546549

research-article2014
FAIXXX10.1177/1071100714546549Foot & Ankle InternationalsApostle et al

Article
Foot & Ankle International®

Subtalar Joint Axis in Patients With

2014, Vol. 35(11) 1153­–1158
© The Author(s) 2014
Reprints and permissions:
Symptomatic Peritalar Subluxation sagepub.com/journalsPermissions.nav
DOI: 10.1177/1071100714546549

Compared to Normal Controls fai.sagepub.com

Kelly L. Apostle, MD, FRCSC1, Nathan W. Coleman, MD2,

and Bruce J. Sangeorzan, MD3

Abstract
Background: The etiology of peritalar subluxation (PTS) is poorly understood and likely mutifactorial. An anatomic
predisposition for posterolateral subluxation of the hindfoot has not been previously described or investigated. The aim
of the current study was to describe the morphology of the subtalar joint axis (STJA) in patients with symptomatic PTS
compared to normal controls.
Methods: We identified patients with symptomatic PTS who had undergone operative correction from hospital records.
The angle of the axis of the posterior facet of the subtalar joint was made on simulated weight-bearing CT (SWBCT)
scans. A control group of patients who had no foot deformity on standing films was used for comparison. The STJA was
defined as the angle between the superior talar dome and the posterior facet of the talus on coronal CT scan. The mean,
maximum, and minimum STJAs were calculated for each cut from anterior to posterior across the posterior facet. The
trend in progression across the posterior facet was also examined.
Results: After exclusions, 22 feet in 20 patients were included in the study group and compared to 20 control subjects.
It was seen that patients with PTS had an increased valgus orientation of the subtalar joint. In patients with PTS the STJA
began in valgus and progressed to even greater valgus from anterior to posterior across the posterior facet. The STJA in
control subjects was seen instead to begin in slight varus and transition to valgus at the junction of the anterior and middle
third and then increase in valgus as the joint progressed posteriorly.
Conclusions: The valgus orientation of the coronal plane of the subtalar joint may represent an anatomic contribution
to the etiology of PTS.
Level of Evidence: Level III, comparative series.

Keywords: adult acquired flat foot, subtalar joint axis, peritalar subluxation, tibialis posterior insufficiency, hindfoot
alignment

Peritalar subluxation (PTS) is a term used to describe the
changes in the hindfoot of patients with a painful valgus
hindfoot, abducted midfoot and supinated forefoot.1
Clinically the medial soft tissues including the spring liga-
ment, tibialis posterior tendon, talonavicular capsule, and
talocalcaneal interosseous ligament are seen to attenuate,
resulting in loss of the medial longitudinal arch. This
results in the anatomic deformity of forefoot supination,
midfoot abduction, plantarflexion of the talus within the
mortise, and posterolateral subluxation of the subtalar joint
resulting in a hindfoot valgus deformity.1 The primary eti-
ology of this deformity is poorly understood. The original
classification system for this pathology was proposed in
1989 and related the severity of the deformity to progres-
sive injury to the tibialis posterior tendon.9 Many authors
have shown that more accurately the observed clinical defor-
mity is attributable to a combination of factors including
BMI, contracture of the gastrocnemius or gastrocsoleous
complex, rupture or attrition of the spring ligament and
talocalcaneal ligament, loss of the windlass mechanism of
the plantar fascia, and global ligamentous laxity.4,5,8,12
However, not all patients with similar clinical findings will
progress to a planovalgus deformity, and those who do
progress at variable rates and to variable severities. There
1
University of British Columbia, New Westminster, BC, Canada
2
University of Washington, Seattle, WA, USA
3
Department of Orthopaedics and Sports Medicine, University of
Washington, Seattle, WA, USA
Corresponding Author:
Kelly L. Apostle, MD, FRCSC, Department of Orthopaedics, University
of British Columbia, Royal Columbian Hospital #403-233, Nelson’s
Crescent, New Westminster, BC V3L0E4, Canada.
Email: kapostle@me.com
1154 Foot & Ankle International 35(11)
Figure 1.  Representative midposterior facet coronal cut for a patients with peritalar subluxation (A) and control (B) showing the
observed difference of the slope of the subtalar joint at that level.
are suggestions that the anatomy of the planovalgus foot
may differ from normal arched feet, however whether these
changes are causative or adaptive has not been explored.2,6
The purpose of the current study was to investigate a pos-
sible underlying anatomic predisposition of the hindfoot to
subluxation at the subtalar joint. The impetus for this study
was the observation that the posterior facet on coronal sim-
ulated weight-bearing CT (SWBCT) in patients with PTS
appeared to have a more valgus orientation that that seen in
anatomically neutral aligned hindfeet (Figure 1). It was
hypothesized that patients with symptomatic PTS would
have an increased valgus coronal plane subtalar joint axis
(STJA) compared to normal controls.
Materials and Methods
The study group was identified via a 4-year consecutive
review of patients who underwent operative correction of
symptomatic PTS presenting to a single surgeon. Inclusion
criteria were skeletally mature patients with symptomatic
PTS severe enough to proceed to surgery who had under-
gone SWBCT scan as per a previously established proto-
col.7,11 Symptomatic PTS was defined as pain to the tibialis
posterior tendon, medial longitudinal arch, or sinus tarsi and
radiologic evidence of PTS deformity on standing AP and
lateral plain films (talo-first metatarsal angle greater than 0 ±
5 degrees on both the lateral and AP film, talocalcaneal angle
of greater than 30 ± 10 degrees on lateral film and talar head
uncovering on AP film). Exclusion criteria were diagnosis
other than idiopathic PTS, advanced subtalar arthritis pre-
cluding accurate determination of the STJA, valgus tilt of
the talus in the mortise (stage 4 flatfoot), and a complex mul-
tiplanar deformity or distal tibial plafond malalignment of
Table 1.  Demographics for Peritalar Subluxation (PTS) and
Control Groups.
PTS Control P
Age (mean, range) 56 (15-85) 44.8 (39-55) .02
Gender (% female) 55 50  
Side (R, L) 10, 12 10, 11  
BMI (mean ± SD) 28.9 ± 6.5 27.4 ± 5.9 .31
greater than 5 degrees. A group of SWBCT scans from a
previous study was used for controls. The control images
were from a group a healthy volunteers with foot X-rays that
were within normal anatomic limits, had no foot pain or
prior foot surgery who had undergone SWBCT scans using
an identical protocol as for patients with symptomatic PTS.
Normal anatomic limits on standing films included a talo-
first metatarsal angle of 0 ± 5 degrees on both the lateral and
AP film, talocalcaneal angle of 30 ± 10 degrees on lateral
film, and no talar head uncovering on AP film. Twenty con-
trol patients were included for comparison.
A demographic review was performed for age, gender,
affected extremity, and body mass index (BMI). SWBCT
scans were performed using a previously published proto-
col.7,11 SWBCT were reviewed by 2 reviewers, and all mea-
surements were made using OSIRIX v3.9.
Review of operative current procedural terminology
(CPT) diagnosis revealed 38 extremities in 35 patients.
Sixteen extremities were excluded: 4 had insufficient imag-
ing, 7 had a diagnosis other than PTS, 3 had severe subtalar
arthritis, and 2 had multiplanar deformities at the ankle hind
mid- and forefoot. This left 22 extremities in 20 patients (1
patient had bilateral extremities excluded). Demographic
Apostle et al 1155

Figure 2.  Determination of the anterior and posterior limits of the posterior facet by linking sagittal and coronal sequences.
Measurements were made for each sequential CT cut between the anterior and posterior limits of the posterior facet.

review is shown in Table 1. Patients in the PTS group were

significantly older, however BMI was comparable for the 2
groups.
The sagittal CT cuts were used to identify the anterior and
posterior limits of the posterior facet of the subtalar joint
(Figure 2). The reformatted images in the coronal plane were
then measured to establish the axis. The horizontal of the
distal tibial plafond was measured relative to the plane of the
weight-bearing frame to ensure no distal tibial malalign-
ment. The intra-articular tibiotalar angle (horizontal of the
tibial plafond relative to the superior dome of the talus) was
also measured to ensure that the talus was not tilted in the
mortise. The STJA was defined as the angle formed between
an axis formed in the coronal plane aligned along the supe-
rior dome of the talus and an axis of the posterior facet of the Figure 3.  Determination of the STJA on the coronal CT cut.
talus (Figure 3). We chose to make this measurement entirely The angle posterior facet of the talus with reference to the
off the talus as it has been previously shown that as PTS superior dome of the talus for each coronal CT cut.
1156 Foot & Ankle International 35(11)

Figure 4.  Subtalar joint axis for the anterior and posterior limits in a subject with peritalar subluxation (A anterior, B posterior) and
a control (C anterior, D posterior).

progresses, the calcaneus subluxes posterolaterally around Table 2.  Mean, Maximum, and Minimum (± SD) Subtalar Joint
the talus, which remains reduced within the ankle mortise. Axis (STJA) for Peritalar Subluxation (PTS) and Control Groups.
The STJA was measured for each cut from the anterior to PTS Control P
posterior limits of the posterior facet. Valgus values were
recorded as negative and varus as positive. For each subject Mean −19.0 ± 5.9 −5.0 ± 3.9 <.001
the mean, maximum, and minimum STJA values were Maximum −34.0 ± 7.6 −18.0 ± 5.5 <.001
recorded. For both the PTS and control groups the mean Minimum −3.6 ± 6.4 5.8 ± 3.0 <.001
STJA value for each CT cut from anterior to posterior was Significance set at P < .05.
determined to evaluate a trend in progression from anterior
to posterior across the posterior facet.
An unpaired Student t test was used to compare demo- more valgus toward the posterior limit of the posterior facet
graphic data as well as mean, maximum and minimum in both the PTS and control groups (Figure 4). The PTS
STJA values. group was seen to begin in valgus and progress to even
greater valgus posteriorly, whereas the control group began
in slight varus anteriorly progressing toward valgus by the
Results middle third of the posterior facet and then increasing in
The mean STJA, maximum STJA, and minimum STJA valgus toward the posterior limit. A graphic depiction of the
were significantly more valgus in the PTS group compared progression of the STJA from anterior to posterior for both
to normal controls (Table 2). The STJA orientation was the PTS and control groups is shown in Figure 5.
Apostle et al 1157

Figure 5.  Mean (± SD) subtalar joint axis (STJA) for each CT cut from anterior to posterior along the posterior facet for both
peritalar subluxation (PTS) and control groups. The control group begins in varus (positive value) and progresses to valgus (negative
values) at the transition between the anterior and middle third of the posterior facet. The STJA group begins in valgus and progresses
into even further valgus posteriorly.

Discussion the increased hindfoot valgus subtalar orientation would

This is the first study to investigate a potential anatomic pre-
disposition to posterolateral subluxation of the hindfoot in
patients with symptomatic PTS using weight-bearing CT
scan. We have shown that patients with PTS have an
increased valgus orientation of the subtalar joint compared
to normal controls. This is an important finding as it contrib-
utes to the current understanding of the underlying etiology
of PTS as well as has implications for operative correction.
Many authors have previously attempted to account for
the progression of the deformity seen in PTS by serial sec-
tioning of the soft tissue supports of the medial longitudinal
arch.4,5,8,10,12 However, cadaveric biomechanical studies
have shown that production of a planovalgus foot by soft
tissue sectioning alone does not re-create the degree of
deformity seen clinically.4,8,10,12 It therefore seems likely
that there are other factors at play in the manifestation of a
planovalgus foot, and an underlying anatomic variation in
the hindfoot would seem logical. The orientation of the sub-
talar joint in the coronal plane is not well studied or
described. It can be assumed that the geometry of the subta-
lar joint will control the distribution of forces across the
hindfoot. We have shown that the STJA on SWBCT is more
valgus in patients with PTS than normal controls. We
hypothesize that this finding is congenital and predisposes
individuals to progressive deformity with age. Over time
cause increased strain across the posteromedial soft tissue
structures, causing them ultimately to fail leading to pro-
gressive posterolateral subluxation as the soft tissue support
of the medial longitudinal arch is lost. This could be consid-
ered akin to a steep tibial plateau slope as a potential risk
factor for anterior cruciate ligament injury.
The orientation of the subtalar joint in PTS also has
implications for successful operative correction of the
symptomatic planus foot. A medializing calcaneal osteot-
omy will bring the tuberosity into a corrected varus posi-
tion, however if the joint angle is not corrected this may be
insufficient to maintain the soft tissue reconstruction.3,9,13
A lateral column lengthening would abduct the midfoot
but also would not address the malalignment of the poste-
rior facet. This may create a compensatory deformity of
hindfoot valgus and midfoot adduction that may cause
altered loading of the foot. Theoretically we hypothesize a
better correction could be achieved by a posterolateral
opening wedge subarticular osteotomy of the talus to
improve the joint orientation, although we have not tried
this to date.
We recognize there are limitations to the current study. It
is a relatively small series. Two-dimensional measurements
were made on weight-bearing CT scans for a 3-dimensional
deformity. Although the talus has been shown to remain
1158 Foot & Ankle International 35(11)
reduced within the mortise in type 1 to type 3 flatfoot as the
calcaneus subluxes posterolaterally, the talus does become
plantarflexed. The degree to which the plantarflexion of the
talus affects the coronal subtalar joint measurement is not
known. A volumetric analysis of the STJA would more
accurately describe the intra-articular deformity. However
by providing a CT-based measurement, this gives the sur-
geon a readily accessible method of evaluating the STJA. In
addition, the images show a clear path for progression of the
calcaneus in a posterior and lateral direction relative to the
talus. This fits the known anatomic progression in severe
flatfoot.
In conclusion, we have shown that the orientation of the
coronal plane STJA is significantly more valgus in patients
with symptomatic PTS compared to normal controls on
SWCT. This may represent an antomic contribution to the
etiology of PTS and may be useful in planning surgical
intervention in this patient population.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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