Hindfoot arthritis affects the joints below the ankle, mainly the subtalar and talonavicular joints, causing deep aching pain and difficulty on uneven ground. It is often the legacy of an old heel or talus fracture. Many are managed with orthotics and injections; when these fail, a hindfoot fusion gives durable relief.
Symptoms
- Deep aching pain below the ankle and around the heel
- Worse on uneven ground and slopes, easier on the flat
- Morning stiffness
- A progressive flatfoot in late disease
Causes & risk factors
- Mostly post-traumatic, especially after a calcaneal fracture from a fall from height
- A fixed adult acquired flatfoot
- Rheumatoid arthritis
- Primary osteoarthritis
Conservative treatment comes first
- Supportive footwear
- A custom AFO for advanced disease
- A rocker sole
- Activity modification
- An image-guided steroid injection into the subtalar joint — also used diagnostically to confirm the pain source
When surgery is considered
An isolated subtalar fusion is used where arthritis is confined, preserving ankle and forefoot movement. A triple fusion (subtalar, talonavicular, calcaneocuboid) is used for more widespread disease. Minimally invasive where suitable — protected for 6–10 weeks, full recovery 6–12 months. Ankle movement is preserved.
Questions & answers
No. A subtalar or triple fusion stiffens the hindfoot but the ankle still moves, so walking on the flat stays comfortable.
If local anaesthetic placed into the joint relieves your pain, it confirms that joint is the source and predicts that fusing it will help.
Often yes for a long time, with orthotics, footwear and injections. Surgery is for when those stop working.
Full specialist guide
Hindfoot arthritis is a degenerative condition affecting the joints at the back of the foot — primarily the subtalar joint beneath the ankle and the talonavicular joint at the midfoot junction. It causes deep, aching pain around the heel and inner ankle, stiffness on uneven ground, and progressive difficulty with walking. It most commonly follows a previous injury such as a calcaneal fracture or talus fracture, or develops secondary to chronic ankle instability and rheumatoid arthritis. Conservative management includes orthotics, injections, and activity modification. When these are no longer sufficient, hindfoot fusion provides reliable, durable pain relief.
Hindfoot Arthritis: Understanding Pain in the Back of the Foot
Hindfoot arthritis refers to degenerative joint disease affecting the complex of joints that make up the back (posterior) part of the foot — below and around the ankle — most importantly the subtalar joint, and frequently the talonavicular and calcaneocuboid joints. Together, these joints constitute the hindfoot complex, which is responsible for the side-to-side tilting and rotational movements of the foot that allow you to walk on uneven ground, navigate slopes, and absorb impact during activity.
At Mercury Foot and Ankle, we provide specialist assessment and treatment of hindfoot arthritis at The Saxon Clinic, Milton Keynes and Three Shires Hospital, Northampton.
The Hindfoot Joints: What They Do
The subtalar joint sits directly beneath the ankle joint, between the talus bone above and the calcaneum (heel bone) below. It allows inversion and eversion of the heel — the side-to-side rocking that is essential for walking on uneven ground. When this joint is arthritic and stiff, walking on anything other than a flat, predictable surface becomes significantly more uncomfortable.
The talonavicular joint and calcaneocuboid joint together form the transverse tarsal joint complex, which works in conjunction with the subtalar joint to allow the midfoot to adapt to ground irregularities and to control the arch mechanism during gait. Arthritis in these joints, alone or in combination with subtalar arthritis, significantly compounds the functional impact of hindfoot degeneration.
Causes of Hindfoot Arthritis
Hindfoot arthritis is most commonly post-traumatic, occurring as a long-term consequence of calcaneal (heel bone) fractures, talus fractures, or previous ankle injuries that disturb the subtalar joint alignment. Calcaneal fractures in particular — typically sustained in fall-from-height accidents — have a high rate of subsequent subtalar arthritis, sometimes presenting many years after the original injury.
Other causes include the progression of posterior tibial tendon dysfunction and adult acquired flatfoot to a fixed deformity with arthritic change in the hindfoot joints; inflammatory arthritis (particularly rheumatoid arthritis); and primary osteoarthritis, which is less common in the hindfoot than in larger weight-bearing joints but does occur.
Symptoms
The characteristic symptom pattern of hindfoot arthritis is deep, aching pain located below the ankle and around the inner and outer aspects of the heel. It is worsened by weight-bearing activity — particularly walking on uneven ground, slopes, or cobbled surfaces — and eases with rest. Morning stiffness that loosens with movement is typical.
Patients frequently report that walking on flat, predictable surfaces is more manageable than uneven terrain, and that they have developed compensatory strategies — avoiding hills, cobbles, grass, and uneven paths — to manage their symptoms. The classic presentation is of a patient who can walk reasonably on a flat shopping precinct but becomes significantly symptomatic on natural terrain.
Swelling may be present around the inner and outer aspects of the heel. In later stages, patients develop a progressive flatfoot deformity as the hindfoot joints collapse and the arch is lost.
Diagnosis
Weight-bearing X-rays of the foot and ankle are the primary imaging modality, showing joint space narrowing, subchondral sclerosis, and osteophyte formation. CT scanning provides more detailed assessment of the subtalar and transverse tarsal joints, including the degree of deformity and bone quality, and is important for surgical planning. MRI is used when inflammatory arthritis or avascular necrosis is suspected.
Diagnostic injection — instilling local anaesthetic into the subtalar joint under image guidance — is a highly useful clinical tool that both confirms the joint as the source of symptoms and predicts the likely benefit of surgical fusion at that joint.
Conservative Treatment
Conservative management is the appropriate starting point for most patients with hindfoot arthritis and can provide satisfactory symptom control for months to years.
Footwear and orthotics: A supportive shoe with good cushioning and a motion-control element reduces hindfoot loading. A custom-moulded ankle-foot orthosis (AFO) immobilises the subtalar joint and significantly reduces arthritic pain for patients with more advanced disease. A rigid rocker sole reduces the arc of motion required during gait.
Activity modification: replacing high-impact and terrain-variable activities with lower-impact alternatives (swimming, cycling, walking on flat paths) reduces symptomatic flares significantly.
Intra-articular injections: subtalar joint steroid injections provide medium-term pain relief and are performed under fluoroscopic or ultrasound guidance at our clinics.
Surgical Treatment: Hindfoot Fusion
When conservative management is no longer providing adequate pain control and quality of life, hindfoot fusion (arthrodesis) offers reliable, durable relief. The specific procedure depends on which joints are arthritic:
Isolated subtalar fusion is performed when arthritis is confined to the subtalar joint, fusing the talus to the calcaneum and eliminating motion — and pain — at that joint while preserving motion at the ankle and transverse tarsal joints.
Triple fusion — simultaneous fusion of the subtalar, talonavicular, and calcaneocuboid joints — is performed when all three hindfoot joints are involved. It provides a stable, plantigrade foot and reliable pain relief, though it significantly reduces hindfoot movement and affects walking on uneven ground.
Modern techniques use percutaneous or minimally invasive approaches where possible, reducing soft tissue disruption and improving recovery. Surgery is followed by a period of non-weight-bearing or protected weight-bearing in a cast or boot, typically 6 to 10 weeks, with gradual return to activity over 6 to 12 months.
Frequently Asked Questions
Can hindfoot arthritis be confused with ankle arthritis?
Yes — symptoms overlap significantly, and many patients are uncertain which joint is causing their pain. Clinical examination, weight-bearing X-rays, CT scanning, and diagnostic injection reliably distinguish the two and guide appropriate treatment.
What happens to ankle movement after hindfoot fusion?
Ankle joint movement is preserved after subtalar fusion or triple fusion. The ankle continues to flex and extend normally. What is lost is the side-to-side rocking of the heel, which makes uneven ground somewhat more challenging than before surgery, though most patients find this a very acceptable trade-off for pain freedom.
Book a Specialist Assessment
If deep heel or hindfoot pain is limiting your walking or lifestyle, our specialist team is ready to provide a thorough assessment and discuss all available options. Call 01908 014 486 or book at /book. We see patients at The Saxon Clinic, Milton Keynes and Three Shires Hospital, Northampton.
This article is for educational purposes only and does not constitute individual medical advice.
Sources & further reading
- OrthoInfo (AAOS) — arthritis of foot and ankle
- BOFAS patient information
