Talotarsal displacement is a pathologic condition that will not "fix" itself. This condition leads to excessive strain on the structures within the foot and ankle as well as to the knees, hips and back while standing, walking, or running. There are clear clinical and radiographic signs that are used to diagnose this disease as well as to show improvement after treatment. Unfortunately, this disease is usually ignored or over-looked while the focus of attention is aimed at the secondary symptoms rather than to the realignment of what lead to the development of those secondary symptoms. Learn more at www.GraMedica.com.

1. Primer on
Talotarsal Joint Dislocation

2. Introduction
When it comes to the meaning of a word, there
can be many opinions and assumptions.
At the end of the day, however, it’s about what
can be proven.
Assumptions are not always based on fact but a
on a perceived belief.

3. What is a Word?
A “word”
is the unit of language
that functions as
a principal carrier of meaning.

4. Dislocation
“the displacement of any part, more especially
of a bone”
Dorlands Medical Dictionary

5. Dislocation
Types of dislocation:
closed, open, complete, incomplete,
traumatic, congenital, compound, simple,
complicated, fracture, habitual/recurrent,
partial, pathologic, subluxation, luxation.

6. Dislocation
“A dislocation is a separation of two bones
where they meet at a joint. A dislocated bone is
no longer in its normal position, which may
result in damage to ligaments, nerves, and blood
vessels.” Medline Plus
Note: there is no modifier on “separation,” i.e. it does not
state incomplete/partial or complete/total separation.

7. Historical Use of Dislocation

8. A Practical Treatise on Fractures &
Dislocations – Frank Hasting Hamilton, 1863
“ A dislocation is the displacement of one bone from
another at its placed of natural articulation.”
“Dislocations may be divided into accidental or
traumatic, spontaneous or pathologic, and
congenital.”
“A complete dislocation is one in which no portions
of the articular surfaces remain in contact. A partial
dislocation is one in which the articular surfaces are
not completely removed from each other.”
Page 30

9. Fractures and Dislocation –
Thomas Pickering Pick, 1885
“The word “dislocation” etymologically means
‘displacement’ (Lat. dis, a preposition, denoting
separation, and locus, a place), but in surgery it
is for the most part applied to that condition of a
joint in which the two articular surfaces are
either partially or completely displaced from one
another, and no longer occupy their normal
position.”
page 308

10. Fractures and Dislocation –
Thomas Pickering Pick, 1885
“Dislocations, or displacements of the articular surfaces
of a joint, are divided into three classes as regards their
cause. (1) Traumatic, where the displacement has been
produced by violence. (2) Spontaneous or
pathological, resulting from gradual destructive changes
in the joint and surrounding tissues, so that the bones no
longer remain in apposition, but are displaced by
muscular contraction or the weight of the limb or trunk.
(3) Congenital, arising from some congenital defect in the
joint.”
page 308

11. Fractures and Dislocation –
Thomas Pickering Pick, 1885
“Dislocations may be complete or partial: complete
when the two articular surfaces which enter into the
formation of a joint are completely separated from
each other, so as to be no longer in contact; and
partial when the two articular surfaces are
displaced as regards their normal relation to each
other, but are not completely separated, so that
some portion of the one articular surface still
remains in contact with some part of the other.”
page 309

12. Fractures and Dislocation –
Thomas Pickering Pick, 1885
“The effects of a dislocation upon the structures
entering into the formation of a joint, or in its
immediate neighborhood, are always of
importance and frequently serious. The
bones, ligaments, muscles, vessels, and
nerves, may all suffer.”
Page 313

13. Fractures and Dislocation –
Thomas Pickering Pick, 1885
“When the diagnosis of dislocation has been
established, the first indication is to effect
reduction as speedily as possible.”
Page 322

14. A Practical Treaties on Fractures and
Dislocations – Lewis Atterbury Stimson, 1899
“A Dislocation is a permanent, abnormal, total
or partial displacement from each other of the
articular portions of the bones entering into the
formation of a joint.”
Page 393

15. A Practical Treaties on Fractures and
Dislocations – Lewis Atterbury Stimson, 1899
“When the articular surfaces are so far displaced
that they no longer touch each other, or that
they touch only by their edges, the dislocation is
said to be complete; if the displacement is less, it
is called incomplete dislocation or subluxation.”
Page 393

16. Surgery: Bones; Joints; Fractures;
Dislocations, Orthopedics;… Keen & Costa, 1907
“A dislocation is a displacement from each other
of the articular ends of the bones which enter
into the formation of a joint.”
“Dislocations may be divided into complete and
incomplete, according to the degree of
displacement.”
page 377

17. Textbook of Disorders and Injuries of the
Musculoskeletal System – Robert B. Salter, 1970
“Displacement of a joint. When the normal
reciprocal relationship between the two joint
surfaces is lost, the joint is said to be displaced.
The joint may be completely displaced or it may
be partially displaced. In either case the joint is
unstable and is associated with deformity.”
Page 27

18. Foot and Ankle Trauma – Barry Scurran, 1989
“Dislocation represents (disease) not to osseous
joint structures or to the tendons that move
them but to the soft tissues that bind them.”
Page 271

19. Foot and Ankle Trauma – Barry Scurran, 1989
“The capsular and ligamentous soft tissues
paradoxically provide the strength for joint
stability and yet permit the freedom for joint
motion. When the end range of motion for a
joint is reached, the joint soft tissues limit
further excursion.”
Page 271

20. Foot and Ankle Trauma – Barry Scurran, 1989
“Limitation of joint motion is further aided by
joint biomechanics, osseous contours, and active
muscular agonist and antagonist function.”
Page 271

21. Foot and Ankle Trauma – Barry Scurran, 1989
“…dislocations are radiographically evident by
the incongruity of the osseous components.
Postreduction radiographs or spontaneously
reduce dislocation may appear “normal”
because no osseous compromise or fracture has
occurred.”
Page 271

22. Dislocation
• is a disease process
• is not normal
• needs to be treated/fixed
• failure to fix leads to other pathologic
conditions
• Doesn’t matter if it’s a partial or full

23. Clinical Signs of
Talotarsal Joint Dislocation
Aligned TTJ Dislocated TTJ
Balanced/aligned hindfoot. Imbalanced/malaligned hindfoot.
Articular facets are Articular facets are NOT
in constant congruent contact. in constant congruent contact.
Minimal strain on the supporting Excessive strain on the supporting
soft tissues- ligaments/tendons. soft tissues- ligaments/tendons.
Hindfoot is in neutral/slightly Hindfoot is in a hyperpronated
pronated position. position.

24. Radiographic Evidence of
Talotarsal Joint Dislocation

25. Radiographic Evidence of
Talotarsal Joint Dislocation
Normal TaloTarsal Joint TaloTarsal Joint Dislocation/Displacement
“Open” sinus tarsi Partial to full obliteration
of the sinus tarsi
Clinical significance: this is the easiest sign to show displacement. This immediately
indicates that the talus is, at minimum, partially dislocated on the tarsal mechanism. The
joints/articular facets are no longer in constant congruent contact.

26. Radiographic Evidence of
Talotarsal Joint Dislocation
Normal TaloTarsal Joint TaloTarsal Joint Dislocation/Displacement
Normal Talar Declination Angle Abnormal Talar Declination Angle
Normal = < 21 degrees Abnormal = > 21 degrees
Clinical significance: an increased talar declination angle indicates a sagittal plane
deformity. This creates an imbalance to the leg, pelvis and back. Also, it is directly
responsible for increased strain on the medial column of the foot. This deformity occurs
above the bottom of the foot.

27. Radiographic Evidence of
Talotarsal Joint Dislocation
Normal TaloTarsal Joint TaloTarsal Joint Dislocation/Displacement
Normal navicular height Navicular drop due to the dislocation
Clinical significance: navicular drop directly leads to excessive strain to the supporting
structures of the medial column of the foot such as the spring ligament, medial band of the
plantar fascia and especially the posterior tibial tendon. It can also lead to disorders of the
first ray/hallux.

28. Radiographic Evidence of
Talotarsal Joint Dislocation
Normal TaloTarsal Joint TaloTarsal Joint Dislocation/Displacement
Normal cyma line Anterior plantar angulated cyma
Clinical significance: the anterior displacement of the talus forces the navicular forward.
This pushes the medial cuneiform forward, which in turn pushes the first metatarsal head
into the base of the proximal phalanx (hallux), leading to limited joint motion. This also
unlocks the midtarsal joint leading to an excessively long period of pronation.

29. Radiographic Evidence of
Talotarsal Joint Dislocation
Normal TaloTarsal Joint TaloTarsal Joint Dislocation/Displacement
Notice that the calcaneal inclination angle (CIA) is the same.
Clinical significance: a lower than normal CIA indicates a “flat foot” (pes planovalgus). It is
possible to have a talotarsal dislocation without a “flat foot”.

30. Several Examples of Radiographic
Evidence of Talotarsal Joint Dislocation
Normal Talotarsal Joint
Abnormal Talotarsal Joints

31. Normal Talar Second Metatarsal Angle
Indicator of transverse
plane talotarsal alignment.

32. Talar Second Metatarsal Angle
• The bisection of the talus
compared to the forefoot
or the bisection of the 2nd
metatarsal.
• The outer/upper angular
range of normal is < 16
degrees.
• > 16 degrees is
considered pathologic
indicating a medially
displaced talus on the
tarsal mechanism.

33. Radiographic Evidence of
Normal Talotarsal Joint Alignment
• Aligned talotarsal joint.
• Talar second metatarsal
angle in the perfectly
aligned talotarsal joint
is 3-5 degrees. Anything
lower than 16 degrees
is considered to be
normal.

34. Pathologic Talar Second
Metatarsal Angle
Normal Abnormal

35. Partially Dislocated Talotarsal Joint
Anterior/Middle
Facets.
Posterior
Facets

36. Radiographic Evidence of
Talotarsal Joint Dislocation
• Talar Second Metatarsal
Angle (T2MA) > 16.
• Significant transverse
plane deformity.
• This shows an
anteriomedial talotarsal
joint displacement.

37. Radiographic Evidence of
Talotarsal Joint Dislocation
Weightbearing image Weightbearing image
with talotarsal joint in alignment/ exhibiting talotarsal joint displacement/
neutral stance position relaxed stance position.
Clinical significance: This comparison of normal to abnormal shows a flexible dislocation of
the talus on the tarsal mechanism. This is a recurrent dislocation. Excessive abnormal stain
is placed on the medial column of the foot when weightbearing. Also, there are excessive
forces acting on the knee and possibly the hip.

38. Radiographic Evidence of
Talotarsal Joint Dislocation
• Relaxed stance
weightbearing
radiograph.
• T2MA > 16.
• Talotarsal joint
displacement.

39. Radiographic Evidence of
Talotarsal Joint Dislocation
• Relaxed stance
weightbearing
radiograph.
• T2MA > 16.
• Talotarsal joint
displacement.

40. Radiographic Evidence of
Talotarsal Joint Dislocation
• Relaxed stance
weightbearing
radiograph.
• T2MA > 16.
• Talotarsal joint
displacement.

41. Extra-osseous Talotarsal Stabilization
with internal fixation
Clinical significance: Talotarsal joint is realigned, articular facets remain in constant
congruent contact. Internal fixation device allows normal/natural talotarsal motion without
blocking/limiting motion. Restoration of the pathologic pre-existing deformities. Both
sagittal and frontal plane correction exhibited.

42. Extra-osseous Talotarsal Stabilization
with internal fixation.
Clinical significance: Talotarsal joint is realigned, articular facets remain in constant
congruent contact. Internal fixation device allows normal/natural talotarsal motion without
blocking/limiting motion. Restoration of the pathologic pre-existing deformity showing
transverse plane correction with normalization of the talar second metatarsal angle.

43. Extra-osseous Talotarsal Stabilization
with internal fixation
does not fix pes planovalgus/flatfeet.
Clinical significance: The calcaneal inclination angle is still pathologic while the talotarsal
joint has been restored.

44. Extra-osseous Talotarsal Stabilization
Type I Arthroereisis and Type II Non-Arthroereisis.
Type I Arthroereisis Type II Non-Arthroereisis
Clinical significance: Type I device is placed into the sinus tarsi so that the tip touches the bisection of the talus/lateral ½ of
the sinus tarsi and functions to block or limit motion of the lateral process of the talus. Type II device is placed much deeper
along with the natural oblique orientation of the sinus tarsi and functions with the natural motion of the talotarsal joint as
opposed to the natural motion.
Journal of Foot and Ankle Surgery
Volume 51, Issue 5 , Pages 613-619, September
2012

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