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Talocalcaneal Coalition

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Written by: Dr Don Ponnamperuma ā€“ created: 16 August 2025; last modified: 16 August 2025

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Talocalcaneal coalition refers to complete or partial abnormal union between the talus and calcaneus.[1]

Epidemiology

Can affect up to 13% of the population and is one of the commonest tarsal coalition conditions, along with calcaneonavicular coalition; most cases are asymptomatic.[2] TCC accounts for 45% of cases or tarsal coalitions.[3] A large portion of coalitions may not be identified due to not being seen on plain x-ray.[4] Up to 50% may be bilateral, but bilateral symptoms are uncommon.[5]

Pathology

Connections between the talus and calcaneus can be fibrous (syndesmosis), cartilaginous (synchondrosis) or osseous (synostosis).[4] The talocalcaneal joint (TCJ) is a complex joint with anterior, middle and posterior components; the anterior TCJ is the smallest, where the superomedial aspect of the anterior process of calcaneus articulates with the lateral aspect of the talar head. The middle TCJ is formed by the sustentacular articular facet of calcaneus articulating with the middle talar articular facet of the talus. In some individuals, this may connect with and be contiguous with the anterior TCJ.

An important anatomical variant is thickening of the posterior capsule to the middle TCJ, which can be confused with a coalition. The posterior TCJ is formed by articulation of the posterosuperior aspect of calcaneus with the postero-inferior aspect of the talar body, immediately posterior to sinus tarsi. There are several intracapsular and extracapsular ligaments that may be confused for a fibrous coalition. Additionally, the posterior TCJ has several known anatomical variations that can complicate radiological assessment of a symptomatic individual.[6][5] The middle facet is most commonly involved in TCC.[3]

Aetiology

TCC may be congenital, due to a failure of normal embryological segmentation; this is thought to be an autosomal dominant trait with variable penetrance.[5] Acquired TCC can be due to trauma, degenerative changes, surgery, infection and inflammatory arthritis.[7]

Presentation

Patients commonly present with foot pain at the level of the subtalar joints on activity; onset is between the ages of 12-16, thought to be due to ossification of the coalitions. Additionally, there can be frequent ankle sprains that fail to improve (Landorf et al., 2023; Myerson et al., 2024). Coalitions can also alter the biomechanics of the foot, leading to pain at other parts of the foot.[8]

Observation of gait may demonstrate a valgus heel, flattened medial arch and forefoot abduction on weight bearing; there can also be a rigid flat foot that is not correctable on tiptoeing.[9] Examination may demonstrate decreased movement at the subtalar and mid-tarsal joints, with pain at the end- ranges of movement.[8]

Management

The initial investigation is plain x-ray; a Harris-Beath view can be used to visualise the calcaneal body, middle facet and sustenaculum tali. A lateral view can demonstrate the C-sign, which is a continuous cortical line between the talus and the sustentaculum tali, but a syndesmosis or synchondrosis may not be visible on x-ray. Additionally, there can be a talar beak, where the periosteum at the insertion of the talonavicular ligament is repeatedly lifted, and repeated healing by ossification creates a beak-like projection of the anterior dorsal talus on lateral x-ray.

Secondary signs of TCC can include a dysmorphic sustentaculum tali, narrow posterior subtalar joints, absence of the middle facet and a rounded lateral talar process. CT scan can completely visualise a synostosis, while MRI is the imaging of choice for syndesmosis or synchondrosis. [3][10][8][4][11]

Initial management of a symptomatic patient is rest and NSAIDs, aiming to decrease inflammation in any of the affected subtalar joints. Orthoses may help address altered biomechanics but may also affect motion at subtalar joints necessary for gait. Additionally, orthoses may need to be worn for 36 months for effective pain relief. Immobilisation with short leg cast or a walking boot for 3-8 weeks may also improve pain and decrease the risk of progressing onto surgery.[8][12]

Subtalar corticosteroid injections may delay progression to surgery but does not decrease the rate of those going onto require surgical intervention.[13] Surgical management is reserved for those who failed conservative management; first line surgery is resection of the coalition and fat grafting with or without osteotomy to correct any deformities. This is associated with up to 85% experiencing long term relief of pain. Those who fail this may under arthrodesis, either of affected subtalar joints or most extensive arthrodesis of subtalar, calcaneocuboid or talonavicular joints.[14][15]

References

  1. ā†‘ Myerson, Mark S.; FernĆ”ndez-Rojas, Enrique; Monteagudo, Manuel; Araya-Bonilla, VĆ­ctor; Barra-Dinamarca, Emilio; Elgueta-Grillo, Jaime (2024-08). "Talocalcaneal coalition classifications: A critical analysis review and suggested new classification system with implications for treatment". Foot and Ankle Surgery. 30 (6): 450ā€“456. doi:10.1016/j.fas.2024.03.010. ISSN 1268-7731. Check date values in: |date= (help)
  2. ā†‘ RĆ¼hli, F.J.; Solomon, L.B.; Henneberg, M. (2003-09). "High prevalence of tarsal coalitions and tarsal joint variants in a recent cadaver sample and its possible significance". Clinical Anatomy (in English). 16 (5): 411ā€“415. doi:10.1002/ca.10146. ISSN 0897-3806. Check date values in: |date= (help)
  3. ā†‘ 3.0 3.1 3.2 Amini, Behrang; Rasuli, Bahman; Collins, Evangeline (2008-05-02). "Talocalcaneal coalition". Radiopaedia (in English). Radiopaedia.org. doi:10.53347/rid-2145 Check |doi= value (help).
  4. ā†‘ 4.0 4.1 4.2 Nalaboff, Kenneth M.; Schweitzer, Mark E. (2008). "MRI of tarsal coalition: frequency, distribution, and innovative signs". Bulletin of the NYU hospital for joint diseases. 66 (1): 14ā€“21. ISSN 1936-9719. PMID 18333823.
  5. ā†‘ 5.0 5.1 5.2 Lawrence, David A.; Rolen, Michael F.; Haims, Andrew H.; Zayour, Zakaria; Moukaddam, Hicham A. (2014-07). "Tarsal Coalitions: Radiographic, CT, and MR Imaging Findings". HSS JournalĀ®: The Musculoskeletal Journal of Hospital for Special Surgery (in English). 10 (2): 153ā€“166. doi:10.1007/s11420-013-9379-z. ISSN 1556-3316. Check date values in: |date= (help)
  6. ā†‘ Moore, K., & Agur, A. M. R. (2007). Lower limb. In Essential Clinical Anatomy 3rd edition (pp. 313ā€“400). Lippincott, Williams and Wilkins.
  7. ā†‘ Bohne, Walther H. O. (2001-02). "Tarsal coalition". Current Opinion in Pediatrics (in English). 13 (1): 29. ISSN 1040-8703. Check date values in: |date= (help)
  8. ā†‘ 8.0 8.1 8.2 8.3 Landorf, K., Simons, S., Jordan, C., & Rathleef, M. (2023). Foot Pain. In Brukner and Khanā€™s Clinical Sports Medicine Vol 1 (pp. 937ā€“972). McGraw Hill.
  9. ā†‘ Kulik, Steven A.; Clanton, Thomas O. (1996-05). "Tarsal Coalition". Foot & Ankle International (in English). 17 (5): 286ā€“296. doi:10.1177/107110079601700509. ISSN 1071-1007. Check date values in: |date= (help)
  10. ā†‘ Knipe, Henry (2021-03-29). "Harris Beath projection". Radiopaedia (in English). Radiopaedia.org. doi:10.53347/rid-87871 Check |doi= value (help).
  11. ā†‘ Newman, Joel S.; Newberg, Arthur H. (2000-03). "Congenital Tarsal Coalition: Multimodality Evaluation with Emphasis on CT and MR Imaging: (CME available in print version and on RSNA Link)". RadioGraphics (in English). 20 (2): 321ā€“332. doi:10.1148/radiographics.20.2.g00mc03321. ISSN 0271-5333. Check date values in: |date= (help)
  12. ā†‘ Shirley, Eric; Gheorghe, Radu; Neal, Kevin M.; Shirley, Eric; Gheorghe, Radu; Neal, Kevin M. (2018-07-08). "Results of Nonoperative Treatment for Symptomatic Tarsal Coalitions". Cureus (in English). 10 (7). doi:10.7759/cureus.2944. ISSN 2168-8184. PMC 6128590.CS1 maint: PMC format (link)
  13. ā†‘ Zide, Jacob R.; Shivers, Claire; Adair, Christopher; Le, Thanh; Kanaan, Yassine; Rathjen, Karl; Jo, Chan-Hee; Riccio, Anthony I. (May/June 2022). "The Efficacy of Intra-articular Subtalar Steroid Injection for Symptomatic Talocalcaneal Coalitions: A 30-Year Single Institution Experience". Journal of Pediatric Orthopaedics (in English). 42 (5): e453. doi:10.1097/BPO.0000000000002132. ISSN 0271-6798. Check date values in: |date= (help)
  14. ā†‘ Gantsoudes, George D.; Roocroft, Joanna H.; Mubarak, Scott J. (2012-04). "Treatment of Talocalcaneal Coalitions". Journal of Pediatric Orthopaedics (in English). 32 (3): 301ā€“307. doi:10.1097/BPO.0b013e318247c76e. ISSN 0271-6798. Check date values in: |date= (help)
  15. ā†‘ Watts, E., & Sink, E. (2022). Tarsal Coalition - Pediatrics - Orthobullets. Orthobullets.com. https://www.orthobullets.com/pediatrics/4068/tarsal- coalition?section=bullets

Literature Review

Literature Review

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