Tarsal coalition

What is a tarsal coalition?

A tarsal coalition is an abnormal bridge between tarsal bones. This connection can be connective tissue, cartilaginous or bony. It reduces mobility in the hindfoot, especially in the subtalar joint, and can therefore promote pain and misalignment.

• Common forms: calcaneonavicular coalition (heel bone–scaphoid) and talocalcaneal coalition (talcane–heel bone)
• Material of the connection: fibros (connective tissue), cartilaginous (cartilaginous) or bony
• Symptoms often begin between the ages of 8 and 16 when the coalition hardens

The prevalence is estimated to be around 1–2%; many of those affected remain symptom-free. In up to 50-60% the change occurs on both sides.

Anatomy and pathomechanics

The hindfoot is made up of the talus (ankle bone) and calcaneus (heel bone); In front of it are the navicular (scaphoid), cuboid (cube bone) and the sphenoid bones. The fine tuning of these bones allows adaptations to uneven terrain through inversion and eversion in the subtalar joint.

• Calcaneonavicular coalition: often in the area of ​​the front outer foot; Pain on the lateral side of the foot or in the sinus tarsi is typical.
• Talocalcaneal coalition: primarily affects the middle facet of the subtalar joint; leads to greater restriction of movement.
• Consequences: limited hindfoot mobility, rigid arched or flat feet, compensatory additional load on neighboring joints.

The reduced joint movement can trigger peroneal spasm (protective tension of the peroneal muscles). Affected people then complain about side foot pain and recurring “kneeling events”.

Typical symptoms

• Stress-dependent pain in the hindfoot, on the side (often) or inside
• Stiffness in the hindfoot, limited in/eversion; Problems on uneven surfaces
• Recurrent ankle sprains
• Rigid-looking flat foot or arched arch foot, often with heel valgus
• Protective muscular tension of the peroneal muscles (peroneal spasm)
• Sometimes bilateral complaints; Often begins in adolescence or early adulthood

Warning signs that should be clarified quickly include pain at night when resting, significant swelling, fever, numbness or acute, persistent inability to exercise.

Causes and risk factors

It is usually a congenital developmental variant in which bone systems do not completely separate from each other during the embryonic period. Complaints often only emerge later, when the coalition becomes more solid.

• Congenital, sometimes familial accumulation
• Often bilateral
• Increase in symptoms during puberty
• Rarely acquired after injury, inflammation or degenerative changes

Diagnostics in our practice in Hamburg

Multiplane radiographs may show indirect signs; Special settings help: oblique image for calcaneonavicular coalition, Harris-Beath image for talocalcaneal coalition. MRI is suitable for assessing fibrocartilaginous connections and accompanying inflammatory reactions. A CT offers a very precise bony representation and supports surgical planning - we use it specifically and according to indications.

Differential diagnoses: flexible flatfoot, accessory navicular, sinus tarsi syndrome, osteochondral lesions, stress fractures, tarsal tunnel syndrome, juvenile idiopathic arthritis. A precise distinction is important in order to avoid over- or under-treatment.

Conservative therapy (first choice)

The aim of conservative treatment is to relieve pain, improve function and calm inflammation. Many affected people benefit noticeably from a structured, non-surgical approach.

• Immobilization/relief: temporary with walker boots or plaster for 2-6 weeks, depending on the symptoms
• Insole supply: stabilizing UCBL shells, medial support, if necessary heel wedge to reduce heel valgus
• Physiotherapy: stretching of the calf and hamstring muscles, strengthening of the intrinsic foot muscles, coordination and proprioception training, mobilization that is gentle on the joints
• Shoe modification: stiffer sole, good heel cap, sufficient support; Exercise with shock-absorbing shoes
• Medical pain therapy: anti-inflammatory painkillers upon consultation and for a limited time
• Targeted infiltrations: in individual cases image-supported for short-term pain relief; careful indication and risk assessment
• Activity adaptation: Reduction of stressful jumping and turning movements in phases of increased stimulation

A conservative treatment cycle often lasts 6-12 weeks. The progress is closely monitored. If severe symptoms remain or the stiffness permanently restricts everyday life and sport, we will discuss surgical options.

Operational options – when do they make sense?

Surgery is considered when appropriate conservative measures have been exhausted and significant functional impairment or pain persists. The choice of procedure depends on the type, size and location of the coalition, the condition of the articular surfaces, age and axial position.

• Resection of the coalition with interposition tissue: common in calcaneonavicular coalition; Interposition e.g. B. with fatty tissue or extensor digitorum brevis muscle to reduce regrowth
• Resection for talocalcaneal coalition: selectively possible if less than about half of the articular surface is affected and the quality of the joint is preserved
• Arthrodesis (joint fusion): subtalar or combined fusion in large coalitions, advanced osteoarthritis or failure of resection
• Corrective osteotomy: sometimes supplementary in cases of pronounced heel valgus in order to harmonize the axis

After resection, pain and function can be improved in appropriate cases. There can be no guarantee. With arthrodesis, the painful movement is eliminated; the neighboring joints must be observed over the long term.

Possible risks that we explain: wound healing disorders, infection, nerve irritation, persistent pain, remaining stiffness, non-healing (with arthrodesis), regrowth after resection.

Follow-up treatment and rehabilitation

The follow-up treatment depends on the procedure and the individual situation. After resection, there is usually a phase of partial weight-bearing in the boot for a few weeks with early functional physiotherapy. After arthrodesis, longer periods of unloading are common until the bony has healed safely.

• Pain and swelling management, elevation, lymphatic drainage
• Gradual increase in load after medical clearance
• Physiotherapy: mobilization of adjacent joints, gait training, strength and coordination training
• Individual return to sport and work; the time frame varies and is adjusted during follow-up

Everyday life, sport and prevention tips

• Wear shoes with good heel support and sturdy soles
• Use insoles consistently and check the fit regularly
• Care for calf and foot muscles: stretching, sensorimotor training
• Warm up before exercise, increase the load slowly; Choose alternative sports during periods of discomfort (cycling, swimming)
• Keep your body weight within a healthy range to relieve pressure on your ankles
• In children, watch out for repeated twisting and persistent foot pain

When should you seek medical advice?

• Hindfoot pain lasting more than 6-8 weeks despite rest
• Recurrent ankle sprains
• Marked stiffness or visible misalignment of the hindfoot
• Pain at rest, pain at night, fever or significant swelling
• Newly occurring numbness, reduced strength or circulatory problems

Your orthopedic foot consultation in Hamburg

We will advise you personally at Dorotheenstrasse 48, 22301 Hamburg. Our focus is on conservative, everyday solutions. Imaging and further measures are used according to indications. If an operation seems sensible, we transparently explain options, processes and realistic expectations.