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The Related Anatomy & Description
Tarsal Coalition Defined
A tarsal coalition is an abnormal connection or union that develops between two or more bones (the tarsal bones) in the back of the foot and in the heel. This abnormal connection, which can be composed of bone, cartilage or fibrous tissue, may result in a severe, rigid flatfoot presented with limited or no motion and pain in one or both feet.
Although tarsal coalition is often congenital (present at birth), signs of the disorder is not shown generally by children until early adolescence. The foot by then may become stiff and painful, and everyday physical activities are often difficult to perform.
For a majority of children with tarsal coalition, symptoms are relieved with simple, conservative treatments such as usage of custom orthotics and physical therapy. If a child presents severe symptoms that fail to respond to simple treatments and continue to interfere with their daily activities, surgery may be recommended to rectify the problem.
The Anatomical Background
The human foot is divided into three parts: the hindfoot, midfoot, and forefoot. Seven bones, known as tarsals, compose the hindfoot and midfoot. Of these bones, the calcaneus, talus, and navicular are most commonly involved in tarsal coalition condition.
Tarsal coalitions are relatively rare in occurrence and most are asymptomatic. Owing to this condition the subtalar joint loses both of its movements, rotation and gliding, are considerably restricted or lost. The pain symptoms associated with tarsal coalitions may be attributed to:
- Ligament Sprain
- Peroneal Muscle Spasm
- Sinus Tarsi Irritation
- Subtalar Joint Irritation
- Arthritic Changes
An Elaborate Overview
The condition of tarsal coalition most commonly takes place between the calcaneus and navicular bones, or between the calcaneus and talus bones. However, other joints can also be affected.
A tarsal coalition occurs when any two above-mentioned bones grow into one another, connected together by a bridge of bone, cartilage, or strong, fibrous tissue similar to a scar. These bridges are often referred to as “bars” that can cover a small amount or a large portion of the joint space between the bones.
According to a rough estimation, 1 out of every 100 people may suffer from tarsal coalition. In about half the cases, both feet are affected (bilateral coalition). The exact incidence of the disorder is difficult to determine precisely since most of the coalitions never give rise to noticeable symptoms.
In most people, the condition begins before birth. It is the outcome of a gene mutation that affects the cells which produce the tarsal bones. Although the coalition forms before birth, its presence is often not discovered until late childhood or adolescence. Tarsal coalitions often produce a dramatic symptom complex which is ultimately identified as rigid peroneal spastic flatfoot. The stiffness and stress that tarsal coalitions lead to may culminate in arthritis over time. The male-to-female ratios range from 1:1 to 4:1 with respect to the condition.
The Causative Factors
It should be noted that tarsal coalition is primarily a congenital condition that is directly related to a mutant gene that contains the “information” which initiates the vicious process of the abnormal union of the bones in the foot and their ossification at a later stage, with its ill-effects masked until the passage of several years. The tarsal coalitions, whatever the type, present with the following characteristics:
- Tarsal Coalition Is Hereditary, occurring in an autosomal dominant fashion.
- Tarsal Coalition Begins During Fetal Development, resulting in the individual bones not forming properly.
- Tarsal Coalition Generally Remains Hidden Or Masked until the suffering individual reaches maturity.
The less common causes of tarsal coalition include:
- Infection
- Arthritis
- Former Injury To The Area
The Associated Signs & Symptoms
While subjects who have a tarsal coalition are usually born with this condition, the symptoms generally are not discovered until the bones begin to ossify and mature, usually around ages 9 to 16. Sometimes, no symptoms or any obvious foot deformity can be observed during early childhood. However, pain and symptoms may develop and become conspicuous at a later stage in life.
When symptoms of tarsal coalition do occur, they may include one or several of the following:
- Tired Or Worn Out Legs
- Pain (Mild To Severe) While Standing Or Walking
- Muscle Spasms In The Leg
- Stiffness Of The Foot And Ankle
- Foot Caused To Turn Outward When Walking
- Recurrent Ankle Sprains Due To Abnormal Ankle Rolling
- Rigid Flatfoot (In One Or Both Feet)
- Walking Turned Difficult Due To A Limp
The Various Types
The different forms of tarsal coalitions have been categorized by the orthopedics into 3 types:
- Osseous (Synostosis) Coalition, involving the bone
- Fibrous (Syndesmosis) Coalition, involving the fibrous tissue
- Cartilaginous (Synchondrosis) Coalition, involving the cartilage
The various types of anatomical tarsal unions can be classified as follows:
- Talocalcaneal (Intra-articular)
- Calcaneonavicular (Extra-articular)
- Talonavicular
- Calcaneocuboid
- Cubonavicular
- Naviculocuneiform
The Diagnostics
Until a child’s bones begin to mature, a tarsal coalition is often difficult to identify. Your specialist would be able to diagnose and properly evaluate a tarsal coalition condition through a combination of the characteristic symptom complex, imaging techniques and his professional orthopedic expertise. The process comprises of the below-mentioned steps:
- Taking down your symptoms, their duration and general health history
- Doing complete, thorough physical examination of the foot and ankle
- Carrying out the following imaging tests to accurately diagnose the number, location and extent of the coalition(s) presented:
- Plain X-ray Films
- CT Scans
- MRI Scans
Certain foot deformities, syndromes and other conditions may accompany tarsal coalition in an individual, listed below:
- Cavovarus Deformity
- Talipes Equinovarus
- Fibular Hemimelia
- Nievergelt-Pearlman Syndrome
- Apert Syndrome
The Course Of Treatment
Tarsal coalition treatment methodology is initiated by your podiatric specialist only after carefully gauging the coalition depth, location and quantity. It is now an established fact that talocalcaneal coalitions usually respond only about 33% of the time to conservative treatment, but are still better off than the response displayed by calcaneonavicular coalitions.
The Conservative Mode Of Treatment
The primary goal of nonsurgical treatment mode of tarsal coalition is to reduce the motion at the affected joint, and the accompanying symptoms. One or several in combination of the following options may be employed, depending on the intensity of the condition and the delivered response to treatment:
- Immobilization is often necessary to give the affected area a rest. For this purpose the foot is placed in a cast or cast boot.
- Non-weight Bearing is ensured by using crutches are used to avoid placing weight on the affected foot while walking.
- Orthotic Devices that are custom-made be beneficial in distributing weight away from the joint, limiting motion at the joint and relieving from painful conditions.
- Oral Medications in the form of NSAIDs are often helpful in reducing the pain and inflammation.
- Steroid Injections administered in the form of cortisone into the affected joint reduces the inflammation and pain, and sometimes multiple injections are required.
- Injection Of An Anesthetic Agent injected into the leg may be used to relax spasms and their associated discomfort prior to immobilization.
- Physiotherapy of the affected region may include massage, range-of-motion exercises and ultrasound therapy.
The Surgical Mode Of Treatment
If nonsurgical treatment proves inadequate in relieving the patient’s discomforting symptoms or improving function, surgery is an advisable option. Your foot and ankle surgeon will determine the best surgical approach to be adopted based on the patient’s age, condition, arthritic changes and activity level.
- Resection Or Arthrodesis is the procedure whereby the coalition is removed and replaced with muscle or fatty tissue from another area of the patient’s own body. This being the most common surgery for tarsal coalition preserves normal foot motion and successfully relieves symptoms in most patients who do not present signs of arthritis.
- Fusion is the procedure whereby larger, more severe coalitions that cause significant deformity and involve arthritis may be treated. The aim of fusion is to restrict movement of painful joints and place the bones in the proper position and alignment with the help of large screws, pins, or screw-and-plate devices.
The Postoperative Care & Precautions
Postoperative treatment includes:
- Complete Immobilization for 3 weeks in a non-weight bearing cast
- Partial Immobilization for 3 more weeks in the same cast
- Range-Of-Motion Exercises out of the cast
- Gradual Advance to full weight-bearing & range-of-motion exercises
- Aggressive Physiotherapy to relieve pain, inflammation & speed up healing
The Probable Complications
The general complications and risks associated with any surgical procedure include the following:
- Bacterial Infection In The Wound
- Damage To Nerves & Blood Vessels
- Excessive Bleeding
- Blood Clot Formation
- A Bad Reaction To The Anesthesia
- Delayed Wound Healing
The complications associated specifically with the tarsal coalition surgery are as beneath:
- Subluxation Of The Navicular On The Talus leading to abnormal motion of the midfoot and risk of pain and degenerative changes
- Accidental Resection Of The Middle Facet 50% or greater than the posterior facet often yielding a poor outcome