Tarsal Coalition Clinical Presentation

Updated: Sep 08, 2016
  • Author: Louis P Vu, MD; Chief Editor: Vinod K Panchbhavi, MD, FACS  more...
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Presentation

History and Physical Examination

Patients with tarsal coalition usually present during the second decade of life, but presentations in adulthood have been documented. [24] Complaints include mild pain deep in the subtalar joint and limitation of range of motion. The patient usually presents after some traumatic event such as an ankle sprain. Indeed, what seem to be repetitive sprains should raise suspicions of tarsal coalition. Often, the symptoms are relieved by rest and aggravated by prolonged or heavy activity.

In cases of calcaneonavicular coalition, pain may be more superficial and originate from the area of the coalition in the sinus tarsi. Palpation may elicit pain at the calcaneonavicular junction laterally. In cases of talonavicular coalitions, the pain is usually more vague, but tenderness may be elicited with palpation of the middle facet region, just anterior to the medial malleolus.

Different coalitions ossify at different ages, possibly explaining the difference in ages of presentation of different coalitions. Slight limitations of range of motion and mild valgus are thought to be possibly all that is present prior to ossification. Talonavicular coalitions begin to ossify in children aged 3-5 years; calcaneonavicular coalitions begin to ossify in children aged 8-12 years; and talocalcaneal coalitions begin to ossify in adolescents aged 12-16 years.

Loss of subtalar motion and valgus position of the hindfoot become more apparent as the coalition ossifies, leading to the appearance of pes planus. Middle-facet talocalcaneal coalitions are associated with the greatest loss of subtalar motion and are the most likely to generate valgus.

This loss of subtalar motion may be evaluated with the heel-tip test, wherein the examiner supinates the foot of a standing patient by raising the medial border of the forefoot and keeping the heel and lateral border in contact with the floor. In patients with limited or decreased subtalar motion, compensatory external tibial rotation is decreased and the patella is not observed to rotate outward as in a persons without tarsal coalition.

Other tests include toe standing and the Jack toe-raise test; both demonstrate the fixed nature of the pes planus and the loss of hindfoot inversion. [25]

Studies have shown that patients with neutral hindfeet have fewer symptoms; it is likely secondary to decreased peroneal shortening. Cases of hindfoot varus have been reported in the literature in conjunction with calcaneonavicular coalitions. Repeated sprains may actually mask loss of subtalar motion by allowing motion because of ligamentous laxity.

Although peroneal spasticity was often attributed to tarsal coalitions in the older literature, this actually is relatively infrequent. Peroneal spasticity may be intermittent or continuous, varying with activity or stress of the ankle joint.

Tibialis spastic varus foot has also been described, albeit rarely. Kurashige et al reported a case of tibialis spastic varus foot with calcaneonavicular coalition in an 11-year-old boy with intellectual disability. [26]  Conservative treatment failed, but surgical resection of the coalition led to a good outcome.

Rocchi et al proposed a new physical finding in talocalcaneal coalition: the so-called double medial malleolus, a palpable medial prominence just below the medial malleolus. [27]  They determined this finding to be strongly associated with the presence of talocalcaneal coalition and suggested that it could be useful to help guide the ordering of confirmatory diagnostic imaging (eg, CT with 3D images) and surgical planning.