Examination and management of a patient with tarsal coalition.

Key Words: Ankle, Case report, Foot, Subtalar joint.

A commonly misunderstood pathological condition of the foot is peroneal spastic flatfoot (PSFF). Mosier and Asher[1] define peroneal spastic flatfoot as a syndrome that consists of a painful and rigid valgus deformity of the foot and peroneal muscle spasm or spasticity. The early literature suggested that this syndrome was attributable primarily to nervous system disease.[2,3] More contemporary literature has demonstrated that PSFF is not a neurological condition but rather a pathological condition of the tarsal joints of the foot.[4-6] Since the 1950s, the literature has used the term "tarsal coalition" almost exclusively in place of the term "peroneal spastic flatfoot." Although PSFF is a relatively rare condition, physical therapists managing patients with foot complaints should be aware of its signs and symptoms. The purposes of this case report are (1) to describe the physical therapy evaluation and problem-solving method used for a patient referred by a physician with a diagnosis of PSFF, (2) to review the literature that guided our clinical decisions regarding the potential cause of this patient's PSFF, and (3) to define and describe the pathology and clinical findings associated with PSFF (tarsal coalition).

Case Description

Subject

The patient was a 14-year-old boy referred for physical therapy with complaints of right foot pain and a diagnosis of PSFF. The patient reported that he had walked with a limp for several years and that he had difficulty running. He had no pain until 5 months prior to his referral for physical therapy. He believed his onset of symptoms began after wrestling with his older brother, who twisted his foot into what was apparently an inverted position. Right-sided lateral ankle pain occurred with "walking and any movement of the right ankle and foot." He reported that his foot was pain-free at rest in a non-weight-bearing position. His goals were to be able to walk to school and to run and play games with his friends without discomfort.

Examination

The examination began with the patient positioned supine. His right forefoot was observed to be resting in a prorated position (Fig. 1).

[Figure 1 ILLUSTRATION OMITTED]

A goniometer was used to take passive and active forefoot measurements using the methods described by Alexander.[7] One arm of the goniometer was placed on the planter surface of the patient's foot at the level of the metatarsal heads. The other goniometer arm was placed perpendicular to the long axis of the lower leg. Measurements of range of motion for the forefoot are reported in the Table. Because the right forefoot could not be positioned in neutral (0 [degrees] position), all motions are reported relative to the resting position. The resting position for forefoot measurement was defined as the position of the foot while the patient was relaxed in a supine position. When the examiner attempted to invert the right forefoot, a clonus response of several repeated contractions was elicited from the peroneal muscles. To test the reliability of the clonus response, this maneuver was repeated several times. A similar clonus response was elicited each time.

Table Measurements of Forefoot and Rear-Foot Range of Motion (ROM) (in Degrees)

                         Right           Left
                         (Involved)      (Uninvolved)
Variable                 Foot            Foot

Forefoot ROM(a)
  Active inversion       32              64
  Passive inversion      38              64
  Active eversion         0              41
  Passive eversion        0              41

Rear-foot ROM(b)
  Active inversion        0              31
  Passive inversion       0              31
  Active eversion         0               3
  Passive eversion        0               3

(a) The right forefoot was everted 27 degrees and the left forefoot was inverted 8 degrees while the patient was in the resting position. The motions reported represent total arcs of motion from this resting position.

(b) The right rear foot was everted 15 degrees and the left rear foot was everted 8 degrees while the patient was in the resting position. The motions reported represent total arcs of motion from this resting position.

With the patient positioned prone, we used the methods described by Elveru et al[8] to obtain passive rear-foot measurements. Active rear-foot measurements were obtained by asking the patient to move his foot in the same directions as those for the passive motions. Rearfoot measurements are reported in the Table. The resting position for rear-foot measurement was defined as the position of the foot while the patient was relaxed in a prone position. Figure 2 illustrates the resting position of the patient's rear feet.

[Figure 2 ILLUSTRATION OMITTED]

End-feel assessment has been suggested as a particularly useful procedure for making inferences about the type of tissue limiting motion at a joint.[9] Because of the unusual position of our patient's feet at rest, we thought the end-feel assessment would be especially useful. Because of the clonus response of the right foot and the lack of any motion of the rear foot, however, we were unable to assess end feel as it is routinely done. Because of the lack of motion of the right rear foot, we deduced that the structures limiting foot motion were likely to be bony in nature, which is similar to what an examiner might conclude when finding a hard end feel. Kaltenborn[9] defined a hard end feel as resistance encountered by the examiner presumably attributable to a bone-against-bone limit in motion. The end feels on the left side appeared to correspond to a firm end feel. Kaltenborn[9] defined a firm end feel as a rapid increase in resistance at the end range.

With the patient positioned supine, passive planter flexion and dorsiflexion were measured. Elveru et al[8] found their measurements of these movements to have good intratester reliability. Thus, all tests were performed by one person (MJK). Plantar flexion was 15 degrees on the right side and 65 degrees on the left side. Dorsiflexion was 2 degrees on the right side and 13 degrees on the left side. These sagittal-plane measurements were difficult to obtain on the right side due to the unusual resting position of the foot. Due to concerns regarding reliability of these measurements, each measure was repeated 3 times[10] and the same measurements were obtained. We believe that because the examiner obtained the same measurements on 3 occasions, the measurements had adequate reliability for decision making.

Observation of the patient s feet while he was standing showed that each calcaneus was prorated. The position of the calcaneus while standing was measured using the method described by Sell et al.[11] They found that the intratester reliability of measurements obtained on 30 subjects was .85 (intraclass correlation coefficient [2,1]). A pen was used to draw a line bisecting the posterior calcaneus. A digital inclinometer was placed on the floor, with the perpendicular edge at the base of the calcaneal bisection line. The inclinometer was then set at zero and angled to match the bisection line. Using this method, the right calcaneus was everted 15 degrees, compared with 8 degrees on the left side. In the same position, the patient s attempts to actively supinate the right foot produced no observable calcaneal movement. The patient was able to move the left calcaneus through its available range while standing.

Observational analysis of gait showed the right foot to be maintained in a prorated position throughout the entire gait cycle, whereas the left foot appeared to resupinate during late stance and during the swing phase of gait. This observation was supported by the shoe wear pattern, which had normal posterolateral wear of the left sole but a medial wear pattern on the right side. The right heel counter also was worn and pushed medially to match the everted position of the calcaneus.[12]

Palpation over the area of the lateral right calcaneus and the lateral calcaneocuboid joint reproduced his chief complaint of pain. The tissues thought to be inflamed were the peroneal tendons in this area and the calcaneocuboid joint ligaments. Palpation of the same areas on the left side elicited no complaint of discomfort.

Based on this patient's initial evaluation findings, we hypothesized that the patient had a motion restriction at the joint. At this point, we were unable to attribute the examination findings to a pathological condition that could explain what appeared to be a complete loss of talocalcaneal motion on the right side. Thus, we were unable to develop a hypothesis that could account for the patient s impairments. We also needed a rationale to explain why the patient would state that he had walked with a limp for years, yet did not have pain until an inversion trauma occurred several months ago. We also were unable to explain the presence of clonus on the right side. We needed to gather information that would aid in the development of a hypothesis. As discussed by Rothstein and Echternach,[13] hypothesis development is a critical step in the problem-solving approach because all subsequent patient management must be directed toward affecting the hypothesis.

Literature Review

We began our literature review by examining the work of Jahss.[14] We found that the diagnostic term "tarsal coalition has essentially replaced the term "peroneal spastic flatfoot" in the more recent literature. We therefore conducted a MEDLINE search using the key words "peroneal spastic flatfoot" and "tarsal coalition" for the years 1970 to present. We used the reference lists of articles found in the MEDLINE search to identify additional relevant literature. We also used the 3-volume series on the foot and ankle by Jahss[14] to identify additional references. After reviewing the literature, we found what we thought was a potential explanation for our patient's condition. Percy and Mann[15] described tarsal coalition as the condition that exists when movement between two or more tarsal bones is absent or restricted. The cause of the restriction is thought to be a congenital abnormality, with a fibrous (syndesmosis), cartilaginous (synchondrosis), or bony (synostosis) union at the involved tarsal joint(s).[1,15]

Tarsal coalitions are thought to occur in about 1% to 2% of the US population,[4,16] although this is only an estimate because not all individuals with tarsal coalitions develop symptoms.[3] The most common sites of tarsal coalitions are at the calcaneonavicular and talocalcaneal joints.[16] Talocalcaneal coalitions are reported to be most common over the middle and posterior facets.[3,16] Anterior subtalar joint coalitions have been reported, but they are considered to be quite rare.[16] Coalitions at other joints are so rare that fewer than 10 of each type have been reported in the literature.[16]

Because a tarsal coalition often results in an involuntary contraction in response to passive stretch of the peroneal muscles, some authors[2,3] have suggested that the problem is caused by pathology of nerve tissue. Lapidus[3] was the first author to suggest that "peroneal spastic flatfoot" is attributable not to peroneal muscle involvement but to an anomalous articular fusion at one of a variety of tarsals. Over time, the term "tarsal coalition" has become accepted as the preferred diagnostic term for this condition because it describes the cause of the condition.[1,5,12,15,17,18]

Not all persons with a tarsal coalition have symptoms.[1,3,5] If symptoms do occur, they usually occur during adolescence, but they occasionally occur in adulthood.[5,19,20] In most cases, symptoms are provoked by mild traumatic episodes, usually inversion sprains that cause disruption of the fusing or fused articulation.[5,15,17,21] Jayakumar and Cowell[20] found that talocalcaneal coalitions ossify between the ages of 12 and 16 years and that calcaneonavicular ossification occurs between the ages of 8 and 12 years. Because symptoms occur due to disruptions of the fusing or fused articulation, it is important for clinicians to know the age of ossification. Palpable local tenderness may be present over the involved joint line.[17,18] line.[17,18] Danielsson[22] reported being able to palpate a bony bridge between the talus and calcaneus below the medial malleolus. A patient with an osseous subtalar joint coalition is likely to have a rigidly prorated foot.[1,3,15,17-20,23]

Persons who have a fixed prorated deformity are likely to have shortening of the peroneal musculature if they have symptoms.[17,22] Not all tarsal coalitions produce a pronated foot. Stuecker and Benett[24] and Simmons[25] described 6 patients with tarsal coalitions who developed a fixed cavus foot with neutral or supinated calcanei and shortening of muscles other than the peroneal muscles. Several theories exist as to why this phenomenon might occur.[1,3,5,15,21,24,25] Because these theories are beyond the scope of this article, they will not be discussed here.

Computed tomography scans are the diagnostic test of choice in confirming a diagnosis of tarsal coalition.[5,26-30] Radiographs also can be effective.[5,30,31] As discussed by Ehrlich and Elmer[5] and other authors,[1,30,31] common observations seen on radiographs of persons with talocalcaneal coalitions are a talar beak, narrowing of the talocalcaneal space, rounding of the lateral process of the talus, failure to visualize the middle facet of the subtalar joint in a lateral view, and inability to visualize the tarsal sinus. All of these observations were seen on our patient's radiograph (Fig. 3). There was also a positive halo sign (labeled with the arrow in Fig. 3). In most persons with a talocalcaneal coalition, an increase in trabecular bone density is seen in the calcaneus below the lateral process of the talus.[31] Due to its ring-like design, this increased trabecular bone density is called a halo sign. It is thought to be caused by altered compressive forces from the talus due to the loss of subtalar joint motion.[31]

[Figure 3 ILLUSTRATION OMITTED]

The literature provided us with some support for conservative management as the initial treatment option for persons with talocalcaneal coalition[1,3,5,12,15,17,20,22,23,32] Cowell[6] reported using a medial heel wedge and a medial longitudinal arch support to provide relief in a few patients. He argued that if support does not help, a short-leg walking cast can be applied in a subtalar neutral position. Cowell reported a success rate of 25% to 30% in patients treated with casting, but he did not define what was meant by the term "success." Kumar et al[23] found that nearly one third of symptomatic coalitions were improved by using foot supports, anklefoot orthoses, injections, and casting for 6 weeks. Although they reported casting to be the most effective conservative treatment, none of these interventions were reported to provide lasting relief. O'Neill and Micheli[33] developed an ankle-foot scoring tool to measure impairments and, to a lesser degree, disability in 16 adolescents (20 feet) with coalitions. All patients reportedly did not improve with conservative care based on use of the impairment-disability scale. Elkus[17] advocated the use of foot supports, casting the calcaneus in a varus position, and physical therapy to restore motion. Elkus did not clarify why he recommended conservative methods. These conservative therapies failed in all 20 athletes (26 feet) studied, which resulted in all patients requiring surgery. Cowell and Elener[18] observed that patients with talocalcaneal coalitions that are in or near a subtalar neutral position have better nonoperative results compared with patients who are in a prorated position.

Based on the literature review, the patients' responses to conservative care for a tarsal coalition generally appear to be poor. At best, two thirds of the patients treated with a conservative approach were judged to have not benefited from conservative treatment. If the coalition involves the talocalcaneal joint, however, a greater rate of success may be achieved if the subtalar joint is fixed at or near a neutral position as compared with subtalar joints fixed in an inverted or everted position.[18] No form of conservative treatment seemed to produce better results than another form; therefore, we received little guidance as to what type of physical therapy our patient should receive. In addition, because our patient's rear foot appeared to be fixed in a prorated position, we had little evidence to suggest that a conservative approach would be effective.

Surgical treatment options are discussed at great length in the literature. Triple arthrodesis, calcaneal osteotomy, and resection of the coalition have been described as appropriate options.[1,6,15,18,21-24,33-35]

Hypothesis Revision and Treatment

As described in the literature, the signs and symptoms of talocalcaneal coalition, a form of tarsal coalition, appeared to match our patient's medical history, examination findings, age at onset of symptoms, and site of pain. We revised our hypothesis to state that the patient had a talocalcaneal joint coalition. We then reviewed the radiographs taken at the referring physician's office 2 weeks prior to our examination and found what we thought was evidence of a talocalcaneal coalition. The information gathered led us to believe that we should attempt to regain some supination. The literature suggested that patients with a talocalcaneal joint coalition positioned at or near the neutral position will likely have a better outcome than those with a coalition resulting in a prorated foot. We believed, however, that there would be little likelihood of increasing supination (inversion) at the subtalar joint. Because the literature suggests the likelihood of effective conservative treatment of patients with a tarsal coalition is on the order of 30%, we thought it appropriate to continue with treatment.[6] Our patient's rear foot was rigidly positioned in a 15-degree everted position. Because we believed this patient was probably not a good candidate for physical therapy, we chose to see him for only 5 visits to determine whether we could influence the amount of subtalar joint motion that was present.

Our treatment approach was to attempt to increase subtalar joint motion into supination. We used ultrasound, joint mobilization, and foot orthoses to try to generate forces during weight bearing that would assist the foot in movement out of the prorated position.[17] Active and passive supination exercises also were used so that the patient could work toward his goals with a home program.[3,12,17]

Following the initial evaluation, the patient was treated for 15 minutes with Hydrocollator heating pads to the area of the subtalar joint and the peroneal muscles on the involved side. Joint mobilization procedures were then performed with the patient positioned supine. With one hand, the therapist grasped the area of the distal tibia, fibula, and talus. With the other hand, the therapist grasped the area of the calcanus on the medial and lateral sides. The therapist then attempted to move the calcaneus into an inverted position several times each treatment. The patient received passive and active range-of-motion exercises in an attempt to move his foot into inversion. His uninvolved foot was moved passively into a supinated position several times. The patient was then asked to reproduce this movement on his own. When he was able to perform supination on his uninvolved side, he was asked to do the same movement on the involved side. Attempts at active supination of the right foot produced no observable calcaneal motion and only a small amount of forefoot motion.

Passive inversion of the right foot was attempted, but a clonus response prevented the use of this procedure. This treatment was repeated for the 5 physical therapy sessions. Home program exercises consisted of attempts at active inversion of the right foot at home and at school. These exercises were to be performed 4 times every hour and were to be held in the end-range position for approximately 30 seconds. The patient's father was instructed in the calcaneal mobilization techniques. He was instructed to perform these procedures at least 1 time each evening for a set of 50 repetitions to be held for approximately 5 seconds at the end range.

During treatment sessions 2 through 4, the patient exercised on a BAPS ([dagger]) boards for 5 sets of 20 repetitions each session using the 2 small ball attachments. The patient was instructed to emphasize the inversion component of the movement while on the board. Gait training was done in an attempt to incorporate the movements of right foot inversion into his gait pattern. During session 2, the patient was fitted with a pair of temporary orthoses designed to support the medial side of the right forefoot and rear foot. The orthoses were made of orthopedic felt padding and Plastazote ([double dagger]) wrapped with athletic tape. The felt was approximately 1.3 cm (approximately 1/2 in) thick on the medial side and approximately 0.3 cm (approximately 1/8 in) thick laterally. The intent of the posting on the medial side of the orthosis was to facilitate a less pronated position of the patient's foot during gait. The orthosis for the involved side provided 10 degrees of forefoot posting and 5 degrees of rear-foot posting. A ruler was used to measure the thickness of the felt used to post the orthosis. The orthosis for the uninvolved side had no posting.

On the patient's arrival for his third treatment session, and after 4 days of wear, the material of the right orthosis was deformed to the extent that the posting had diminished to only a few degrees. After this session, we contacted the referring physician and informed him that we had gained no inversion motion and that the temporary orthoses appeared to be ineffective. The physician requested that we try permanent orthoses made of a more rigid material, hoping that the more rigid material would be more effective in producing the needed rear-foot movement into inversion. These permanent orthoses were fabricated by the primary author (MJK) using a rigid plastic shell and Plastazote. The ideal position for the patient's foot would have been in or near the subtalar neutral position, but his foot deformity did not allow us to attain this position. We therefore chose not to cast his foot but to fabricate orthoses based on the foot position that we believed would place his foot near the subtalar joint neutral position. We believed that this position gave us the best chance for gaining inversion range of motion. During the fourth treatment (approximately 10 days after the initial evaluation), the patient was given the permanent orthoses.

Following the 5 physical therapy sessions, the patient still had no active or passive calcaneal supination. Passive range-of-motion testing at the subtalar joint still revealed no available movement. The use of orthoses created no measurable difference in foot angles during stance. Our treatment was ineffective in achieving this patient's goals. We expected this to be the case based on our hypothesis of a talocalcaneal joint coalition with the rear foot fixed in a prorated position.

We concluded from our literature review that we had only a weak chance for success with our treatment approach. We believed, however, that the only treatment alternative to our approach was surgery. We could therefore justify 5 visits with this patient. After the patient demonstrated no improvement in subtalar joint motion, function, or pain following 5 sessions of physical therapy over a 4-week period, we referred him back to his physician with the recommendation for further diagnostic study to test the physical therapy hypothesis. The patient saw a second orthopedic surgeon, and radiographs were obtained that confirmed the revised physical therapy hypothesis. A podiatrist also reviewed the radiographs and confirmed the presence of a tarsal coalition at the talocalcaneal joint. At the time of this writing, the patient and his parents decided not to undergo any surgical procedure. The patient continues to experience discomfort with running and prolonged standing (ie, longer than 1 hour).

Conclusion

Based on our review of the literature and our experience, we believe that physical therapists should be aware of signs and symptoms that may indicate the presence of tarsal coalition. If a person with talocalcaneal coalition is identified, the therapist should determine whether the calcaneus is in a neutral, inverted, or everted position. The position of the rear foot while the person is at rest appears to predict the effectiveness of treatment. The literature suggests that conservative treatment approaches may be more effective if the rear foot is positioned at or near the neutral position. Conservative treatment is less likely to be successful if the rear foot is everted. The results obtained with our patient support the notion that conservative treatment is not likely to be successful for a person with talocalcaneal coalition and an everted rear foot.

(dagger]) [Biomechanical Ankle Platform System, Camp International, PO Box 89, Jackson, MI 49204.

([double dagger]) Zote Foams, 319 Airport Rd, Hackettstown, NJ 07840.

References

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[2] Malkin SAS. Discussion on spasmodic flat foot. Proceedings of the Royal Society of Medicine. 1930;23:973-981.

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[12] Sanghi JK, Roby HR. Bilateral peroneal spastic flatfeet associated with congenital fusion of the navicular and talus: a case report. J Bone Joint Surg Am. 1961;43:1237-1239.

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[14] Jahss MH, ed. Disorders of the Foot and Ankle: Medical and Surgical Management. Vols I, II, and III. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1991.

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[19] Jack EA. Bone anomalies of the tarsus in relation to "peroneal spastic flatfeet." J Bone Joint Surg Br. 1954;36:530-542.

[20] Jayakumar S, Cowell HR. Rigid flatfoot. Clin Orthop. 1977;122:77-84.

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[23] 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;74:529-535.

[24] 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;14:540-544.

[25] Simmons EH. Tibialis spastic varus foot with tarsal coalition. J Bone Joint Surg Br. 1965;47:533-536.

[26] Stoskopf CA, Hernandez RJ, Kelikian A, et al. Evaluation of tarsal coalition by computed tomography. J Pediatr Orthop. 1984;4:365-369.

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[28] Bower BL, Keyser CK, Gilula LA. Rigid subtalar joint--a radiographic spectrum. Skeletal Radiol. 1989;17:583-588.

[29] Herzenberg JE, Goldner JL, Martinez S, Silverman PM. Computerized tomography of talocalcaneal tarsal coalition: a clinical and anatomic study. Foot Ankle. 1986;6:273-288.

[30] Pachuda NM, Lasday SD, Jay RM. Tarsal coalition: etiology, diagnosis, and treatment. J Foot Surg. 1990;29:474-488.

[31] Perlman MD, Wertheimer SJ. Tarsal coalitions. J Foot Surg. 1986;25:58-67.

[32] Olney BW, Asher MA. Excision of symptomatic coalition of the middle facet of the talocalcaneal joint. J Bone Joint Surg Am. 1987;69:539-544.

[33] O'Neill DB, Micheli LJ. Tarsal coalition: a followup of adolescent athletes. Am J Sports Med. 1989;17:544-549.

[34] Scranton PE Jr. Treatment of symptomatic talocalcaneal coalition. J Bone Joint Surg Am. 1987;69:533-539.

[35] Swionthowski MF, Scranton PE, Hansen S. Tarsal coalitions: long-term results of surgical treatment. J Pediatr Orthop. 1983;3:287-292.

MJ Kelo, PT, OCS, is Clinic Manager, Sheltering Arms Rehabilitation Hospital, 11601 Ironbridge Rd, Suite 110, Chester, VA 23831 (USA), and Clinical Instructor, Department of Physical Therapy, Virginia Commonwealth University, Richmond, VA 23298-0224. Address all correspondence to Mr Kelo at the first address.

DL Riddle, PhD, PT, is Associate Professor, Department of Physical Therapy, Virginia Commonwealth University, Richmond, Va.

This article was submitted May 6, 1997, and was accepted November 18, 1997.