(Radiographics. 2000;20:321-332.)
© RSNA, 2000
Congenital Tarsal Coalition: Multimodality Evaluation with Emphasis on CT and MR Imaging1
(CME available in print version and on RSNA Link)
Joel S. Newman, MD and
Arthur H. Newberg, MD
1 From the Department of Radiology, New England Baptist Bone and Joint Institute, New England Baptist Hospital, 125 Parker Hill Ave, Boston, MA 02120. Presented as a scientific exhibit at the 1998 RSNA scientific assembly. Received March 1, 1999; revisions requested April 26 and received June 11; accepted June 14. Address reprint requests to J.S.N. (e-mail: jnewman@nebh.org).
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Abstract
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Congenital tarsal coalition is a diagnosis that is often overlooked in young patients who first present with foot and ankle pain. Calcaneonavicular and talocalcaneal coalitions are encountered most frequently; fusion at other sites is much less common. Tarsal coalitions may be osseous, cartilaginous, or fibrous. Calcaneonavicular coalitions are readily detected on oblique radiographs. Radiographic confirmation of talocalcaneal coalition is more difficult than for fusion at other locations, although several secondary radiographic signs may indirectly suggest the diagnosis. Computed tomography (CT) and magnetic resonance (MR) imaging are invaluable for assessment of tarsal coalitions because they allow differentiation of osseous from nonosseous coalitions and because they depict the extent of joint involvement as well as secondary degenerative changes, features of vital importance in surgical planning. Short-inversion-time inversion recovery MR images may reveal bone marrow edema along the margins of the abnormal articulation, an important clue to the diagnosis. Moreover, CT or MR imaging may be required to confirm the diagnosis of talocalcaneal coalition when radiographic findings are equivocal. Because the diagnosis of tarsal coalition is often not entertained by the clinician ordering a CT or MR imaging examination, multiplanar imaging of the ankle and hindfoot is required.
Index Terms: Ankle, abnormalities, 464.143 • Bone, dysostoses, 464.143 • Foot, abnormalities, 464.143
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Introduction
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Tarsal coalition represents abnormal fusion between two or more tarsal bones and is a frequent cause of foot and ankle pain. Congenital tarsal coalition is a diagnosis that is often overlooked in young patients who first present with foot and ankle pain. In fact, coalitions of all types may be initially detected at computed tomography (CT) or magnetic resonance (MR) imaging examinations performed for an unrelated indication. For this reason, familiarity with the appearances of coalitions on cross-sectional images is essential. This article reviews the clinical characteristics of congenital tarsal coalition; describes the evaluation of the foot and ankle with conventional radiography, CT, and MR imaging; and discusses treatment of tarsal coalition.
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Clinical Characteristics
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Congenital tarsal coalition likely results from abnormal differentiation and segmentation of primitive mesenchyme with resultant lack of joint formation (1). An autosomal dominant inheritance pattern with variable, if not nearly full penetrance, has been suggested (2). The true prevalence of tarsal coalition is not known; estimates range from far less than 1% of the population (3) to approximately 1%–2%. There is a probable, slight male predominance, and the condition is bilateral in approximately 50% of cases (4).
Approximately 90% of tarsal coalitions involve the talocalcaneal or calcaneonavicular joints. Although many investigators believe that calcaneonavicular coalitions are the most commonly encountered type (3), others report a nearly equal prevalence of talocalcaneal and calcaneonavicular coalitions (5) or even a slightly greater prevalence of talocalcaneal coalitions (6). Calcaneonavicular coalitions are more readily diagnosed with conventional radiography, which may contribute to their reported higher prevalence. Talonavicular coalitions are far less common, and many are asymptomatic (4); calcaneocuboid and cubonavicular coalitions are very rare (4,7,8). Navicular–first cuneiform joint coalitions have also been reported (9,10). Occasionally, multiple coalitions in one foot may be seen.
Tarsal coalitions are further subclassified on the basis of the morphology of the abnormal bridging as either fibrous, cartilaginous, or osseous. Although this subclassification has important implications for imaging, the pathogenesis of tarsal coalitions is best viewed as a continuum, with progressive osseous bridging occurring with increasing age (11) and with various histologic components often coexisting (4).
The onset of symptoms related to tarsal coalition is variable, and patients commonly present in the 2nd decade of life (12). Symptoms become more pronounced with progressive ossification of the coalition. Calcaneonavicular coalitions typically ossify sooner than do talocalcaneal coalitions, therefore manifesting earlier in childhood (children aged 8–12 years vs 12–16 years) (11). In many patients, however, diagnosis may not occur until early adulthood. Most patients present with hindfoot or tarsal pain or stiffness, which is often first noted after antecedent trauma, weight gain, or an increase in athletic activity (7). Tarsal coalition is a common cause of a peroneal spastic flatfoot or rigid flatfoot. The condition does not represent true spasticity, but rather peroneal spasm or adaptive peroneal shortening to adjust for the heel valgus and to maintain the subtalar joint in the least painful position. Physical examination often reveals decreased hindfoot motion with pes planus and calcaneus valgus (4,7,11). Finally, in some patients, tarsal coalition may be completely asymptomatic (12).
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Radiography of Tarsal Coalitions
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All patients with suspected tarsal coalition are first evaluated with three radiographic views of the foot: anteroposterior, 45° internal oblique, and lateral. Use of conventional radiography alone is often sufficient to diagnose most calcaneonavicular and talonavicular coalitions (Figs 1, 2). The diagnosis of talocalcaneal coalitions, however, generally requires cross-sectional imaging (either CT or MR imaging) for confirmation and characterization. Axial or Harris-Beath radiographic views may aid in the depiction of talocalcaneal coalitions (13), but these projections have largely been supplanted by CT or MR imaging.
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Figure 1a. Calcaneonavicular coalition in an 11-year-old boy. (a) Oblique radiographs of both feet reveal a nonosseous coalition on the left (arrow). (b) Lateral radiograph of the left foot shows enlargement of the anterior dorsal calcaneus (arrows), referred to as the "anteater sign."
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Figure 1b. Calcaneonavicular coalition in an 11-year-old boy. (a) Oblique radiographs of both feet reveal a nonosseous coalition on the left (arrow). (b) Lateral radiograph of the left foot shows enlargement of the anterior dorsal calcaneus (arrows), referred to as the "anteater sign."
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Figure 2. Talonavicular and calcaneocuboid coalitions in a 7-year-old boy. Oblique radiographs of both feet demonstrate bilateral talonavicular (arrows) and calcaneocuboid (arrowheads) coalitions.
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Calcaneonavicular Coalition
Calcaneonavicular coalitions are best depicted on 45° internal oblique radiographs. The calcaneus and navicular do not normally articulate. With osseous coalition, a bony bar that bridges the two bones is seen. With fibrous or cartilaginous coalition, the bones are in close proximity, both have irregular surfaces, and the anteromedial calcaneus is abnormally widened or flattened. On lateral radiographs, elongation of the anterior dorsal calcaneus may simulate an anteater's nose (14) (Fig 1). Hypoplasia of the talus may also be observed with calcaneonavicular coalition (15).
Talocalcaneal Coalition
The subtalar joint consists of the anterior, middle, and posterior facets. Talocalcaneal fusion most commonly involves the middle facet at the level of the sustentaculum tali (15). Coalitions centered just posterior to the sustentaculum tali have been reported in children (16).
Talocalcaneal coalitions may be difficult to visualize on the three standard radiographic views of the foot because of the complex orientation of the subtalar joint.
A number of secondary radiographic signs of talocalcaneal coalition have been described, including a talar beak, narrowing of the posterior subtalar joint, rounding of the lateral talar process, and lack of depiction of the middle facets on lateral radiographs (4,12,15). These secondary findings may develop because of alteration in hindfoot biomechanics secondary to the coalition. A talar beak (Fig 3) occurs because of impaired subtalar joint motion, which results in the navicular overriding the talus. Periosteal elevation occurs at the insertion of the talonavicular ligament, and, ultimately, a cycle of osseous repair results in formation of the talar beak (12,15,17). However, a talar beak is not always present with talocalcaneal coalition. In some cases, a hypertrophied talar ridge may occur in the absence of tarsal coalition in patients with diffuse idiopathic skeletal hyperostosis, acromegaly, or rheumatoid arthritis or in certain athletes (12,17). In severe cases of juvenile coalition, a ball-in-socket tibiotalar joint may form as a consequence of limited subtalar motion (7).
Another radiographic finding seen on lateral views in talocalcaneal coalition is the "C sign," as described by Lateur et al (18) (Fig 4). A C-shaped line outlines the medial talar dome and posteroinferior sustentaculum. The C sign results from bone bridging between the talar dome and sustentaculum, as well as the prominent inferior outline of the sustentaculum. As the x-ray beam strikes the posteroinferior outline of the abnormal sustentaculum tangentially over a long distance, an uninterrupted "C" results. The C sign may be observed in both osseous and nonosseous coalitions. Variations in sustentacular size and orientation may affect the reliability of this sign (18). Moreover, the ability to assess subtalar joint anatomy accurately from lateral radiographs may be impaired by subtle changes in patient positioning.
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CT of Tarsal Coalitions
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CT of the ankle and hindfoot should be performed in both coronal (perpendicular to the ankle joint and long axis of foot) and axial (parallel to the ankle joint and long axis of foot) planes. Both feet should be positioned symmetrically in the gantry and should be imaged simultaneously. The coronal images may be obtained in a plane perpendicular to the plantar surface of the foot, or, as described by Wechsler et al (19), in a plane perpendicular to the plane of the subtalar joint. Section thickness should be approximately 3 mm. Although conventional multiplanar CT of the foot is performed at our institution, a spiral CT may be performed in axial and coronal planes with 3-mm collimation, reconstructions at 3-mm intervals, and a pitch of 1–1.5. Use of direct, nonreformatted CT imaging in the sagittal plane has also been described (19), although coalitions of all types are usually easily diagnosed with conventional axial and coronal imaging.
CT is invaluable in the diagnosis of talocalcaneal coalition and may be useful in surgical planning by helping determine if resection is feasible or if arthrodesis is indicated. CT offers a more precise evaluation of the extent of coalition, particularly at the subtalar joint, than does radiography with axial views (20,21) or conventional tomography and readily depicts associated degenerative changes (19). Moreover, familiarity with the CT appearance is essential, since the diagnosis of unsuspected coalition is often made from CT scans obtained for unrelated indications.
In calcaneonavicular coalition (Figs 5–7), axial CT scans show broadening of the medial aspect of the anterior and dorsal calcaneus as it lies in apposition to the navicular. The obliquity of the calcaneonavicular bridging, whether osseous or nonosseous, makes it difficult to visualize the entire coalition on only one axial or coronal image. In some cases of nonosseous coalition, changes may be subtle (22), with narrowing of the space between the two bones and minimal marginal reactive bone changes. Cross-sectional imaging is also helpful in the diagnosis of rare cubonavicular coalition (Fig 8).
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Figure 5a. Calcaneonavicular coalition in an 11-year-old boy. Axial (a) and coronal (b) CT scans show apposition of the anterior dorsal calcaneus with the navicular in the left foot, with narrowing and reactive sclerosis (arrow).
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Figure 5b. Calcaneonavicular coalition in an 11-year-old boy. Axial (a) and coronal (b) CT scans show apposition of the anterior dorsal calcaneus with the navicular in the left foot, with narrowing and reactive sclerosis (arrow).
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Figure 8a. Cubonavicular coalition in a 10-year-old girl. (a) Oblique radiograph of the right foot shows abnormal narrowing of the space between the cuboid and navicular (arrow) and apparent narrowing of the calcaneonavicular space. (b) Coronal CT scan helps confirm a cubonavicular coalition (arrow). No calcaneonavicular coalition was identified.
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Figure 8b. Cubonavicular coalition in a 10-year-old girl. (a) Oblique radiograph of the right foot shows abnormal narrowing of the space between the cuboid and navicular (arrow) and apparent narrowing of the calcaneonavicular space. (b) Coronal CT scan helps confirm a cubonavicular coalition (arrow). No calcaneonavicular coalition was identified.
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Talocalcaneal coalitions (Figs 9, 10) are best depicted on coronal CT scans (23). In osseous coalition, a bony bar bridges the middle facet of the subtalar joint. Involvement of the posterior and anterior facets is variable, and abnormal narrowing or even fusion of the posterior facet may be observed in advanced cases. In nonosseous coalition, the middle facet of the subtalar joint may be narrowed with reactive cystic and hypertrophic changes of the underlying bone (22). Careful attention should be directed to the orientation of the sustentaculum and middle facet of the articulation. Normally, the sustentaculum slopes upward medially; however, in talocalcaneal coalition it slopes generally downward or the articular surface is oriented in the horizontal plane (Fig 10) (18). In some fibrous coalitions, periarticular reactive bone changes and joint space narrowing may be minimal (22,24); the only findings suggestive of a coalition may be minimal narrowing of an abnormally oriented middle facet. Although the sustentaculum itself is frequently broadened in talocalcaneal coalition, it may occasionally be hypoplastic (18). Finally, some coalitions are localized only to the most posterior aspects of the middle facet (23).
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Figure 9a. (9) Talocalcaneal coalitions in a 25-year-old woman. (a) Lateral radiograph of the left foot shows narrowing of the posterior subtalar joint (arrow). (b, c) Coronal CT scans show bilateral osseous coalitions (arrows) involving the middle facets (b) and posterior facets (c).
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Figure 9b. (9) Talocalcaneal coalitions in a 25-year-old woman. (a) Lateral radiograph of the left foot shows narrowing of the posterior subtalar joint (arrow). (b, c) Coronal CT scans show bilateral osseous coalitions (arrows) involving the middle facets (b) and posterior facets (c).
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Figure 9c. (9) Talocalcaneal coalitions in a 25-year-old woman. (a) Lateral radiograph of the left foot shows narrowing of the posterior subtalar joint (arrow). (b, c) Coronal CT scans show bilateral osseous coalitions (arrows) involving the middle facets (b) and posterior facets (c).
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MR Imaging of Tarsal Coalitions
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MR imaging of the ankle and hindfoot should be performed in three planes: axial or oblique axial, coronal, and sagittal. T1-weighted, fast spin-echo proton density–weighted, and fast spin-echo T2-weighted images are generally sufficient for the evaluation of most tendon, ligament, and articular abnormalities. Use of at least one fat-suppressed sequence (eg, short-inversion-time inversion recovery [STIR] or frequency-selective fat-suppressed proton density–weighted and T2-weighted), usually in the coronal or sagittal plane, is recommended to help identify bone marrow and soft-tissue edema or inflammatory changes. Tarsal coalitions should be readily depicted with this or similar protocols.
Calcaneonavicular coalitions are best visualized on sagittal and axial MR images (Figs 11, 12). Sagittal images are particularly valuable because of the orientation of the calcaneonavicular bridging. The elongated anterior dorsal calcaneus (anteater's nose) may be visualized on a single image. As in CT scanning, the coronal plane is best for evaluating talocalcaneal coalitions with MR imaging (Figs 13–16).
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Figure 11a. Calcaneonavicular coalition in a 47-year-old woman. (a) Oblique radiograph of the left foot shows abnormal apposition of the calcaneus and navicular (arrows). (b) Sagittal T1-weighted MR image shows the anteater sign (arrows). (c) Sagittal T2-weighted MR image reveals the nonosseous coalition (arrow). Marked narrowing between the calcaneus and navicular with reactive "cystic" changes in the underlying bone are seen on both MR images.
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Figure 11b. Calcaneonavicular coalition in a 47-year-old woman. (a) Oblique radiograph of the left foot shows abnormal apposition of the calcaneus and navicular (arrows). (b) Sagittal T1-weighted MR image shows the anteater sign (arrows). (c) Sagittal T2-weighted MR image reveals the nonosseous coalition (arrow). Marked narrowing between the calcaneus and navicular with reactive "cystic" changes in the underlying bone are seen on both MR images.
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Figure 11c. Calcaneonavicular coalition in a 47-year-old woman. (a) Oblique radiograph of the left foot shows abnormal apposition of the calcaneus and navicular (arrows). (b) Sagittal T1-weighted MR image shows the anteater sign (arrows). (c) Sagittal T2-weighted MR image reveals the nonosseous coalition (arrow). Marked narrowing between the calcaneus and navicular with reactive "cystic" changes in the underlying bone are seen on both MR images.
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Figure 13a. Talocalcaneal coalition in a 39-year-old woman. (a) Coronal proton density-weighted image shows an abnormal middle facet (arrows). (b) On a STIR image, bone marrow edema is evident about the posterior subtalar joint (arrows).
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Figure 13b. Talocalcaneal coalition in a 39-year-old woman. (a) Coronal proton density-weighted image shows an abnormal middle facet (arrows). (b) On a STIR image, bone marrow edema is evident about the posterior subtalar joint (arrows).
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Figure 14a. Talocalcaneal coalition in a 20-year-old man. (a) Sagittal T1-weighted scan shows a talar beak (arrow). (b) Coronal proton density-weighted image reveals a middle facet coalition (arrow). Note the abnormal broadening and downsloping of the sustentaculum. (c) Coronal STIR image shows the associated bone marrow edema (arrows).
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Figure 14b. Talocalcaneal coalition in a 20-year-old man. (a) Sagittal T1-weighted scan shows a talar beak (arrow). (b) Coronal proton density-weighted image reveals a middle facet coalition (arrow). Note the abnormal broadening and downsloping of the sustentaculum. (c) Coronal STIR image shows the associated bone marrow edema (arrows).
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Figure 14c. Talocalcaneal coalition in a 20-year-old man. (a) Sagittal T1-weighted scan shows a talar beak (arrow). (b) Coronal proton density-weighted image reveals a middle facet coalition (arrow). Note the abnormal broadening and downsloping of the sustentaculum. (c) Coronal STIR image shows the associated bone marrow edema (arrows).
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Figure 15a. Osseous talocalcaneal coalition in a 39-year-old woman. Coronal proton density-weighted (a) and sagittal T1-weighted (b) images show bone marrow contiguity across fused articulation (arrow).
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Figure 15b. Osseous talocalcaneal coalition in a 39-year-old woman. Coronal proton density-weighted (a) and sagittal T1-weighted (b) images show bone marrow contiguity across fused articulation (arrow).
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Figure 16a. Multimodality imaging of osseous talocalcaneal coalition in a 25-year-old woman. (a) On a lateral radiograph, the right foot appears relatively normal. (b) On a bone scan, there is increased uptake of radiotracer (arrow) along the right subtalar joint. (c) Coronal CT scan reveals a middle facet coalition (arrow). (d) Coronal proton density-weighted MR image shows bone marrow contiguity (arrow) across the bridged middle facet.
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Figure 16b. Multimodality imaging of osseous talocalcaneal coalition in a 25-year-old woman. (a) On a lateral radiograph, the right foot appears relatively normal. (b) On a bone scan, there is increased uptake of radiotracer (arrow) along the right subtalar joint. (c) Coronal CT scan reveals a middle facet coalition (arrow). (d) Coronal proton density-weighted MR image shows bone marrow contiguity (arrow) across the bridged middle facet.
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Figure 16c. Multimodality imaging of osseous talocalcaneal coalition in a 25-year-old woman. (a) On a lateral radiograph, the right foot appears relatively normal. (b) On a bone scan, there is increased uptake of radiotracer (arrow) along the right subtalar joint. (c) Coronal CT scan reveals a middle facet coalition (arrow). (d) Coronal proton density-weighted MR image shows bone marrow contiguity (arrow) across the bridged middle facet.
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Figure 16d. Multimodality imaging of osseous talocalcaneal coalition in a 25-year-old woman. (a) On a lateral radiograph, the right foot appears relatively normal. (b) On a bone scan, there is increased uptake of radiotracer (arrow) along the right subtalar joint. (c) Coronal CT scan reveals a middle facet coalition (arrow). (d) Coronal proton density-weighted MR image shows bone marrow contiguity (arrow) across the bridged middle facet.
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In osseous coalitions, there is bone marrow contiguity across the fused articulation. In nonosseous coalitions, the joint space is reduced. In cartilaginous coalitions, an area of signal intensity similar to that of fluid or cartilage may be present in the joint space. Intermediate- to low-signal intensity in the affected joint may indicate a fibrous coalition (22). As in CT scanning, reactive periarticular bone changes may be evident with MR imaging. On proton density–weighted and T2-weighted fat-suppressed images or STIR images, bone marrow edema is frequently identified along the fused articulation (Figs 12–14). This edema may be observed in both calcaneonavicular and talocalcaneal coalitions and helps identify an unsuspected coalition when MR images are obtained for unrelated indications. Some investigators believe that MR imaging may be superior to CT in the diagnosis of fibrous coalition (22,25), because structural alterations at the joint are often minimal.
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Treatment
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Initially, all patients with tarsal coalition are treated conservatively (11,24,26) with orthotics, casting, nonsteroidal anti-inflammatory medications, steroid injections, or physical therapy. Many patients fail conservative therapy and are then treated operatively. Calcaneonavicular coalitions may be treated with resection (27,28). Regrowth of the bony bridge may be obviated with extensor digitorum brevis interposition. If excision fails or if significant talonavicular degenerative joint disease is present, a triple arthrodesis may be performed (27). Talocalcaneal coalitions are treated surgically with resection of the middle facet bony bridge (26,29–31), often with fat interposition. Severe cases, such as those with concomitant degenerative joint disease, may require subtalar fusion or triple arthrodesis (30,31).
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Summary
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The vast majority of tarsal coalitions involve the calcaneonavicular or talocalcaneal joints. The initial diagnostic study for the evaluation of patients with hindfoot symptoms and suspected tarsal coalition remains conventional three-view radiography of the foot. Most calcaneonavicular coalitions are identified on oblique radiographs. The diagnosis of talocalcaneal coalition, however, may be more difficult with radiography given the anatomy of the subtalar joint, and CT or MR imaging is generally indicated for further evaluation.
Osseous coalitions manifest with solid bone bridging on CT scans and bone marrow contiguity on MR images. Nonosseous coalitions manifest with abnormal articular orientation, joint space narrowing, and reactive bone changes. On MR images, bone marrow edema is frequently identified adjacent to the abnormal joint. Coalitions of all types may be initially detected at CT or MR imaging examinations performed for an unrelated indication. For this reason, familiarity with the appearances of coalition on cross-sectional images is essential.
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Footnotes
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Abbreviation: STIR = short-inversion-time inversion recovery
LEARNING OBJECTIVES After reading this article and taking the test, the reader will be able to:
• Describe the various types of congenital tarsal coalition, their relative prevalence, and their clinical manifestations.
• Describe the imaging features of congenital tarsal coalition on radiographs, CT scans, and MR images.
• Recognize secondary radiographic signs of tarsal coalition that may provide an important clue to the diagnosis.
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Abstract
Introduction
