Hindfoot Conditions - When is Surgery Needed? 

As a foot and ankle surgeon, I often meet patients who’ve been struggling with persistent pain around the back of the foot; sometimes for months, often for years.

The hindfoot (the area including the heel bone and joints just in front of it) plays an important role in walking, running and standing. When something’s not quite right here, it can really affect your mobility, comfort, and activity levels.

So what kind of problems affect the hindfoot, and when might surgery be the right option?

Ankle Joint Anatomy

The ankle joint, also known as the talocrural joint, is a hinge joint formed where the tibia and fibula (the two bones of the lower leg) meet the talus bone of the foot. This joint allows the up-and-down movement of the foot (dorsiflexion and plantarflexion), which is essential for walking and running.

Just beneath the ankle lies the hindfoot, made up of the talus and the calcaneus (heel bone). These two bones form the subtalar joint, which enables side-to-side motion (inversion and eversion) and plays a critical role in adapting to uneven surfaces and maintaining balance.

Together, the ankle and hindfoot act as a dynamic unit that absorbs shock, facilitates propulsion, and stabilises the leg during movement. When any part of this complex structure is damaged, be it bone, joint, or surrounding soft tissue, it can have a significant impact on overall mobility and function.

A Closer Look at the Hindfoot

The foot is divided into three sections: the forefoot - toes and metatarsals, midfoot – the arch and its supporting bones, and the hindfoot.

The hindfoot consists primarily of two bones:

• The talus, which sits at the top of the foot and forms part of the ankle joint
• The calcaneus, or heel bone, which lies beneath the talus

These bones form important joints:

• The subtalar joint, between the talus and calcaneus, which allows the foot to move side to side (inversion and eversion), helping you adapt to uneven ground
• The talonavicular and calcaneocuboid joints, which help with shock absorption and propulsion when walking

This part of the foot is responsible for translating the rotational movement of the leg into foot motion.

It also absorbs ground reaction forces and helps stabilise the body during standing and dynamic movements.

When the hindfoot isn't functioning properly, due to injury, arthritis, or deformity - it often leads to compensatory issues higher up the chain, including knee, hip, or back pain.

Symptoms People Commonly Report

Patients with hindfoot pathology tend to describe a fairly typical set of symptoms, although the exact pattern can vary depending on the underlying condition.

Some of the things I frequently hear in clinic include:

• A dull, aching or sharp pain at the back or inner side of the foot, especially when walking on uneven ground
• A feeling of instability or weakness, especially when changing direction or walking downhill
• Swelling and stiffness around the ankle or heel that worsens with activity
• Difficulty standing or walking for prolonged periods
• Flattening of the arch or a visible change in the shape of the foot
• Trouble wearing certain shoes, particularly if the foot becomes misaligned or painful under pressure

One gentleman I saw recently described a ‘persistent pain on the inside of the ankle and foot’ and a ‘rolling-in’ sensation whenever he walked, and he had also started to notice his trainers wearing unevenly. This ultimately turned out to be early-stage posterior tibial tendon dysfunction.

How is the Hindfoot Assessed?

A big part of my job as a foot and ankle specialist, is being able to make an accurate diagnosis, in order to determine the best cause of action; whether surgery is appropriate, or whether the problem can be managed conservatively.

All my assessments starts with a thorough history and physical examination.

In clinic, I will typically:

• Ask about the onset and nature of the symptoms - was there a triggering injury, or did the problem come on gradually?
• Observe alignment, swelling, and any signs of deformity when the patient is standing and walking
• Test for joint mobility, tendon strength, and foot flexibility
• Perform specific functional tests, such as heel raises or balance assessments

Within the facilities that I work, I have excellent access to imaging test, which can help to confirm the diagnosis:

• X-rays help to identify arthritis, bone alignment, and any structural abnormalities
• MRI scans give detailed information about soft tissues. This is particularly helpful in tendon injuries or subtle coalitions.
• CT scans may be used to assess more complex deformities or injuries that might be affecting both bone and softy tissue.
• Weightbearing or standing CT scans can provide highly detailed, 3D imaging of the bones in their natural loaded position, which is particularly helpful for surgical planning.
• Ultrasound, on the other hand, is an excellent tool for assessing soft tissue injuries around the hindfoot and ankle, such as tendon tears or inflammation, and can be performed dynamically in clinic to see how tissues behave during movement.

Only after a full clinical picture is built can we confidently determine what the diagnosis and prognosis is, and whether surgery is likely to be needed.

This decision process is always patient led, and discussed in full. Every patient and case is different; I help to facilitate that informed, decision making process.

Common Conditions That May Require Hindfoot Surgery

While many hindfoot issues can be managed without surgery, especially if caught early, however some conditions progress to the point where an operation becomes the most effective option.

Here are some of the most frequent causes of hindfoot pain that I see in clinic, and how we approach treatment:

Posterior Tibial Tendon Dysfunction (PTTD)

PTTD is one of the most common causes of adult-acquired flatfoot. It occurs when the posterior tibial tendon - which runs along the inside of the ankle and supports the arch - becomes inflamed, overstretched or torn.

This can result from overuse, trauma, or age-related degeneration. Left untreated, the arch collapses, the heel begins to drift outward, and the foot becomes increasingly rigid and painful.

In the early stages (known as Stage I), non-surgical treatments can be very effective:

• Custom orthotics to support the arch and reduce strain on the tendon
• Physiotherapy to strengthen supporting muscles
• Ankle bracing to stabilise the foot
• Anti-inflammatory medications and activity modification

However, once the injury develops and the foot becomes fixed in a deformed position (Stage II, III or IV), surgery is usually required.

Procedures may include:

• Tendon reconstruction or transfer, often using another tendon such as the flexor digitorum longus (FDL)
• Calcaneal osteotomy, to reposition the heel bone and restore alignment
• Fusion of joints in more advanced cases, to eliminate pain and improve function

Hindfoot Arthritis

Arthritis may involve one or more joints, most commonly the subtalar joint (between the talus and heel bone), the talonavicular joint, the calcaneocuboid joint, or the ankle joint itself (talocrural joint).

Arthritis can result from osteoarthritis (wear and tear), rheumatoid arthritis (inflammatory), or post-traumatic arthritis following previous injuries such as fractures or ligament damage.

Symptoms typically include:

• Deep, aching pain in the ankle or hindfoot, often worse with activity
• Stiffness and reduced range of motion, especially first thing in the morning
• Swelling and tenderness around the ankle or hindfoot joints
• Difficulty walking on uneven ground or slopes
• Pain with weightbearing, sometimes causing a limp

Early treatment focuses on:

• Activity modification to avoid aggravating movements
• Supportive footwear, often with stiff soles or rocker-bottom shoes
• Orthotics or ankle-foot orthoses (AFOs) to offload the affected joints
• Physiotherapy to maintain strength, flexibility, mobility and balance
• Corticosteroid injections to reduce inflammation and pain

If symptoms persist despite these measures, surgical options include:

• Subtalar fusion – This is the most common procedure for isolated subtalar arthritis
• Triple fusion - Where the subtalar, talonavicular, and calcaneocuboid joints are fused in cases of widespread disease
• Joint-sparing osteotomies – This surgery is more common in younger patients or those with milder deformity

If conservative treatment fails and quality of life is significantly affected, surgery may be considered. The choice of surgery depends on which joints are involved, the extent of damage, and the patient’s activity level.

Surgical options include:

• Subtalar fusion: for isolated subtalar arthritis, stabilising the joint by fusing it into one solid bone to eliminate painful movement
• Triple fusion: when arthritis affects the subtalar, talonavicular, and calcaneocuboid joints, all three are fused to restore stability and relieve pain
• Joint-sparing osteotomies – This surgery is more common in younger patients or those with milder deformity
• Ankle fusion (arthrodesis): a highly effective option for severe ankle arthritis, particularly in younger, high-demand patients, where the joint is fixed in a functional position
• Total ankle replacement: an increasingly popular option for suitable patients with isolated ankle arthritis who wish to preserve more natural movement. It involves replacing the damaged joint surfaces with a metal and plastic implant, similar to a knee or hip replacement. It can offer excellent pain relief and maintain ankle motion, though it may not be suitable for everyone, especially those with poor bone quality or deformity

Tarsal Coalition

Tarsal coalition is a congenital condition in which two or more bones in the hindfoot are abnormally connected, usually by fibrous, cartilaginous or bony tissue. It’s often diagnosed in adolescence, when the previously flexible foot starts to stiffen, causing pain and recurrent ankle sprains.

Symptoms may include:

• Aching or fatigue in the foot, especially after activity
• Reduced motion, particularly in side-to-side foot movements
• Frequent ankle injuries or a tendency to trip or fall
• A rigid flatfoot that doesn't improve when standing on tiptoe

Initial management includes:

• Rest and temporary immobilisation
• Custom insoles or orthotics
• Physiotherapy and anti-inflammatories

Unfortunately, not everyone responds to conservative treatment, so when symptoms persist or the coalition significantly restricts movement and quality of life, surgery may be recommended.

Tarsal Coalition Surgery 

Depending on the type and location of the coalition, options include:

• Excision (removal) of the coalition – This is often replaced with fat or muscle to prevent regrowth – it is more commonly used in young patients.
• Subtalar fusion - if the joint is already arthritic or the coalition is too extensive to remove, then a joint fusion is performed.

With the right procedure and rehab, many patients regain good mobility and return to sports or daily activity without pain.

Severe Flatfoot Deformity or Cavus Foot (High Arches)

Structural deformities such as flatfoot (pes planus) or high arch foot (pes cavus) can cause abnormal loading through the hindfoot, leading to pain, imbalance, and degeneration of joints over time.

Flatfoot deformity is often progressive and may be caused by PTTD, arthritis, or congenital issues. If left unaddressed, it can lead to hindfoot valgus (outward heel tilt), midfoot collapse, and forefoot abduction.

Conversely, cavus foot causes the heel to tilt inward (hindfoot varus), leading to pressure on the outer foot and frequent ankle sprains.

Symptoms include:

• Pain and fatigue in the foot and ankle
• Calluses or ulcers from abnormal pressure
• Instability and difficulty with balance
• Trouble finding comfortable footwear

Conservative treatments may include:

• Custom orthotics
• Supportive footwear
• Bracing or ankle supports
• Physiotherapy focused on lower leg alignment and strengthening

When non-surgical measures are no longer effective, surgery aims to realign the hindfoot, correct soft tissue imbalance, and offload painful joints.

Surgical options include:

• Osteotomies, to shift the heel bone or correct arch alignment
• Tendon transfers, to restore dynamic support
• Joint fusion, when arthritis is present or deformity is severe

Each surgical plan is tailored to the individual – there is no one size fits all, and I make sure that surgery is only used as a last resort and when it is in the best interest of my patients.

What’s Recovery Like?

Hindfoot surgery is not a quick fix. Most procedures require a period of non-weightbearing, followed by gradual rehabilitation. I always make this very clear to patients. But if you’re prepared for the recovery journey, the improvement in pain and function can be transformative and life-changing.

Final Thoughts

Every foot is different. And every patient has different goals; whether it’s walking the dog again without limping, chasing after grandchildren, getting back to five-a-side football, or back to elite level sport.

If you’ve been living with ongoing hindfoot pain or deformity, it’s worth having a proper assessment. Often, the right diagnosis and early intervention - whether surgical or not - can spare you months or years of discomfort.

If you have any concerns or questions, I’d be happy to see you in clinic.