Talonavicular Arthritis

Talonavicular arthritis is degeneration of the articulation between the talar head and the navicular. The joint is the apex of the medial longitudinal arch, so its failure profoundly affects foot biomechanics: the arch collapses, the forefoot abducts and the gait pattern changes.

It rarely exists in isolation. Isolated talonavicular arthritis is uncommon, 10-15% of cases. The joint usually fails as part of triple-complex pathology, often alongside posterior tibial tendon dysfunction (PTTD), so the subtalar and calcaneocuboid joints are assessed in every patient.

• PTTD stage 3 - the most common association
• Subtalar arthritis - coexists in 60-70%
• Calcaneocuboid arthritis - involved in 30-40%
• Ankle valgus - a secondary deformity
• Hallux valgus - forefoot compensation

Causes. Post-traumatic arthritis is the most common.

• Trauma - midfoot fracture or dislocation
• Rheumatoid and inflammatory arthropathy - erosive changes are common
• Adult-acquired flatfoot (PTTD) - stage 3 disease causes talonavicular degeneration
• Undercorrected clubfoot - the residual deformity leads to arthritis
• Hindfoot malalignment, varus or valgus - abnormal loading patterns
• Avascular necrosis of the navicular - Müller-Weiss disease in adults
• Systemic causes - gout, septic and neuropathic arthritis, all less common

Where it comes from. The ball-and-socket ankle is most classically associated with tarsal coalition, especially talocalcaneal, with congenital longitudinal limb deficiencies such as fibular hemimelia, and with previously operated or fused hindfeet.

Never fuse the talonavicular joint alone in its presence. The reasons:

• The hindfoot already offloads onto the ankle for inversion and eversion; a stiffening TN fusion pushes even more demand onto that single joint, accelerating ankle degeneration
• The "spared" subtalar joint is not truly mobile when a coalition underlies the adaptation, so the motion-sparing rationale for isolated fusion collapses
• The primary pathology is unaddressed, whether coalition or deficiency, so deformity and symptoms recur

What to do instead. Treat a ball-and-socket ankle as a red flag for an underlying coalition and investigate accordingly (see the dedicated tarsal coalition topic). Plan around the whole abnormal hindfoot, not the talonavicular joint in isolation, and counsel that the ankle is the motion reserve, to be protected rather than further loaded.

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The joint. A ball and socket: the talar head is the ball and the concavity of the navicular the socket. It is the keystone at the apex of the medial longitudinal arch, and with the subtalar and calcaneocuboid joints it forms the triple joint complex, which functions as an integrated unit. That is why isolated pathology is rare.

What it does. The talonavicular joint lies on the oblique axis of the hindfoot and is the primary site of midfoot motion, contributing 50% of total hindfoot inversion and eversion. It also carries the jobs that make the foot both adaptable and rigid:

• Inversion - 50% of total hindfoot inversion (20-30 degrees)
• Eversion - 50% of total hindfoot eversion (10-15 degrees)
• Forefoot locking - critical for a rigid lever during push-off, giving stability at toe-off
• Shock absorption - hindfoot adaptability on uneven ground
• Hindfoot-forefoot coupling - transmits forces between the segments

The medial restraints. The spring ligament complex gives plantar support from the calcaneus to the navicular; when it fails, the talar head subluxes plantarwards. The posterior tibial tendon inserts on the navicular tuberosity and is intimately related to talonavicular stability, and its dysfunction causes medial column collapse and stresses the joint.

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When the joint fails. Loss of talonavicular function shifts motion demands onto the adjacent subtalar, ankle and calcaneocuboid joints, potentially accelerating their degeneration. Within the joint, cartilage loss is progressive, abnormal loading produces subchondral sclerosis, and osteophytes form, with dorsal beaking the characteristic one. As the keystone support goes the arch collapses and the forefoot abducts, a compensatory malalignment.

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Two things are graded: how severe the arthritis is on radiographs, and how far it has spread across the hindfoot and midfoot. The severity grade guides the choice between conservative and operative care; understanding the distribution pattern helps determine the surgical strategy and predict outcome.

Müller-Weiss disease has its own staging, Maceira's, shown in the two figures below.

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History. The pain is dorsomedial, over the navicular: an ache at rest and sharp with activity, made worse by walking, stairs and uneven ground. Patients notice the arch collapsing and the forefoot drifting into abduction, and the functional cost is walking distance and an altered gait. Ask about previous midfoot trauma and ankle sprains.

Examination. Work through the foot in a fixed order:

1. Standing - medial arch height, collapsed or normal; forefoot abduction; hindfoot alignment, where valgus suggests PTTD and varus suggests other pathology; the too-many-toes sign, lateral toes visible from behind, indicating flatfoot
2. Single heel rise - the patient stands on the affected leg and rises onto the toes. Inability to rise or hold the position means PTT dysfunction, and the heel, which normally inverts during the rise, does not invert in PTTD
3. Palpation - talonavicular joint tenderness and dorsal osteophytes
4. Hindfoot motion - stabilise the talus and move the navicular, looking for crepitus and pain; hindfoot inversion and eversion are reduced. Compare subtalar motion with the contralateral side, judge whether the deformity is rigid or flexible, which affects the surgical options, and check the ankle and first-ray mobility
5. Provocative tests - direct pressure over the joint (TN stress test) reproduces the pain; forefoot abduction stress worsens it if the joint is unstable; in the tiptoe test, pain stops the patient reaching or holding tiptoe
6. Gait - antalgic, with loss of push-off power

Weight-bearing radiographs come first. Standing AP, lateral and oblique views of the foot show the joint space, osteophytes and dorsal beaking, the alignment (how much of the talar head the navicular covers, and forefoot abduction), and the state of the subtalar and calcaneocuboid joints.

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CT is for surgical planning and for judging how severe the deformity is. It shows bone stock quality and the size of subchondral cysts, informs preparation for fusion, and its 3D reconstructions help in understanding complex deformity.

MRI is selective, used before surgery when soft-tissue pathology is suspected. It assesses the integrity of the posterior tibial tendon and spring ligament and the articular cartilage, showing cartilage loss, bone marrow oedema and tendon pathology.

The decision rests on the distribution of the arthritis, the severity of the deformity, the patient's age and activity level, and the state of the adjacent joints. Conservative measures come first; arthrodesis, isolated or extended according to the adjacent joints, follows when they fail.

Conservative ManagementSurgical Management

Who. Mild to moderate symptoms, early arthritis (Grade 1-2), and the patient who prefers it or whose medical comorbidities weigh against surgery. The trial lasts a minimum of 6 months before surgery is considered.

The programme.

• Activity modification (initial) - reduce high-impact activities such as running, jumping and prolonged standing, and lose weight if applicable, to decrease stress on the joint in daily life
• Footwear - supportive shoes with a rigid rocker-bottom sole and stiff midsole
• Orthoses (weeks 0-6) - custom orthoses with medial arch support and forefoot posting, or off-the-shelf rigid support with an Arizona brace or UCBL orthosis, to support the arch, reduce talonavicular motion and offload the joint
• Pharmacological (ongoing) - NSAIDs first-line for pain and inflammation; image-guided corticosteroid injection into the joint, which is both diagnostic and therapeutic, to a maximum of 2-3 injections a year
• Physiotherapy (weeks 6-12) - strengthen the posterior tibial tendon and intrinsic foot muscles, stretch the gastrocnemius-soleus complex to reduce forefoot load, and retrain gait to reduce talonavicular stress

Success Rate of Conservative Management

Approximately 40-50% of patients with mild to moderate TN arthritis achieve satisfactory symptom control with comprehensive conservative management. Predictors of success include flexible deformity, mild radiographic changes, and absence of significant PTTD.

Indications.

• Failed conservative management (minimum 6 months)
• Moderate to severe arthritis (Grade 2-3)
• Functional limitation affecting quality of life
• Progressive deformity despite bracing

Choosing the operation. The procedure follows the distribution of disease (see Pattern Recognition under Classification). Isolated arthrodesis spares the cartilage of the subtalar and calcaneocuboid joints but not their motion (see Biomechanical Coupling below). Arthroplasty remains emerging, for the young, high-demand patient with isolated disease, moderate arthritis and preserved bone stock.

Isolated TN arthrodesis

Indications

Isolated TN arthritis, subtalar preserved

Advantages

Spares adjacent-joint cartilage, high fusion rate; residual hindfoot motion minimal (about 2 degrees, Astion)

Disadvantages

Adjacent joint stress, 10-15% nonunion risk

Double arthrodesis (TN + STJ)

Indications

TN and subtalar arthritis both involved

Advantages

Addresses both pathologies, corrects deformity

Disadvantages

Further motion loss, 15-20% nonunion rate

Triple arthrodesis

Indications

Pan-hindfoot arthritis, severe flatfoot, PTTD stage 3

Advantages

Complete deformity correction, predictable pain relief

Disadvantages

Loss of all hindfoot motion, adjacent joint degeneration

TN arthroplasty (emerging)

Indications

Young, high-demand, isolated arthritis

Advantages

Motion preservation, shorter recovery

Disadvantages

Limited long-term data, implant longevity unknown, technical challenge

Procedure	Indications	Advantages	Disadvantages
Isolated TN arthrodesis	Isolated TN arthritis, subtalar preserved	Spares adjacent-joint cartilage, high fusion rate; residual hindfoot motion minimal (about 2 degrees, Astion)	Adjacent joint stress, 10-15% nonunion risk
Double arthrodesis (TN + STJ)	TN and subtalar arthritis both involved	Addresses both pathologies, corrects deformity	Further motion loss, 15-20% nonunion rate
Triple arthrodesis	Pan-hindfoot arthritis, severe flatfoot, PTTD stage 3	Complete deformity correction, predictable pain relief	Loss of all hindfoot motion, adjacent joint degeneration
TN arthroplasty (emerging)	Young, high-demand, isolated arthritis	Motion preservation, shorter recovery	Limited long-term data, implant longevity unknown, technical challenge

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Malalignment reaches the ankle. Residual hindfoot malalignment after a talonavicular-subtalar fusion can show up as ankle valgus, which is why the ankle and the axis of correction are assessed before fixation.

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After isolated fusion the foot is protected and kept off the ground until the radiographs show bridging, then loaded progressively.

Who does well. The patient with a successful fusion free of complications, restored alignment and isolated talonavicular disease, who does not smoke, has well-controlled diabetes and holds moderate activity expectations. The outcome is worse with a nonunion that needs revision, malalignment or malunion, pre-existing adjacent-joint arthritis, smoking or uncontrolled diabetes, and high-impact demands.

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The hindfoot behaves as a coupled linkage: the talonavicular, subtalar, and calcaneocuboid joints move together about a shared oblique axis, so stiffening any one of them constrains the others. The classic cadaveric evidence quantifies exactly how dominant the TN joint is within that linkage.

Reconciling the two figures. The joint contributes 50% of hindfoot inversion and eversion, yet fusing it leaves only about 2 degrees at the joints that remain, because they are coupled to it. Isolated TN arthrodesis is therefore preferred over a triple fusion when the subtalar and calcaneocuboid joints are healthy because it keeps those articular surfaces and their ligamentous support intact and shortens rehabilitation, and series such as Popelka et al and Chiodo et al confirm good function despite the coupled loss of motion.

What to tell the patient. The hindfoot is not left substantially mobile. What compensation develops comes chiefly at the ankle and the naviculocuneiform joint, gait mechanics change, and push-off and adaptation on uneven ground will feel stiffer than the "motion-sparing" label implies.

Related pages: Adult Flatfoot Deformity and Rigid Flatfoot are the deformity context for most of the operations on this page, and the reason a talonavicular fusion is so often part of a larger correction rather than an isolated procedure; Posterior Tibial Tendon Dysfunction is the commonest route into this joint's failure - and note the Astion finding carded above, that talonavicular fusion cuts posterior tibial excursion to 25 percent, which is why a tendon reconstruction adds nothing once the joint is fused; Subtalar Arthritis for the neighbouring joint whose involvement converts an isolated fusion into a double, and for the diagnostic block that separates the two; Midfoot Arthritis for the naviculocuneiform and tarsometatarsal joints that inherit load and degenerate afterwards, as Saltzman documented at 44 years; Muller-Weiss Disease for the avascular navicular pattern the Fornaciari tension-band card addresses, which is a varus rather than valgus hindfoot and follows different rules; Tarsal Coalition for the ball-and-socket ankle this page names as a contraindication, and for why the 'spared' subtalar joint may not be mobile at all; Rheumatoid Foot and Ankle for the inflammatory population that supplies both the Popelka and Chiodo series and in which early fusion is preventive rather than salvage; Spring Ligament Insufficiency for the static restraint whose failure accompanies talonavicular subluxation; Navicular Fractures for the post-traumatic route to the same endpoint; and Ankle Arthritis for the joint that absorbs the motion this operation removes, and which every ankle in the Saltzman series had degenerated by the second review.