- 1 Other Names
- 2 Background
- 3 Pathophysiology
- 4 Risk Factors
- 5 Differential Diagnosis
- 6 Clinical Features
- 7 Evaluation
- 8 Classification
- 9 Management
- 10 Rehab and Return to Play
- 11 Complications and Prognosis
- 12 See Also
- 13 References
- Talocalcaneal coalition
- Calcaneonavicular coalition
- Peroneal spastic flatfoot
- This page refers to abnormal connections of the tarsal bones, commonly referred to as 'tarsal coalition'
- First described by Buffon in 1750 or 1769 (need citation)
- In 1948, Harris and Beath were the first to identify tarsal coalition as a cause of painful and rigid pes planovalgus
- Definition: abnormal osseous, cartilaginous or fibrous connection between two or more tarsal bones
- Due to a failure of differentiation and segmentation of primitive mesenchyme into the distinct tarsal bones
- The coalition can be bony (synostosis), cartilaginous (synchondrosis), or fibrous (syndesmosis)
- May involve fusion of the accessory ossicles
- It is an often unrecognised cause of foot and ankle pain
- Natural history
- Majority are cartilaginous at birth and are therefore asymptomatic
- Evidence suggests coalitions remain asymptomatic into adulthood
- When symptoms arise, thought to be a result of microfractures of the coalition and inflammation of the surrounding soft tissue from repetitive overload
- Age of presentation varies, depending on which bones are involved
- Appears to be approximately 3--4 years after ossification of the coalition
- Talocalcaneal and calcaneonavicular coalitions are its most common subtypes, represent about 90% of junctions
- Other investigators have reported a nearly equal prevalence of talocalcaneal and calcaneonavicular coalitions
- More readily diagnosed with conventional radiography, which may contribute to their reported higher prevalence
- Thought to be due to a failure of segmentation of primitive mesenchyme during development
- May occur due to may occur because of degenerative joint diseases
- Examples: inflammatory arthritis, fibular hemimelia, congenital talipes equinovarus, Apert syndrome, arthrogryposis, and Nievergelt--Pearlman syndrome
- Pes Planus
- Other congenital malformations
- Including carpal fusions, carpal synostosis with radial head subluxation, symphalangism, and partial adactyly
- Ankle Sprain
- Tarsal Bones
- Fractures & Osseous Disease
- Traumatic/ Acute
- Stress Fractures
- Other Osseous
- Dislocations & Subluxations
- Muscle and Tendon Injuries
- Ligament Injuries
- Symptoms initiate with the onset of ossification, calcaneonavicular (8-12 years), talocalcaneal (8-12 years), talonavicular (3-5 years)
- Mid-, hindfoot or tarsal pain, sometimes diffuse
- Trouble walking on uneven surfaces
- If there is a precipitating event, trauma, weight gain, or an increase in athletic activity
- Pain is diffuse, exacerbates during physical activity, and may be triggered by minimal trauma
- Progressing to decreased range of motion, especially inversion/eversion of the subtalar joint
- Rigid deformity is usually the end point
- Physical Exam: Physical Exam Foot
- Rigid pes planus, hindfoot valgus
- Inability to roll onto lateral side of foot (secondary to rigid pes planus)
- Tightness of peroneal muscles, long extensors which may be obvious dorsally
- "Double medial malleolus" with talocalcaneal coalition
- Ankle range of motion is normal while subtalar range of motion is restricted
- Special Tests
- Standard Radiographs Foot, Standard Radiographs Ankle
- Initial imaging modality of choice
- Views should include anteroposterior, lateral, oblique, and axial weight-bearing
- Harris axial view (Harris-Beath)
- Sometimes termed Harris projection or penetrated axial projection
- Special radiographic view that is used for assessment of talocalcaneal coalition
- X-ray beam is angled between 35 and 45 degrees
- Calcaneonavicular coalitions
- Talocalcaneal coalitions
- 'C' sign
- Absent middle facet may be a more accurate radiographic finding
- Dorsolateral talar beak
- Thought to occur due to impaired subtalar joint motion, subsequently the navicular overrides the talus.
- Periosteal elevation occurs at the insertion of the talonavicular ligament, a cycle of osseous leads to formation
- Alternatively, may occur due to peroneal spasm with repetitive dorsolateral overload, compression of the talar head
- Note: may occur absent a tarsal coalition
- More sensitive, more specific than xray
- Also assesses for soft tissue injuries, bone edema
- Similar utility for osseous connections, but less for fibrous
- offers a more precise evaluation of the site and size of coalition
- Help determine determine surgical approach, i.e. resection, arthrodesis
- Can exclude multiple coalitions and readily depicts associated degenerative changes
- Considers joint involvement, arthrosis extension to help in recommending surgical therapy
- Type IA: extra-articular coalition without secondary arthritis
- Type IB: intra-articular coalition with secondary arthritis
- Type IIA: extra-articular coalition without secondary arthritis
- Type IIB: intra-articular coalition with secondary arthritis
- Based on three-dimensional reconstructed computed tomography images
- Type I: linear coalitions (41%)
- Type II: linear coalitions with posterior hook (17%)
- Type III: shingled coalitions (15%)
- Type IV: complete osseous coalitions (11%)
- Type V: posterior coalitions (17%)
- Asymptomatic or incidentally discovered lesions
- Most symptomatic lesions upon initial presentation
- Initial therapy
- Shoe inserts
- Activity modification
- If symptoms persist, consider
- Custom orthotics
- Cast immobilization
- Failure of conservative management
- Achieve painless functional hindfoot movement without deformity
- Subtalar or triple arthrodesis
- Excision of coalition with or without interposition of fat or tendon
Rehab and Return to Play
- Needs to be updated
Return to Play/ Work
- Needs to be updated
Complications and Prognosis
- Incidental or asymptomatic lesions
- No evidence suggesting that asymptomatic coalition may lead to future problems
- Conservative vs surgical management
- Calcaneonavicular coalitions respond less to conservative treatment than talocalcaneal coalitions
- Surgical outcomes
- Mahan et al observed 73% of patients achieved good results, regardless of the type of coalition
- Khoshbin et al reevaluated patients after resection of calcaneonavicular and talocalcaneal coalitions, found that 85% of the patients did not require additional procedures
- Mosca showed 87% of patients achieved good results after talocalcaneal coalition resection
- Predictors of good outcome with conservative management (need citation)
- Skeletal immaturity at presentation
- Nonathletic patient
- Ankylosed subtalar joint in neutral
- Pes Planus
- Chronic pain
- Inability to return to sport
- Surgical complications
- Incomplete resection
- Superficial Peroneal Nerve Injury
- Sports Medicine Review Foot Pain: https://www.sportsmedreview.com/by-joint/foot/
- Harris RI, Beath T. Etiology of peroneal spastic flat foot. J Bone Joint Surg Br 1948; 30B:624–634.
- Bohne WH. Tarsal coalition. Curr Opin Pediatr 2001; 13:29–35.
- Stormont DM, Peterson HA. The relative incidence of tarsal coalition. Clin Orthop 1983; (181):28–36.
- Solomon LB, Rühli FJ, Taylor J, et al. A dissection and computer tomograph study of tarsal coalitions in 100 cadaver feet. J Orthop Res. 2003;21:352–358
- Mosier KM, Asher M. Tarsal coalitions and peroneal spastic flat foot: a review. J Bone Joint Surg. 1984;66-A:976–984
- Conway JJ, Cowell HR. Tarsal coalition: clinical significance and roentgenographic demonstration. Radiology. 1969; 92:799--811.
- Kumai T, Takakura Y, Akiyama K, et al. Histopathological study of nonosseous tarsal coalition. Foot Ankle Int. 1998; 19:525--531.
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- Leonard MA. The inheritance of tarsal coalition and its relationship to spastic flat foot. J Bone Joint Surg Br 1974; 56B:520–526.
- Graham JM, Braddock SR, Mortier GR, et al. Syndrome of coronal craniosynostosis with brachydactyly and carpal/tarsal coalition due to Pro250Arg mutation in FGFR3 gene. Am J Med Genet 1998; 77:322–329.
- Swensen SJ, Otsuka NY. Tarsal coalitions–calcaneonavicular coalitions. Foot Ankle Clin 2015; 20:669–679.
- Burnett SE, Wilczak CA. Tarsal and tarsometatarsal coalitions from Mound C (Ocmulgee Macon Plateau site, Georgia): implications for understanding the patterns, origins, and antiquity of pedal coalitions in Native American populations. Homo Int Z Vgl Forsch Am Menschen 2012; 63:167–181.
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- Fuson S, Barrett M. Resectional arthroplasty: treatment for calcaneonavicular coalition. J Foot Ankle Surg 1998; 37:11–15.
- Rocchi V, Huang M-T, Bomar JD, Mubarak S. The ‘double medial malleolus’: a new physical finding in talocalcaneal coalition. J Pediatr Orthop 2018; 38:239–243.
- Newman JS, Newberg AH. Congenital tarsal coalition: multimodality evaluation with emphasis on CT and MR imaging. Radiographics 2000; 20:321–332.
- Kernbach KJ. Tarsal coalitions: etiology, diagnosis, imaging, and stigmata. Clin Podiatr Med Surg 2010; 27:105–117.
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- Taniguchi A, Tanaka Y, Kadono K, et al. C sign for diagnosis of talocalcaneal coalition. Radiology 2003; 228:501–505.
- Brown RR, Rosenberg ZS, Thornhill BA. The C sign: more specific for flatfoot deformity than subtalar coalition. Skeletal Radiol. 2001; 30:84--87.
- Liu PT, Roberts CC, Chivers FS, et al. ‘Absent middle facet’: a sign on unenhanced radiography of subtalar joint coalition. AJR Am J Roentgenol 2003; 181:1565–1572.
- Resnick D. Talar ridges, osteophytes, and beaks: a radiologic commentary. Radiology. 1984; 151:329--332.
- Wechsler RJ, Schweitzer ME, Deely DM, et al. Tarsal coalition: depiction and characterization with CT and MR imaging. Radiology. 1994; 193:447--452.
- Downey MS. Tarsal coalitions. A surgical classification. J Am Podiatr Med Assoc 1991; 81:187–197.
- Rozansky A, Varley E, Moor M, et al. A radiologic classification of talocalcaneal coalitions based on 3D reconstruction. J Child Orthop 2010; 4:129–135.
- Klammer G, Espinosa N, Iselin LD. Coalitions of the tarsal bones. Foot Ankle Clin 2018; 23:435–449.
- Mahan ST, Spencer SA, Vezeridis PS, Kasser JR. Patient-reported outcomes of tarsal coalitions treated with surgical excision. J Pediatr Orthop 2015; 35:583–588.
- Khoshbin A, Bouchard M, Wasserstein D, et al. Reoperations after tarsal coalition resection: a population-based study. J Foot Ankle Surg 2015; 54:306–310.
- Mosca VS. Subtalar coalition in pediatrics. Foot Ankle Clin 2015; 20:265–281.