Returning to Triathlon with Tarsal Coalition

author : AMSSM

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I have tarsal coalition and it is affecting both of my ankles. Ankle fusion surgery could take away some of the pain but what about my ability to walk, cycle or swim?

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About four years ago I finally got a good diagnosis for ankle issues I'd been having for years prior. It's called tarsal coalition, and it is affecting both of my ankles. Essentially, where most people have space in their joint for it to move and bend properly, I just have more bone. Some of the bones that make up my ankle joint never separated properly and instead formed a coalition. I was born like this but didn't feel it until I started being more active in my 20s (I'm looking at you, triathlon!). 

Answer by by Joshua Lenhof DO, and Millisa Novak, DO
Member AMSSM

Many people are born with birth defects that materialize themselves as deformities or symptoms at various stages of development. Bony deformities are unique in that many present gradually as our bones start to “calcify” or harden during our teenage years. Tarsal coalition, which literally means a union of two bones that make up the heel and arch of the foot, is one such insidious birth deformity seen in ~1% of Americans. (10) Of these individuals, roughly 50-60% of individuals will have x-rays and CT images showing the same condition on their feet. Additionally, the union can be composed of cartilage (bendable tissue making up your ear and nose), fibrous tissue or more problematic bone. Unlike more obvious bony disorders, this malformation is typically overlooked as recurrent ankle instability and foot sprains, thus it is diagnosed later in life between 16-20 years old. (10)

So what is this “coalition,” that remains so elusive at young ages? Well, there are two primary types that make up 90% of these deformities. The first is calcaneonavicular deformity which is an outer union between your heel bone (calcaneous) and the bone in front of your ankle (navicular). The second is an inner attachment between the lower ankle bone (talus) and the heel bone called the Talocalcaneal deformity. Normally, these bones form the sub-talar (heel) joint allowing the foot to rotate and glide when walking, as well as inversion and eversion of the ankle when suspended off the ground. At birth these bone and their attachments are made of flexible cartilage, which allows motion of the joint despite the extra attachment. Between 8-16 years of age the cartilage is replaced with rigid bone that resists joint motion causing pain at the defect, and excess wear at other joints in the foot and ankle. (9,10) 

Symptoms often include recurrent, deep ankle pain with high impact activities such as running, dancing, jumping sports, soccer, football, ice hockey, baseball etc. Ankle deformities are commonly seen in conjunction with flat feet. (9) In such instances the ankles are bent inwards permanently flattening the foot arch, thus increasing strain and encouraging sprains of the mid-foot. Finally, these foot and ankle changes tendencies to illicit muscle spasm pain of the outside ankle, a phenomenon called “peroneal spastic flat foot.” (2) 

In addition, if you’re unlucky enough to win this genetic lottery ticket there are limited non-surgical treatment options that vary in success based on the degree of deformity, imaging results and specific fused bones. For example, calcaneonavicular coalitions and advanced arthritis yield poor results with conservative therapy. (7) Remember you have probably been dealing with this for a while and the extra wear could be developing into arthritis. In addition, non-surgical approaches often fail in individuals with significant inward ankle deviation greater than 16-21° and permanent flat foot deformity. (4) If none of these apply to your situation then a 3-6 week ankle immobilization cast followed by another 3-6 weeks of wearing special shoe orthotics is indicated. (9)

Fortunately there are two surgical methods that provide significant pain relief when conservative treatments fail, these include resection (removing the extra bone) and joint fusion. The vast majority of studies show roughly 77-100% pain improvement after resection surgery. (1,6) Another resection study showed ~87% of patients had improved joint mobility with return to sport/activity 1 year after surgery. (7,6) However, resection is typically limited to younger patients between 14-16yrs or in patients without arthritis in the foot. (1) In the case of calcaneonavicular deformities, ~1cm of extra bone is removed and replaced by fat or muscle to prevent the regeneration of the extra bone. Talocalcaneal procedures are also very similar without needing fillers. Revision surgeries are also fairly infrequent with more than 85% never requiring additional surgery. (3)

Finally, with resection “off the table” due to joint deformity or extended joint damage, permanent joint fusion of 2-3 foot bones with screws and bone grafts offers a reasonable compromise between foot motion loss and pain relief. In fact, 69-95% of individuals reported being absolutely satisfied with permanent fusion results. The primary drawback to fusion involves loss of foot flexion, toe pointing, inversion and eversion effectively limiting high-impact activities. (5) However, there are few limitations to individuals who engage in low-impact activities such as walking, cycling and swimming. Thus, returning to these low-impact sports is a reasonable postoperative goal. (8)

Overall, tarsal coalition is a bone fusion birth defect of the foot that has a tendency to become problematic in active teenagers and is often overlooked for several years. There are few conservative treatments with high success rates. If caught early before joint arthritis has occurred, resection has the best long term outcomes with high odds of restoring previous activity levels. When resection is not on an option, joint fusion offers limitation in foot motion and high impact activities while providing significant pain relief, patient satisfaction and return to low-impact activity.

References

1. Gonzalez P, Kumar SJ. Calcaneonavicular coalition treated by resection and interposition of the extensor digitorum brevis muscle. J Bone Joint Surg Am. 1990; 72: 71-77.
    
2. Jack EA. Bone Anomalies of the Tarsus in Relation to "Peroneal Spastic Flatfoot". J Bone Joint Surg Br. 1954: 36, 530-542.
    
3. Lisella J, Bellapianta J, Manoli A. Tarsal Coalition Resection with Pes Planovalgus Hindfoot Reconstruction. J Surg Orthop Adv. 2011: 20,102-105. 
    
4. Mubarak S, Patel P, Upasani V, Moor M, Wenger D. Calcaneonavicular Coalition: Treatment by Excision and Fat Graft. Journal of Pediatric Orthopedics. 2009: 29, 418-426. 
    
5. Khoshbin A, Bouchard M, Wasserstein D, Leroux T, Law P, Kreder H, Daniels T, Wright J. Reoperations after Tarsal Coalition Resection: A Population-based Study. Journal of Foot and Ankle Surgery. 2014: 1-5.
    
6. Mahan, S, Spencer S, Vezeridis P, Kasser J. Patient-reported Outcomes of Tarsal Coalitions Treated With Surgical Excision. Journal of Oediatric Orthopedics. 2014: 0: 1-6. 
    
7. Morgan RC, Crawford AH. Surgical management of tarsal coalition in adolescent athletes. Journal of Foot and Ankle Surgery. 1986: 7, 183-193.
    
8. Turturro F, Montanaro A, Labianca L, Di Sanzo V, Calderaro C, Ferretti, A. Correction of Foot Deformities by Tripple Arthrodesis. American Academy of Orthopaedic. 2013: V13024.
    
9. Wheeless C, Nunley J, Urbaniak J. Wheeless Textbook of Orthopedics. Data Trace Internet Publishing LLC, 1996. http://www.wheelessonline.com/. 1 Dec. 2014.
    
10. Zaw H, Calder J. Tarsal coalitions. Clinical Journal of Foot and Ankle. 2010: 15, 349.

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date: February 13, 2015