Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Tarsal Coalition Workup

  • Author: Louis P Vu, MD; Chief Editor: Jason H Calhoun, MD, FACS  more...
 
Updated: Dec 16, 2014
 

Imaging Studies

Plain anteroposterior (AP) and lateral radiographs of the foot are usually not diagnostic but may be suggestive of tarsal coalitions. Classic secondary signs of tarsal coalition are mainly seen in the lateral view. These include talar beaking seen on the anterior talar side of the talonavicular junction, broadening and rounding or flattening of the lateral talar process, and narrowing of the posterior facet. The last 2 are signs of degenerative changes. Any rotation of the foot may result in the appearance of a tarsal pseudocoalition on the lateral view secondary to off-plane view of the subtalar joint facets.

Some have suggested that the C-sign of Lateur, a C-shaped line composed of the dome of the talus and the inferior outline of the sustentaculum tali, is pathognomonic for subtalar coalition.[25] A study by Sakellariou et al examined lateral radiographs of 20 patients with clinical and radiographic diagnosis of talocalcaneal coalition and compared them to 22 asymptomatic volunteers.[26] CT scans were used as the diagnostic standard. They concluded that the C-sign was highly sensitive and specific for the diagnosis. However, in a retrospective review of 48 patients who had lateral ankle radiographs and CT scans for nontraumatic indications, Brown et al found that the C-sign was specific but not sensitive for a flatfoot deformity and was neither specific nor sensitive for talocalcaneal coalition.[27]

Calcaneonavicular coalition may be suggested by the presence of the anteater-nose sign on the lateral view corresponding to an elongated anterior calcaneal process.[28] This radiographic sign may be found on the lateral radiograph of patients aged 9 years or older with tarsal coalition. Oblique 45º views of the foot demonstrate a calcaneonavicular coalition 90-100% of the time. Only approximately 10% of the cases demonstrate a frank osseous coalition, with the remainder demonstrating increased proximity of the 2 tarsals, indistinct juxtaposed cortices, hypoplasia of the head of the talus, and flattening or narrowing of the navicular as it approaches the anterior calcaneus process.

A talocalcaneal coalition is best seen with the Harris-Beath axial or "ski-jump" view. This is taken with the patient standing on the cassette, bending 10º at the ankle. Harris and Beath recommended a 45º beam view originally, but they later expanded their views to beam angles of 30º, 35º, and 45º. Cowell recommended first taking the 45º beam view and then, if the middle and posterior facets are not well visualized, using a standing lateral view to measure the appropriate angle for the axial view.[29] In cases in which the middle and posterior facets are not parallel, 2 different angles would have to be measured and 2 corresponding axial views taken. If a middle facet coalition is present, the coalition is seen on the medial side. If the coalition is osseous, no joint is visualized. If it is fibrous or cartilaginous, the joint appears irregular and angled inferior medial. In normal feet, the middle facet is usually parallel to the posterior facet on axial views.

In the past, tomograms have been necessary to demonstrate anterior facet coalitions and to confirm the presence of more difficult middle or posterior facet coalitions. Since the mid-1980s, however, coronal CT scans have become the criterion standard in the evaluation of tarsal coalitions.[30] In 1986, Herzenberg et al correlated the use of the coronal CT views to evaluate tarsal coalitions to cadaver specimens. In their study, the patient's feet were placed in a plantar position on the gantry with the CT ring in the neutral position.[10] Other studies have used a special apparatus to dorsiflex the foot and rotate the ring to maintain a coronal axis of the subtalar joint. The advent of high-speed spiral CT scanners and advanced image reconstruction software has prompted some to accept coronal reconstructions of noncoronal CT views, but no study has demonstrated equal diagnostic ability.

Upasani et al evaluated three-dimensional (3D) multiplanar CT images of calcaneonavicular coalitions and adjacent tarsal relationships in 74 feet (37 patients).[30] In 32 of the 37 patients (86%), bilateral involvement (69 coalitions) was present. Coalitions were categorized into 4 types: type I (forme fruste), 28%; type II (fibrous), 23%; type III (cartilaginous), 45%; and type IV (osseous), 4%. The average shape of the coalition was found to be a curved wedge, which was, on average, 16 mm wide dorsally, 7 mm wide on the plantar surface, 10 mm in length, and 25 mm in depth. According to the authors, the shape of the cuboid correlated with the extent of ossification. In type I or type II coalitions, the cuboid extended medially plantar to the fibrous connection, and in more complete type III and type IV coalitions, the cuboid was squared off and remained lateral to the osseous bridge. The authors noted that it is important to understand 3D anatomy when diagnosing milder forms of coalitions and duringresection, so as to avoid iatrogenic injury to the calcaneus, head of the talus, or cuboid.

MRIs have been advanced as another tool to evaluate cases of fibrous or cartilaginous coalitions that may not be well seen in CT scans, but no good study has been performed demonstrating significant diagnostic utility over CT scans. Although MRI has been found to be very good at detecting tarsal coalition, CT scanning is still considered to be the criterion standard and to be more cost-effective than MRI.[31]

Bone scintigraphy has been advanced as a way to confirm suspected coalitions that are not well seen in plain radiographs or as a screening tool. However, the decreasing expense of CT and the ability of CT scans to depict detail has reduced the utility of scintigraphy.

Next

Histologic Findings

The tissue of a tarsal coalition may be osseous, cartilaginous, or fibrous. Histopathologic analysis of resected nonosseous coalitions has revealed no evidence of neural elements. This absence of nerve tissue argues against the abnormal coalition tissue acting as a primary pain generator. Microfractures and histologic signs of bone remodeling near a coalition's boundary with normal bone have been identified and are likely pain generators via periosteal nerve fibers.

Previous
 
 
Contributor Information and Disclosures
Author

Louis P Vu, MD Orthopedic Surgeon, Private Practice

Louis P Vu, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Charles T Mehlman, DO, MPH Professor of Pediatrics and Pediatric Orthopedic Surgery, Division of Pediatric Orthopedic Surgery, Director, Musculoskeletal Outcomes Research, Cincinnati Children's Hospital Medical Center

Charles T Mehlman, DO, MPH is a member of the following medical societies: American Academy of Pediatrics, American Fracture Association, Scoliosis Research Society, Pediatric Orthopaedic Society of North America, American Medical Association, American Orthopaedic Foot and Ankle Society, American Osteopathic Association, Arthroscopy Association of North America, North American Spine Society, Ohio State Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Jason H Calhoun, MD, FACS Department Chief, Musculoskeletal Sciences, Spectrum Health Medical Group

Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Michigan State Medical Society, Missouri State Medical Association, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, Texas Orthopaedic Association, Musculoskeletal Infection Society

Disclosure: Nothing to disclose.

Additional Contributors

James K DeOrio, MD Associate Professor of Orthopedic Surgery, Duke University School of Medicine

James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society

Disclosure: Received royalty from Merete for other; Received royalty from SBi for other; Received royalty from BioPro for other; Received honoraria from Acumed, LLC for speaking and teaching; Received honoraria from Wright Medical Technology, Inc for speaking and teaching; Received honoraria from SBI for speaking and teaching; Received honoraria from Integra for speaking and teaching; Received honoraria from Datatrace Publishing for speaking and teaching; Received honoraria from Exactech, Inc for speaking a.

References
  1. Lemley F, Berlet G, Hill K, Philbin T, Isaac B, Lee T. Current concepts review: Tarsal coalition. Foot Ankle Int. 2006 Dec. 27(12):1163-9. [Medline].

  2. Petrover D, Schweitzer ME, Laredo JD. Anterior process calcaneal fractures: a systematic evaluation of associated conditions. Skeletal Radiol. 2007 Jul. 36(7):627-32. [Medline].

  3. Heiple KG, Lovejoy CO. The antiquity of tarsal coalition. Bilateral deformity in a Pre- Columbian Indian skeleton. J Bone Joint Surg Am. 1969 Jul. 51(5):979-83. [Medline].

  4. Cruveilhier J. Anatomie Pathologique du Corps Humain, tome 1, Paris, J.B. Balliere. 1829.

  5. Badgley CE. Coalition of the calcaneus and the navicular. Arch Surg. 1927. 15:75-88.

  6. Harris RI, Beath T. Etiology of peroneal spastic flatfoot. J Bone Joint Surg Br. 1948. 30:624-34.

  7. Kirmission E. Double pied bot varus par malformation osseuse primitive associe a des ankyloses congenitales des doigts et des arteils chez quatre membres di' une meme Famille. Rev Orthop. 1998. 9:392-8.

  8. Conway JJ, Cowell HR. Tarsal coalition: clinical significance and roentgenographic demonstration. Radiology. 1969 Mar. 92(4):799-811. [Medline].

  9. Deutsch AL, Resnick D, Campbell G. Computed tomography and bone scintigraphy in the evaluation of tarsal coalition. Radiology. 1982 Jul. 144(1):137-40. [Medline].

  10. Herzenberg JE, Goldner JL, Martinez S, Silverman PM. Computerized tomography of talocalcaneal tarsal coalition: a clinical and anatomic study. Foot Ankle. 1986 Jun. 6(6):273-88. [Medline].

  11. Wechsler RJ, Schweitzer ME, Deely DM, et al. Tarsal coalition: depiction and characterization with CT and MR imaging. Radiology. 1994 Nov. 193(2):447-52. [Medline].

  12. Rankin EA, Baker GI. Rigid flatfoot in the young adult. Clin Orthop. 1974 Oct. 0(104):244-8. [Medline].

  13. Vaughan WH, Segal G. Tarsal coalitions, special reference to roentogenographic interpretation. Radiology. 1953. 60:855-63.

  14. Shands AR, Wentz IJ. Congenital anomalies, accessory bones, and osteochondritis in the feet of 850 children. Surg Clin North Am. 1953. 33:1643-66.

  15. Leonard MA. The inheritance of tarsal coalition and its relationship to spastic flat foot. J Bone Joint Surg Br. 1974 Aug. 56B(3):520-6. [Medline].

  16. Snyder RB, Lipscomb AB, Johnston RK. The relationship of tarsal coalitions to ankle sprains in athletes. Am J Sports Med. 1981 Sep-Oct. 9(5):313-7. [Medline].

  17. Cooperman DR, Janke BE, Gilmore A, et al. A three-dimensional study of calcaneonavicular tarsal coalitions. J Pediatr Orthop. 2001 Sep-Oct. 21(5):648-51. [Medline].

  18. Stormont DM, Peterson HA. The relative incidence of tarsal coalition. Clin Orthop. 1983 Dec. (181):28-36. [Medline].

  19. Jack EA. Bone anomalies of the tarsus in relation to "peroneal spastic flatfoot". J Bone Joint Surg Br. 1954. 36:530-42.

  20. Thorpe SW, Wukich DK. Tarsal coalitions in the adult population: does treatment differ from the adolescent?. Foot Ankle Clin. 2012 Jun. 17(2):195-204. [Medline].

  21. Lisella JM, Bellapianta JM, Manoli A 2nd. Tarsal coalition resection with pes planovalgus hindfoot reconstruction. J Surg Orthop Adv. 2011 Summer. 20(2):102-5. [Medline].

  22. Bettin D, Karbowski A, Schwering L. Congenital ball-and-socket anomaly of the ankle. J Pediatr Orthop. 1996 Jul-Aug. 16(4):492-6. [Medline].

  23. Pistoia F, Ozonoff MB, Wintz P. Ball-and-socket ankle joint. Skeletal Radiol. 1987. 16(6):447-51. [Medline].

  24. Takakura Y, Tamai S, Masuhara K. Genesis of the ball-and-socket ankle. J Bone Joint Surg Br. 1986 Nov. 68(5):834-7. [Medline].

  25. Lateur LM, Van Hoe LR, Van Ghillewe KV, et al. Subtalar coalition: diagnosis with the C sign on lateral radiographs of the ankle. Radiology. 1994 Dec. 193(3):847-51. [Medline].

  26. Sakellariou A, Sallomi D, Janzen DL, et al. Talocalcaneal coalition. Diagnosis with the C-sign on lateral radiographs of the ankle. J Bone Joint Surg Br. 2000 May. 82(4):574-8. [Medline].

  27. Brown RR, Rosenberg ZS, Thornhill BA. The C sign: more specific for flatfoot deformity than subtalar coalition. Skeletal Radiol. 2001 Feb. 30(2):84-7. [Medline].

  28. Oestreich AE, Mize WA, Crawford AH, Morgan RC Jr. The "anteater nose": a direct sign of calcaneonavicular coalition on the lateral radiograph. J Pediatr Orthop. 1987 Nov-Dec. 7(6):709-11. [Medline].

  29. Cowell HR. Tarsal coalition--review and update. Instr Course Lect. 1982. 31:264-71. [Medline].

  30. Upasani VV, Chambers RC, Mubarak SJ. Analysis of calcaneonavicular coalitions using multi-planar three-dimensional computed tomography. J Child Orthop. 2008 Aug. 2(4):301-7. [Medline]. [Full Text].

  31. Nalaboff KM, Schweitzer ME. MRI of tarsal coalition: frequency, distribution, and innovative signs. Bull NYU Hosp Jt Dis. 2008. 66(1):14-21. [Medline].

  32. Mubarak SJ, Patel PN, Upasani VV, Moor MA, Wenger DR. Calcaneonavicular coalition: treatment by excision and fat graft. J Pediatr Orthop. 2009 Jul-Aug. 29(5):418-26. [Medline].

  33. Philbin TM, Homan B, Hill K, Berlet G. Results of resection for middle facet tarsal coalitions in adults. Foot Ankle Spec. 2008 Dec. 1(6):344-9. [Medline].

  34. Migues A, Slullitel GA, Suárez E, Galán HL. Case reports: symptomatic bilateral talonavicular coalition. Clin Orthop Relat Res. 2009 Jan. 467(1):288-92. [Medline]. [Full Text].

  35. Comfort TK, Johnson LO. Resection for symptomatic talocalcaneal coalition. J Pediatr Orthop. 1998 May-Jun. 18(3):283-8. [Medline].

  36. Wilde PH, Torode IP, Dickens DR, Cole WG. Resection for symptomatic talocalcaneal coalition. J Bone Joint Surg Br. 1994 Sep. 76(5):797-801. [Medline].

  37. Luhmann SJ, Schoenecker PL. Symptomatic talocalcaneal coalition resection: indications and results. J Pediatr Orthop. 1998 Nov-Dec. 18(6):748-54. [Medline].

  38. Mann RA, Baumgarten M. Subtalar fusion for isolated subtalar disorders. Preliminary report. Clin Orthop. 1988 Jan. (226):260-5. [Medline].

  39. de Wouters S, Tran Duy K, Docquier PL. Patient-specific instruments for surgical resection of painful tarsal coalition in adolescents. Orthop Traumatol Surg Res. 2014 Jun. 100(4):423-7. [Medline].

  40. Skwara A, Zounta V, Tibesku CO, Fuchs-Winkelmann S, Rosenbaum D. Plantar contact stress and gait analysis after resection of tarsal coalition. Acta Orthop Belg. 2009 Oct. 75(5):654-60. [Medline].

  41. Khoshbin A, Bouchard M, Wasserstein D, Leroux T, Law PW, Kreder HJ, et al. Reoperations after Tarsal Coalition Resection: A Population-based Study. J Foot Ankle Surg. 2014 Jul 5. [Medline].

  42. Asher MA, Mosher K. Coalition of the talocalcaneal middle facet: treatment by surgical excision and fat graft interposition. Orthop Trans. 1983. 7:149-150.

  43. Berman AT, Finn CA, Van Horne J, Fye MA. Answer please. Tarsal coalition. Orthopedics. 1990 Aug. 13(8):910-1, 915-7. [Medline].

  44. Cowell HR. Diagnosis and management of peroneal spastic flatfoot. Instr Course Lect. 1975. 24:94-103.

  45. Cowell HR. Talocalcaneal coalition and new causes of peroneal spastic flatfoot. Clin Orthop. 1972. 85:16-22. [Medline].

  46. Cowell HR, Elener V. Rigid painful flatfoot secondary to tarsal coalition. Clin Orthop. 1983 Jul-Aug. (177):54-60. [Medline].

  47. Crim JR, Cracchiolo A, Bassett LW, et al. Magnetic resonance imaging of the hindfoot. Foot Ankle. 1989 Aug. 10(1):1-7. [Medline].

  48. Danielsson LG. Talo-calcaneal coalition treated with resection. J Pediatr Orthop. 1987 Sep-Oct. 7(5):513-7. [Medline].

  49. Elkus RA. Tarsal coalition in the young athlete. Am J Sports Med. 1986 Nov-Dec. 14(6):477-80. [Medline].

  50. Emery KH, Bisset GS 3rd, Johnson ND, Nunan PJ. Tarsal coalition: a blinded comparison of MRI and CT. Pediatr Radiol. 1998 Aug. 28(8):612-6. [Medline].

  51. Gonzalez P, Kumar SJ. Calcaneonavicular coalition treated by resection and interposition of the extensor digitorum brevis muscle. J Bone Joint Surg Am. 1990 Jan. 72(1):71-7. [Medline].

  52. Graham JM Jr, 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 May 26. 77(4):322-9. [Medline].

  53. Hark FW. Congenital anomalies of the tarsal bones. Clin Orthop. 1960. 16:21-5.

  54. Haygood TM. Magnetic resonance imaging of the musculoskeletal system: part 7. The ankle. Clin Orthop. 1997 Mar. (336):318-36. [Medline].

  55. Jacobs AM, Sollecito V, Oloff L, Klein N. Tarsal coalitions: an instructional review. J Foot Surg. 1981 Winter. 20(4):214-21. [Medline].

  56. Jayakumar S, Cowell HR. Rigid flatfoot. Clin Orthop. 1977 Jan-Feb. (122):77-84. [Medline].

  57. Kitaoka HB, Wikenheiser MA, Shaughnessy WJ, An KN. Gait abnormalities following resection of talocalcaneal coalition. J Bone Joint Surg Am. 1997 Mar. 79(3):369-74. [Medline].

  58. Kulik SA Jr, Clanton TO. Tarsal coalition. Foot Ankle Int. 1996 May. 17(5):286-96. [Medline].

  59. Kumai T, Takakura Y, Akiyama K, et al. Histopathological study of nonosseous tarsal coalition. Foot Ankle Int. 1998 Aug. 19(8):525-31. [Medline].

  60. Kumar SJ, Guille JT, Lee MS, Couto JC. Osseous and non-osseous coalition of the middle facet of the talocalcaneal joint. J Bone Joint Surg Am. 1992 Apr. 74(4):529-35. [Medline].

  61. McCormack TJ, Olney B, Asher M. Talocalcaneal coalition resection: a 10-year follow-up. J Pediatr Orthop. 1997 Jan-Feb. 17(1):13-5. [Medline].

  62. Morgan RC Jr, Crawford AH. Surgical management of tarsal coalition in adolescent athletes. Foot Ankle. 1986 Dec. 7(3):183-93. [Medline].

  63. Mosier KM, Asher M. Tarsal coalitions and peroneal spastic flat foot. A review. J Bone Joint Surg Am. 1984 Sep. 66(7):976-84. [Medline].

  64. Newman JS, Newberg AH. Congenital tarsal coalition: multimodality evaluation with emphasis on CT and MR imaging. Radiographics. 2000 Mar-Apr. 20(2):321-32; quiz 526-7, 532. [Medline].

  65. Pachuda NM, Lasday SD, Jay RM. Tarsal coalition: etiology, diagnosis, and treatment. J Foot Surg. 1990 Sep-Oct. 29(5):474-88. [Medline].

  66. Percy EC, Mann DL. Tarsal coalition: a review of the literature and presentation of 13 cases. Foot Ankle. 1988 Aug. 9(1):40-4. [Medline].

  67. Pineda C, Resnick D, Greenway G. Diagnosis of tarsal coalition with computed tomography. Clin Orthop. 1986 Jul. (208):282-8. [Medline].

  68. Plotkin S. Case presentation of calcaneonavicular coalition in monozygotic twins. J Am Podiatr Med Assoc. 1996 Sep. 86(9):433-8. [Medline].

  69. Resnik CS, Aiken MW, Kenzora JE. Case report 780. Fracture of talar beaks in tarsal coalition. Skeletal Radiol. 1993. 22(3):214-7. [Medline].

  70. Sakellariou A, Claridge RJ. Tarsal coalition. Orthopedics. 1999 Nov. 22(11):1066-73; discussion 1073-4; quiz 10. [Medline].

  71. Smith RW, Staple TW. Computerized tomography (CT) scanning technique for the hindfoot. Clin Orthop. 1983 Jul-Aug. (177):34-8. [Medline].

  72. Spero CR, Simon GS, Tornetta P 3rd. Clubfeet and tarsal coalition. J Pediatr Orthop. 1994 May-Jun. 14(3):372-6. [Medline].

  73. Stoskopf CA, Hernandez RJ, Kelikian A, et al. Evaluation of tarsal coalition by computed tomography. J Pediatr Orthop. 1984 May. 4(3):365-9. [Medline].

  74. Stuecker RD, Bennett JT. Tarsal coalition presenting as a pes cavo-varus deformity: report of three cases and review of the literature. Foot Ankle. 1993 Nov-Dec. 14(9):540-4. [Medline].

  75. Sullivan JA. Pediatric flatfoot: evaluation and management. J Am Acad Orthop Surg. 1999 Jan. 7(1):44-53. [Medline].

  76. Takakura Y, Tanaka Y, Kumai T, Sugimoto K. Development of the ball-and-socket ankle as assessed by radiography and arthrography. A long-term follow-up report. J Bone Joint Surg Br. 1999 Nov. 81(6):1001-4. [Medline].

  77. Tanaka Y, Takakura Y, Sugimoto K, Kumai T. Non-osseous coalition of the medial cuneiform-first metatarsal joint: a case report. Foot Ankle Int. 2000 Dec. 21(12):1043-6. [Medline].

  78. Thometz J. Tarsal coalition. Foot Ankle Clin. 2000 Mar. 5(1):103-18, vi. [Medline].

  79. Varner KE, Michelson JD. Tarsal coalition in adults. Foot Ankle Int. 2000 Aug. 21(8):669-72. [Medline].

  80. Vincent KA. Tarsal coalition and painful flatfoot. J Am Acad Orthop Surg. 1998 Sep-Oct. 6(5):274-81. [Medline].

  81. Warren MJ, Jeffree MA, Wilson DJ, MacLarnon JC. Computed tomography in suspected tarsal coalition. Examination of 26 cases. Acta Orthop Scand. 1990 Dec. 61(6):554-7. [Medline].

  82. Wheeler R, Guevera A, Bleck EE. Tarsal coalitions: review of the literature and case report of bilateral dual calcaneonavicular and talocalcaneal coalitions. Clin Orthop. 1981 May. (156):175-7. [Medline].

  83. Wright DG, Desai SM, Henderson WH. Action of the subtalar and ankle-joint complex during the stance phase of walking. J Bone Joint Surg Am. 1964. 46:361-82.

 
Previous
Next
 
Plain radiograph (Slomann view) showing typical appearance of calcaneonavicular coalition.
CT scan appearance of talocalcaneal coalition.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.