Posterior Crossroads Syndrome
Astragalus tail syndrome (or posterior crossroads syndrome) is a common disease of the back foot in athletes.
Pain caused by astragalus tail syndrome is secondary to the entrapment of tissues or bones between the heel bone and the tibia during plantar flexion. We are talking about a nutcracker mechanism.
Indeed, the posterior crossroads is a space located at the back of the ankle, before the Achilles heel. It is delimited:
- Through the posterior tibia
- By the upper face of the calcaneus
- Through the space in front of the Achilles heel
Conflict may involve the bone or posterior soft parts of the ankle.
We distinguish 3 variants of the syndrome of the tail of the astragalus according to the following:
- Posterior Crossroads Syndrome is a “too long tail” bone conflict where the astragalus is stuck between the tibia and the calcaneus.
- The trigon bone syndrome. It is a bone conflict causing the deformation or pain of a posterior bone (probable synchondrosis) by crushing between the tibia and the calcaneus.
- Posterior crossroads syndrome on “short tail”. It is a conflict between bone and soft tissue where the synovial capsule and the talo-crural joint are crushed between the tibia and the calcaneus.
In case of posterior crossroads syndrome, the symptoms are numerous. The pathology is first manifested by a pain in the heel which intensifies during the plantar flexion. The pain is localized in the upper part of the calcaneus (the heel bone). This pain in the ankle astragalus is usually accompanied by swelling in the ankle and hindfoot.
This syndrome is the result of a lesion usually caused by repetitive strain injuries caused by the practice of a sports activity. Some sports are more likely to cause this type of injury, including:
- Jumping sports such as basketball, handball or volleyball
- Sliding sports such as skiing, snowboarding or skating
- Sports with pressure on the toes such as ballet or cycling
Multiple exams may be prescribed to confirm the diagnosis if there is a problem with the ankle astragalus.
On clinical examination, the passive plantar flexion of the ankle awakens the pain of the astragalus and allows to confirm the diagnosis with certainty. Palpation allows to highlight any swelling on the tendon path.
Doctor Julien Lopez can also prescribe several medical imaging tests:
- Standard radiography
- Magnetic resonance imaging (MRI)
- Single scanner or arthroscanner
- Bone scan
In case of doubt, it is possible to perform a test infiltration at the posterior crossroads. Reduced pain confirms the diagnosis of astragalus tail syndrome.
In the case of posterior crossover syndrome, non-surgical treatment is the first-line treatment. Doctor Julien Lopez is likely to offer you several medical treatments:
- Oral painkillers and anti-inflammatory therapy to reduce pain
- Cold treatment (cryotherapy)
- A strapping to limit plantar flexion
- A temporary immobility
- Use of an orthopedic shoe
- Rehabilitation accompanied by a physiotherapist
- Infiltration treatment depending on the type of injury
In case of posterior crossroads syndrome, it is necessary to implement certain adaptations and changes of habits. It is particularly advisable not to wear high heels and to limit risky sports practices.
In case of failure of the conservative treatment, the specialist in sports trauma will direct you to an operation of the tail of the astragalus.
The operation of the astragalus tail syndrome usually takes place on an outpatient basis. The patient goes to the clinic in the morning and can go home only a few hours after surgery.
The procedure can also be carried out in hospitalization according to the associated pathologies: diabetes, hypertension…) or various constraints.
Pre-operative consultation with an anesthetist is mandatory. It will show you the different types of anesthesia possible depending on your case and the pathologies you suffer from.
Anesthesia may be:
- Locoregional and concern the limb operated in its entirety from the leg to the toes.
- Spinal like spinal anesthesia
- General anesthesia
The anesthetist may also prescribe specific drug treatments to take before or after the procedure (antibiotics, anticoagulants, anti-inflammatory drugs, etc.).
The procedure usually takes between 30 minutes and an hour. It involves freeing the posterior crossroads and removing anything else that needs to be removed. It can be carried out in the open or under arthroscopy.
In open air, the surgeon makes an incision of a few centimeters vertically at the back of the ankle.
The procedure is mainly arthroscopic: Doctor Julien Lopez makes 2 incisions of about 1 cm at the back of the ankle on both sides of the Achilles tendon. The patient is placed on the stomach. These incisions allow the surgeon to insert optical and surgical instruments. He will then remove the pincer structures in the posterior crossroads (trigon bone, astragalus, synovial capsule, etc.).
Several surgical procedures can be performed during the procedure and will be adapted according to the type of lesion:
- Tendon release
- Regulation of the tail of the astragalus if too long
- Removing a bone fragment
- Removal of a trigon ossicle
- Removal of a proliferation of synovial tissue
- Resection of a low muscular body inserted on the fibular tendons or the long flexor tendon of the hallux
Support is available immediately after the operation. Doctor Julien Lopez can prescribe a walking boot for the first 2-3 weeks after the operation.
The rehabilitation process can begin immediately or during the 3rd post-operative week.
Driving is possible after 2 weeks.
In case of astragalus tail syndrome, sick leave can range from 2 to 4 weeks.
The resumption of sports activities may take place 30 to 45 days after the intervention.
Foot swelling can last up to 6-9 months after surgery.