US-guided corticosteroid injection to treat symptoms related to juvenile idiopathic arthritis.

Intra-articular Subtalar Joint Injection with steroid has been used anecdotally in patients with symptomatic talocalcaneal coalitions. This intervention does not appear to decrease the need for surgery when compared with traditional nonoperative therapies. In patients failing other forms of conservative treatment, subtalar steroid injections can delay surgical intervention by an average of nearly 2 years.

References

1. Injection Techniques in Musculoskeletal Medicine. A Practical Manual for Clinicians In Primary And Secondary Care. Fifth Edition
2. Zide JR, Shivers C, Adair C, Le T, Kanaan Y, Rathjen K, Jo CH, Riccio AI. The Efficacy of Intra-articular Subtalar Steroid Injection for Symptomatic Talocalcaneal Coalitions: A 30-Year Single Institution Experience. J Pediatr Orthop. 2022 May-Jun 01;42(5):e453-e458. doi: 10.1097/BPO.0000000000002132. PMID: 35250016.
3. Young CM, Horst DM, Murakami JW, Shiels WE 2nd. Ultrasound-guided corticosteroid injection of the subtalar joint for treatment of juvenile idiopathic arthritis. Pediatr Radiol. 2015 Jul;45(8):1212-7. doi: 10.1007/s00247-015-3291-2. Epub 2015 Feb 12. PMID: 25672519.