Question on Diagnosis ? Tarsal Coalition in 11 y/o

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Hi All,

Had an 11 year old boy in to clinic yesterday. Presented with a 6 month Hx of pain on the medial aspect of both ankles equally, very localised to a point just inferior to the medial malleolus. Painful on palpation of the area of the deltoid ligament. Pt c/o pain on activity, painful when walking and running, also painful when swimming freestyle but not breast stroke. Painful on activity and sometimes first thing in the morning. Rest relieves pain.

O/e the pt has ltd calcaneal inversion and eversion (approc 5 degrees in each direction bilaterally). Pt has ltd plantarflexion. Dorsiflexion of 25+ degress bilaterally. Pt also displays very early stage bilateral JHAV. Pt c/o pain when the foot is passively inverted and no pain in passive eversion. Pain is greatly reduced when I put the patient in lateral heel wedges.

My thoughts were that there could be some tarsal coalition or bony impingement on that medial aspect somewhere, so i had a chat with the friendly docs who agreed to x-ray him and attached are the results. The radiographer reports that there are no acute bony abnormalities. I feel there is a hint of a tarsal coalition which may be seen on the AP view, and some bony distal impingement. Although the xrays really don't look too bad.

I would really really appreciate a few opinions on the x ray before I proceed.. For some reason I am having real trouble uploading pictures to the arena, so if you email me at samuel_james_randall@nuhs.edu.sg I will reply to you with the attachment of the x-ray.

I am considering looking at laterally posted insoles for treatment.

Kind regards,

Sam Randall

p.s. if I figure it out I will post the x-ray online....

 

Sam,
Tarsal coalition would definitely be number 1 suspect.
CT will show it best whereas an changes on xray are rarely reported.
While it is nice to be able to confirm a coalition, at the end of the day, you have to look at treating to minimise pain by whatever biomechanical means possible.
Surgery should be considered as a last resort.
I have seen many coalitions which are asymptomatic- including elite athletes, so people can live with them...
Would still be interesting to see the xray.

 

I understand the rationale for having surgery as a last resort, but I have recently had a couple of 10-12 year olds with coalitions diagnosed by x-ray. 1 in particular that was poly-articular. Both these patients were asymptomatic, they had been bought in by parents worried about foot position.

The decision I find difficult is around the fact that they are asymptomatic, so may develop and function in a normal, non-pathological way. So surgery would not be justified. But if there is a block in motion at 1 or more of these joints, then my biomechanical knowledge tells me that compensation must be happening elsewhere, placing strain on tissues and if not corrected at an early stage over-use/wear and tear injuries may occur from compensatory movement.

So does this warrant surgery?

 

Sam,
In concern to the radiographer reports and x-rays...Although there are many brilliant radiographers out here who can be a wealth of informative knowledge, sometimes they can miss things, especially if they are not familiar with x-rays and pathologies of the foot.

Of all the coalition patients I have had, not one report has reported an abnormality.

Look especiallt at joint margins of bones. In a young person they should be very clear and smooth. If there is any blurryness (looks like OA) this can suggest a cartilagenous coalition.

Good Luck

Sally Belcher

 

It is a tricky one. My understanding is that there are 2 options- fuse or resect.
If you fuse, then the compensatory forces are still there, unless more is done to correct alignment.
If you resect- which may be an option in this case as he is young- it is not always successful...
Perhaps our surgical colleagues can weigh in here and clarify this?
My comment above was more that if they were not symptomatic, then I wouldn't be suggesting anything as aggressive as surgery.

They may never have any problems at all...
If surgery was guaranteed successful and no risk, then I would probably recommend it. It is similar to the argument with orthoses on the asymptomatic, but apparently pathological foot, except that orthoses are very low risk.

 

I agree with all y'all but would add--Usually I see sinus tarsi acute tenderness-you might try a diagnostic joint block using a little contrast medium in the local to get a clinical feel-definite CT with 2mm cuts look at them yourself. tRY TO GET SOME IDEA OF THE LOCATION AND SIZE. You might look at some literature that Albert Burns published regarding surgical decision making with coalitions. look for ANY early signs some can be very subtle of periarticular joint changes in STJ complex.

 

Hi Sam:

Once you have a Dx please reassess your Tx options.

Given the area of symptoms (assuming CT supports this) I would predict a middle facet coalition. Please sent this patient out if this is what you find since EARLY resection is fairly successful vs waiting until 15 or 16 years old, or later. The earlier the better.

If it's a CN bar you have a bit more time.


Steve

 

Thanks for your comments Steve.
I can't say that I have seen any coalitions post surgery- perhaps this is an indication that they have good results- but I was wondering what the expectations are.
I would assume if it was symptomatic that you would have symptom resolution. Do you gain ROM so that function is improved?
Do you recommend surgery for the asymptomatic?
Do you organise vigorous post surgical rehab combined with orthoses to try to get the foot functioning more normally? (I say this is often- but not always- the midfoot compensation which is occuring is significant)
What is the long term effect of the procedure on the STJ?
Appreciate your thoughts!

 

Hi Craig:
For Middle Facet coalitions, the earlier /better is due to the outcomes. Better ROM post op due to lack of remodeling (as in older patients).

I do not perform surgery on asymptomatic coalitions, although you could make an argument for doing so. Pain with these is usually right over the coalition at the sus. tali with pain on attempted eversion, lack of ROM with possible ankle and peroneal pain. CT makes for easy Dx. As you know there are several types of coalitions (partial, complete, etc.....)

Once the patients are older (15+ in males) and the STJ has adapted there is little chance that a resection will improve the ROM although many times resection does alleviate the localized symptoms.

The only problem with resecting these early is the reported occurrence of recurrence.

Steve

 

Sam:

Flat rearfoot posted, relatively rigid foot orthoses that help brace the foot and limit subtalar joint motion are very effective in treating tarsal coalitions. When this orthosis therapy is performed correctly, less than 25% of patients with symptomatic tarsal locations require subsequent surgery for resection of the tarsal coalition. Dr. John Weed taught us these techqiques over a quarter century ago at CCPM and I still use them today with great clinical success.

Hope this helps.

 

If we are discussing Middle Facet Coalitions........
Kevin, I do not agree with you on this.
These patients will have progressively less and less ROM which normally translates into more pain and or life style change. The earlier you resect these the more ROM you can recover. Once the STJ had remodeled you have lost the ROM battle.
Even if your 25% is accurate (and I'm not saying it is) then 1 in 4 will require symptomatic surgery due to failure of orthotic therapy and you have lost valuable time. If they are over 16 it's normally too late.
That's 1 in 4 that will have chronic and life long pain and deformity. That figure is unacceptable.
If you are able to Dx these early, then surgery is indicated.
Steve

 

still not able to post the x ray..

Another question:

Are there any recognised timelines for the formation then ossification of a tarsal coalition in the medial aspect of the talo-calcaneal joint? The patient has been in pain for 6/12 already..

Bearing in mind he already has calcaneal in/eversion limited to approx. 5 degrees each way.. Will the insoles I get him be likely to stop the coalition forming, or is it just that I am reducing force on the painful structures, and thus symptoms, until they have ossified? If he then takes the insoles out will the coalition then continue to form or is this something that will not happen after he has stopped growing?

Regards,

Sam

 

Hi Sam:

If indeed your patient has a TaloCalcaneal Coalition you just don't want him to end up with a peroneal spastic flat foot.

As you know, the TCC can vary in type and interference of ROM. Also, the physical age of your patient, his weight, etc., comes into play. Certainly a 120 pound mature 12 year old with a complete Middle Facet coalition will more likely have symptoms and require quicker aggressive treatment than a 100 pound 14 year old with an incomplete talar component type.

Early X-Ray Dx for some of these are tricky and a CT Scan is often required, if only for verification.
I've seen 16 year old boys with a complete Talo Calcaneal coalition with rigid flatfoot and talonavicular remodeling with obvious changes on plain films; I've seen the opposite as well where the plain films are only suggestive and one has to depend on physical findings. CT (or MRI for very young patients) Scans should ALWAYS be obtained for these.

Kevin has much more experience and expertise than I do in treating these via orthoses and hopefully he can discuss treatment from his perspective. I think my opinion on surgical excision has been stated here already.

Good luck.

Steve

 

Sam:

Regardless of age, I think it is in the patient's best medical interests to treat the foot with tarsal coalition with foot orthoses for at least 4 months before any decisions are made regarding surgical resection of the coalition. I have had many very athletic patients in their 20's and 30's who run miles a day with tarsal coalations that were not diagnosed with tarsal coalition until their foot is x-rayed for some other pathology. Therefore, not all tarsal coalitions become symptomatic, but we would reasonably expect a higher rate of problems developing in the future in these individuals.

Hope this helps.