Hindfoot Arthroscopy

Hindfoot Arthroscopy (Subtalar Arthroscopy)

Ankle and foot pain can significantly affect our daily life and mobility. The source of the pain is not always the ankle joint itself (the tibiotalar joint). Sometimes the problem originates from hindfoot joints such as the subtalar joint, which lies just below the ankle and enables the foot’s inward/outward movements. Conditions occurring in the joints of this region — such as osteoarthritis, impingement syndromes, cartilage damage, intra-articular loose bodies, or chronic inflammation — can lead to persistent pain and loss of function that does not respond to conservative treatments. This is where Hindfoot Arthroscopy (Subtalar Arthroscopy), a minimally invasive (closed) surgical technique, emerges as an important option for the diagnosis and treatment of these problems. Prof. Dr. Murat Bozkurt, an Orthopedics and Traumatology Specialist in Ankara, applies arthroscopic surgical techniques with modern approaches in the treatment of hindfoot problems.

The Hindfoot and the Subtalar Joint

The hindfoot region, located just below the ankle joint, is essentially made up of two important bones: the Talus (ankle bone) and the Calcaneus (heel bone). The main joint between these two bones is the Subtalar Joint (Talocalcaneal Joint).

  • Subtalar Joint: Unlike the up-down movement of the ankle joint (flexion-extension), it is responsible for the foot’s side-to-side movements — inward (inversion) and outward (eversion). These movements are critical for the foot to adapt to the ground and for balance to be maintained, especially when walking on uneven or sloped surfaces.

What Is Hindfoot Arthroscopy?

This is a closed surgical technique used to diagnose and treat problems in the hindfoot (particularly in the subtalar joint), in which a thin camera (arthroscope) and specialized surgical instruments are inserted through several small incisions (portals) made around the joint. Unlike standard ankle (tibiotalar) arthroscopy, this procedure targets the subtalar joint or the space behind the ankle, which is deeper and anatomically more complex.

Purpose: To directly visualize the pathologies causing pain (inflamed tissue, bone spurs, loose bodies, cartilage damage) and treat them with minimal tissue damage, relieve pain, improve joint motion, and restore function.

In Which Situations Is Hindfoot Arthroscopy Performed?

Hindfoot arthroscopy is generally considered when other treatment methods have failed. The main indications are as follows:

  • Subtalar Arthritis (Early-to-Mid Stage): In cases of pain, stiffness, and limited motion due to osteoarthritis in the joint, it may be performed to clean out worn cartilage fragments within the joint (debridement), remove the inflamed joint lining (synovium) (synovectomy), and shave down bone spurs causing pain. Its effectiveness is limited in advanced-stage osteoarthritis.
  • Posterior Ankle Impingement: A condition that causes pain behind the ankle, particularly when pointing the toes downward (plantarflexion). It is common among dancers and athletes. Soft tissue impingement (inflamed synovium, scar tissue) or bony impingement (an accessory ossicle called the Os Trigonum, or the posterior process of the talus) can be cleaned out or removed arthroscopically.
  • Sinus Tarsi Syndrome: Persistent inflammation (synovitis) or sequelae of ligament injury causing ongoing pain in the space on the outer side of the ankle called the “sinus tarsi” can be cleaned out arthroscopically if it does not respond to conservative treatment.
  • Subtalar Instability: In instability conditions that develop after repeated ankle sprains and also affect the subtalar joint, it can be used to assess intra-articular damage and, at times, perform limited debridement (ligament repair generally requires an open approach).
  • Intra-Articular Loose Bodies: Removal of bone or cartilage fragments that have fallen into the joint as a result of trauma or cartilage damage. These fragments can cause catching and locking.
  • Osteochondral Lesions (OCL): Treatment of limited cartilage and bone damage (debridement, microfracture, etc.) on the subtalar joint surfaces (talus or calcaneus).
  • Synovitis: Removal of chronic synovitis (inflammation of the joint lining) that develops in inflammatory rheumatic diseases such as rheumatoid arthritis or after trauma.
  • Tarsal Coalition Resection (Selected Cases): Arthroscopic removal of certain types of abnormal bony fusions (coalitions) between the bones of the hindfoot.
  • Infection Treatment / Diagnostic Biopsy: Rarely used to clean out joint infections or to obtain a tissue sample for diagnostic purposes.

What Are the Symptoms of Hindfoot Problems?

The symptoms of conditions that may require hindfoot arthroscopy generally include:

  • Deep Hindfoot or Heel Pain: Pain that is usually difficult to pinpoint and is felt deep within the foot. The pain worsens especially with walking on uneven ground, running, jumping, or turning the foot inward/outward. In posterior impingement, pain when pointing the toes downward is typical.
  • Stiffness: A feeling of limitation or stiffness in subtalar joint movements (inward/outward tilting).
  • Mechanical Symptoms: A clicking sound, popping, catching, or locking sensation in the ankle or heel area.
  • Feeling of Insecurity: A sensation of giving way or instability in the ankle while walking or running.
  • Swelling: Recurrent swelling around the ankle, particularly on the outer or posterior side.

Diagnostic Methods

A comprehensive evaluation is carried out to establish the correct diagnosis and determine suitability for arthroscopy:

  • Detailed History: The location, onset, character, and triggering factors of the pain, mechanical symptoms, and any prior trauma or illnesses are questioned.
  • Physical Examination: The ankle and hindfoot are examined carefully. Tender points (the subtalar joint line, sinus tarsi, front/back of the Achilles tendon) are palpated. Subtalar joint range of motion (inversion/eversion) and whether it is painful are assessed. Ankle movements, ligament stability, and gait pattern are examined. Diagnostic Subtalar Joint Injection: To confirm that the pain definitively originates from the subtalar joint, a local anesthetic is injected into the joint under imaging guidance (usually fluoroscopy or ultrasound). A marked reduction in pain supports the diagnosis and can help guide the surgical decision.
  • Imaging Methods:
    • X-ray: Standard and special subtalar joint views of the foot and ankle (e.g., the Broden view) are obtained. Signs of osteoarthritis, bone spurs, Os Trigonum, tarsal coalition, fractures, or joint congruence are assessed.
    • Computed Tomography (CT): Particularly useful for showing bony detail, coalitions, the extent of osteoarthritis, the size of bone spurs, and intra-articular loose bodies. Frequently used for surgical planning.
    • Magnetic Resonance Imaging (MRI): The best method for demonstrating soft tissues (cartilage, synovium, ligaments, tendons), cartilage damage (OCL), bone marrow edema, synovitis, and soft-tissue pathologies that may cause impingement.

How Is Hindfoot Arthroscopy Surgery Performed?

Hindfoot arthroscopy is a technique performed less frequently than ankle arthroscopy and requires specialized experience:

  1. Anesthesia: General or spinal (lower-body numbing) anesthesia is administered.
  2. Positioning: The patient is usually placed on the operating table in a prone or lateral position. Mild traction may sometimes be applied to relax the joint.
  3. Portal Placement: Two or three very small (approximately 0.5 cm) surgical incisions (portals) are made on the posterolateral and posteromedial sides of the ankle, usually on either side of the Achilles tendon. For sinus tarsi problems, a portal may sometimes also be opened anteriorly. The placement of these portals requires great care to avoid damaging important nerves (the sural nerve, posterior tibial nerve) and blood vessels in the area.
  4. Visualization and Diagnosis: A thin camera (arthroscope) is inserted through one portal into the subtalar joint or the space behind the ankle. Using the magnified image projected onto the screen, the joint surfaces, cartilage, synovium, ligaments, and bony structures are examined in detail.
  5. Surgical Treatment: Specialized fine surgical instruments (shaver, probe, cutter, grasper, etc.) are inserted through the other portals to perform procedures targeting the identified pathologies:
    • Removal of inflamed synovium (Synovectomy).
    • Shaving of frayed cartilage (Debridement/Chondroplasty).
    • Removal of loose bone/cartilage fragments.
    • Shaving of bone spurs or the Os Trigonum (Impingement treatment).
    • Microfracture technique for cartilage damage.
    • Resection of the tarsal coalition by cutting it free.
  6. Closure: Once the procedure is complete, the instruments are removed and the portals are typically closed with a single stitch or special adhesive strips.

Prof. Dr. Murat Bozkurt has the necessary expertise and experience in hindfoot arthroscopy and performs this surgery in Ankara.

Risks, Benefits, and Recovery Process

  • Benefits: Being a minimally invasive method, it potentially offers less postoperative pain, smaller scars, and faster initial recovery compared to open surgery. It allows detailed visualization of the inside of the joint and treatment of multiple pathologies at the same time. It is particularly effective in the treatment of impingement syndromes, loose bodies, and synovitis.
  • Risks:
    • General surgical risks (infection, DVT, anesthesia risks).
    • Specific Risks: The most important risk of hindfoot arthroscopy is nerve injury. In particular, the sural nerve (numbness/burning on the outer ankle and outer edge of the foot) and the posterior tibial nerve or its branches (numbness/burning in the heel and sole of the foot) carry a risk of injury because they lie close to the portal sites. This is usually temporary but can rarely be permanent. Other risks include tendon injury (Achilles, peroneal, FHL), joint stiffness, persistent pain, wound-healing problems at the portal sites, and complex regional pain syndrome (CRPS).
  • Recovery Process: This varies depending on the procedures performed during surgery.
    • Immobilization and Weight-Bearing: If only a simple cleanup (debridement/synovectomy) was performed, a brief period of bandaging and early weight-bearing may sometimes be allowed. However, if procedures such as bone shaving or microfracture were performed, non-weight-bearing or protected weight-bearing in a cast or walking boot for several weeks (2–6 weeks or longer) is generally required.
    • Physical Therapy: Absolutely essential. It begins after the immobilization period. The goal is to restore subtalar and ankle joint range of motion, control swelling, increase muscle strength (particularly the peroneal and calf muscles), improve balance and proprioception, and restore a normal gait.
    • Timeline: Return to normal daily activities can take a few weeks to a few months. Return to more strenuous activities and sports generally takes 3 to 6 months or longer.

Hindfoot Arthroscopy in Ankara and Prof. Dr. Murat Bozkurt’s Approach

Hindfoot arthroscopy is an advanced technique requiring specialized expertise and experience in ankle and foot surgery. In Ankara, Prof. Dr. Murat Bozkurt uses this minimally invasive method for the diagnosis and treatment of persistent hindfoot pain that does not respond to conservative treatments:

  • Detailed Diagnostic Process: He makes use of careful examination, diagnostic injections, and advanced imaging methods (CT, MRI) to accurately identify the source of the patient’s complaints (subtalar joint, posterior impingement, sinus tarsi, etc.).
  • Appropriate Patient Selection: He carefully evaluates which patients arthroscopy is suitable and beneficial for.
  • Safe Surgical Technique: During surgery, he pays utmost attention to protecting nerve structures while performing the necessary treatment (debridement, impingement removal, microfracture, etc.) using modern arthroscopic techniques.
  • Personalized Rehabilitation: He plans and monitors the postoperative recovery process according to each patient’s needs.

Hindfoot arthroscopy is an effective, minimally invasive method for treating specific problems below and behind the ankle that do not respond to conservative treatments. However, because it involves an anatomically challenging region and carries a potential risk of nerve injury, it must always be performed by a surgeon experienced in this field. You can benefit from Prof. Dr. Murat Bozkurt’s expertise in Ankara for the diagnosis and treatment of your hindfoot problems.

For detailed information and appointments, you can contact Prof. Dr. Murat Bozkurt by phone at 0312 502 70 74.

Frequently Asked Questions

It is a closed surgery performed by inserting a camera through small incisions into the joints beneath the ankle (particularly the subtalar joint) or into the space behind the ankle.

The subtalar joint (the joint between the talus and calcaneus) is treated most often. Impingements behind the ankle are sometimes addressed as well.

While standard ankle arthroscopy targets the main joint (between the tibia and talus), hindfoot arthroscopy targets the structures below or behind it, and different entry points (portals) are used.

Conditions such as subtalar joint osteoarthritis (early stage), posterior impingement syndrome, sinus tarsi syndrome, intra-articular loose bodies, certain cartilage injuries (OCL), and chronic synovitis can be treated.

In early- and mid-stage subtalar arthritis, debridement and bone shaving can be performed to relieve symptoms (pain, catching). However, it does not treat advanced-stage osteoarthritis.

It is a condition in which soft tissues or bone spurs (such as the Os Trigonum) behind the ankle become pinched and cause pain, particularly when the toes are pointed downward.

There are general risks such as infection and blood clots. The most important specific risk is numbness or pain in the foot resulting from injury to the sural nerve or posterior tibial nerve, which lie close to the surgical site.

It varies depending on the procedure performed. It can take anywhere from a few weeks to 3–6 months or longer. Weight-bearing restrictions and physical therapy are generally required.

Depending on the procedure performed, you may need to use a cast, splint, or a special walking boot for a few weeks.

You can call 0312 502 70 74 to schedule an examination with Prof. Dr. Murat Bozkurt, learn the cause of your pain behind the ankle or in the heel area, and discuss whether hindfoot arthroscopy is an option for you along with other treatment alternatives.

You can get in touch to learn more about the diagnostic and treatment process.

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Hindfoot Arthroscopy in Ankara: Pain-Free Steps with Closed Surgery

Chronic pain felt at the back of the ankle, especially when rising onto the toes or bending the foot downward, is often a sign of “posterior ankle impingement syndrome.” Hindfoot arthroscopy in Ankara, a field in which Prof. Dr. Murat Bozkurt has pioneered, treats problems in this area with a closed (arthroscopic) method through just two small incisions, without opening large incisions.

Offering much faster recovery than traditional open surgeries, this method is the most modern solution for bone spurs behind the Achilles tendon, intra-articular loose bodies, and tendon impingements. In our clinic in Ankara, we use the latest imaging technologies and micro-surgical instruments to minimize our patients’ return time to sport and daily life.

What Is Hindfoot Arthroscopy?

Hindfoot arthroscopy is a closed surgical method used to treat joint and soft-tissue problems in the back portion of the ankle. In our hindfoot arthroscopy in Ankara procedures, entry is made through two small incisions of approximately 0.5 cm opened on either side of the ankle, using cameras (arthroscopes) and specialized surgical instruments.

Because this method does not create large incisions and tissue damage as open surgery does, the recovery process is incredibly fast. Prof. Dr. Murat Bozkurt uses this advanced technique to directly visualize problems deep within the joint and intervene with millimetric precision.

In Which Conditions Is Hindfoot Arthroscopy Performed?

This method is preferred for the following diagnoses in cases of chronic pain at the back of the ankle that does not resolve with rest:

  • Posterior Ankle Impingement Syndrome: The pinching of bone or soft tissue against each other during the toe-raising motion, seen particularly in ballet dancers, footballers, and basketball players.

  • Os Trigonum Syndrome: Removal of a congenital “extra bone” projection behind the ankle that begins to cause pain after trauma or strain.

  • Haglund’s Deformity: Closed-method shaving of the bony prominence at the back of the heel bone (pump bump) and the resulting bursitis.

  • FHL Tendon Problems: Release of the tendon that flexes the big toe (Flexor Hallucis Longus) in cases of impingement or inflammation (tenosynovitis).

  • Intra-Articular Loose Bodies: Removal of cartilage fragments or “joint mice” circulating within the joint due to osteoarthritis.

How Is Hindfoot Arthroscopy Surgery Performed?

Hindfoot arthroscopy in Ankara procedures typically allow our patients to be discharged the same day. The operation is performed through two small points (portals) at the back of the ankle. Prof. Dr. Murat Bozkurt examines the tissues inside the joint magnified 10 to 15 times using high-resolution camera systems. This way, only the problem area is addressed, and healthy tissue is fully preserved.

The weeks of wound healing and severe pain typical of open surgery are minimized thanks to this closed method. There is almost no visible scarring after surgery, and the risk of infection is quite low.

Recovery Timeline After Hindfoot Arthroscopy

For the success of the surgery to be lasting, the personalized rehabilitation process prepared by Prof. Dr. Murat Bozkurt consists of the following stages:

  • First 48 Hours: The operated area is protected with a bandage, and swelling is prevented through ice application and rest.

  • Week 1: Our patients generally begin to place controlled weight on the foot with the support of a special walking boot or bandage.

  • Week 2: Stitches at the small portal sites are removed (or checked, if dissolvable sutures were used), and simple exercises to increase joint range of motion are begun.

  • Weeks 4–6: The physical therapy process intensifies. Tendon strengthening and balance exercises are carried out in coordination with our physical therapy centers in Ankara.

  • Month 3: The necessary tests are performed for return to running, jumping, and high-intensity sports.

Advantages for Athletes: A Fast Return to the Field

Time is the most valuable factor, especially for professional athletes and ballet dancers. Because hindfoot arthroscopy does not damage the ligaments and muscles around the joint, it allows athletes to return to the field without loss of performance. Prof. Dr. Murat Bozkurt‘s deep experience in athlete health ensures that the operation is not only healing, but also performance-preserving.